key: cord-265575-gcaj3p0f authors: shah, pir tariq; xing, li title: increasing and declining of covid-19 cases puzzling the health experts in pakistan date: 2020-10-17 journal: new microbes new infect doi: 10.1016/j.nmni.2020.100791 sha: doc_id: 265575 cord_uid: gcaj3p0f although the comprehensive social measures had been engaged, covid-19 cases remained increasing until mid-july in pakistan, which was followed by unexplained declining. therefore, those countermeasures need to be re-examined to find out the loopholes or defects in implementing policies in order to eventually win the war against covid-19. bangladesh (1.3%) were observed to be lower than that in other regional countries including china (5.2%), iran (5.7%), and afghanistan (3.6%), and major developed countries including the united states of america (usa, 3.1%), the united kingdom (uk, 13%), france (14.9%), germany (4.1%), italy (13.9%) and spain (8.3%) ( figure 3a ). the lower case-fatality rate in pakistan can also be seen in individual regions including azad kashmir, balochistan, gilgit-baltistan, islamabad, khyber pakhtunkhwa, punjab, and sindh ( figure 3b ). the reasons for the lower case-fatality rate have yet to be investigated. one of the possible reasons may be the age demographics of pakistan. pakistan's population is over 220 million with an estimated 64% under the age of 30 years old (10) . globally, individuals with older age have proven to be more susceptible to covid-19 (11). in conclusion, while the comprehensive social measures had been taken even at the early stage of covid-19 pandemic in pakistan, the data shown in this letter suggest that the engagement of countermeasures needs to be re-examined to find out the loopholes or defects in implementing policies in order to eventually win the war against covid-19. the data and information used in this report are available from public sources, including the databases of the world health organisation (who) (https://www.who.int/emergencies/diseases/novelcoronavirus-2019). pts and lx conceived the study, analyzed the data, and wrote the manuscript. all authors read and approved the final manuscript. a pneumonia outbreak associated with a new coronavirus of probable bat origin who. coronavirus disease (covid-2019) situation reports 2020 covid-19 outbreak: current scenario of pakistan is pakistan prepared to tackle the coronavirus epidemic? countrywide lockdown stretched till may 9 the incubation period of coronavirus disease 2019 (covid-19) from publicly reported confirmed cases: estimation and application unexplained decline in covid-19 cases' in pakistan puzzles health experts and policymakers. the news international early successes in the epidemiological battle unleashing the potential of a young pakistan covid-19 and the elderly: insights into pathogenesis and clinical decision-making the authors thank all the persons who contributed to the production and the collection of the data in who database. authors' contributions key: cord-291615-5440k4ax authors: mukhtar, sonia title: preparedness and proactive infection control measures of pakistan during covid-19 pandemic outbreak date: 2020-04-11 journal: res social adm pharm doi: 10.1016/j.sapharm.2020.04.011 sha: doc_id: 291615 cord_uid: 5440k4ax nan a recent study 1 has predicted that if the physical distancing measures began in january, 2020 (started on february, 2020 in pakistan) are relaxed in march then the virus could resurge 3 months later in june and then 5 months later in august (second peak). this study's predictions suggests that an additional month of physical distancing measures could buy 2 additional months before such measures would have to be reinstated to prevent the resurgence of the pandemic covid-19 towards healthcare system. many countries are exercising the first phase of the pandemic lockdown and preventive controlling measures should be identified in this duration. pakistan-specific model at national scaleup plan should incorporate testing, digital crowd-sourced contract tracing, strict quarantine of both confirmed and suspected cases, suggesting self-isolation and self-quarantine as the main alternative widespread strategy, imposed stringent lockdown measures, calculated relaxation of lockdown condition, implement distancing measures (monitor asymptomatic and pre-symptomatic transmission in tested population) and control (effects of emerging drug treatments, fatality rate, healthcare intensive care capacity, equipment and staff, delay or prevent resurgence) the pandemic before the lockdown is lifted. health, social, and economic effects of complete lockdown on mental health and interpersonal violence (verbal and physical display of violence, anger, aggression, frustration, racism, xenophobia, discrimination, stigmatization, and marginalization) should be empirically studied. cultural, entertainment, religious, sports, leisure venues (restaurants, malls, parks, recreational squares, beaches and gyms), social gathering places, mass public-transport system closure, and closing of other institutions could have significant impact on people's lives in the quarantine and lockdown period. 2 pakistan need coordinated national and global efforts to bring empirical data on indigenized level to solve the grave predicament of lockdown and correlated factors with it. this paper presents a proactive infection control measure approach for immediate prevention against all systems outbreaks due to overwhelmed responses from pakistani population. based on the observations of other countries' pandemic outbreak, the utmost importance should be given to infection control preparedness in pakistan's healthcare system. pakistan's partial and complete lockdown situation varies with the perceived alertness to indigenized risk assessment and level of activation of emergency -partial lockdown, complete lockdown, curfew, or emergency. infection control measures and administrative infrastructure support could be enhanced with the unbent willingness of government's preparedness of different levels of pandemic outbreak emergencies. to prepare for the ever-evolving infectious disease, temperature screening at public places like airports and train-stations should not be taken lightly since pakistan contracted covid-19 through the travelers' visitation in pakistan. 3, 4 hospitals' healthcare system (acute medical wards, isolation wards, intensive care units, general wards, ambulatory day centers, pharmacy, physiotherapy and occupational therapy units) should include a surveillance system (standard, contact, droplet, and airborne transmission precautions) to identify, isolate, quarantine and treat suspected and confirmed individuals. state should ensure the hospital preparedness with presence of triage stations in the accident and emergency departments and ensure the availability of personal protective equipment ppe (surgical masks, face shield, gloves, and gown), waste and line management, and environmental cleaning. pakistan should be prepared for the further impact covid-19 given the still-intact mystery behind transmissibility, morbidity, mortality, unavailability of vaccine and effective antiviral therapy so infection control preparedness and preventive measures is the best tool to minimize the risk of nosocomial transmission. the effect of control strategies to reduce social mixing on outcomes of the covid-19 epidemic in wuhan. china: a modelling study lancet public health evidence informing the uk's covid-19 public health response must be transparent lancet novel coronavirus, poor quarantine, and the risk of pandemic mental health of medical workers in pakistan during the pandemic covid-19 outbreak key: cord-260583-n20y2zep authors: haqqi, aleena; khurram, muhammad; din, maryam salah ud; aftab, muhammad nauman; ali, muhammad; ahmed, haroon; afzal, muhammad sohail title: covid‐19 and salmonella typhi co‐epidemics in pakistan: a real problem date: 2020-07-15 journal: j med virol doi: 10.1002/jmv.26293 sha: doc_id: 260583 cord_uid: n20y2zep recent articles have pointed the impact of co-epidemics/co-infections of covid-19 and other infectious diseases on an already overburdened healthcare infrastructure 1, 2 . with the present toll of covid-19 cases reaching beyond 10,922,324 infected cases and claiming 523,011 lives 3 . this article is protected by copyright. all rights reserved. reported along with covid-19. 5 such conditions would result in the havoc and would take a heavy toll on the public health sector thus losing lives as a result of an inability to cater all patients at the same time with a limited financing and healthcare resources. 6 typhoid fever is a public health concern mainly in middle and lowerincome countries due to their poor sanitation and unhygienic environfebruary 2020, from sindh province of pakistan. among these almost 16 thousand cases were characterized as extensively drug-resistant typhoid cases (xdr). the estimated attack rate of typhoid was calculated to be 15.5/10 000 population. this strain of typhoid is resistant to all antibiotic treatments available for its treatment, which makes it extremely costly and challenging to treat. the outbreak of typhoid in pakistan is currently characterized as xdr, which has infected more than 19 thousand people, most of them are from sindh province of pakistan. 9 in november 2019, pakistan became the first-ever country to introduce who recommended typhoid conjugate vaccine. 10 a total of 220 patients were tested for salmonella typhi in lahore from 15th march to 15th june 2020. lahore is a metropolitan city and showed the highest burden of covid-19 in punjab province. study group includes 122 (55.4%) male and 98 (44.5%) females. out of total patients tested 48% patients were found to be typhoid positive. typhoid was most prevalent in the age group of 21 to 40 years (44%), followed by 25% in 41 to 60, 24% in 0 to 20, and lowest of 7% in 61 to 80 years. the overall incidence of typhoid was observed to be higher in males as shown in figure 2 . since 2016, the highest incidence of xdr typhoid was reported in the year 2019 to be 9994 infected individuals. 11 the year wise distribution of typhoid cases is shown in figure 3 . 12 there is no data available from the whole country therefore available data from sindh province is shown in the figure. the surveillance and reporting of typhoid in pakistan is quite inadequate and haphazard. to conclude the actual prevalence of typhoid in pakistan is difficult due to low sample size and unavailability of proper clinical diagnosis. according to a study conducted by umer rashid and co-workers, typhoid was most prevalent in age ranging from 21 to 30 (42.32%) followed by age group based incidence in 11 to 20 (30.42%) and 1 to provision of filtered water, and good sanitation. 13 according to several reports the export of xdr typhoid has been observed in many countries; united states, united kingdom, australia, denmark, taiwan, and canada from pakistani travelers. 14 the morbidity and mortality reported from asia constitute 90% of all cases worldwide. in asia, the estimated disease burden is based on the compilation of clinically diagnosed patients of typhoid by the government with uncertain denominators. the specified typhoid clinical diagnosis requires access to a competent laboratory that is scarce in such developing countries. typhoid can range from acute to severe symptoms that occur after 0 to 36 days after the onset of the disease. in poor resource countries medications are usually prescribed without the proper diagnosis in such cases. besides, to the presentation of nonspecific symptoms of typhoid, they are similar to other diseases like malaria, dengue, and covid-19. due to the common symptoms of these diseases, it is difficult to identify the actual underlying cause without the proper diagnosis tests. 15 in the covid-19 pandemic, healthcare workers are overburdened with the high influx of patients with covid-19 in hospitals, in such situations rise in the number of typhoid cases has also been observed. doctors are facing complications in the diagnosis and differentiating both diseases due to almost common symptoms like fever, fatigue, body pain, and diarrhea in some cases. out of a total of 20 000 typhoid patients, 8000 cases have been identified in five major hospitals of lahore, punjab, pakistan. 5 the government of pakistan has taken various measures for the containment of the virus, but they are proving to be insufficient as the numbers of covid-19 infected cases are continually on the rise. the overburdened and poor health infrastructure of pakistan's health system due to covid-19 is at the brink of collapsing. in such cases, another epidemic in the country can prove to be quite devastating. to the authors declare that there are no conflict of interests. covid-19 and dengue virus co-epidemics in pakistan: a dangerous combination for overburdened healthcare system influenza and covid-19 coinfection: report of 6 cases and review of the literature situation report-166. accessed 04 pakistan cases details (covid-19 dashboard) doctors report increasing typhoid cases in punjab than covid-19 covid-19 and fiscal space for health system in pakistan: it is time for a policy decision progress in typhoid fever epidemiology over 19 000 typhoid cases reported in sindh in three years pakistan first country to introduce new typhoid vaccine into routine immunization programme weekly field epidemiology report weekly field epidemiology report surveillance report on typhoid fever epidemiology and risk factor assessment in district gujrat increase of xdr typhoid fever in travellers returning from pakistan a study of typhoid fever in five asian countries: disease burden and implications for controls key: cord-265996-97xxpe8m authors: din, m.; asghar, m.; ali, m. title: delays in polio vaccination programs due to covid-19 in pakistan: a major threat to pakistan's long war against polio virus date: 2020-10-13 journal: public health doi: 10.1016/j.puhe.2020.09.004 sha: doc_id: 265996 cord_uid: 97xxpe8m nan letter to the editor delays in polio vaccination programs due to covid-19 in pakistan: a major threat to pakistan's long war against polio virus the disruptions caused by the covid-19 pandemic have devastating impact over vaccination programs around the globe especially in underdeveloped countries. the delays in immunization campaigns could increase infectious diseases such as polio, measles, and human papillomavirus. the pandemic is overstretching the health-care sectors and countries with limited capacity to deal major outbreaks are at breaking point. in accordance with world health organization (who), more than 116 million infants were vaccinated in 2019, and still more than 13 million children miss vaccination around the world and that the number could have been increased due to covid-19. 1 during the ongoing covid-19 pandemic, pakistan has had to delay vaccination for another life-threatening contagion, poliovirus. since april, around 40 million children missed the polio vaccination due to the cancellation of vaccination campaign nationwide. pakistan stopped the mass vaccination on the 26th of march under the commands of global polio eradication initiative (gpei). millions of the children are at risk of missing lifesaving vaccines due to rising urge of social distancing, vaccine supply disturbance, blocked borders, and elevated shipment costs which led to the deferment of polio campaigns. although majority of the countries have already removed all the three types of polioviruses, pakistan, alongside afghanistan, is one of the two countries in the whole world where polio is still endemic. it was nearly close to become polio free with only 12 reported cases in 2018 but unfortunately, the number of cases rose to 147 in 2019. 2, 3 in the same year, pakistan was accused of facing the emergence of the p2 virus strain with 22 reported cases. this strain was thought to have been removed in 2014. the year 2020 was thought to be the year for the transformation in polio campaigns to halt transmission in 2021 but the country is now facing covid-19 operations. therefore, any disruption due to covid-19 in the polio program plans would have significant and drastic impact on this objective. it could be concluded that diverting public health funds to fight against other outbreaks disrupted polio eradication plans, which could lead to the spread the of poliovirus in areas of low immunization coverage and immunity. pakistan could face setbacks due to suspension in the polio vaccination due to covid-19. on july 26 of 2020, there have been 107 reported cases of polio in pakistan. 2 the immunization campaigns have been paused or delayed in various countries as the local health-care authorities are putting all their efforts to control coronavirus. therefore, the planned vaccination in many countries may now not take place. this will cause a serious threat to the recently born infants who might now miss out their routine vaccination services. moreover, those children who have not yet received the significant amount of polio vaccine are also at high risk. the who is ready to resume the vaccination plans but as pakistan is witnessing an increase in the number of covid-19 cases, with the next few weeks crucial, the resumption of polio vaccination campaigns might be delayed. meanwhile, if the polio outbreak gets out of hand, it would pressurize the already overstretched health-care sectors across the countries. at worst, it could even lead to the next global health emergency. the health-care experts in pakistan, agree to resume the polio vaccination campaigns, otherwise the covid-19 would destroy all the progress being carried out in the last thirty years against the polio virus. the consequences of gaps in vaccination programs could have long lasting drastic effects. the gpei has recommended the countries to postpone the vaccination programmed until the second half of the 2020, taking the decision in deep regret by knowing that as a result of delaying immunization plans, more of the children may get paralyzed by polio. postponing or pausing the routine vaccination campaigns for now seems to be the correct decision, given the urge to avoid further transmission of covid-19. however, the fear is that having won the fight against the novel threat basically exhausted and overburdened the health-care sector which could be inundated with other infections especially polio cases. in accordance with who, past outbreaks have clearly showed that when the health-care sectors are overwhelmed, mortality from vaccine preventable and other treatable diseases also increase drastically. in fact, during the 2014e2015 ebola outbreak, majority of the deaths caused by malaria, measles, aids, tb and polio, and these deaths exceeded from the deaths due to ebola. 4 given the complexity of the issue, the health-care authorities do need to prioritize the fight against covid-19, they must try to mitigate the effect of older diseases reappearing. there is an urge to resume the polio vaccination campaign to aid protecting children's lives in outbreak. similar to the climate crises, the covid-19 pandemic could be regarded as a child-rights crisis because it will have life-threatening impact over all the children, who need immunization, now and in long-term. therefore, the health-care authorities must intensify the efforts to track the unvaccinated children so that most susceptible populations such as pakistan, can be supplied with the polio vaccines as soon as possible. otherwise, the impact could span the generations and even borders. public health j o u r n a l h o me p a g e : w w w . e l s e v i e r . c o m/ l o ca t e / p u h e polio cases in provinces efforts to eradicate polio virus in pakistan and afghanistan ebola virus disease outbreak in west africa key: cord-279405-1d6gznls authors: butt, muhammad hammad; ahmad, abrar; misbah, shahzadi; mallhi, tauqeer hussain; khan, yusra habib title: dengue fever and covid‐19 co‐infection; a threat to public health for co‐epidemic in pakistan date: 2020-08-27 journal: j med virol doi: 10.1002/jmv.26464 sha: doc_id: 279405 cord_uid: 1d6gznls the rapid expansion of covid‐19 has caused around 16 million confirmed cases with approximately 0.65 million deaths worldwide. recently with the geographical spread of covid‐19 and more involvement of adults, there have been increasing reports of co‐infections with various other infectious diseases. this article is protected by copyright. all rights reserved. geographical spread of covid-19 and more involvement of adults, there have been increasing reports of co-infections with various other infectious diseases. during the on-going pandemic where health authorities are primarily engaged to contain the infection, any other infectious disease outbreak will hinder the manoeuvres combating covid-19 and will create the diagnostic challenges for healthcare professionals. according to a recent estimate, pakistan ranks 12 th globally with 0.27 million cases along with 5865 deaths till july 28, 2020 [1] . recently, national institute of health (nih) in pakistan issued 'high alert' for dengue viral infection (dvi) as monsoon season (july -december) is considered a vulnerable period for dengue spread [2] . this alert poses critical and logistic challenges for overwhelmed and under-resourced healthcare system of pakistan. a timely and stern action plan is need of hour and must be implemented in haste to quell the increasing risks of co-infection. dengue virus is transmitted to humans by the female aedes mosquito (aedes aegypti). from january 2014 to may 2020, pakistan has reported 99,264 laboratory confirmed cases in almost all four major provinces of the country. epidemiological data from last five years indicate that pakistan has experienced major outbreaks from july to december with peak onset observed in october. in 2019, approximately twenty-five thousand cases were reported and possibly same pattern is expected this year. currently, monsoon season has already started in pakistan with record rainfall. moreover, cases of covid-19 is expected to surge due to the recent increase in mobility and social interactions during eid-ul-adha, an annual religious festival in the country. on the other hand, poor sanitation system is facilitating the habitat for aedes mosquitos [2] . this chronological coincidence indicates a co-epidemic of covid-19 and dvi. keeping in view the fragile healthcare system and economic turmoil in pakistan, dengue outbreak will pose serious challenges for which country is not this article is protected by copyright. all rights reserved. accepted article readily prepared [3] . as timely and stern measures can curb the situation, we felt inclined to share few suggestions in this regard. recent studies show that majority of the symptomatic covid-19 patients present with fever, cough and headache, and some have also presented with fever only [4] . available literature on dengue demonstrates that these patients present with fever and sometimes headache [5] . skin rash, a cardinal feature of dvi, has also been observed in covid-19 patients [6] . moreover, both dvi and covid-19 share similar laboratory features [7] . keeping in view the high similarity between two infections and increased workload on healthcare professionals, the propensity of misdiagnosis is substantially high. it must be noted that both infections progress differently. in this context, the differential diagnosis is of utmost importance during the era of pandemic. as both viral diseases portend substantial morbidity and mortality if timely management is not initiated, misdiagnosis of any disease may deteriorate the patient`s conditions and portend additional burden on healthcare system. singapore where patients were initially tested negative for dvi but later hospitalized due to persistent fever and final diagnosis revealed co-infection with dengue and sars-cov-2 [8] . two cases of coinfection have also been reported bangladesh, resulting in death in one patient [9] . another case of co-infection associated death has been reported in india [10] . in thailand, a patient who presented with petechial rashes was treated as dengue case but declared as co-infected with covid-19 following advanced clinical diagnosis [6] . keeping in view the complex scenario of outbreaks, the under resourced healthcare system in pakistan is at risk of drastic collapse with increasing socio-accepted article economic concerns. we suggest, appropriate measures be taken to discriminate patients with appropriate diagnosis. we suggest few precautionary measures in addition to the already established guidelines to take in account during the covid-19 pandemic by the health authorities in pakistan. effective and timely vector control measures such as prioritise spraying in high risk areas, public awareness on clinical manifestations of dvi and methods for prevention of mosquitoes infestation should be considered immediately. patients presenting to healthcare professionals with fever, rash, headache and respiratory problems must be subjected to dvi and covid-19 diagnosis. moreover, these patients should be treated in a parallel way such as fluid replacement therapy for div and specific drugs for covid-19. all the hospitals must consider preparing the treatment guidelines and algorithm for suspected cases as a component emergency preparedness. laboratory testing facilities must be increased such as antibodies testing and polymerase chain reaction (pcr). since medication shortage has been reported during the pandemic, drug regulatory authorities should focus their efforts to ensure the availability of essential medicines, particularly in dengue hotspots. since both infections require isolation wards in hospitals, health authorities should arrange necessary space. since co-infected patients are source of both infections, an isolated ward must be established for these patients. the district and provisional authorities should develop sops of water management for timely cleaning of road and places to avoid any stagnant water and government should provide funds to authorities. all authors declare no conflict of interest. coronavirus disease 2019 (covid-19) situation report -190 covid-19 and dengue virus co-epidemics in pakistan: a dangerous combination for overburdened healthcare system clinical characteristics of coronavirus disease 2019 in china a survey of clinical and laboratory characteristics of dengue fever epidemic from covid-19 can present with a rash and be mistaken for dengue epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study. the lancet covert covid-19 and false-positive dengue serology in singapore. the lancet infectious diseases a double struggle: home ministry pro battling covid-19, dengue stung by dengue patient dies of coronavirus co-infection in bhopal mhb, aa, thm conceptualize the work; mhb, aa, sm drafted the work; thm, yhk revised the manuscript; all authors give final approval for publication of the content. key: cord-310293-0s7l0l4k authors: salman, saima; saleem, syed ghazanfar; khatri, adeel; jamal, imran; maroof, quratulain; alam, ashar title: inter-hospital communication and transfer practices during covid-19 pandemic in karachi, pakistan. a brief overview date: 2020-05-17 journal: pak j med sci doi: 10.12669/pjms.36.covid19-s4.2803 sha: doc_id: 310293 cord_uid: 0s7l0l4k objective: to discuss the referral mechanisms established for safe and expeditious inter-facility transfer of covid 19 positive patients to ensure their referrals through establishing proper communication channels. methods: mobile phone and whatsapp based groups, administrated by the indus hospital were established in april 2020. through detailed reports and frequent communication, factors like bed and ventilator availability across these facilities are shared. weekly reports through zoom meetings updating the key stake holders, discussion of problems faced and planning for the week ahead are also done. result: the establishment of these groups has been successful in ensuring referral to and from the indus hospital to various healthcare facilities across karachi using appropriate ambulance services. conclusion: the development of referral mechanisms is the need of the day that has been highlighted through the covid 19 pandemic. it is our hope that these mechanisms are sustained after the pandemic and result in improvement in patient outcome through proper referrals. covid-19 (novel coronavirus-19) is a new strain of coronavirus that had previously not been identified in humans. it first emerged in wuhan, china, in december 2019, and has since been declared as an outbreak by world health organization (who). the global burden of disease is 3,349,786 with a mortality of 238,628 till date. 1 in addition to the extensive planning required to cater to patients with covid 19 in hospitals as well as instructions for home quarantine in stable patients, the undertaking also involves establishment of state run quarantine facilities, establishment of protocols for surge capacity and liaison between healthcare facilities and government for proper patient management. 2, 3 with pakistan facing double burden of disease under normal environmental conditions and total expenditure on health just 2.6% of the gross domestic product (gdp), the situation calls for a wise utilization of existing resources and prompt decision making on part of healthcare officials in emergency departments (ed) as well as inpatient admissions. [4] [5] [6] informal and haphazard communication and transfer processes may result in delays in care, inappropriate triage, overcrowding at tertiary hospitals, and compromised patient outcomes. 7 the knowledge gaps in covid 19 and ever evolving disease pattern with its varied presentation has made the patients' ed disposition very challenging. adding on to this problem is the lack of centralized emergency medical services (ems), absence of systematic referral systems that result in delays, improper referrals to hospitals lacking the desired facilities and unnecessary exposure of healthcare workers in this delayed undertaking. keeping in mind the problems related to referrals of covid 19 patients with our limited resources and challenges in karachi, mobile phone and whatsapp based groups called, "covid unit coordination" and a subgroup "covid karachi daily updates", were established that became operational on 20 april, 2020, with six hospitals on board. these groups are administrated by the indus hospital (tih) with an excel based dashboard and collaborative institutes include the aga khan hospital, sindh institute of urology and transplant (siut), civil hospital karachi, ojha campus of dow university hospital and jinnah post graduate medical centre (jpmc). the line is manned 24/7 and updates by all stake holders are frequently posted. focal persons have been nominated form all hospitals, ranging from medical directors, superintendents and administrative leads in critical care units and eds. a detailed report is shared every morning comprising of variables like available hospital beds and number of ventilated and non-ventilated patients. since all hospitals are functioning on 100% occupancy during the pandemic, frequent referrals need to be made as soon as beds become vacant. this is facilitated expeditiously through text messages and direct phone calls, all the while ensuring the availability of desired patient needs. a detailed report of this activity is shared on weekly basis with all the stake holders with weekly zoom meetings, updating the key stake holders, discussing the problems faced and planning for the week ahead. another step taken is the establishment of liaison with ems, aman and edhi ambulance services. although no written standard operative procedures (sops) exist, aman ambulances have been designated by the government for the interhospital transport of all covid patients, whether stable or unstable, after arrangements have been made through the covid groups. the dead bodies of the suspected covid deceased patients are transported by edhi ambulance with clear burial instructions. since the inception of the groups, nineteen patients have been referred from the indus hospital to various other facilities. all the referred patients were covid 19 positive, tested through nasophyrangeal swabs and pcr. three patients were intubated and sixteen patients required just high flow oxygen. one patient had renal compromise and had to be dialysed. all nineteen patients underwent investigations including cbc, chest x ray, renal profile and blood cultures and received broad spectrum antibiotics with methyl prednisolone. all the cases were discussed with infectious diseases department at tih prior to their referrals. these patients were referred out after clear communication regarding their ventilator needs and covid related complications by tih team. three patients were referred to siut, seven to civil hospital, three to ojha campus of dow university of health sciences, five to jpmc and one to the aga khan hospital. similarly, five patients were received from other facilities and were admitted at tih in established covid inpatient according to their requirements in intensive care units, high dependency units and ward setup. verbal feedback was taken from the receiving facilities post referral and safe referral was ensured. verbal feedback was also taken from the patients and attendants prior to their transfer and they also expressed their satisfaction, knowing that they were being shifted to a facility, catering to their needs. there is ample opportunity to strengthen referral systems and practices in pakistan. the pakistani health system consists of public, private for-profit, and private non-profit institutions that vary greatly in their capabilities in managing the burden of covid 19 pandemic. many institutes have stepped up during this time with the establishment of designated covid emergencies consisting of respiratory and non respiratory emergencies along with inpatient and intensive care units (icus) across the country. government led initiatives have included establishment of web pages with regular updates, 8 social, electronic and print media based campaigns to create awareness regarding social distancing and regular hand washing with enforcing lockdown. according to national disaster management authority (ndma)of pakistan till may 6 th , the total number of confirmed cases of covid19 in pakistan were 22,550, total deaths were 526 and the number of cases who have recovered were 6,217. the number of confirmed cases in sindh province till may 6 th were 8189 9 pakistan has also become the 25 th country in the world which has recorded over five hundred deaths from covid19. the capital of sindh, karachi has an estimated population of 14.91 million. 10 many slum areas with people living in close quarters and variation in scope of healthcare facilities. the need for expeditious transfer of patients among various hospitals has always been voiced at various forums but no measures have been taken so far in the form of well-defined pathways and sops, neither between hospitals nor at the level of policy makers. in situations of mass disasters, natural and manmade, this need becomes all the more visible. the current pandemic of covid 19 has established this fact, yet once again. through establishment of mobile phone and whatsapp based informal referral system, the transfer of very sick, infectious patients has been found to be expeditious and safe. the liaison between transferring facilities ensures that preparations are made before the arrival of the patient by the receiving facility and delays are minimized. another facet for improvement that has been brought into play through this exercise is the judicious use of ambulance services in transferring patients to the appropriate facilities, based on the expertise and capacity of the ambulance. all these endeavors have the potential to be scaled up to be continued once the pandemic is contained as proper referral systems and ems are the need of the day in a busy city like karachi. none. who. coronavirus disease (covid-19) situation report -104 accessed on considerations for quarantine of individuals in the context of containment for coronavirus disease (covid-19): interim guidance hospital surge capacity in a tertiary emergency referral centre during the covid-19 outbreak in italy world health organisation pakistan continues to face double burden of diseases in 2019. international the news infectious diseases in pakistan: a clear and present danger how vital are the vital signs? a multi-center observational study from emergency departments of pakistan see the realtime pakistan and worldwide covid-19 situation! isalamabad: government of pakistan karachi population key: cord-025667-ta7n2u31 authors: jawaid, shaukat ali title: medical journal publishing: continued struggle is essential to achieve and maintain standards date: 2020 journal: pak j med sci doi: 10.12669/pjms.36.4.2685 sha: doc_id: 25667 cord_uid: ta7n2u31 nan during the year 2019, pakistan journal of medical sciences received a total of one thousand four hundred nineteen manuscripts. out of this, three hundred twenty five were published, nine were rejected due to plagiarism, thirty one were withdrawn by the authors as they were keen to get it published immediately while the remaining were not accepted for further processing during initial screening for various reasons. tablei. during the same period thirty manuscripts were accepted for fast track processing, twenty five such requests were rejected. fast track processing facility was started to help those authors who either had to appear in some examination or had to submit their thesis for phd or m. phil and it was essential to get a paper published before that. however, it was also observed that an attempt was made by some authors to misuse this facility as their promotion was due or they just wanted to get their manuscripts published early. since our objective is to help facilitate authors to publish their research work and not to make money, as a policy it was decided that those who wish to get their papers processed on fast track must first ask for permission, specify the reasons and if accepted only then they should opt for this and arrange fast track processing fee. the idea was to discourage authors to make use of this facility unless it was extremely essential. we do publication audit regularly every year as it helps to identify the strength and weaknesses that is very helpful in improving the contents as well as standard of the journal. [1] [2] [3] yet another policy decision taken was that if the authors had any doubt about acceptance of their paper for further processing, they were asked to first share the abstract of their manuscript by e-mail and get an opinion whether we can process their manuscript or not and if they get a positive response, only then complete the other formalities of submission on the journal website with all the necessary documents like letter of undertaking of exclusive submission and ethics committee approval besides arranging processing fee. it not only helped the authors to save their money but also saved the time of the editorial team to reduce the number of submissions on the website for initial screening and further processing. that is one of the reasons that the graph of submission during the year 2019 shows a little downward trend. fig.1 . a detailed analysis of the submissions during the year under review also showed that as usual more submissions from overseas were from countries like turkey, china, and saudi arabia i.e. three hundred thirty four, one hundred forty seven and one hundred thirty eight respectively. table-ii. over the years the number of submissions from china, iran has drastically reduced simply because we are more careful, selected only good quality manuscripts besides encouraging the authors to publish their manuscripts in their local journals. as such the number of manuscripts published from these countries since 2010-2019 has varied. table-iii. total number of papers received from pakistan during the year 2019 was five hundred fifty nine while the number of papers published from pakistan was one hundred sixty eight. over the years there has been a progressive increase in the number of papers published from pakistan because we wish to encourage more pakistani authors to publish in local journals. while in the past the percentage of papers from pakistan in each issue of pakistan journal of medical sciences used to just about 20%, now it has increased to almost 50%. we have also observed an appreciable improvement in the quality of manuscripts that we attract from the authors from pakistan as well. tabletable-v . a further analysis of submission from pakistan revealed that maximum number of manuscripts was submitted from karachi followed by lahore, peshawar and rawalpindi despite the fact that a large number of medical journals are also published from these cities but it is also a fact that more research work is also undertaken in these cities for various reasons. tablevi. however, it was heartening to note that the journal attracted manuscripts from many small cities from all over the country as well which is a witness of increasing readership and popularity of the journal among the healthcare professionals. since the objective of the journal and its editorial team is not just to accept, reject and publish papers but also teach and train the authors, editorial team of pakistan journal of medical sciences has been actively participating in organizing as well as facilitating workshop on scientific writing, peer review and training courses on journal publishing not only in pakistan but in the emro region as well. 4 such academic activities were organized in riyadh saudi arabia, gulf countries as well in addition to pre-conference workshops at various medical institutions in collaboration with different professional specialty organizations. however, still there is lot of pressure from the authors and those whose manuscripts are not accepted for further processing or publication are not happy. it is this strict policy and peer review system that has helped us to retain the highest impact factor among the pakistani biomedical journals for the last many years. fig.2 . however, the authors must realize that we have our own financial as well as human resource constraints. hence, even if we entertain more manuscripts for further processing, it will take too long to get them published and the authors will have to wait much longer which they will neither like nor it will be in their interest. hence, it is better if they submit their manuscripts to those journals which can process them early. every author is keen to get their research work published as soon as possible but at times it is not possible. the solution lies in having more and more good quality peer reviewed biomedical journals. keeping the above in view, pakistan journal of medical sciences as a member of pame in collaboration with some other distinguished editors has initiated a certificate course in medical editing at university of health sciences at lahore. it is a joint project of pame with uhs in which we have the support of many distinguished researchers and editors from pakistan as well as overseas who have agreed to help and mentor these course candidates. sixty candidates applied for the first course out of which thirty were selected, preference being given to those who were already affiliated with some journal. the first batch has completed the course and their final portfolio assessment and viva exam was scheduled on march 16 th 2020 which had to be postponed due to covid19. we hope to organize this as soon as the situation improves and arrangement will be made to induct the second batch hopefully before august 2020. 5 yet another decision we have taken is to publish two special issues every year exclusively of case reports. though they usually have a low priority with us but many authors are keen to get their case reports published and it is also the ideal way to start publishing for many young authors. these issues will be only online publications and no print copies will be available. however, they will go through the routine initial screening, plagiarism check, peer review, will have doi number and they will also be visible online through pubmed central. publication of some other special issues, thematic issues will also grand 2019 2019 2019 2019 2019 2019 total algeria --------1 --1 australia --------1 --1 china 8 8 9 6 10 5 46 cyprus articles 52 48 51 51 51 46 299 review article 1 ----1 --1 3 short communication 1 1 ------1 3 special communications ----1 ------1 systematic review --3 --1 1 --5 grand total 55 54 55 55 54 52 325 be considered. in view of the current covid19 pandemic, a special issue on corona virus has also been planned which will be published in the next two months. submissions in this issue have been processed on fast track on complimentary basis just to help authors. in short every effort is being made to help authors by following an author friendly policy to promote research culture, the art of medical writing and scientific publishing in the country. numerous informative manuscripts which provide details about the manuscript processing system, peer review policy, guidelines for the authors following which they can minimize trauma to their submitted manuscripts are published from time to time all aimed at helping the authors. [6] [7] however, it is extremely difficult to please everyone and our experience also shows that those who are more impatient and keen to get their manuscripts processed on fast track, the quality of most of these manuscripts is not so good. in a hurry, these authors even do not bother to carefully read and follow the instructions for authors on journal website which leads to enormous delay in processing of their manuscripts. it is in their own interest to read and follow these instructions in letter and spirit and also look at some of the published papers on our website before making their submissions. need to have more biomedical journals with impact factor and importance of publication audit importance of publication audit, fast track processing and categorization of manuscripts publication audit -a useful tool to evaluate progress and plan for the future proceedings of workshop on scientific writing and publishing professional capacity building of health science journal editors common reasons for not accepting manuscripts for further processing after editor's triage and initial screening author's failure to read and follow instructions leads to increased trauma to their manuscripts key: cord-258126-8ityzjjh authors: mamun, mohammed a.; ullah, irfan title: covid-19 suicides in pakistan, dying off not covid-19 fear but poverty? – the forthcoming economic challenges for a developing country date: 2020-05-11 journal: brain behav immun doi: 10.1016/j.bbi.2020.05.028 sha: doc_id: 258126 cord_uid: 8ityzjjh • suicide increment during and afterwards a pandemic is highly common. • this study reports covid-19 suicide cases in pakistan for the first time. • most of the suicides occur due to lockdown-related economic recession. • fear of infection is the second suicide contributing factor. • lockdown-related unemployment aggravates the life-threatening situation. the coronavirus disease (covid-19) pandemic has created a major mental health challenge throughout the world . like the previous pandemics, the unimaginable mental sufferings such as depression, panic, trauma, adjustment disorder, etc. are reported in general people as well as healthcare professionals (ahorsu et al., 2020; frank et al., 2020; jahanshahi et al., 2020; montemurro, 2020) . these psychiatric sufferings are also accounted for about 90% of the global suicide occurrences in the extreme cases . thus, suicide rate increment during and afterwards a pandemic is not highly unexpected, but more common. for instance, the covid-19 fear leads to suicide completion that is reported in pakistan's neighborhood countries like bangladesh, india (e.g., goyal et al., 2020; . besides, another non-representative study utilizing only 7-cases claims that the global covid-19 suicide risk factors to be -(i) social isolation and distancing, (ii) economic recession, (iii) mental problems among healthcare professional, and (iv) social boycott and discrimination etc. (thakur & jain, 2020) . the study is not representative as of it does not consider the covid-19 suicide cases based on either global or a representative country. hence, the conclusion of the global covid-19 risk factors is arguably limited by selecting one suicide case for each causality, that also limits in overrating the prominent risk factors more generally in the crisis time. besides, the decreasing of german finance minister is reported for economic recession suicide case rather than considering the general economic recession victims, that is totally unable to convey the evidence of lockdown-related economic recession suicides among the general people (thakur & jain, 2020) . these non-representative and selective findings lead us to investigate the actual covid-19 suicide causalities by considering all the covid-19 suicide cases from a developing country (e.g., pakistan). like the previous retrospective suicide researches conducted in the pakistan's neighborhood south asian countries (e.g., india, armstrong et al., 2019; bangladesh, mamun et al., 2020a, b) where the national suicide database is unavailable, the present study followed the methods of extracting suicide data from press reports. since january 2020, a total 29 suicide cases were p a g e | 3 reported in pakistani press media (i.e., news reports in both english and urdu languages). of these, 16 suicidality cases (i.e., 12 completions and four attempts) were directly related to covid-19 issues and were included in this study. about 12 were males,13 victims had suffered from economic recession and only three were feared of covid-19 infection (table 1) . based on the aforementioned covid-19 suicide cases, it is clear evident that most of the pakistani cases occur due to the lockdown-related economic recession. although previous case studies from the pakistan neighborhood countries, such as in bangladesh and in india, covid-19 suicides are reported to be due to fear of infection and social boycott (goyal et al., 2020; mamun & griffiths, 2020) . besides, social isolation and distancing and economic recession are also reported for suicide causality in another non-representative study (thakur & jain, 2020) . however, the present study provides an actual covid-19 suicides figure on economic recession in general people more rigorously that is not reported in the previous study by thakur and jain (2020) . the economic recession is defined as the contractions within an economic cycle, which reduces the economic productivity that is usually measured by gross domestic product and unemployment rate (oyesanya et al., 2015) . any destructions in economic cycle leads to lower gross domestic product and higher unemployment rates in a country. the economic recessions are estimated to affect significantly on the people mental health and wellbeing by magnitude the relative and attributable risks. research indicates a significant adverse effect of job loss and unemployment on mental health sufferings like depression, anxiety, stress etc. (rafi et al., 2019) , which act as the mediators of suicide attempt and completion . based on a systematic review, 31 global studies exhibit a positive association between economic recession and increased suicide rates (oyesanya et al., 2015) . however, the present findings also support the previous literatures of increasing suicide rates during the financial crisis and economic constraints in the lockdown. the covid-19 crisis threatens to excessively by hitting undeveloped and developing countries like pakistan, not only as a public health crisis in the short term but as a devastating economic and social crisis over months and years to come. for instance, $220 billion income losses are expected in developing countries according to the united nations development program (undp, 2020) . for the pakistani economy, was projected by the asian development bank to decrease by 3.3% in 2019 to 2.6 % by 2020, and this inflation likely to persist around 11.5% for insecurity and unceasing natural and manmade disasters etc. the country has a 24% of the total population living below the national poverty line and 38.8% are poor based on the multidimensional poverty index (humanitarian response, 2019). this nastiest situation is also reflected in food security as a bleak picture. for instance, 20.5% of the total population is reported to be undernourished during the 2015-2017 time-period according to a recent report (humanitarian response, 2019) . thus, the covid-19 lockdown is a tough choice for a country like pakistan as a large number of poor people will be starving to death. the present suicide reports from pakistan are not only tensing the country, but also rising concerns for other underdeveloped and developing countries around the world. globally 55% of the people are estimated to have no proper social protection, these losses will reverberate through societies, will impact on education system, human rights as well as basic food security and nutrition in the most extreme cases (undp, 2020) . at the covid-19 pandemic time, such statistics alarms for the uprising unemployment status, poverty and starvation in the months to come, which are the mental health sufferings (as well as suicide completion, in the extreme cases) driving factors. but, we have no estimations on -how many periods the covid-19 pandemic will persist, how many people have to starve, how many lives to sacrifice, and what will be the end of this crisis . however, the national and international authorities should focus on and support the unprivileged people for voluntary basis. besides, no interest and optional moratorium on emis loans can be provided for reducing the financial recessions and burdens if the free succors are not possible with the worldwide limited resources. lastly, the all types previous loans should permit to grant a moratorium up to the end of covid-19 pandemic in combating the economic recession. the study can be limited due to not documenting all the suicide cases in pakistani press media, because of suicide being crime and related to social issues (i.e., fear of harassment, stigma and taboos, complicated legal proceedings etc.) in the country under the penal code -article section 325. despite the limitations, the present study by reporting all the available pakistani covid-19 suicide cases, provides a novel data on lockdown-related economic crisis and recession that has not studied elsewhere. and it is anticipated that the present findings will be helpful in safeguarding the unprivileged people by turning national and international authority's attentions. scale: development and initial validation mass media representation of suicide in a high suicide state in india: an epidemiological comparison with suicide deaths in the population covid-19 to slowdown pakistan's economic growth: asian development bank. retrieved fear of covid 2019: first suicidal case in india depression, dependence and prices of the covid-19-crisis. brain, behavior, and immunity. epub ahead of print baluchistan drought needs assessment (bdna) report -february 2019. retrieved the distress of iranian adults during the covid-19 pandemic-more distressed than the chinese and with different predictors. brain, behavior, and immunity, epub ahead of print first covid-19 suicide case in bangladesh due to fear ofcovid-19 and xenophobia: possible suicide prevention strategies a rare case of bangladeshi student suicide by gunshot due to unusual multiple causalities suicide of bangladeshi medical students: risk factor trends based on bangladeshi press reports student suicide risk and gender: a retrospective study from bangladeshi press reports the emotional impact of covid-19: from medical staff to common people. brain, behavior, and immunity, epub ahead of print systematic review of suicide in economic recession psychological implications of unemployment among bangladesh civil service job seekers: a pilot study covid 2019-suicides: a global psychological pandemic. brain, behavior, and immunity, epub ahead of print covid-19: looming crisis in developing countries threatens to devastate economies and ramp up inequality. retrieved key: cord-296363-qgoxlqoq authors: khan, yusra habib; mallhi, tauqeer hussain; alotaibi, nasser hadal; alzarea, abdulaziz ibrahim; alanazi, abdullah salah; tanveer, nida; hashmi, furqan khurshid title: threat of covid-19 vaccine hesitancy in pakistan: the need for measures to neutralize misleading narratives date: 2020-06-22 journal: am j trop med hyg doi: 10.4269/ajtmh.20-0654 sha: doc_id: 296363 cord_uid: qgoxlqoq immediately after declaring covid-19 as a pandemic, numerous wild conspiracy theories sprouted through social media. pakistan is quite vulnerable to such conspiracy narratives and has experienced failures of polio vaccination programs because of such claims. recently, two well-known political figures raised conspiracy theories against covid-19 vaccines in pakistan, stating that covid-19 is a grand illusion and a conspiracy against muslim countries. this theory is much discussed in the local community, supporting covid-19 vaccine hesitancy. we urge healthcare authorities in pakistan to take necessary measures against such claims before they penetrate to the general community. anti-vaccine movements could undermine efforts to end the covid-19 pandemic. we believe that ethical and responsible behavior of mass media, a careful advisory from the pakistan electronic media regulatory authority, stern measures from healthcare authorities, effective maneuvers to increase public awareness on covid-19, vigorous analysis of information by data or communications scientists, and publication of counter opinions from health professionals against such theories will go a long way in neutralizing such misleading claims. because pakistan is experiencing a large burden of disease, with a sharp rise in confirmed cases, immediate action is of paramount importance to eradicate any potential barriers to a future covid-19 vaccination program. vaccine hesitancy remains a substantial challenge for pakistan amid various conspiracy theories. the failure to eradicate polio from the country is primarily attributed to such theories. of these, alleged poor quality of vaccines, questioning of dosing recommendations, religious prohibitions ("infidel vaccine"), and rumors related to the presence of active virus in the vaccines are some leading claims obstructing the anti-polio campaign in the country. 1 unfortunately, a conspiracy theory against covid-19 vaccine is currently being spread in pakistan. recently, a renowned political commentator and columnist in pakistan claimed that the virus was a grand illusion to target islamic nations, designed to allow jews to rule the world, and to include nano-chips imbedded in the bodies of people to gain control through 5g towers. 2 a similar theory was presented by an ex-foreign minister of pakistan, accusing the united states of inventing the virus in the united kingdom, with subsequent transfer to china for global spread. 3 these theories are actively discussed in the pakistani community through social media. in the country, where vaccine hesitancy is a prime barrier to curb vaccine-preventable diseases, such conspiracy narratives may plant seeds of resistance against upcoming covid-19 vaccination programs. since a long-term lockdown is not possible for many countries due to economic turmoil, availability of vaccines may be the only way to limit persistence of the pandemic. because of a weak healthcare system, dense population, and poor compliance with hygiene practices in pakistan, the propensity for disease spread is high. as pakistan has already experienced vigorous resistance against polio vaccination, any negative perception among the population toward covid-19 vaccines would have devastating implications regarding efforts to end the pandemic. we urge the government of pakistan to take necessary measures before anti-vaccine campaigns penetrate into the local community. in this context, we share possible measures to neutralize circulating false claims against covid-19 vaccines. because the volume of disparate falsehoods against covid-19 is increasing every day, the primary responsibility lies with pakistani media to play a sensible and professional role during the ongoing health crisis. media should avoid any exaggerated or amplified statements triggering negative perceptions related to covid-19 among the general community. television channels in pakistan should avoid airing unsupported conspiracy theories about covid-19. the most reasonable and ethical approach would be limiting discussions on covid-19 to healthcare professionals, rather than political or business figures. although free speech is a fundamental right of every citizen, public harm associated with false claims must be carefully weighed. another approach that could be useful is debates that offer opinions from researchers or healthcare professionals to counter conspiracy theories. the pakistani mass media is dynamic and has witnessed robust growth in recent years. there are more than 30 news channels in different languages currently aired in pakistan. the pakistan electronic media regulatory authority (pemra), 4 which works in collaboration with the ministry of information, regulates media activities in the country and holds power to suspend or cancel licensure of news channels. moreover, pemra also issues advisories to news channels on airing ethical content and refraining from airing mis-or disinformation. although pemra publishes regular reports on fake and misleading news, we did not come across any action against misleading information related to covid-19. the pakistan electronic media regulatory authority should issue guidelines on statements regarding the covid-19 pandemic. moreover, any person spreading unfounded theories without evidence should be accountable to law enforcement agencies. current conspiracy narratives are tied to religious beliefs. we suggest that religious elements can be addressed by involving enlightened islamic scholars in health promotion and awareness regarding covid-19. a similar approach was adopted by the country when the polio vaccine campaign was hindered by a conspiracy theory claiming that these vaccines were monkey-or pig-derived products, which are forbidden in islam. because most of the population in pakistan regards the advice of islamic scholars highly, the government invited scholars to educate the public on the polio vaccine, particularly in regions highly resistant to vaccination. these scholars highlighted the religious underpinning for the use of preventive medicine according to sharia law. 5 we believe that increased involvement of local religious authorities will facilitate appropriate covid-19 control efforts in pakistan. immunization campaigns in pakistan are controlled by the expanded program on immunization (epi), begun in 1978 in collaboration with the who and unicef. currently, the epi focuses on immunizing all children against eight vaccine-preventable diseases (diphtheria, tetanus, pertussis, polio, measles, tuberculosis, hepatitis b, and haemophilus influenza type b). 6 because the epi staff remain in contact with the public, their role in neutralizing misleading vaccine claims and in maximizing vaccine acceptance is of paramount importance. we suggest that the epi should swiftly respond to any anti-vaccine campaign in the country by providing accurate information to the public. recently, it was documented that confidence about vaccines is directly related to public awareness of infectious diseases. 7 a large survey on "attitudes to vaccines" involving 140,000 participants around the globe showed that countries with active public-awareness campaigns against various infectious diseases achieved very high rates of agreement on vaccine safety, effectiveness, and importance. 8 because conspiracy theories offer ammunition to vaccine deniers, timely intervention is of utmost importance. health authorities in pakistan must ensure stern measures to disseminate accurate and honest information to the public. health authorities should make it clear that they are listening and responding to the public's questions and concerns. keeping in view the large circulating volume of mis-or disinformation, researchers and public health educators need to build a society that is resilient to falsehood about covid-19, a task that will only become more vital as vaccines near. data scientists and communications researchers have the responsibility to analyze data related to such misleading information. it is not possible to stop people from spreading ill-founded rumors. however, analysis of information sources, patterns of spread, and impacts on the general community will foster effective strategies to flatten the curve of the infodemic so that misleading information cannot spread as far and as fast. 9 in the case of vaccines, transparent information on how vaccines are made, how they work, what they contain, how they will be tested, and their effectiveness, possible risks, and side effects will useful to ensure confidence in covid-19 vaccines when they are available. the government of pakistan has not taken a hard line against misleading covid-19 claims. we believe that putting full effort into the implementation of the aforementioned measures will go a long way to mitigating the proliferation of false claims in the country, and thereby help greatly in the control of the covid-19 pandemic in pakistan. polio vaccination controversy in pakistan bill gates' coronavirus vaccine will have nano trackers, will be controlled via 5g satellites to take islam out of muslims: pakistani 'expert' zaid hamid coronavirus is not natural but invented in a laboratory by israel, us and uk: former pakistan foreign minister comes up with a bizarre conspiracy theory pakistan electronic media regulatory authority 2002, as amended by the pemra amendment act polio vaccination in pakistan: by force or by volition? factors associated with non-utilization of child immunization in pakistan: evidence from the demographic and health survey 2006-07 don't demonize parents who are hesitant to vaccinate-discuss their worries instead how does the world feel about science and health? available at the epic battle against coronavirus misinformation and conspiracy theories this is an open-access article distributed under the terms of the creative commons attribution (cc-by) license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. key: cord-256676-b7p92sb1 authors: syed, faiza; sibgatullah, syed title: estimation of the final size of the covid-19 epidemic in pakistan date: 2020-04-06 journal: nan doi: 10.1101/2020.04.01.20050369 sha: doc_id: 256676 cord_uid: b7p92sb1 the covid-19 infections in pakistan are spreading at an exponential rate and a point may soon be reached where rigorous prevention measures would need to be adopted. mathematical models can help define the scale of an epidemic and the rate at which an infection can spread in a community. we used an sir model to predict the magnitude of the covid-19 epidemic in pakistan and compared the numbers with the reported cases on the national database. our results indicate that pakistan could hit peak number of infectious cases on may 26th, 2020 and by june 24th, 2020, 90% of the population will have become infected with the virus if policy interventions seeking to curb this infection are not adopted aggressively. the first case of covid-19 emerged in pakistan on 26 th february 2020 in karachi, the most populous city of pakistan. the patient zero had a travel history to iran and immediately quarantined upon testing positive for the virus. however, the patient was followed by hundreds of pilgrims returning from iran which were likely carrying the virus that ultimately led to the spread of covid-19 into the community. since then the infections have been increasing exponentially and without proper intervention the situation may escalate enough to overwhelm the already struggling healthcare system in the country. recovered cases (r) are compartments and each individual of a given population will pass through the susceptible phase then to the infected phase and finally to the recovered phase. the sir model is a steady state model, therefore the population that is analysed is static i.e. no one is being born or is dying. additionally, the model assumes that once a person is infected, they are immune to the disease and therefore cannot contract it again. the sir model is ideal for modelling the spread of diseases spread through person to person contact. in this study we aim to model the covid-19 epidemic in pakistan, which will indicate the peak infection day, rate of increase of infections per day and a 90-day forecast to assess the final size of the epidemic. the model is built on the following set of assumptions, based on the methodology described by ronald ross and william hammer 1 , is expressed as the following differential equations: the basic assumption of the sir model is that the total number of susceptible infected and recovered cases at any given time is equivalent to the test population, so the equations can be represented as: the basic reproduction number (r˳), is a ratio between the fraction of individuals susceptible per day (β) and the fraction of recoveries (γ); represented as: the value of r˳ plays a significant role in determining the infectiousness of a certain diseasecausing organism. therefore, the rate of change in infected individuals is directly dependent on the r˳, given by: . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/10.1101/2020.04.01.20050369 doi: medrxiv preprint further assumptions of the sir model assume that if the r˳ is greater than the ratio of total population and the susceptible cases at time zero then it would imply that the outbreak will turn into a full-fledged epidemic. similarly, if the r˳ is less than n/s (0), then it would imply that the outbreak will not cause an epidemic. therefore, the r˳ plays a crucial role in determining the fate of an epidemic. the data was extracted from daily situation reports published on the national institute of health (nih) pakistan for a period of 33 days, (from 26 february 2020 to 28 th march 2020) and was corroborated with the simulation results. in the case of covid-19, the value of r˳ is highly variable and varies from country to country. several sources 2-7 report a range of r˳ values, between 1.4 -3.9, therefore we took an average value of 2.65 for our current analysis. the value of r˳ will continue to evolve as the epidemic progresses throughout the globe; till then, we do not have an exact figure 2 . the value of γ was considered based on the average infectious period for covid-19, so γ=0.14. the value of β was calculated to be 0.378 from equation 2.2. the s0 was assumed to be 220,000,000 since the entire population of pakistan is susceptible to covid-19, as the disease is new and is spreading across all regions of the country. the initial time t was set to be day 1, when the first 2 cases of covid-19 arrived in karachi. the simulation was used to predict the number of susceptible, infected and recovered cases for a period of 120 days starting from the day the first cases arrived. . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/10.1101/2020.04.01.20050369 doi: medrxiv preprint the nih pakistan data for the cumulative cases and daily reported cases was plotted to observe the increase in number of cases for a period of 33 days. the current trajectory suggests an exponential increase in the number of cases since the epidemic started in pakistan on 26 th february 2020 (figure 5.1). the data on the number of daily reported cases also reflects a general increasing trend as testing for covid-19 gathers pace (figure 5.2). is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/10.1101/2020.04.01.20050369 doi: medrxiv preprint . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/10.1101/2020.04.01.20050369 doi: medrxiv preprint (r=0.97, p<0.001) . the modelled data is represented as a blue line and the reported data is represented as an orange line. the x-axis represents the number of days, whereas the y-axis represents the number of cases. . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/10.1101/2020.04.01.20050369 doi: medrxiv preprint our study was focused on modelling the covid-19 epidemic in pakistan in order to estimate the number of infections, the peak infection day, the rate of increase of infections per day and the resolution of the end-point of the epidemic 1 . the simulation parameters were adjusted according to the population of pakistan. our model simulated the conditions where covid-19 is spreading in a closed population of 220,000,000 people, without the effect of any extraneous variables such as social distancing, hand washing or travel restrictions. the values of r˳=2.65, β=0.378 and γ=0.14 generated data which was quite close to the actual reported cases in pakistan ( figure 5.4) . furthermore, the trends of the modelled i and the reported number of infections coincide significantly (r=0.97, p<0.001). thus, we can safely assume that these results can be used as a predictor of a likely scenario of covid-19 for pakistan. according to the simulations the peak infection day will occur on 26 th may 2020, where 5,921,1209 persons could get infected with the virus in a single day. previous reports from china 8 have indicated that covid-19 initially follows an exponential growth pattern 9 coupled with asymptomatic carriers 10 , leads to a rapid increase in the number of infections. correlating the reported data with our simulations, we can assume that if left unchecked, the disease can spread at an unprecedented rate in pakistan, especially in closely knit communities and densely populated areas. the results of our study also predict that within a time span of 120 days, 90% of the population will have been infected with covid-19. these include asymptomatic carriers, which could account for approximately 20% of the population 11 and will have the tendency to unknowingly infect others. however, the major concern for pakistan would be the healthcare system which would not be able to cope with the overwhelming number of patients if the trajectory remains the same. studies place the mortality rate of covid-19 at 2.3%, severe cases at 14% and critical cases at 5% 12, 13 , which would imply that potentially 50,000 could die; 30,800,000 cases could become severe and 11,000,000 could become critical during the aftermath of epidemic in pakistan. therefore, there is an urgent need to implement effective measures to curb the rise . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/10.1101/2020.04.01.20050369 doi: medrxiv preprint our study gives a well-balanced estimate of how the covd-19 could spread in pakistan. however, the study has a few limitations, such as the effect of extraneous variables has not been considered in the modelling. this could also serve as a future direction for us to model an epidemic where these factors come into play. in conclusion, the sir modelling of the covid-19 in pakistan revealed that the infection could spread at an exponential rate if proper measures are not taken to reduce its transmission, through safe practices such social distancing, hand-washing and large scale testing of suspected cases in the region. mathematics of infectious diseases estimating clinical severity of covid-19 from the transmission dynamics in wuhan, china early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia euro surveillance: bulletin europeen sur les maladies transmissibles = european communicable disease bulletin time-varying transmission dynamics of novel coronavirus pneumonia in china. biorxiv phase-adjusted estimation of the number of coronavirus disease 2019 cases in wuhan properties of adeabc and adeijk efflux systems of acinetobacter baumannii compared with those of the acrab-tolc system of escherichia coli. intergovernmental panel on climate change characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese. jamanetwork the reproductive number of covid-19 is higher compared to sars coronavirus presumed asymptomatic carrier transmission of covid-19. jamanetwork estimating the asymptomatic proportion of coronavirus disease 2019 (covid-19) cases on board the diamond princess cruise ship potential association between covid-19 mortality and health-care resource availability. the lancet global health characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72314 cases from the chinese center for disease control and prevention key: cord-221652-rsxw0q0e authors: farooq, fizza; khan, javeria; science, muhammad usman ghani khan al-khawarizmi institute of computer; pakistan, uet lahore; science, department of computer title: effect of lockdown on the spread of covid-19 in pakistan date: 2020-05-18 journal: nan doi: nan sha: doc_id: 221652 cord_uid: rsxw0q0e a novel coronavirus originated from wuhan, china in late december 2019 has now affected almost all countries worldwide. pakistan reported its first case in late february. the country went to lockdown after three weeks since the first case, when the total number of cases were over 880. pakistan imposed a lockdown for more than a month which slowed the spread of covid 19 effectively, however in late april relaxation in lockdown was allowed by the government in stages to lift the strain on the economy. in this study, the data has been analyzed from daily situation reports by the national institute of health pakistan and the effects of initial strict lockdown and later smart lockdown have been studied. our analysis showed a 13.14 percentage increase in cases before lockdown which drops down to 6.55 percent during the lockdown. it proved the effectiveness of lockdown. however, the percentage increase in case grows up to 7.24 during a smart lockdown. if it continues to rise in this manner, pakistan may need to enter again into a strict second lockdown. covid-19, previously named as 2019 novel coronavirus (2019-ncov) is a severe acute respiratory syndrome caused by a virus named as sars-cov-2. it is the third coronavirus disease after sars-cov in 2002 to 2003 and middle east respiratory syndrome coronavirus (mers-cov) in 2012. both sars and mers have a high fatality rate than sars-cov-2 but less spread rate. at the end of the sars epidemic in 2003, there were 8098 people infected worldwide and 774 died with a 9.6% fatality rate [1] . by november 2019, 2494 confirmed cases of mers have been reported with 858 deaths and a fatality rate of 34.4% [2] . on the other hand covid-19, according to who situation report of may 4, 2020, has 3,435,894 confirmed cases with 239,604 deaths (fatality rate of 6.9%) worldwide [3] . covid-19 originated in wuhan, hubei province of china in late december 2019, when some patients with an initial diagnosis of pneumonia of unknown etiology were admitted to hospitals. these patients were epidemiologically linked to the seafood and wet animal wholesale market in wuhan[4] [5] . as of january 22, 2020, a total of 571 cases of covid-19 were reported in 25 provinces in china [6] . on january 30, 2020 who declared it as public health emergency of international concern (pheic) when the virus has spread to 18 countries outside china with a total of 7818 cases worldwide [7] . on march 11, 2020 when the disease has spread to 114 countries with more than 118,000 confirmed cases and over 4200 deaths, who declared it a global pandemic [8] . pakistan reported the first two cases of covid-19 on 26 february 2020. both patients had a travel history of iran [9] . within two weeks the number of cases reached up to 20 and all have travel history of iran, china, syria, and london [10] . by 23 march the total number of cases was 892 with 6 causalities. with no vaccine currently available, the only solution is to prevent and contain the disease by lockdown and social distancing. the countrywide lockdown was enforced on 24 march which continued for more than a month. a major cause of the initial spread of the virus in pakistan is pilgrims returning from iran at taftan border. over 7000 pilgrims returned from iran out of which 1433 have been tested positive according to the situation report by nih on 4 may [11] . another cause of rapid spread is the religious mass gathering at raiwind, lahore in early march. about 80000 to 1250000 people participated out to which 3000 were foreigners from 40 different countries [12] . by 4 may, over 3033 cases had a history of attending this gathering. on 11 may 2020, a total number of 30941 cases have been reported with 8212 recoveries and 667 deaths [13] . as the vaccine of covid-19 is not currently available, the only solution to handle this outbreak is to prevent its spread and take effective measures to contain it. more than 100 countries had to go into either full or partial lockdown to contain this outbreak [14] . china went into partial lockdown after three weeks of the first reported case and lasted till mid of march. iran was a hard-hit country in middle-east asia by this outbreak. the first cases were reported in late february and more than 107 thousand people have been affected by it in iran. iran went into complete lockdown in early march. pakistan, india, saudi arabia, turkey, and kuwait also practiced massive lockdowns. europe became the epicenter of the outbreak after china. italy and spain were the worst-hit countries with over 219,070 and 224,350 confirmed cases respectively. both countries imposed initially partial lockdown but later more restrictive and extensive lockdowns which helped in slowing down the spread [15] . the objective of this study is to highlight the effects of lockdown on the spread of covid-19 in pakistan. the government did not impose full lockdown abruptly in the country instead it was imposed gradually. the statistical analysis of covid-19 data has been performed depending upon the actions taken by the government and the timeline of lockdown has been into three categories. finally, the impact of each category on the growth rate of the disease in pakistan has been studied. we used the dataset of pakistan available at kaggle [16] . the source of this data is covid-19 daily situation report generated by the national institute of health (nih) pakistan from 10 march 2020 to 9 may 2020. the lockdown in pakistan was not enforced abruptly but gradually in different stages. based on these stages we divided the whole timeline into three phases. phase a is before actual lockdown, phase b is a full lockdown, and phase c is smart lockdown or relaxation in lockdown. table 1 shows the steps taken by the government of pakistan gradually towards lockdown and smart lockdown. we presented data in a way to get insight into the trend of the spread of covid-19 during different phases of lockdown in pakistan. we calculated the average rise of confirmed cases in each phase. we also calculated the average value of percentage increase in each phase from daily incident data. a constantly increasing trend in the daily confirmed cases can be seen in figure 1 . the relatively slow spread in phase a can be justified by a smaller number of testing capacity and facility as the disease has just started in pakistan. the actual number of infected patients in phase a must be higher as reported. pakistan imported pcr based testing kits mostly from china and extensive testing started from phase b. a linear trend is calculated and displayed for each phase. there is a sudden increase in trend in phase c as an effect of relaxation in lockdown. figure 2 shows that on an average approximately 67 new cases were reported daily in phase a, 358 in phase b while 1195 in phase c. the highest number of new cases were reported on 9 may 2020 which is 1991 as shown in figure 3 . figure 4 shows the percentage increase in the number of cases in each phase. before lockdown it was 13.14%, during lockdown it decreased significantly to 6.55% (-6.59% drop) and in smart lockdown it goes up to 7.24% (+0.69% rise). the strict lockdown which we named phase b, showed a relatively slow, steady, and controlled spread of covid-19 quite as expected. it was fulfilling its purpose effectively towards the control of pandemic in the country but on the other hand it was causing difficulties for daily wagers, and small businesses. the complete strict lockdown continued for more than a month. it affected the country's economy as all industries and import exports were ceased. for a developing country like pakistan, it was difficult to keep strict lockdown for a long time. hence, the government announced a smart lockdown to be enforced in stages. it means to re-open low-risk industries like manufacturing businesses, construction, industries related to food and agriculture, and factories with daily wagers and labor. all businesses that were re-opened were directed to follow sop regarding workplace cleanliness, use of hand sanitizers and masks, and maintaining social distance. after this relaxation in the lockdown, the number of new daily cases increased abruptly. an increase in free-roaming and unnecessary movement of people was also noticed which should be handled strictly by special forces in every district. if this situation is not controlled then in a very short time it could be unmanageable and our health facilities could not capacitate them. there may be a need for a second lockdown for that which could have even worse effects on the economy. the lockdown from 23 march 2020 to 25 april 2020 proved quite effective in slowing down the growth of the outbreak in pakistan. during this period, the number of daily reported cases drop by 6.55%. due to the economic condition of the country, the government allowed some low-risk businesses to re-open, and hence mobility of people increased causing a 0.69% rise in daily reported cases. there is an immense need of following strictly to the guidelines provided by nih for all re-opening businesses. the general public should also abide by the rules of home quarantine, hygiene, and all preventive measures. if the situation deteriorates then pakistan might need to enter again into full second lockdown. summary of probable sars cases with onset of illness from 1 middle east respiratory syndrome coronavirus (mers-cov) coronavirus disease (covid-2019) situation reports outbreak of pneumonia of unknown etiology in wuhan, china: the mystery and the miracle pneumonia of unknown etiology in wuhan, china: potential for international spread via commercial air travel drug treatment options for the 2019-new coronavirus (2019-ncov) who timeline -covid -19 features, evaluation and treatment coronavirus pakistan confirms first two cases of coronavirus, govt says 'no need to panic covid-19 outbreak : current scenario of pakistan 000 pilgrims have returned from iran since february: fo," dawn tableeghi jamaat in hot water in pakistan too for covid-19 spread covid-19 dashboard coronavirus: the world in lockdown in maps and charts evaluation of the lockdowns for the sars-cov-2 epidemic in italy and spain after one month follow up kaggle dataset repository key: cord-302497-5tydrrz1 authors: bukhari, nadia; rasheed, huma; nayyer, bismah; babar, zaheer-ud-din title: pharmacists at the frontline beating the covid-19 pandemic date: 2020-04-20 journal: j pharm policy pract doi: 10.1186/s40545-020-00210-w sha: doc_id: 302497 cord_uid: 5tydrrz1 as the lockdowns are being observed all over the globe and the national level pharmacy professionals are performing frontline roles, this editorial highlights the role of pharmacists in the covid − 19 pandemic. pharmacists globally are providing services amidst pandemic, including triage services, seeing patients and reducing the patients’ burden on health care facilities such as hospitals and gp practices. pharmacists are also working to providing home deliveries, as well as dealing with the increasing number of patients coming through to pharmacies with the other ailments. pharmacy associations have issued their guidelines and in this editorial, several global examples of pharmacists’ role in the covid 19 are being discussed. pakistan is used as a country case study in this editorial. the editorial also elaborates how pharmacists in the uk and pakistan have teamed up together to compile 10-steps protection guidelines for the pharmacy teams in pakistan in english and urdu language. this 10-point guidance educates community pharmacies for safety and standard operation as the number of patients in the country continues to rise. these guidelines are endorsed by the government and private bodies. these can be adopted and adapted by any country; keeping in view their laws and regulations. through public preventative measures advocated by who, the public are working together in their respective countries to 'flatten the curve'. with a near enough global lockdown there seems to be an even greater dependence on pharmacists as the first point of contact to fulfil the public's healthcare needs. pharmacies around the world are one of the few places that are kept open for public service even during the strict lockdowns [1] . community pharmacists and their teams are a vital healthcare provider during the outbreak; they remain on the frontline of public health by serving as direct points of access for their patients. hospital pharmacists have an important role during the outbreak in infection control as well as patient care and support [2] . countries severely hit by pandemic are exceedingly facing overburdened health facilities and shortages as well as burnouts of health care professionals. triage service has emerged as a supportive modality in this time of crisis which includes pharmacists along with other primary health care workers [3] . a provision of covid-19 trained health care professionals exists for supporting these services in the time of shortage of medical and nursing staff members and to increase the outreach of the service in australia as well. the international pharmaceutical federation (fip) has issued a pack of 10 summaries for guidance on covid-19 [4] . american pharmacist association (apha) has also issued guidelines and resource documents for the strengthening and preparedness of the community pharmacies as front line health care workers in the global health crisis [5] . reliability of information and control of scare and misinformation are important concerns during the worldwide spread of the disease. community pharmacists also continue to play their role towards public uninterrupted for regular supplies of medicines, as well as supporting governments [6] for disseminating information on precautions related to covid-19 spread including hand washing technique to availability of face masks and instructions for their proper use and disposal. usp has issued guidelines for the compounding and pharmacists and manufacturers for preparation of hand sanitizers to cope with the stock outs [7] . the community pharmacy has a unique credible role with ease in accessibility. in france, the campaign against domestic violence also involved the use of the code "mask 19" to report domestic violence by the victims [8] . pharmacists are an integral component of healthcare performing extraordinary roles in the earlier pandemics and health crisis, with some like ebola and zika posing global health security risks as well [2] . likewise, by contributing in the prevention, preparedness and response to covid-19 pandemic community pharmacists are delivering their role towards public health in dealing with this crisis [9] . in many countries, pharmacies have worked in close collaboration with the international humanitarian organizations like red cross and local community workers to increase its outreach to public and ensure home delivery of medicines [10] . in new zealand, the pharmacist's contribution is appreciated by the government by extra remuneration for their support. hotline numbers have been issued for encouraging on phone consultation and prescription orders for home supplies to reduce public visits which are to be avoided in case of suspected and confirmed covid cases [11] . it is encouraged for pharmacies in australia to support remote dispensing of prescriptions using prescriptions received through mails/faxed/emailed or making use of electronic transfer of prescriptions (etp) technology couples with home delivery services in particular for the old and vulnerable populations [12] . lower middle-income countries (lmic) are in a greater need for pharmacists' support where patients are unable to afford the doctor fees for a consultation. in absence of a standard treatment the importance of provision of pharmaceutical care by pharmacists managing the covid-19 cases increased many-folds [13] . similarly a different set of attributes then the routine conditions were observed in the pharmaceutical care provided by the chinese community pharmacists in dealing with the pandemic situation including maintaining controlled work environment, provision of information and necessary medical supplies as well as ensuring the regular medication and counselling are managed at best to avoid undue patient visits to healthcare facilities. the community pharmacists in china were made use all possible resources to perform their role as care providers and custodian of patient safety regarding medicine use. they used mobile applications, coordination with neighbourhood committees and medicine companies to ensure delivery of medicines to patients in their homes [10] . the response to covid-19 pandemic in countries have differed drastically. in columbia, a lesser incidence of hospitalization and no intensive care need was attributed to better preparedness, higher exposure to multiple strains of viral respiratory infections as well as early adoption of containment strategies [14] . as of 6 april, there are 3059 confirmed cases & 45 deaths with covid-19 in pakistan [15] . since the first case reported on 26 feb 2020, pakistan has put in place its mitigation strategies which are framed around suspension of flight operations both international and domestic, social distancing, point of entry screening, contact tracing, clinical management of covid-19 patients, home quarantine and isolation & burial procedures for covid-19 patients [16] to ramp up the efforts of containing the spread of covid-19, the federal government imposed a partial lockdown on 21 march 2020 in which schools and pupil places are closed. public transport is suspended. public hospitals are turned into isolation wards and the working class has been advised to work from home. bakeries, utility stores, vegetables shops and dairy shops are opened but that too between specific hours. people can come outside of their homes for essential trips and emergencies only [17] . after re-evaluating the situation based on increasing cases within pakistan, federal government has extended the partial lockdown on 1 apr 2020 for two more weeks [18] . economical effects re-aligning the access to pharmacies during covid-19 crisis in pakistan the response to this covid-19 pandemic in the shape of social distancing requiring country lockdown and close of businesses, is a death sentence to the daily wagers and low working class in pakistan. according to experts the number of people who can lose their jobs in various sectors are between 12.3 million and 18.5 million [19] . although, pakistan as a fragile and indebted economy has come up to the rescue of its vulnerable people with a multi-trillion-rupee relief package, allocating 200 billion rupees for the labour class. under the package, some 10 million people, categorized under low-income groups, will get a lump sum amount of 12,000 pkr, initially for a period of four months in the form of ehsaas emergency cash program [20] . however, this amount is lower than the daily wages they were getting before lockdown [19] . these economically pressured masses don't have much to spend on their health especially when the public hospitals have closed their opds for the general public. with no were to go and no money to spend, they access their nearby pharmacies which can get them medical advice without paying for consultation and they only have to pay for the medicine if it's needed. this could be a great window to showcase the role of community pharmacists in lmics particularly during a time of a health emergency. with the closure of opds in the private and public hospitals, there has been a great unrest among the patients with other diseases. with nowhere to go and to exercise and save themselves from the virus exposure at the hospitals, opens the door for telemedicine provisioning in this time of crisis. there is a growing demand for telehealth and telemedicine has already been in use pakistan for a while [21] . with the doctors, nurses and paramedics physically present in the emergency, isolation wards and quarantine centers, pharmacists can hold onto this end and can ease the patient distress by providing triaging and basic consultations via telemedicine, taking the burden off the doctors and health system. in pakistan, majority of the pharmacists are engaged with the pharmaceutical industry, however there is a growing number which is now working in the community pharmacies or at retail pharmacies. while the organizations, authorities, hospitals were arranging personal protection equipment (ppes) for doctors, nurses and paramedics, little attention was being paid towards the protection of pharmacy teams even though they are the first line of contact for the public in normal situation and even more in this covid-19 pandemic with closing of public opds. assessing this scenario worldwide, pharmacists in the uk and in pakistan team up together to compile 10-steps protection guidelines for the pharmacy teams in pakistan in english and urdu language. these guidelines are shown in table 1 . the covid-19 guidance for pharmacy teams in these guidelines can be adopted and adapted by any country keeping in view their own laws and regulations. all authors participated in the conceptualisation, drafting and revision of the manuscript. the guidelines were developed by nb and bn. thanks to hr for providing expert advice on the guidelines. all authors have read and approved the final text of the manuscript. ethics approval and consent to participate not applicable. all authors approved the manuscript. 2020) £300 million announced for community pharmacies to support them during coronavirus outbreak weaving the health and pharmaceutical care agenda through the themes of the commonwealth heads of government meeting (chogm) novel coronavirus (covid-19) standard operating procedure-community pharmacy international pharmaceutical federation. coronavirus/covid-19 preparedness press release-community pharmacists in the frontline in the fight against the novel corona-virus disease (covid-19) the united states pharmacopoeia commission women are using code words at pharmacies to escape domestic violence during lockdown: cnn sars-cov-2 outbreak: how can pharmacists help? res social adm pharm recommendations and guidance for providing pharmaceutical care services during covid-19 pandemic: a china perspective covid-19: guidance provided by the society for pharmacy 19-national-health-plan-primary-care-homemedicines-services-to-support-the-response-to-covid-19 hospital pharmacists' pharmaceutical care for hospitalized patients with covid-19: recommendations and guidance from clinical experience. res social adm pharm covid-19 in colombia endpoints. are we different, like europe? res social adm pharm covid-19 dashboard (last updated: 05 regulations and coordination. advisory on mitigation strategies covid-19 pakistan's fight against the coronavirus threat pakistan: workers face health, economic risks poverty alleviation and social safety division. pm launches ehsaas emergency cash initiative worth rs. 144 billion to support 12 million needy families affected by covid19 crisis health care for all: effective, community supported, healthcare with innovative use of telemedicine technology publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-270898-7ap8lcxm authors: javed, bilal; sarwer, abdullah; soto, erik b.; mashwani, zia-ur-rehman title: is pakistan's response to coronavirus (sars-cov-2) adequate to prevent an outbreak? date: 2020-04-21 journal: front med (lausanne) doi: 10.3389/fmed.2020.00158 sha: doc_id: 270898 cord_uid: 7ap8lcxm nan after the dreadful outbreak in wuhan, china and scientific evidence of its human-to-human transmission, in an effort to stem the virus' reach and spread and to try to contain it at the source, governments across the world-most notably the united states-began putting in place and enforcing travel restrictions to and from china (1). however, because it was a new virus with little known about it and because there was a huge global dearth in the availability of screening and testing equipment, the disease spread rapidly across the world (2) . in fact, it spread so rapidly that by 26th february 2020, the number of new infections outside of china had increased 13-fold when compared to the number of new infections inside of china. additionally, the number of countries infected with covid-19 had tripled. on 11th march 2020 who declared that covid-19 could be categorized as a pandemic. on 27 february 2020, pakistan reported its first two patients of covid-19 (3) . the first two cases were from individuals who had recently traveled back to pakistan from iran (4). as of 7 march 2020, the number of confirmed covid-19 cases globally had surpassed 100,000, with 3,073 of them ending in death. of these, 80,813 cases were from china while 21,110 confirmed cases with 413 deaths were from outside of china. on that date, the number of cases in iran was 4,747 with 121 of them ending in death (5) . pakistan reported 7 cases with no mortalities. by the 7th april 2020, who reported 1,214,466 confirmed cases and 67,767 deaths across 211 countries, areas, or territories (4) (figure 1 ). china, an epicenter of covid-19, is located northeast of pakistan. additionally, pakistan shares its southwest border with iran where the number of cases and deaths are increasing exponentially. the geographical locations of extremely severe outbreaks in two countries that border pakistan (china and iran), in addition to the declaration of covid-19 as a pandemic by who, forced pakistan's government to take drastic, severe, and quick actions to stop the further transmission of the virus in the country (6) . notwithstanding this, the current trade agreements with china and the politico-religious relationship with iran has resulted in the influx of infected individuals from these two regional epicenters of the virus. to curtail further transmission, as a first-line response pakistan closed the border with china and put very strict screening methods at the pakistani-iranian border (2) . additionally, in coordination with the civil aviation authority, the government of pakistan enforced the screening of passengers before they would be allowed to enter the country (7) . however, in the earlier days of the pandemic, pakistan lacked the ability to diagnose covid-19 directly and therefore the country had to rely on china, japan, and the netherlands to test their samples. this resulted in a crucial time lag and caused delays in the government's ability to adequately respond to the virus. fortunately, the government did eventually receive diagnostic kits from china and primers from japan to be able to test samples on their own (5) . who also designated seven hospitals nationwide to test suspected covid-19 patients (8). pakistan's federal government, with the collaboration of the ministry of health, devised a plan which was called, "the national action plan for the corona virus disease (covid-19) pakistan" (6) . the purpose of this plan was to devise policies and a template to help provincial governments and states across pakistan with a guide for them to develop methods and strategies to best deal with the covid-19 outbreak. using this guidance, provincial governments established quarantine centers at lahore and karachi's (two of the country's biggest cities) exposition centers with the help of the armed forces of pakistan (9) . a newly constructed apartment building in the city of sukkur was also designated as a quarantine camp by the government with 2,000 beds (10) . additionally, another quarantine center was also established in the city of taftan along the pakistani-iranian border to help identify and quarantine individuals returning to pakistan after spending time in iran (11) . a very modern quarantine center was established in islamabad with 300 beds. the government also ordered the closure of all hotels and, by invoking special powers, designated some of them as quarantine centers. apart from these containment facilities, the government also established isolation wards in many hospitals (12). the ministry of health also managed to provide crucial supplies to the fight of this disease such as face masks, gloves, and protective suits to protect the paramedical staff and doctors at the frontlines of this pandemic. hospitals started primarily dealing with crucial emergencies and covid-19 patients (5). telephone helplines were established by the provincial governments for people to inquire about covid-19 related healthcare issues. they also used this platform to let callers know that they should stay at home if they start experiencing any symptoms of the virus. campaigns were launched throughout the nation's traditional media and social media outlets to increase awareness among the general public about proper hand sanitization techniques and the importance of social distancing to break the chain of transmission. the government distributed alcohol-based sanitizers to people in need and the manufacturing of disinfectant walkthrough gates also began, with some installed at the entrance of some food markets (6) . however, even with all of these efforts, major lapses existed at every step. issues include the inconsistent implementation of immigration policies dealing with the influx of people from the borders and airports (7) to the lack of crucial protective suits and other supplies in hospitals (2) . consequently, the lack of facilities, poor infrastructure, and inconsistent implementation of government policies resulted in the rapid and continuous spread of covid-19 throughout the country (10, 11, 13) . hospital staff protested working without adequate protective supplies (14) . what is more, quarantine centers were perceived as under-performing in serving to isolate infected individuals from the healthy populace. the one-room one-person policy was badly neglected along with the lack of clean bathrooms and drinking water. five people were reported to be living in one single containment camp (11) . meanwhile, the government planned to shift covid-19 infected individuals directly to multan and faisalabad (large pakistani urban centers) after changing some of those cities' public university dormitories to quarantine centers (13). hoarding and black-market selling of protective goods to the public resulted in a lack of protective supplies for the country's healthcare practitioners. to mitigate this issue, the national disaster management authority (ndma) and the drug regulation authority (dra) stepped in to help the government prevent hoarding and the black-market trade of protective supplies (5) . fear of a national economic downturn to an already troubled economy coupled with the fear of a decline in jobs and in the ability of the average citizen to earn and provide for their families further hampered the ability of the government to lockdown cities and markets to curtail the transmission of the pathogen, as ordinary citizens ignored governmental calls and ordinances urging people to stay at home (15). the package worth 900 billion pakistani rupees ($5.66 billion) was approved in a cabinet meeting to support low-income groups, particularly labor, and to improve health care facilities in public hospitals (16) . however, the shortcomings and challenges mentioned above maintained an ineffective containment of the covid-19 outbreak in pakistan. the initial response of the public to the emerging threat of covid-19 was that of a generally reported apathy and indifference. lack of public awareness was commonplace throughout the country and mass prayer events continued even as alarms were set off as to how such public activities could exacerbate the spreading of the pathogen (17) . the spread of misinformation, of fears, rumors, and false facts was initially rife throughout social media. the price of common utilities quickly grew in the face of regional countries severing international trade in an attempt to hamper the spread of the virus, in addition to the black-market selling of essential goods and the public hoarding of many products (18) . however, the regional price control authorities started monitoring commodity prices on the instruction of the federal government (18) . individual incidences came to light, such as how a person traveling from spain managed to evade the airport screening booth after testing positive which resulted in the transmitting of the disease to his family and community (19) . what is more, some people broke their quarantine at the sukkur camp and left their rooms, coming into direct contact with others and further spreading the disease (10) . the indifference and non-cooperative attitude displayed by the general public further fueled the rapid transmission of the disease across the country. the ministry of health on 27 february 2020 reported the first two covid-19 cases in the city of karachi by individuals who had traveled to iran and then returned to pakistan (6) . in less than a month from then, who reported 784 (∼392-fold increase) cases and five mortalities. conversely, the number of cases in the us jumped to 15 in the first month after they reported their first infection in late january. italy (59,138) and iran (21, 638) also reported a surge in transmission and deaths ( figure 1a) . a comparison of who's reported day-by-day data from pakistan, the us, italy, and iran shows ( figure 1b ) that pakistan could be the next country to see an exponential rise in covid-19 transmission and death (4). pakistan's scientific community is working alongside scientists, health professionals, and various governments from across the world to find a cure or different ways to manage this condition. pakistan's biological community volunteered to help health professionals perform diagnostic tests such as pcr. a scientific team from the national university of science and technology and the university of punjab separately developed low cost diagnostic kits that will be manufactured en masse within pakistan, saving time and money (5) . dr. tahir shamsi (20) , head of the national institute of blood diseases (nibd) in karachi, has advocated for the use of a medical technique known as passive immunization, that involves the administration of antibodies from a covid-19 cured patient to a non-immune individual and is used when the risk of infection is high, the time for the human body to generate an immune response is low, and no vaccine is available (21) . however, the current pandemic which stemmed from china and has resulted in the large-scale illness and deaths of both people in iran and italy and across the globe, should compel the pakistani government to take further drastic and timely measures. the current situation requires the politicians, health professionals, scientists, and the general community to band together in taking steps to fight this pandemic. it is highly regarded that the us, italy, and iran have a better health care system than pakistan (5) . notwithstanding this, these countries have failed drastically to contain the virus largely due to inconsistent policies and late decisions and actions. their failures should prompt the pakistani government to make timely decisions and enforce them to prevent further transmission of the disease. otherwise, with the limited available health care facilities and poor infrastructure in place, the outbreak in pakistan may soon mirror the situation in iran and italy. bj devised the study, designed, collected, analyzed the data, and wrote the first draft. as, es, and zm edited and revised the subsequent drafts. the authors reviewed and endorsed the final submission. travelers give wings to novel coronavirus (2019-ncov) coronavirus outbreaks: prevention and management recommendations virtual press conference on covid-19: epidemiological status and disease data is pakistan prepared to tackle the coronavirus epidemic? national action plan for corona virus disease (covid-19) pakistan available online at available online at quarantine facility inaugurated at karachi expo centre. the nation coronavirus patients, suspects break out of sukkur quarantine facility pakistan's spike in coronavirus cases raises quarantine concerns 1,270 corona suspects arriving from iran shifted to multan quarantine centre protesting-doctors-and-medical-staff-in-quetta 15. pak economy under dark shadow of coronavirus vs deep chronic economic crisis covid-19: pakistan unveils economic relief package god will protect us': coronavirus spreads through an already struggling pakistan coronavirus prices of food item increase in islamabad. mm news single covid-19 patient infects 27 others in gujrat preventing infectious disease with passive immunization the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © 2020 javed, sarwer, soto and mashwani. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-275897-j9cwlzxu authors: hashmi, ali m.; saleem, haider ali title: new horizons: covid-19 and the burden of neuropsychiatric illness in pakistan date: 2020-05-17 journal: pak j med sci doi: 10.12669/pjms.36.covid19-s4.2792 sha: doc_id: 275897 cord_uid: j9cwlzxu this manuscript reviews the current state of knowledge about the burden of mental illness and assesses the impact of covid-19 illness on mental health in pakistan. for this we analyzed secondary data obtained from the institute of health metrics and evaluation. the global burden of disease (gbd) study draws from a wide range of data sources to quantify global and regional effects of a disease. we also did a literature search on the effects of covid-19 illness on mental health and the psychosocial effects of covid-19 and other corona virus related illnesses such as sars-cov and mers-cov. data from the studies obtained was utilized to extrapolate the anticipated effects of covid-19 illness on healthcare workers, covid-19 patients and the general public in pakistan. mental illness poses a significant challenge to pakistan’s under resourced health care system. covid-19 has the potential to strain pakistan’s healthcare system to the breaking point. so far, the general morbidity from covid-19 illness in pakistan has been low compared to other countries but this could change in the coming weeks and months. hidden within this crisis are also some opportunities for both healthcare and education. neuropsychiatric illnesses pose an enormous burden both socially and economically in pakistan. the prevalence of common mental illnesses is high and resources to deal with these illnesses are limited leading to considerable morbidity. lack of adequate mental health services imposes a significant public health burden since untreated mental illnesses contribute both directly and indirectly to morbidity and mortality from physical illnesses. covid-19 has posed a tremendous challenge to pakistan's already strained healthcare system particularly with regards to mental health and psychosocial support services. covid-19 illness has the potential to further impact pakistan's already overburdened health system but is also accelerating some positive changes both in healthcare delivery and education. pakistan is the world's fifth most populous country with an estimated population of 220 million as of 2020. 1 neuropsychiatric illnesses, including mental illness pose a huge economic burden on society globally. 2 with an increase in societal awareness and much needed de-stigmatization in recent years, increasing numbers of people are seeking help for common mental illnesses and the few studies that have been done in pakistan have documented a much higher prevalence of mental health issues in pakistan compared to western countries. one systematic review estimated the mean prevalence of anxiety and depressive disorders in the community to be 34% (29%-66% for women, 10%-33% for men). 3 there are an estimated six million drug addicts in the country. serious mental illnesses such as schizophrenia are estimated to have a prevalence rate of 1.5% in the population. 4 child mental health problems also are common with a mean prevalence of 15%. 5 while local data are scarce, one study estimated that the cost of mental illness to society in pakistan was pkr 250,483 million (usd 4,264 million) in 2006 6 , with direct costs in the form of medical care accounting for 37%, with the rest being indirect costs. these costs have, undoubtedly, grown exponentially larger since 2006. importantly this burden falls entirely on individuals who have to make out of pocket payments for all health care, as the country has no national health insurance plan. why mental health? the link between mental and physical health: increasing evidence points to the importance of mental health as a critical measure of overall health with more and more research emerging to show how mental and physical health are linked. multiple studies have documented how untreated mental illness causes significantly worse outcomes in medical illness and conversely, how various medical illnesses can be a risk factor for, and worsen the prognosis for, mental illness e.g. depression can worsen the health outcomes of other chronic illnesses, such as angina, asthma, diabetes, and arthritis. 7 the risk of dying from an initial myocardial infarction is higher in patients with depression and varies with the severity of the depressive episode, and clinically severe depressive symptoms significantly increase the risk of death from cardiovascular disease and stroke. 8 in bipolar disorder too, there exists a higher risk of mortality from both cardiovascular and respiratory diseases. 9 patients with anxiety disorders often have multiple medical co-morbidities including chronic pain, gastrointestinal, respiratory, cardiovascular and endocrine illnesses. 10 individuals with schizophrenia and other severe mental illnesses die at a younger age than the general population and this excess mortality results in part from a higher prevalence and greater severity of multiple co-morbid medical conditions including diabetes, respiratory illness, and cardiovascular disease. 11 neuropsychiatric and medical illnesses can thus no longer be viewed in isolation. effective treatment of medical illnesses requires that equal attention be paid to neuropsychiatric (including mental) illness to reduce the functional burden of disease and prevent excess morbidity and mortality from medical illness. pakistan's mental health gaps: despite the massive economic burden of mental diseases and the clear connections between mental and psychological illnesses, mental health has always been a low priority for pakistan's governments. pakistan's public health budget is less than one percent of the country's gdp and mental health does not even have a separate budget. the world health organization-assessment instrument for mental health systems (who_aims) report on the mental health system in pakistan published in 2009 12 reported alarming deficiencies in financial, human and logistical resources. only 0.4% of all health care expenditure by the government, estimated to be us$ 82,304.24, was allocated for mental health, with 3729 outpatient mental health facilities, only five mental health hospitals, a total of 5,056 beds (2.7 beds per 100,00 population), and 342 psychiatrists (0.2 per 100,000 population). no significant amendments in government policy addressing mental health have been made since then, while the burden of neuropsychiatric illness has continued to grow across all age groups and genders. decades of political and social instability, terrorism, natural disasters, inflation and unemployment are just some of the many risk factors that contribute to the increasing prevalence of mental disorders in pakistan. with an ever deteriorating socioeconomic situation, pakistan's public health system stood at a breaking point in mental health even before the covid-19 pandemic, perhaps the most serious global public health emergency in the last 100 years. the who declared covid-19 a pandemic on 11 th march 2020. since then the number of cases worldwide have grown to 3,588,773 with two lac forty seven thousand five hundred three (2,47,503) deaths (as of 6 th may 2020) 13 . low income countries are particularly susceptible due to a severe shortage of healthcare resources. as of may 6 th , 2020, pakistan has reported 22,533 positive cases with about five hundred twenty six deaths 13 with experts predicting that the worst is yet to come. the country remains in a state of partial lockdown. data about this novel virus continues to evolve at a rapid pace but similar outbreaks involving viruses from the same family such as sars-cov in 2003 and mers cov in 2012 14 offer some guidance. both these outbreaks were also caused by viruses belonging to the corona virus family and featured high infectivity. by reviewing their impact on the psychological and emotional health of people, we can reasonably predict the psychological effects of covid-19 illness. the psychological effects on any community affected by covid-19 illness can be broadly divided into three categories: the uninfected public, patients and healthcare workers (hcws). in the public (uninfected people), a general sense of fear and uncertainty prevails (of being infected, of family members especially children, the elderly or the medically ill getting sick or dying), worsened by the constant media reports of new cases including deaths. during the sars outbreak, studies reported a greater sense of personal danger due to constant media coverage of the spreading disease. 15 a survey of over 1200 people in china reported that during the initial phase of the current outbreak, half the respondents rated the psychological impact of the pandemic at moderate to severe and about one third reported moderate to severe anxiety. 16 while data specific for pakistan does not yet exist, it is safe to say that the psychological burden will be significant due to a multitude of reasons: overcrowded and under resourced hospitals may get overwhelmed if cases spike; low literacy rates mean people have an incomplete understanding of the situation and may continue with 'life as usual' despite warnings by healthcare workers and the government and an economic downturn in a country where millions depend on daily wages may leave many with no income at all for extended periods of time. patients with the illness also undergo significant mental trauma and stress. being infected with a viral illness with no approved 'cure', poorly understood modes of transmission and no lab tests to monitor daily progress causes a lot of anxiety for the patients. 17 a study during the sars outbreak showed that apart from fear of the disease itself and its prognosis, patients were worried about being stigmatized, about the wellbeing of family and friends and about lost income. 18 in quarantine centers, spikes of anxiety were seen in patients correlating with spikes in their fevers and feelings of loneliness and helplessness were prevalent in patients. in pakistan, there have been multiple reports of patients running away from treatment centers and many refusing to seek medical help due to a fear of being quarantined. 19 the outbreak also has a severe psychological impact on the hcws. hcws, especially the ones caring for covid 19 patients, report high levels of stress all across the world. shortage of supplies including required medicines, personal protective equipment (ppe) and inadequate support are some factors contributing to the psychological burden of health care professionals. 20 they report symptoms of anxiety, depression, psychological distress and insomnia. during the sars outbreak, hcws reported exhaustion due to hours spent putting on and taking off protective equipment in the day and the greatest fear reported was that of infecting a loved one at home after duty hours. 15 hcws also witness the trauma of colleagues contracting the virus, being intubated and switching roles from health provider to patient and many losing their lives in the process. hcws also have a higher chance of experiencing "moral injury" as they put their lives on the line for professional duty amidst a dire shortage of appropriate resources. 21 an upcoming study from lahore (the first in pakistan) by nazish imran and colleagues documents the high incidence of anxiety, depression and insomnia in hcws caring for covid-19 patients. silver linings: despite the dire situation around the world and in pakistan, all is not doom and gloom. pakistan's current case fatality ratio from covid-19 illness is relatively low compared to many western countries including the uk, usa and italy. 22 the reasons for this are unclear at the moment but may include lower number of tests being performed and statistical under reporting of all-cause mortality as well as other, yet to be investigated factors including difference in virus strains, pre-existing cross immunity in the population etc. the fact remains though that pakistan's poorly resourced healthcare system has so far been able to manage the rising cases of covid-19 in adequate fashion, no doubt partly due to the dedication and hard work of its hcws. in addition, the unprecedented global lock down due to covid-19 has hastened the adoption of computer technology by both healthcare institution as well as institutions of higher learning with tele-health centers blossoming all across the country. 23 this will, in the longer term, enable quality healthcare to reach hither to underserved periurban and rural areas to provide higher quality healthcare to these areas. pakistan's higher education commission, the regulatory body for all higher education in the country has also mandated that all institutions of higher learning (including medical colleges and universities) move to 'virtual/online' teaching and assessment with immediate effect. 24 while this may involve some initial obstacles, in the medium to long term, it will enable a much broader reach of institutions of higher education to segments of pakistan's population that were deprived of quality education. in addition, the move to virtual/online teaching, training and healthcare service and delivery will enable easier links with international educational institutions for much needed technology and expertise transfer to pakistan. covid-19 continued to pose an unprecedented challenge to healthcare workers and to humanity at large. pakistan, with an already severely underresourced health care system, is particularly vulnerable to these challenges. so far, pakistan's public healthcare system, despite longstanding structural challenges has responded admirably to the threat of covid-19 illness. in addition, covid-19 illness has accelerated some much needed changes in pakistan's healthcare and education systems that, if sustained, have the potential to transform these crucial social sectors for the benefit of the most deprived segments of pakistan's population and take the country forward into the twenty first century. resources for mental health: scarcity, inequity, and inefficiency risk factors, prevalence, risk factors, prevalence, and treatment of anxiety and depressive disorders in and treatment of anxiety and depressive disorders in pakistan: systematic review. pakistan: systematic review state of mental health in pakistan: service, education & research. hamdard foundation child and adolescent mental health in pakistan economic burden of mental health in pakistan depression, chronic diseases, and decrements in health: results from the world health surveys. the lancet five-year risk of cardiac mortality in relation to initial severity and one-year changes in depression symptoms after myocardial infarction excess mortality in bipolar and unipolar disorder in sweden generalized anxiety disorder and medical illness living well: an intervention to improve self-management of medical illness for individuals with serious mental illness who-aims report on mental health system in pakistan world health organization world health organization. corona virus disease (covid-19) pandemic covid-19: lessons from sars and mers survey of stress reactions among health care workers involved with the sars outbreak immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china mental health strategies to combat the psychological impact of covid-19 beyond paranoia and panic the immediate psychological and occupational impact of the 2003 sars outbreak in a teaching hospital apocalyptic chaos in sukkur: coronavirus patients escape quarantine center factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 managing mental health challenges faced by healthcare workers during covid-19 pandemic johns hopkins coronavirus resource center telemedicine centers to be set up in medical institutions: governor chaudhry sarwar amh: general supervision of the research group, acquisition of patient data, interpretation of data, critical appraisal of data, write-up of manuscript, final approval of version to be published. has: acquisition of patient data, analysis, interpretation of the data, drafting of the article, write up and revision of the manuscript and final approval of version to be published. key: cord-034495-gvtv8o96 authors: hussain, kashif; ambreen, gul; muzammil, mehreen; raza, syed shamim; ali, umer title: pharmacy services during covid-19 pandemic: experience from a tertiary care teaching hospital in pakistan date: 2020-11-02 journal: j pharm policy pract doi: 10.1186/s40545-020-00277-5 sha: doc_id: 34495 cord_uid: gvtv8o96 the coronavirus disease 19 (covid-19) is rapidly spreading across the world. pharmacy services play a vital role in public health in preventing and containing the covid-19 pandemic. all over the world, especially in the developed countries pharmacists have responded smartly and speedily for public health, such as establishing professional protective and service guidance for pharmacy staff and services, creating and updating drug formularies, addressing the issues of drug shortages, providing public education for prevention and management of infection, contributing in drug evaluation and clinical trials. in this commentary, we review the exclusive demands from pharmacy services in pakistan during coronavirus disease 2019 pandemic and sharing the responses of our hospital pharmacy to these demands and needs with the international pharmacy community, especially of the low and middle-income countries like pakistan. after the outbreak of coronavirus disease 2019 in china in december 2019, it spread all over the world. novel covid-19 is caused by severe acute respiratory syndrome coronavirus (sars-cov-2) [1] . the sars-cov-2 is different from human sars cov and middle eastern respiratory syndrome (mers) cov with respect to genetic characteristics [2] . fever, shortness of breath, cough, breathing difficulties, and respiratory symptoms are the common signs of this infection. pneumonia, severe acute respiratory distress syndrome, organ failure, and death are possible complications [1] . this dangerously infectious virus spreads rapidly through human-to-human transmission. the first case reported on 26 february 2020, in pakistan. as of 19 july, there are 263,496 confirmed cases and 5568 deaths with coronavirus disease in pakistan (available on: https :// covid .gov.pk/stats /pakis tan). in low middle-income countries, like pakistan, medical services are under great pressure while responding to this pandemic. in a tertiary care hospital pharmacy, along with the other approaches and responses in pandemic crises such as supply of emergency medications according to the treatment guidelines and resolving drug shortage, it is also required to provide and continue the event-driven pharmaceutical care. after the rapid transmission and influx of covid-19 patients in our hospital, pharmacy department has adopted the national guidelines and modified the activities to reduce humanto-human infections transmission. all the modifications in the pharmacy activities based on the theme to provide event-driven pharmaceutical care with the least interaction and medication wastage caused by exposure to covid-19 positive patient areas. here we are sharing our response to covid-19 pandemic and provision of inpatient hospital pharmacy services in a tertiary care hospital, karachi, pakistan to disseminate to the open access international pharmacy society what we are practicing despite being in the resource-limited region of the world. pharmacists ensure medication safety, assist health care team to have best therapeutic outcome. the clinical pharmacy team is valued for directly making the difference for best possible outcome. since 26th february 2020, when the first covid-19 case was reported in pakistan [3] , health and health care systems have been disrupted extensively and most of the countries are still facing and fighting against the immediate consequences of higher mortality and morbidity rate due to severe acute respiratory syndrome coronavirus (sars-cov-2) [3] . improving patient safety and work quality involve coordinated efforts of multidisciplinary health care team, including clinical pharmacist as the vital team member. in this evolving situation where the covid-19 patients needed new therapies and experimental drugs been used for them, the need for a clinical pharmacist was more than ever before. to combat this challenging situation clinical pharmacy lead redesigned the front-line clinical pharmacist activities and job responsibilities. in normal routine our clinical pharmacists are involved in all the critical care wards of adult and pediatric units, where they participate in daily patient bedside rounds with the health care team. after the outbreak of covid-19 and influx of infected patients, national guidelines were developed [3] , and to stop the human-to-human transmission of infections minimum staff were allowed to be involved, isolation wards and rooms were created and allocated for covid-19 patients [4] . with these fears and limitations, clinical pharmacy lead planned to provide event-driven pharmaceutical care in our hospital both for adult and pediatric covid-19 patients. these practices go beyond the routine activities of the clinical pharmacist, including patient medications profile review, prescribing supports to physicians, and counseling the patients. the most important aspect of the event-driven pharmaceutical care is to ensure the usage of off-label drugs appropriately, as several drugs are prescribed off-label for treating this lifethreatening infection [5] . the role of clinical pharmacist demands to evaluate the recent literature and published guidelines of these off-label used medications as the associated adverse drug reactions (adrs) of few of the offlabel used drugs include flu-like symptoms, fever, and fatigue, which are actual symptoms of the covid-19 disease. liver damage is reported in covid-19 patients [6] , which might be related to sars-cov-2 or drug-induced. newly developed kidney damage has been reported in renal histopathological analysis of covid-19 patients' postmortem findings [7] . here the role of the clinical pharmacist is very crucial to save the lives through monitoring the patients on drugs which may cause hepatoxicity, renal toxicity, or any other adr and finally adjust the doses based on organ functionality. activities redesigned and now clinical pharmacists are doing round virtually specifically in covid-19 unit. distinctive challenges may be experienced while physically distant from the patient's bedside round. pharmacists must be more productive and more efficacious in transmitting input and knowledge to the team independently. established relationships with the team had positive effect. teamwork as multidisciplinary and collaboration is amazing. physician, pharmacist, nurses, and respiratory therapists, infectious diseases and other specialties like cardiology, nephrology, etc., put the input of their expertise. with persistence compassion for medication safety, patient medication profiles have been reviewed by clinical pharmacists through computerized pharmacy system and health information management system. room discussion planned where whole team sits together and discusses patient management without exposure to the bedside. all medical staff engaged in this activity wearing all personal protective equipment (ppe). bedside staff and doctors get connected to this discussion group through video conference calls and discuss the matters related to the patients. when needed telephonic communication was arranged and created a whatsapp group of all health care professionals. it is always made sure that pharmacist can be approached for any information required and all the medication adjustments are done with pharmacist recommendations. this initiative significantly helped in covid-19 recovery in terms of providing them safe and effective pharmaceutical care. the number of clinical pharmacist interventions also support this initiative. another important aspect of event-driven pharmaceutical care is to provide online real-time clinical supports to health care providers working in the battle zone, including front-line physicians, nurses, and pharmacists. despite resource limitations and restrictions due to pandemic situations, clinical pharmacy lead created several communication ways, available 24 h. a whatsapp group was created including all the clinical pharmacists and front-line physicians for immediate communication with all at a time and for timely decision-making. infectious disease (id) faculty directly involved id-clinical pharmacist in realtime for pharmacotherapy consultation and quick decision-making after the approval of off-label drugs. presently, there is no defined treatment option for treating covid-19 and none of the used medicine has been specifically tested for its safety and efficacy for covid-19 [8] . in the ongoing evolving situation of the covid-19 pandemic, the need for drugs increased and is very uncertain, especially for those drugs used off-label. in pakistan where pharmacists are already mitigating drugs shortage by various strategies [9] , it requires more dedicated pharmacy support to conduct evidence-based drug evaluations and establishing the guidelines for our population. for example, judicious use of chloroquine phosphate and antivirals for preventing and treating covid-19 [10] , evaluating efficacy and safety of antivirals [11] , and glucocorticoids [12] with monitoring throughout. further assisting front-line physicians for optimal dosing schedules, appropriate routes of administration. establishing local rational drug use guidelines is always a practical approach to mitigate the drugs-related issues in the local population. in our hospital, clinical lead pharmacists play a vital role with the hospital leads to establish these guidelines. for updating all the health care providers about the use of medications in covid-19 patients regularly updated through the generalized mail for all. addressing the drug indications, available dosage form, dosing schedule, suitable solvents, possible routes of administration, associated adrs, precautions, and conditions requiring dose adjustment, such as pregnancy, lactation, pediatric and elderly patients, renal and hepatic dose adjustments, etc. [13] . in addition, to keep all the front-line pharmacists updated is highly crucial and challenging. team members share their learnings and aim for the distinctive goal to overcome this challenge. recent literature and treatment updates are regularly shared to provide the best possible care to the patients. all this activity is done through emails, what-sapp groups, and online meetings [14] . health care staff exposure to the hospital during the pandemic of covid-19 includes the risk of being infected. to continue the services and to keep the front-line pharmacy staff safe and fit to work, we decided to decrease the exposure of staff to hospital and to minimize the cluster. as in the case, if any staff gets covid-19 infected quarantine is required, thus this initiative of duty hours redesign helped to have enough backup staff to keep the functionality of the department. in addition, due to reduced hospital admissions and clinic visits [4] this redesigned duty hours also reduced the institutional financial burden. in this situation of persistent anxiety, pharmacy lead maintaining the staff morale high through appreciation and showing empathy for hospital staff directly dealing with the patients and appreciating their selflessness. staff is specifically trained and reinforced to adhere to personal protective equipment use guidelines. drug shortage during the covid-19 pandemic has affected almost all the countries. shortage of both prescribed and over-the-counter drugs may develop. disruption in the local production process and international transport are the main reasons for the short supply in our country. in our pharmacy, we established an early warning system by following the american society of health-system pharmacists (ashp) guidelines, through ongoing active surveillance conducted by pharmacists and addressing the shortage issues promptly. the pharmacy department has always been an integral section of the hospital for managing and treating the patient. when faced with major public health emergencies from infectious diseases, 2019-ncov, the concern is to protect staff so that they do not become infected and protect them from becoming vector or carriers. prevention and control is done in inpatient pharmacy medication distribution within the hospital. physicians enter medication orders for inpatient through physician order entry system (cpoe) and pharmacist verifies the orders while sitting in the satellite pharmacy. in our hospital normally medications are supplied for 24 h to the nursing station by practicing modified-unit-dosage-drug-delivery system. medication carts are prepared by technicians and pharmacist check for accurate dispensing before sending to the wards [15] . practicing modified 24-h medications supply, in return, increases the number of medications return to pharmacy because of extra dose dispensing of more than one time and new order entry for the admitted patients [16] . various medications are returned to pharmacy from the ward where they were not used. before the covid-19 pandemic, a number of unused medications are return to pharmacy in the form of regular credit that was about 15% of the total medications dispensed. in critical areas after positive cases being treated in hospital, the drugs exposed directly to the environment of the wards of covid-19 were decided not to be returned for credit to protect the staff [17, 18] . we decided to make changes in the process flow to stop this wastage of expensive medications and ultimately save the cost. modified unit dosage form (24 h supply) was switched to unit dosage form (one dose of a drug dispensed at a time). as a result, not only the wastage is prevented, but the number of medicine return to pharmacy also decreased and saved the pharmacy staff time previously wasted in rework. along with the implementation of the actual unit dosage system, we also modified the process and placed drugs cassette in the area entry, only the drugs need to be administered were taken to the isolation ward and all others kept outside so that they can be returned. dedicated medication staff were assigned to handover the medicine to the assigned staff. implementing actual unit dose dispensing system is a big challenge in resource-limiting settings, but we accepted and met the goals of reduced wastage and improved safety. sars-cov-2 is an extremely transmissible virus, with rapid disease progression. all the front-line healthcare providers nonstop explore the most appropriate prevention, treatment, and diagnostic techniques. in this pandemic situation in pakistan, a country with limited resources, all the clinical pharmacists under the leadership command collaborated to actively participate and give maximum utility of their pharmacological expertise with activities modification. we conclude that the clinical pharmacist holds the stout position of academic leader for formulating directions and recommendation, and simultaneously a strong practitioner of pharmaceutical services, through the provision of medical advice to front-line healthcare providers and safeguarding the rational drug usage during the pandemic. equally, we explored that despite limited resources this pandemic situation has driven the leaders of clinical pharmacy in pakistan to develop innovative and remote pharmaceutical services. recent insights into 2019-ncov: a brief but comprehensive review a novel coronavirus from patients with pneumonia in china pharmacists at the frontline beating the covid-19 pandemic impact of covid-19 pandemic on paediatric services at a referral centre in pakistan: lessons from a low-income and middle-income country setting. arch dis child treating covid-19-off-label drug use, compassionate use, and randomized clinical trials during pandemics pathological findings of covid-19 associated with acute respiratory distress syndrome renal histopathological analysis of 26 postmortem findings of patients with covid-19 in china roles of the clinical pharmacist during the covid-19 pandemic medicines shortages in pakistan: a qualitative study to explore current situation, reasons and possible solutions to overcome the barriers breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of covid-19 associated pneumonia in clinical studies systematic review of the efficacy and safety of antiretroviral drugs against sars, mers or covid-19: initial assessment the use of anti-inflammatory drugs in the treatment of people with severe coronavirus disease 2019 (covid-19): the experience of clinical immunologists from china fighting against covid-19: innovative strategies for clinical pharmacists preventing intra-hospital infection and transmission of covid-19 in healthcare workers. saf health work unit-dose drug distribution systems. making health care safer: a critical analysis of patient safety practices evaluation of medicine return from wards to inpatient pharmacy in tertiary care hospital preparing for a covid-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore corona virus international public health emergencies: implications for radiology management springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations authors' contributions kh: substantial contributions to the conception of the work. performed the study and wrote the paper. final approval of the version published. ga: cowrote the paper. mm: co-wrote the paper. ss: revised the work critically for important intellectual content. ua: revised the work critically for important intellectual content. all the authors read and approved the final manuscript before submission. no source of funding in the research. not applicable. approval and need of consent to participate were exempted from ethical review committee. not applicable. the authors declare that they have no competing interests in this section.received: 29 september 2020 accepted: 28 october 2020 key: cord-005129-2e6b5tm2 authors: chaudhry, mamoona; ahmad, maqbool; rashid, hamad bin; sultan, bakhat; chaudhry, haroon rashid; riaz, aayesha; shaheen, muhammad shabir title: prospective study of avian influenza h9 infection in commercial poultry farms of punjab province and islamabad capital territory, pakistan date: 2016-10-20 journal: trop anim health prod doi: 10.1007/s11250-016-1159-6 sha: doc_id: 5129 cord_uid: 2e6b5tm2 a prospective study was conducted from november 2013 to february 2014 to estimate the spatial clustering; cumulative incidence and risk factors associated with avian influenza (ai) subtype h9 infection on commercial poultry farms of pakistan. a total of 400 farms were enrolled and followed during the study period. among these, 109 farms submitted samples suspected for ai to the laboratory, and only 47 farms were confirmed positive by hemagglutinin inhibition (hi) test. data was collected from these 109 farms about their demography, management, and biosecurity practices. the cumulative incidence of h9n2 was 11.75 % (95 % confidence interval (ci) 8.76–15.23). the highest number of cases (40.42 %) was reported in january. one most likely cluster (p = 0.009, radius = 4.61 km) occurred in the kasur district. multivariable logistic regression analyses showed that the presence of wild birds on the farms (odds ratio (or) = 16.18; 95 % ci 3.94–66.45) was independently associated with h9n2 infection. cleaning of cages before delivery on farm (or = 0.16; 95 % ci = 0.06–0.47), presence of a footbath at the entrance of farm (or = 0.24; 95 % ci 0.08–0.79), and changing of gloves (or = 0.33; 95 % ci 0.11–0.99) were protective factors against h9n2 infection. reducing the exposure to risk factors and adapting biosecurity measures may reduce the risk of ai h9n2 infection on commercial poultry farms in pakistan. influenza is a continuing threat to human and animal health. every year, thousands of people are infected with seasonal influenza and may be exposed to subtypes of avian (h5, h6, h7, h9, and h10) and swine (h1 and h3) origin (garcía-sastre and schmolke 2014). avian influenza viruses (aivs) of subtype h9n2 have spread widely since their first identification in turkeys in wisconsin, usa, in 1966 (homme and easterday 1970) . h9n2 viruses were isolated from pigs in 1998 and were subsequently isolated from humans with an influenza-like illness in both hong kong and mainland china (peiris et al. 1999) . h9n2 are significantly important due to their extensive circulation in domestic poultry in different regions of world from the far east to the middle east (fusaro et al. 2011) . genetic analysis of h9n2 viruses has showed extensive re-assortment of these viruses with many subtypes of aivs including hpai h5n1 and h7n3 viruses (chaudhry et al. 2015; fusaro et al. 2011) . in pakistan, commercial poultry production has attained the shape of an industry in recent years with investment of billions of rupees. since 1995, aiv subtypes h9, h7, and h5 are responsible for five massive epidemics in pakistan affecting poultry and poultry products across the country (naeem et al. 2007) . although h9n2 viruses are of low pathogenicity, the frequent heavy losses caused by them have raised serious concerns for the poultry industry in many countries. advancement has been made in disease investigations with new tools like geographic information system (gis), which is used for spatiotemporal analysis of important emerging infections, e.g., severe respiratory syndrome (sars), aiv h5n1, and influenza a (h1n1) (tiensin et al. 2009; martin et al. 2011; lai et al. 2013) . disease clustering can be detected by using space-time scan statistics (kulldorff et al. 2005) . few studies have examined the association of risk factors with ai on poultry farms in pakistan (abbas et al. 2012; chaudhry et al. 2015) . to date, very little information is available on spatial clustering of h9 infection in this region. awareness about risk factors responsible for disease introduction and spatial clustering is critically important in developing risk-based surveillance strategies, policies, and timely recommendation for control. the primary objectives of this study were to calculate attack rate (ar) of h9n2 infection and to identify risk factors associated with this infection among poultry farms of pakistan. the other objective was to identify any clustering of unusually high number of h9 cases than expected for early detection of any emerging outbreak of this disease in different areas of pakistan when only the number of cases is available. a prospective study was conducted from november 2013 to february 2014. all commercial poultry farms of pakistan raising domesticated poultry for sale were considered as the target population of study. the final study population was commercial poultry farms submitting samples for laboratory analysis to the collaborating private poultry laboratory for routine screening and suspected infections. each commercial farm was taken as a sampling unit. all poultry farms, which were included in the study, were considered negative for h9 at the start of study due to the absence of any influenza or influenzalike illness in the flock. none of broiler flock was vaccinated against h9, h5, or h7. breeder and layers were vaccinated against h9. a total of 400 commercial poultry farms of different production categories (breeders, broiler, and layer farms) located in punjab province and islamabad capital territory of pakistan were enrolled in the study. out of these 400 farms, only 109 farms submitted samples to laboratory for suspected infection with aiv, and a pretested questionnaire was filled from the owner/supervisor of these 109 farms in a face-to-face interview after explaining the objectives of study to the farmers. prior to interview, written consent of the owner/ attendant was obtained. the questionnaire contained 26 questions about risk factors, which were known to influence the disease occurrence and were selected after reviewing literature about ai (nishiguchi et al. 1999; ward et al. 2008; mcquiston et al. 2005; fang et al. 2008; woo and park 2008; abbas et al. 2012; chaudhry et al. 2015; nishiguchi et al. 2007 ) and from the observations of technical staff working on these farms. the farmers were requested to provide five to ten dead birds from total mortality on farm, which were carefully examined by conducting postmortem examination for specific disease lesions. typical pathological lesions in respiratory system, i.e., rhinitis, sinusitis, congestion, and inflammation in the trachea (swayne 2008) , were suspected for aiv. confirmation was done by anigen rapid aiv ag detection kit (bionote inc., korea). the outcome of interest was h9 status, i.e., infected and non-infected farms. samples confirmed by rapid test were further tested by virus isolation in embryonated chicken eggs, and subtyping was done by hemagglutinin inhibition (hi) test. ar of h9n2 was calculated (thrusfield 2007) . all biologically plausible and relevant variables were screened in univariable analysis by using glm function of the epicalc package (version, 2.15.1.0) in r statistical software (available at http://www.r-project.org). a multivariable model was derived by forward stepwise selection procedure (dohoo et al. 2003) . variables with significant univariable relationship at p < 0.25 were selected for inclusion in the final model. odds ratios (ors) and corresponding 95 % confidence intervals (cis) were calculated (hosmer and lemeshow 2000) . all laboratory-confirmed cases of h9n2 between december 2013 to february 2014 were geocoded to street addresses. satscan software version 9.1.1 developed by martin kulldorff, havard medical school (boston, usa) prospective space-time permutation scan statistic module was used to detect a local excess of events and to test if this excess could have occurred by chance (hyder et al. 2011 ). this method consists of thousands of cylinders that move across space and/or time. each cylinder has a base, which represents geographical area (in this study, a commercial farm), and height, which is time (in this study, a day). the base of each cylinder comprised a maximum of 50 % of the population, while height was a maximum of 50 % of the study time (60 days). the cylinder with more observed cases than expected, with respect to cases reported outside the cylinder, is called bmost likely cluster.^for each location and size of the cylinder, the number of observed and expected cases is counted. among these, the most bunusual^excess of observed cases is noted. the statistical significance of this cluster is then evaluated taking into account the multiple testing stemming from the many potential cluster locations and sizes evaluated (kulldorff et al. 2005 ). arcgis version 10 was used for the map display. during the study, we followed 400 commercial poultry farms of which 109 submitted samples. among these 109 farms, 47 ). among the infected farms, majority (66 %) reported 5-9 % mortality due to h9 (table 1) . the ar was highest in lahore district (11/28) followed by kasur (24/38) and sheikhupura (6/13) districts (fig. 1) . no sample was positive for newcastle disease virus, h5, and h7 aivs. the study showed a high ar in the month of january (21/ 34) followed by december (11/29), november (9/23), and lowest incidence in february (6/23) (fig. 2) . out of 26, 11 factors were selected for inclusion in final model of multivariable analysis (table 2) . factors with p > 0.25 were excluded from further analysis. in the final multivariable model, four factors were identified as significant (table 3) . among those four factors, one factor was identified as risk factor (or > 1), i.e., wild birds on the farm, and three factors were proved to be protective factor (or < 1), namely cleaning of cages before entering the farm area, having foot bath/dipping area at the entrance of farm, and workers change gloves while entry into bird area. total examined farms in punjab province were 107, while 2 farms were examined from islamabad capital territory (fig. 3) . from november 1, 2013 to february 28, 2014, one most likely cluster (p = 0.009, radius = 4.61 km) occurred in the kasur district of punjab, pakistan (fig. 4) . this signal had four cases observed over 25 days when 0.52 cases were expected [relative risk (rr) = 7.67], with a null occurrence rate of once every 111 days. attack rate was highest in lahore district (17/28) followed by kasur (24/38) and sheikhupura (6/13) districts. the reason for this high ar could be the high density of commercial poultry farms in these districts. association of hpai h5n1 and high and medium density of poultry farms has been studied and was identified as a risk factor in different countries (henning et al. 2009; abbas et al. 2012) . poultry farm densities in these regions ranged from 0.05 to 4 farms per square kilometer (hamilton et al. 2009 ). as distance between the farms plays a significant role in the transmission of infection, poultry farms in these areas are exposed almost every year during the endemic (abbas et al. 2012; chaudhry et al. 2015) . furthermore, in densely populated poultry areas, movement of vehicles and people from farm to farm is considerably high, subsequently facilitating the spread of this virus through fomites. in the current study, the two districts (lahore and kasur) are on the main highway road (grand trunk road), which have a significant number of commercial poultry farms alongside. the vehicles over loaded with infected birds or mortality move on this road routinely. previously, many studies have demonstrated that proximity to major roads was associated with avian influenza (ward et al. 2008; chaudhry et al. 2015) . movement of veterinarian and para-veterinary staff between different farms to implement control measures or to investigate mortalities can also contribute to the spread of virus among farms. in pakistan, poultry farmers who apply strict biosecurity measures sometimes relax these rules for visitors, who enter the bird areas (chaudhry et al. 2015) . spatiotemporal analysis detected a most likely cluster in kasur district (p = 0.009, radius = 4.61 km). poultry farm in this cluster has a significantly higher risk of being infected as compared to poultry farms outside the cluster (rr = 7.67). these results represent the most important hotspot of expected outbreak and are valuable for improving knowledge and understanding of spatial pattern of h9n2 in specific areas. targeted surveillance of these districts is needed for early detection of any future ai outbreak and their possible re-assortment. spatial analyses have been used to study different outbreaks of human and avian influenza infections (tiensin et al. 2009; leveau et al. 2015) . risk factor analyses showed that the presence of wild birds on farm could enhance the probability of infection (or = 16.18; 95 % ci 3.94-66.45). wild birds could serve as a potential source of propagation of ai virus especially when biosecurity measures are poorly implemented on farm. they can act both as mechanical and biological vectors (shedding the virus in droppings) and are important source of introducing virus to new areas (mcquiston et al. 2005; henning et al. 2009; chaudhry et al. 2015) . cleaning of cages before delivery was strongly associated with decrease in risk of h9 (or = 0.16, 95 % ci 0.06-0.47). though statistically non-significant, cleaning of cages has been studied as a protective factor in lowering risk of h9 infection (chaudhry et al. 2015) . poultry traders are well aware about the importance of cleaning cages and vehicles as an effective biosecurity measure (kurscheid et al. 2015) . presence of a footbath/dipping area at the entrance of farm and changing of gloves are also important as part of biosecurity measures on farm and have proved effective in decreasing risk of ai previously (biswas et al. 2009; chaudhry et al. 2015) . this study found evidence of clustering, in space and time, and identified some well-known factors mainly responsible for increasing risk of aiv infection. enhancing good management practices and strict biosecurity can lower the risk of infection among poultry farms. spatial clustering of disease provides information to health authorities to more effectively target and improve their surveillance and control strategies in affected areas. acknowledgments the authors are highly indebted to respondents of the commercial farms, who participated in study for data collection. we also acknowledge the support of staff of commercial poultry laboratory for providing us data from logbook about case farms, which were included in the study. without their great cooperation and help, this study would not have been possible. ethical approval this article does not contain any studies with animals performed by any of the authors. informed consent the manuscript does not contain clinical studies or patient 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low pathogenicity h7n2 avian influenza virus among commercial poultry farms avian influenza in pakistan: outbreaks of low-and high-pathogenicity avian influenza in pakistan during risk factors for the introduction of avian influenza virus into commercial layer chicken farms during the outbreaks caused by a low-pathogenic h5n2 virus in japan in 2005 human infection with influenza h9n2 avian influenza veterinary epidemiology ecologic risk factor investigation of clusters of avian influenza a (h5n1) virus infection in thailand environmental and anthropogenic risk factors for highly pathogenic avian influenza subtype h5n1 outbreaks in romania seroprevalence of low pathogenic avian influenza (h9n2) and associated risk factors in the gyeonggi-do of korea during key: cord-318390-uuz37610 authors: saleem, tayyaba; sheikh, nadeem; abbasi, muddasir hassan; javed, iram; khawar, muhammad babar title: covid-19 containment and its unrestrained impact on epilepsy management in resource-limited areas of pakistan date: 2020-09-25 journal: epilepsy behav doi: 10.1016/j.yebeh.2020.107476 sha: doc_id: 318390 cord_uid: uuz37610 the current pandemic of coronavirus disease 2019 (covid-19) that led to an unprecedented crisis with significant health, social, and economic repercussions presented more serious concerns for those living with some chronic conditions such as epilepsy. this study was aimed to find out impact of the covid-19 pandemic on management of epilepsy. a cross-sectional study was conducted through telephone interviews, targeting 213 caregivers of pediatric patients with epilepsy, belonging to underserved areas of faisalabad, punjab, pakistan. a simple questionnaire was designed to record the responses of participants relevant to the direct and indirect effects of covid-19 pandemic and their knowledge about possible ways that can be accessed for the management of epilepsy during an ongoing pandemic. the current study, which holds 77% of the respondents from rural areas and 23% from urban settings, showed that partial measures of lockdown taken to stop or slow the spread of covid-19 resulted in adverse economic and health outcomes in the said population including cancelation of follow-up visits, worsening of seizures, job loss, burden of antiepileptic drugs (aeds) costs, and discontinuation of medicines. furthermore, knowledge about alternative ways to access health facilities was found very poor among caregivers. income sources of poor people disrupted by lockdown can lead to unintentional nonadherence to medication, which is a clear picture of inequitable distribution of resources. this study highlights the major issues faced by the caregivers during this ongoing pandemic of covid-19. epidemics are always a great menace to global health security. the current pandemic of coronavirus disease 2019 (covid-19) affected all countries around the globe and has changed the entire world within a few months. social isolation is advised throughout the world to prevent the potential transmission of infection. this public health emergency of international concern (pheic) delineates unprecedented crises with significant health, social, and economic repercussions [1] . the medical community is facing many challenges of practical and ethical nature requiring rapid response [2] . lockdown, self-isolation, and social distancing are some of the measures taken by governments of different countries aimed at decelerating the covid-19 spread. the covid-19 pandemic influenced everyone around the globe, but it can cause more concerns for people living with chronic illnesses including neurological disorders like epilepsy [1] . a strict lockdown can affect these patients adversely as they require regular follow-up visits and prescription refills. on the other hand, control of covid-19 pandemic demands discontinuance of all routes of probable transmission [3] . increased probability of being infected by outpatient department visits compelled the patients and their caregivers into postponement of appointments leading to further health consequences [2] . with more than 65 million people affected worldwide, epilepsy is the fourth most commonly occurring neurological disorder. the estimated prevalence of epilepsy in pakistan is 9.99 per 1000 population with the highest prevalence in people living in rural areas [4] . importantly, epilepsy cases are not uniformly distributed; instead, a large number of patients belong to resource-poor regions [5, 6] , places that are more at risk of epidemic outbreaks, thus making epilepsy management more difficult during an epidemic. resourcepoor countries are incapable to take on the enormous medical, economic, and social challenges caused by epilepsy. compromised healthcare systems in these countries are unable to provide costeffective care because of widespread poverty and illiteracy, due to epilepsy & behavior 112 (2020) 107476 abbreviations: gefs+, generalized epilepsy with febrile seizures plus; cae, childhood absence epilepsy; jme, juvenile myoclonic epilepsy; dees, developmental and epileptic encephalopathies; iges, idiopathic generalized epilepsies. ⁎ corresponding author. e-mail address: nadeem.zool@pu.edu.pk (n. sheikh). which a great proportion of these patients remain undiagnosed and untreated, causing the treatment gap and maximizing the overall burden of epilepsy [7] . the health system challenges in developing countries are somewhat different from developed countries [8] . for a low-middle-income country like pakistan, spending less than 1% of gross domestic product (gdp) on health, the management of chronic disorders like epilepsy is a great challenge during this pandemic [9] . like all other chronic disorders, epilepsy management demands regular medical checkup and sustainable supply of antiepileptic drugs (aeds) [6] . however, in the current pandemic situation, community containment is inevitable, which in turn restricts the medical interaction between neurologists and people with epilepsy (pwe), ultimately making epilepsy management tougher than ever [10] . presently, there is a lot of precariousness and queries concerning epilepsy and covid-19. it has been proposed by researchers that the risk of acquiring covid-19 infection for people affected with epilepsy and the general population is the same [11] . however, the paucity of aeds, the presence of comorbidities, and lack of medical assistance during the pandemic situation make pwe (even if seizures are controlled) more prone to covid-19 infection as compared with the healthy population [12, 13] . although current aeds can effectually control seizures, still, onethird of the affected people continue to experience seizures because of drug-resistant epilepsy. therefore, regular visits of outpatient clinics are indispensable for the optimization of antiseizure therapy and better management of behavioral and psychological problems related to epilepsy [14] . the present study was aimed to find out the impact of covid-19 containment measures on the management strategy of low literate caregivers of patients living in resource-limited areas of pakistan, one of the active hotspots of the pandemic. a cross-sectional study was designed to collect data from caregivers of patients with different epilepsy conditions (fig. 1) . it was conducted between july 13 and july 24, 2020,~115 days after partial lockdown was implemented in pakistan. the study was approved by the bioethics committee of the university of the punjab, lahore, pakistan. participants of this study were the caregivers of pediatric patients with active epilepsy, recruited for another study under higher education commission (hec)-funded project before the covid-19 pandemic. all patients belonged to different areas of division faisalabad, punjab, pakistan. most of the participants were from rural settings and illiterate or low-literate (assessed through already present data), so the online survey was not an option to record responses, while in-person interviews were discouraged because of the current dreadful pandemic. a simple self-administered questionnaire holding most of the dichotomous questions was designed after the consensus of all the authors. urdu being a national and frequently used language in pakistan was selected to record responses. initially, a 16-item questionnaire was designed and tested through a pilot study to check the feasibility of comprehension for respondents. all questions relevant to covid-19 testing in patients and close contacts, symptoms, and standard operating procedures (sops) were excluded from the questionnaire after analyzing the reluctance in response due to prevailed covid-19 chaos in low-literate communities. a total of 12 questions containing the questionnaire were finalized to record responses. a telephone interview was conducted to record the responses of all caregivers. although it has some limitations, it can be an efficient method of data collection [15] . all pertinent information like purpose, benefit, and procedures involved in the study were provided to the subjects and given ample opportunity to ask any question regarding data usability. after answering the respondents questions (if they had any) and explaining that all the data collected from patients will be used anonymously and at no stage in the study, their identity will be revealed, a formal verbal consent was obtained by asking "do i have your permission to ask you questions relevant to your child's disease and its management and use this protected health information for research purpose?". after getting a "yes" answer from each caregiver recruited in this study, interview was conducted. three of the caregivers reported unexpected death of their child even though the seizures were under good control, seemingly a sudden unexpected death in epilepsy (sudep) (not confirmed by postmortem), while antiseizure treatment was discontinued by 2 patients, reporting that epileptic seizures of their children have some supernatural explanation and thus, were excluded from the study. thirty-eight contact numbers could not be reached to record the response. after explaining every question to the respondents, a total of 213 responses were recorded successfully (table 1) . gender-wise prevalence of epilepsy in different age groups (fig. 2) , education level of caregivers (fig. 3) , and particular type of epilepsy (fig. 4) were also analyzed. the horrific covid-19 pandemic posed numerous challenges to healthcare systems and economies worldwide. it has forced healthcare professionals and policy makers to shift their prime focus towards patients infected with covid-19 by dedicating major health facilities to them [16] . pakistan was among the countries facing a substantial spike in covid-19 cases due to loosened restrictive measures. face-to-face appointments have been canceled all over the world either by patients or by clinicians forcefully to protect the patients and healthcare professionals from being infected [17] . it is no different from pakistan where because of the lockdown, majority of people canceled or postponed their neurology visits due to nonavailability of transport and fear of being infected after visiting hospitals. it is evident from the current study that majority of the respondents postponed their follow-up visits. a greater number of patients in this study belonged to rural areas following the fact of its prevalence [4] . aledo et al. reported seizure worsening in some cases during lockdown as presented in our study [18] . the pathophysiology of seizures exacerbation is not completely understood; however, selection of inappropriate aed can also aggravate the condition [19] , which urgently requires the medical consultation that is tough during the current situation. uncontrolled seizures can affect the immune system by causing malnutrition; moreover, the mortality rate linked to epilepsy is high among those with uncontrolled seizure conditions [20] [21] [22] . in the current study, trend of medicine discontinuation was observed due to nonaffordability despite the fact that discontinuation of aeds without prior consultation with the neurologist can result in serious medical consequences [23] . rural populations face innumerable constraints including weaker financial status and having out-of-pocket expenses in epilepsy treatment [24] . the lower socioeconomic status (ses) of the patients makes them susceptible to medication nonadherence, but it can be inflamed especially during the current pandemic because of losing jobs and wages associated with a disruption in the source, which makes the provision of drugs accessible as noticed in the present study [25] . nonadherent patients with epilepsy conditions are at greater risk of complications emanating from uncontrolled seizures. the current study holds majority of the respondents from rural settings who largely rely on the partial supply of free of cost aeds from government hospitals, which was disrupted because of lockdown, making the cost of treatment unbearable. services regarding healthcare are disrupted worldwide because of the measures taken in the wake of an ongoing pandemic. it has led to the conversion of onsite visits into telemedicine visits [26] , which can be proven significantly effective in supporting remote delivery of services to patients with chronic conditions including epilepsy [10] . keeping in view the benefits of telemedicine, the punjab government's information technology (it) sector had launched a major project in pakistan that connects 250 rural basic health units to urban centers through video-link, where doctors provide consultation [27] . people belonging to urban areas have access to nearby hospitals, while there are many constraints for rural communities including geographic distance and traveling cost. telehealth in pakistan is comparatively better than it was in previous years, but it still needs more cogitation particularly in underserved and rural areas where it is poorly integrated [28] . because of the current pandemic, various hospitals in pakistan have started telehealth for covid-19 and other ailments rapidly through various platforms including social media (whatsapp) to ensure the regular provision of healthcare services [29] . the use of advanced technology like smartphone applications can greatly facilitate the communication between patients/caregivers and physicians. patients can also share videos of seizure events with the caring physician for better diagnosis and treatment, ultimately implementing telehealth at a larger scale [30] . however, it is only possible when the patients have access to smartphones with enough knowledge about its operation. the current study showed that the majority of the caregivers were illiterate (fig. 3) . many of them do not have smartphones, and more than 90% do not know about telehealth/telemedicine. very few caregivers belonging to urban settings were aware about telemedicine. awareness about telehealth services and all the ways to access it is requisite. the role of nongovernmental organizations (ngos) cannot be negated in sustained awareness activities and reducing the epilepsy treatment gap (etg) through direct and indirect measures of public awareness. in 2001, the comprehensive epilepsy control programme of pakistan (cecp) was initiated under ngo to combat the various challenges and paucities in knowledge, attitude, and practice (kap) about epilepsy, especially stigma and etg. the cecp has two major components named as epilepsy support pakistan (cecp-esp) and national epilepsy centre (cecp-nec), for awareness, mass education, integrated management of pwe, professional education, and the basic research [31] . nongovernmental organizations should come forward during these unwelcoming situations of covid-19 pandemic to spread awareness especially in underdeveloped areas to counter the present health challenges. the world health organization (who) urges pakistan to implement intermittent lockdown to control the spike in new cases. extension of lockdown can promote medication nonadherence among those people who reported the cost of treatment a great burden in the absence of wages. no one knows when this dreadful pandemic will end, so if the government uplifts the restrictive measure to give relief, still fear of this pandemic will probably exist among people and refrain from visiting clinics. our cross-sectional study is one of the first reports from pakistan that provides information about the direct and indirect effects of the pandemic on a vulnerable population. the majority of the caregivers are finding it difficult to continue the same management of the disorder as before the pandemic leading to serious outcomes like seizures exacerbation. lack of awareness hinders the adoption of telemedicine especially in rural areas making the management of epilepsy tough for these people. policies to counter challenges in the management of chronic disorders during the covid-19 pandemic must address the people of resource-limited areas, and they should be provided with free aeds at doorstep at least during such uninviting situations, making their fight against this disorder easy. awareness campaigns through government and ngos should be started at the grassroots level to make people well aware of their disease and all possible ways that can be accessed for the management of it during such inevitable situations. to combat the present challenges posed by an ongoing pandemic, communication through telehealth services and uninterrupted supply of medicines by all means is demanded. unfortunate though inevitable, the covid-19 pandemic exposed the inadequacies of the present healthcare systems. now this pandemic should be exploited to setup better infrastructure including implementation of telehealth to deal with current and future inevitable epidemics. all the relevant data are present in the article. the authors highly acknowledge the role of higher education commission, govt. of pakistan for providing funds under grant no. 8369/punjab/nrpu/r&d/hec/2017. the authors declare that there is no conflict of interest regarding the publication of this paper. epilepsy control during an epidemic: emerging approaches and a new management framework keeping people with epilepsy safe during the covid-19 pandemic characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention epidemiology of epilepsy in pakistan: review of literature estimation of the burden of active and life-time epilepsy: a meta-analytic approach epilepsy in poor regions of the world challenges in the management of epilepsy in resource-poor countries helping poorer countries make locally informed health decisions pakistan economic survey 2017-18. ministry of finance islamabad 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against epilepsy treatment expenditure pattern of epileptic patients: a study from a tertiary care hospital non-communicable disease management in vulnerable patients during covid-19 rapid implementation of virtual neurology in response to the covid-19 pandemic the telemedicine landscape in pakistan-why are we falling behind? world health organization global disability action plan 2014-2021: challenges and perspectives for physical medicine and rehabilitation in pakistan doctor-patient communication in surgical practice during the coronavirus (covid-19) pandemic assessment of the predictive value of outpatient smartphone videos for diagnosis of epileptic seizures epilepsy treatment gap and stigma reduction in pakistan: a tested public awareness model the authors are thankful to the vice-chancellor university of the punjab, lahore, pakistan and all the participants of this study. key: cord-280050-fktc778q authors: tahir, shumaila; tahir, syeda anjala; bin arif, taha; majid, bushra; majid, zainab; malik, farheen; ahmed, ashfaque; memon, arslan; ahmed, jawad title: epidemiological and clinical features of sars-cov-2: a retrospective study from east karachi, pakistan date: 2020-06-17 journal: cureus doi: 10.7759/cureus.8679 sha: doc_id: 280050 cord_uid: fktc778q background severe acute respiratory syndrome coronavirus 2 (sars-cov-2) has spread to almost every country on the globe, and each country is reporting the symptomatic presentation of their patients to give better insight into the various clinical presentations of sars-cov-2. however, the epidemiological literature from pakistan is scanty. methods we retrospectively analyzed data from 412 patients who were residents of east karachi and tested positive for sars-cov-2 between february 26 to april 24, 2020. patients' demographics, symptoms, travel and contact history, and outcomes were recorded. all statistical analysis was performed using the statistical package for the social sciences (spss) version 22 (ibm spss statistics for windows, ibm corp, armonk, ny). results most of the patients were male (64.6%), the majority (43.3%) belonging to the 21to 40-year age group. most of the patients (65.5%) were residents of gulshan iqbal. a total of 15.8% of the patients were admitted to the hospital, and 3.9% of patients expired. the three most common presenting symptoms were fever (74.8%), cough (60.4%), and flu (35.5%). the majority of patients (89.3%) gave a history of contact with sars-cov-2 patients. conclusion the number of sars-cov-2 cases is rapidly increasing in karachi, pakistan. there is a need to educate the population about the most common sign and symptoms of the virus so that individuals can identify these symptoms and get themselves tested. the concerned authorities should devise an adequate and effective plan to flatten the infectivity curve. in december 2019, several locals in wuhan, china presented to the hospital with respiratory symptoms due to a novel pathogen. the pathogen was identified and named as severe acute respiratory syndrome coronavirus 2 (sars-cov-2). sars-cov-2 is classified as a type of rna virus, a member of the coronavirus family, and belongs to the "beta" genus. other members of the same genus include sars-cov-1 and middle east respiratory syndrome coronavirus (mers-cov) [1] [2] [3] . the possible origin of sars-cov-2 from bats could be elucidated by its similarity (88% identical) to two other sars-like covs derived from bats (bat-sl-covzc45 and bat-sl-covzxc21) [1, 2] . since its origin, the virus has spread all over the world, affecting nearly every continent and triggering an international public health emergency in its wake. on march 11, the world health organization (who) declared coronavirus disease of 2019 (covid-19) a pandemic. according to the most recent who covid-19 situation reports (dated may 19, 2020) , a total of 4,731,458 individuals have been infected, with 316,169 confirmed deaths [4] . in the eastern mediterranean region, pakistan has the third-highest number of cases after iran (122,492 cases) and saudia arabia (59,854 cases). pakistan has 45,734 cases (17, 947 in sindh, 16 ,685 in punjab, 6,554 in khyber pakhtunkhwa, 2,885 in baluchistan, 689 in gilgit-baltistan and azad kashmir) with 985 deaths as of may 20, 2020 [5] . the rampant nature of sars-cov-2 is due to its high infectivity. the virus can be transmitted from human to human through physical contact, respiratory droplets produced by coughing, or sneezing [6] . recently, vertical transmission through the mother to the newborn has also been postulated [7] . sars-cov, mers-cov, and the recently identified sars-cov-2 all cause respiratory symptoms. the main clinical manifestations of sar-cov-2 range from mild asymptomatic disease to lifethreatening complications. initially, the patient presents with cough, fever, dyspnea, and fatigue. other less common complaints may include diarrhea, headache, and the production of sputum. the disease can progress to cause pneumonia, leukopenia, and lymphopenia [8] . severe complications may occur, such as acute respiratory distress syndrome (ards), rnaaemia, acute cardiac injury (aci), secondary infection, heart failure (hf), and multiple organ failure requiring intensive care unit (icu) admissions [3, 8] . since its spread in pakistan, the government has taken drastic measures for control and prevention of the further spread of covid-19, including quarantine of suspected individuals carrying the disease and improvement in diagnostic and treatment procedures. nonetheless, the already scarce resources of the healthcare system of pakistan have been stretched thin. the primary aim of this retrospective observational study was to report the epidemiological features and statistics of individuals infected with covid-19 from february 26 to april 24 from east karachi, pakistan, and contribute towards an accurate collection of figures from the country. we also aimed to study the age groups, modes of transmission, and durations and details of symptoms, among other variables, to understand this wide-spreading disease better and work effectively towards prevention and suitable management plans. we carried out a retrospective cross-sectional analysis of the infected population of east karachi (consisting of two towns, gulshan iqbal and jamshed). all records that were found to be positive for the covid-19 virus were analyzed, including cases that presented to the hospitals with screening facilities along with cases traced by the rapid response team of the district's covid-19 control room for the 'at home' suspects, cases and contacts. the data was collected from the daily notifications given to the surveillance line list and updated by the district health office, control room, which included data from the first case, from february 26 to april 24, 2020. the individuals of east karachi were filtered via screening criteria for suspected cases, due to the high cost and lack of testing kits, which evaluated the epidemiological history and clinical manifestations. the first part of criteria comprised the following four points: (1) travel history from a high-risk area within 14 days before the disease onset (2) history of contact with individuals with sars-cov-2 (positive nat result) within 14 days before the disease onset (3) history of contact with individuals with fever or respiratory symptoms in the high-risk area within 14 days before the disease onset (4) disease clustering (two or more cases of fever and/or respiratory symptoms at home/school/office etc.). the clinical manifestations as part of the criteria are as mentioned: (1) fever and/or respiratory symptom (2) significant findings on ct imaging (3) levels of white blood cell count normal or decreased. nasopharyngeal swabs were obtained from individuals with high suspicion for the covid-19, which were tested using polymerase chain reaction (pcr) to confirm the diagnosis. the suspected or confirmed cases were clinically classified as asymptomatic, mild, moderate, severe, and critical, according to the national institute of health, pakistan guidelines and are defined below in table 1 [9]. asymptomatic nasopharyngeal rt-pcr positive for covid-19 without any symptoms mild presence of symptoms consistent with covid-19 such as fever, fatigue, cough (with or without sputum production), anorexia, malaise, muscle pain, sore throat, dyspnea, nasal congestion, or headache without any hemodynamic compromise, need for oxygen or chest x-ray findings moderate hypoxia (oxygen saturation ≤ 94%) or mild infiltrate on cxr persistent high-grade fever for over three days 10. signs of shock: delayed capillary refill; cold, clammy peripheries; mottled skin; systolic bp less than 90 or less than 40 mmhg of baseline in hypertensive; urine output < 0.5 ml/kg/hr rt-pcr (reverse transcription-polymerase chain reaction); cxr (chest x-ray); curb-65 score (confusion, uremia, respiratory rate, bp, age ≥ 65 years); qsofa (quick sequential organ failure assessment) score; pao 2 (partial pressure of arterial oxygen); fio 2 (percentage of inspired oxygen); paco 2 (partial pressure of carbon dioxide in arterial blood); jvp (jugular venous pressure); bp (blood pressure) data in the above table adapted from [9]. due to the lack of resources, including the availability of health workers, personal protective equipment (ppe), and adequate isolation spaces in hospitals, it was proposed to manage asymptomatic and mild cases via home isolation. in contrast, moderate, severe, and critical cases were admitted to a hospital facility. a patient was labeled as recovered upon testing negative for covid-19 on two separate samples after contracting the disease. patients who tested positive for the infection and succumbed to the disease were classified as "expired", contributing to the mortality rate. the criteria mentioned above and guidelines were evolved and developed over time, the main framework being consistent with all cases. all statistical analysis was performed using the statistical package for the social sciences (spss) version 22 (ibm spss statistics for windows, ibm corp, armonk, ny). for the assessment of qualitative variables, frequencies and percentages were used. we analyzed the data of 412 covid-19 patients in our study. the majority of the study participants were male (n=266, 64.6%). additionally, the majority of participants were also young (21 to 40 years [n=179, 43.5%]; 41 to 60 years [n=98, 23.8%]). all participants came from two towns in east karachi, with more than half belonging to gulshan iqbal (n=270, 65.5%), as represented in table 2 . options data collection was started from february 26, 2020, and one case was reported that day. during the month of march, 104 cases were reported, while 307 cases were reported till april 24, 2020, as is illustrated by figure 1 . the differing status of our study participants, all of whom were positive for covid-19, were categorized into four groups. the groups included participants who had recovered, expired, sent into isolation at home, and admitted to the hospital, as shown in table 3 . most of the patients presented with at least one symptom (n=375, 91.0%), whereas only 9.0% (n=37) were asymptomatic. these symptoms varied and the most common that were experienced were fever (n=308, 74.8%), cough (n=249, 60.4%), flu (n=138, 33.5%), and body ache (n=109, 26.5%). the least common symptoms witnessed were nausea (n=8, 1.9%), headache (n=5, 1.2%), chest pain (n=4, 1.0%), decreased appetite (n=2, 0.5%), and lower respiratory tract infection (lrti) (n=2, 0.5%). the symptoms are listed below in table 4 . frequency (%) the vast majority of the patients (n=368, 89.3%) had been exposed to the virus from a person who was covid-19 positive. others had a positive travel history or had attended a big religious congregation ( table 5) . [4] . with a rapid increase in the number of cases and a fragile economy, the country was put under a nationwide lockdown on april 1, 2020. although pakistan was expecting 50,000 cases of covid-19 by april 25, the number remained less than half of the presumption [10] . the government of pakistan has been taking necessary measures to control the outbreak and facilitate its people. many hospitals across the country are working to combat the deadly outbreak of covid-19. early case detection, contact tracing, risk communication, social distancing, isolation and quarantine, and introduction of covid-19 relief funds to receive donations for the welfare of people are other significant measures taken by the country [11] . our study primarily highlights the scenario of covid-19 cases in the east district of karachi, pakistan. on analyzing the demographic profile of patients, males were found to be affected twice as much (64.6%) as females (35.4%). this is significantly higher than a study from wuhan, china, which indicated that 56% of patients with covid-19 were males [12] . similarly, another study of 140 patients from wuhan found that 50.7% were males [13] . gender is a significant risk factor of severity and mortality in patients with covid-19. according to a retrospective study by jin et al., men tended to develop more severe disease. although men and women had similar susceptibility, men were more prone to dying and accounted for approximately 2.4 times that of women in the deceased patients [14] . covid-19 can lead to hospitalization and even death in young and middle-aged adults. it has caused the most severe health issues for adults over the age of 60, with higher fatality over the age of 80. comorbidities like diabetes, hypertension, heart diseases, or other chronic illnesses can cause more intense manifestations and complications in the disease. besides, older adults are more susceptible to infection due to a gradual loss of resilience of the immune system. almost a quarter (23.3%) of italy's population is over 65 years where a significantly higher number of covid-19 cases and deaths were reported with case fatality rate (cfr) of 0.7% in 40-49 years, 27.7% in >80 years, and 96.9% deaths occurring in adults aged 60 years and greater [15] . in contrast, approximately 38.04% population of pakistan falls in 25-54 years age group. our study reported a higher incidence of infection in 21-40 years depicting that age structure is a significant risk factor for incidence and mortality rates of covid-19. according to the who covid-19 situation report, a total of 750,890 confirmed cases and 36,405 deaths were reported across the globe till march 31, 2020. these figures are approximately nine times greater than the statistics recorded on february 29, 2020. by the end of march, pakistan had 2,039 confirmed cases with 82 recoveries and 26 deaths [4] . about 104 cases were reported in march from the eastern towns of karachi, as demonstrated by our study. the global cases increased dramatically to around 2,626,321 confirmed cases by april 24, 2020. pakistan crossed a critical mark of the outbreak in the country as the total number of cases surged to about 11,155 on april 24 with an immediate increase in death rate (237 deaths) secondary to covid-19 [4] . however, our study recorded an approximately three-fold increase in the cases in east karachi with the death of 16 individuals. out of 412 cases, more than half (58%) were sent to home isolation, and 22% recovered while 15.8% were admitted to the hospital for supportive care. the rising covid-19 cases pose a challenge to pakistan's crumbling healthcare system. fragile economy, lack of availability of personal protective equipment for healthcare providers, inadequate quarantine and testing facilities, and periodic ease in lockdown are the principal reasons for the drastic rise in cases [11] . clinical presentations of covid-19 range from asymptomatic or mild symptoms to complicated illness and/or mortality. common symptoms include fever, cough, and shortness of breath, malaise, and respiratory distress. according to the centers for disease control and prevention (cdc), cough and shortness of breath with at least two accessory symptoms (fever, chills, sore throat, muscle pain, headache, and new loss of taste or smell) may indicate covid-19. it can also present as gastrointestinal complaints like nausea, vomiting, anorexia, and diarrhea [16] . symptoms may develop two days to two weeks following exposure to the virus. a pooled analysis of covid-19 cases from january 4 to february 24, 2020, reported a mean incubation of 5.1 days. out of 181 confirmed cases, 97.5% of individuals developed symptoms within 11.5 days [17] . the majority of patients in our study presented with a single complaint. fever (74.8%) was the predominant symptom, followed by cough (60.4%), flu (33.5%), and body ache (26.5%). these findings coincide with an initial report by huang et al., which specified fever (98%) as the most common clinical finding, followed by cough (76%) and myalgia (44%) [8] . asymptomatic infections have been reported, for example, by chan et al., but the exact incidence is unknown [18] . our study found 37 individuals with no symptoms of covid-19. some unusual symptoms included abdominal pain, vomiting, arthralgia, drowsiness, diarrhea, headache, and anorexia. clinicians evaluating patients with fever and acute respiratory disease should obtain details regarding travel history or exposure to an individual who recently returned from a country experiencing active local transmission [19] . furthermore, the cdc has proposed contact tracing as a part of a multipronged approach to fighting the covid-19 pandemic [20] . patients with suspected covid-19 should be immediately reported to the healthcare provider and the local or state health department. candidates with fever, symptoms of lower respiratory illness, and a travel history to wuhan, china or other countries with uncontrolled covid-19 cases or who have been in contact with an individual suspected of covid-19 or with laboratory-confirmed covid-19 in the preceding 14 days should be isolated and tested for the infection promptly [19] . one of the preventive measures proposed by who for protection from the spread of covid-19 is the maintenance of an adequate distance of 1 m (3 feet) from others and avoiding crowded places [21] . about 89.3% of patients in our study contracted the disease from individuals with an existing infection, with a minority of patients reporting a history of travel to covid-19 endemic states or attending religious congregations. the easing of the lockdown across pakistan resulted in 1,637 new cases and 24 new deaths in one day; experts say if social distancing and isolation are not practiced by the overwhelming majority of the population, pakistan would likely experience massive fatalities soon [22] . our study has a few limitations. first, it includes all covid-19 cases from only one district (i.e., east karachi), pakistan. a survey with a large sample size from multiple towns of the city can reflect more accurate statistical figures regarding the epidemiological and clinical features of covid-19. furthermore, the duration of the study was only two months. detailed analysis of the clinical features, laboratory findings, complications, and prognostic indicators is recommended to get a better insight into the infection and its associated entities, which can help the state to think of possible strategies to combat the pandemic. a previous study from karachi has depicted poor knowledge regarding the maintenance of adequate hygiene among healthcare providers [23] . apart from maintaining social distancing, it is recommended to practice all necessary preventive measures like frequent cleansing of hands with running water or a sanitizer, covering coughs and sneezes with disposable tissues or clothing, and avoiding excessive touching of eyes and nose or unprotected contact with animals. sars-cov-2 is infecting the population of karachi rapidly, resulting in an exponential increase in the number of cases. the descriptive analysis of the epidemiological data in our study showed a large majority contracting the virus through contact with an already infected person and highlights the significance of following the guidelines of maintaining social distancing. the public, government, and health authorities of pakistan urgently need to realize their responsibilities and devise efficient plans to curb further spread of the disease, keeping in mind the limited resources and grave health outcomes. human subjects: consent was obtained by all participants in this study. animal subjects: all authors have confirmed that this study did not involve animal subjects or tissue. conflicts of interest: in compliance with the icmje uniform disclosure form, all authors declare the following: payment/services info: all authors have declared that no financial support was received from any organization for the submitted work. financial relationships: all authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. other relationships: all authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. a novel coronavirus from patients with pneumonia in china genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding cardiac manifestations of coronavirus disease 2019 (covid-19): a comprehensive review world health organization: novel coronavirus (covid-19) situation reports covid-19 health advisory platform by ministry of national health services regulations and coordination world health organization: modes of transmission of virus causing covid-19: implications for ipc precaution recommendations -scientific brief possible vertical transmission of sars-cov-2 from an infected mother to her newborn clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet. 2020 pm imran urges pakistanis to be steadfast in their faith amid covid-19 crisis covid-19 outbreak: current scenario of pakistan early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia clinical characteristics of 140 patients infected with sars-cov-2 in wuhan gender differences in patients with covid-19: focus on severity and mortality. front public health demographic science aids in understanding the spread and fatality rates of covid-19 centers for disease control and prevention: symptoms of coronavirus the incubation period of coronavirus disease 2019 (covid-19) from publicly reported confirmed cases: estimation and application a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster evaluating and testing persons for coronavirus disease 2019 (covid-19) case investigation and contact tracing: part of a multipronged approach to fight the covid-19 pandemic world health organization: coronavirus disease (covid-19) advice for the public pakistan eases nationwide lockdown even as coronavirus cases rise compliance and knowledge of healthcare workers regarding hand hygiene and use of disinfectants: a study based in karachi key: cord-117800-jzokod4q authors: umer, hamza; khan, muhammad salar title: evaluating the effectiveness of regional lockdown policies in the containment of covid-19: evidence from pakistan date: 2020-06-04 journal: nan doi: nan sha: doc_id: 117800 cord_uid: jzokod4q to slow down the spread of covid-19, administrative regions within pakistan imposed complete and partial lockdown restrictions on socio-economic activities, religious congregations, and human movement. here we examine the impact of regional lockdown strategies on covid-19 outcomes. after conducting econometric analyses (regression discontinuity and negative binomial regressions) on official data from the national institute of health (nih) pakistan, we find that the strategies did not lead to a similar level of covid-19 caseload (positive cases and deaths) in all regions. in terms of reduction in the overall caseload (positive cases and deaths), compared to no lockdown, complete and partial lockdown appeared to be effective in four regions: balochistan, gilgit baltistan (gt), islamabad capital territory (ict), and azad jammu and kashmir (ajk). contrarily, complete and partial lockdowns did not appear to be effective in containing the virus in the three largest provinces of punjab, sindh, and khyber pakhtunkhwa (kpk). the observed regional heterogeneity in the effectiveness of lockdowns advocates for a careful use of lockdown strategies based on the demographic, social, and economic factors. the world is struggling to combat the covid-19 pandemic, which has spread from wuhan china to over 190 countries. unless there is a viable treatment or vaccine to treat covid-19, the world is taking possible preventive measures to minimize the spread of the disease. lockdown (complete or partial) is one of the most evident and widely used preventive measures. the effectiveness of lockdown in controlling the spread of covid-19, however, is not a well-established outcome for a few reasons. first, so much is unknown about the novel coronavirus and that the situation is evolving, which gives policymakers little time to think through, implement, and properly investigate or foresee the effectiveness of any policy, such as a lockdown. second, while many countries-for instance, new zealand and germanyhave already implemented complete or partial lockdown (mcfall-johnsen et al., 2020) , it is just hard to conduct a long-term ex-ante analysis of the repercussions of policy concerning once-in-a-century pandemic. still, some preliminary studies tried to investigate the effect of lockdown strategies on the spread of covid-19. for instance, walker and colleagues (2020) predicted that interventions and lockdown strategies in almost all countries (precisely, 202 countries in their analysis) would reduce infections and deaths by nearly half. mushfiq mobarak and colleagues (2020) , contrarily argued that while lockdown strategies are viable umer & khan 3 options in high-income countries, low-income countries such as nigeria and pakistan cannot afford to have a fruitful lockdown. because of their weak capacity in enforcing lockdown strategies, these countries may witness counterproductive effects if such strategies make workers and migrants migrate back from heavily populated urban areas and spread the disease to remote rural areas, the researchers argue. similarly, we have a few studies that show different outcomes on the country-level. for example, research (dowd et al., 2020 ) on the italy outbreak shows the effectiveness of early lockdown. in italy, the covid-19 was first detected in the lodi province, which placed restrictions beginning february 22. as opposed to this, bergamo province, which started with fewer cases but did not impose restrictions until march 7, far surpassed the number of cases in lodi (stancati, 2020) . in a similar vein, a study (kumar and nataraj, 2020) on indian regions shows a regional differential in the spread of covid-19 in the face of regional policy variation. overall, the world is divided regarding the use and effectiveness of lockdown policies. on one side, we see countries like japan (du and huang, 2020; ian, 2020) and sweden (karlson et al., 2020) that have used mild lockdown or no lockdown and yet effectively contained the spread of the virus. on the other side, we see countries like new zealand and australia using strong lockdown policies to flatten the spread of the virus (fifield, 2020) . this article offers a systematic contribution to the aforementioned debate by examining the effectiveness of lockdown policies in the containment of covid-19 in the context of pakistan. specifically, the article explores how effective the lockdown strategy has been in combating covid-19 outcomes in the country. this evaluation of lockdown policies is based on the econometric analysis (such as regression discontinuity and negative binomial regressions) performed on official data from pakistan. pakistan is selected because it offers a valuable opportunity to analyze the effects of both complete lockdown and partial lockdown policies on the spread of the covid-19 virus. moreover, the regional use of lockdown policies in pakistan is heterogeneous and hence enables us to perform cross-regional analysis as well. we find that in comparison to no lockdown, complete and partial lockdowns have been ineffective in the containment of the virus in the three largest provinces punjab, sindh, and khyber pakhtunkhwa (kpk). on the other hand, complete and partial lockdowns have been umer & khan 4 very effective in the containment of the virus in the province of balochistan and the three administrative territories/regions of gilgit baltistan (gb), islamabad capital territory (ict), and azad jammu and kashmir (ajk). the observed regional heterogeneity in the effectiveness of lockdowns advocates for a careful use of lockdown based on the demographic, societal, and economic factors. "one size fits all" approach for lockdown could be counterproductive in some regions of the world and subsequently make the spread of virus more acute, as demonstrated by researchers in the context of africa as well (mehtar et al., 2020) . pakistan-home to about 220 million and wobbly health infrastructure that has close to 1.5 million hospital beds (khan & latif, 2020) -reported the first case of the covid-19 on february 26, a returning pilgrim from neighboring iran (hashim, 2020) . on the same day, the pakistan federal ministry of health confirmed another positive case in islamabad (ali, 2020) . since then, the virus has diffused quickly. by march 18, all the administrative regions of pakistan, including four provinces (punjab, sindh, kpk, and balochistan), the two autonomous territories (ajk and gb), and the federal territory of islamabad registered positive cases. the entire country reported over eighty-five thousand confirmed cases and 1,770 deaths, as of june 4, 2020. 1 in terms of the total number of cases and deaths, pakistan ranks 17 th and 21 th worldwide, respectively. 2 while now the virus has entered the community transmission stage, initially, all the confirmed cases in pakistan had recent travel history from iran, syria, london, and saudi arabia. the covid-19 pandemic has spread unevenly across regions within pakistan, with the four regions (provinces) making up more than 95 percent of the cases as of june 4, 2020. sindh registered the most cases at over 39,900, followed by punjab (31,104), kpk (11, 373), and balochistan (5, 224) . 3 the province of punjab reported 607 deaths, the most in the country, followed by sindh (555) and kkp (500) and balochistan (51). the situation in the three special regions or territories is not that bad, with islamabad, gb, and ajk reporting 3,544, 1 this data was obtained from worldometers: https://www.worldometers.info/coronavirus/ the data was cross-verified here: https://www.cdc.gov/coronavirus/2019-ncov/global-covid-19/world-map.html 2 ibid. 3 official government website for data on covid-19 was consulted: http://covid.gov.pk/stats/pakistan source: http://covid.gov.pk/stats/pakistan as a nascent federalist country, 5 when the interior ministry of pakistan announced a lockdown on march 23 to combat the spread of the virus, all the seven administrative regions also implemented their regional lockdown measures at or around march 23. army troops were deployed throughout the country to help the divisions in tackling the spread of the virus. 6 initially, the regions implemented a full or complete lockdown, with ict shutting down as early as on march 12, punjab on march 22, and all other divisions on march 24. 7 4 ibid. 5 pakistan is a federalist country, with provincial governments having the right to decide on important issues, according to the eighteenth amendment of the constitution of pakistan. 6 https://www.geo.tv/latest/278812-government-calls-in-pakistan-army-troops-amid-coronavirus-outbreak 7 complete lockdown and partial lockdown information is extracted from several newspapers and online sources. these include: business recorder, dawn news, radio pakistan, technology times. also please refer to the report (covid-19 legislation and measures in pakistan) published by zafar kalanuri (2020). complete lockdown refers to complete shutdown of socioeconomic, religious activities and mobility pathways while partial lockdown refers to controlled opening of the aforementioned. complete description of lockdown types is mentioned on page 6. the duration of this full lockdown also varied, with ict and kpk observing a short duration lockdown for less than a week, punjab, sindh, and balochistan observing a medium duration lockdown for about two weeks, and ajk and gb observing a long duration lockdown for almost a month. later, the divisions moved to a partial or controlled lockdown (please see table 3 for details). policy-wise, pakistan acted quickly and formulated a national action plan for covid-19 early in february 2020 (mukhtar, 2020) . the ministry of national health services, regulation & coordination pakistan presented the plan, that was supposed "to provide (a) policy framework for federal, provincial, and regional stakeholders for building capacity to prevent, detect and respond to any events due to covid-2019 in pakistan." 8 along with the health ministry, national and provincial disaster management authorities, national command and operation center (ncoc), and national coordination committee (ncc) have been formulating, coordinating, analyzing, and implementing policy efforts about covid-19. with federal directives, regions have been managing outbreaks according to their circumstances. table 1 provides details about the total number of positive cases, deaths caused by and total tests performed in the seven regions of pakistan. workplaces, parks and other public places, ban on social gatherings and social events, closing of land and air transport and people are restricted to stay home unless they need medical help or require grocery shopping. partial lockdown refers to the controlled opening of economic activities for a specific time every day, limited resumption of land and air transport, and maintaining social distance during outdoor activities. most of the educational institutes, however, remain closed. 11 the data covers a time period of 60 days (march 12 to may 11, 2020) and encompasses no lockdown, complete lockdown, and partial lockdown phases. the entire data variables are described in table 2 . it is a time variable that represents day. in table 3 , the summary of the variables is reported. punjab, sindh, and kpk are three provinces witnessing the highest number of average daily positive cases and average daily deaths. ict had the longest complete lockdown (34 days), while kpk had the shortest one (5 days). 3/12--5/11 3/12--5/11 3/12--5/11 3/12--5/11 3/12--5/11 3/12-lockdown 12 note: n = observations; m = mean. standard deviations are in parentheses. *ajk did not report any death during the data duration specified in this paper. all the econometric analyses are performed in stata 16. the outcome variables include the number of daily deaths due to ccovid-19 and the number of people testing positive for ccovid-19. the main explanatory variables are lockdown and partial lockdown dummies. the starting point of the analysis is a visual representation of the impact of lockdown policies on the outcome variables. this is achieved by using regression discontinuity (rd) with the date as running variable and the lockdown and partial lockdown dates as multiple cutoffs. in stata and kpk) cumulatively representative of 96% of covid-19 cases are in figure 2 . as these four provinces account for the majority of the positive cases, we discuss them at length here, while binned scatter plots for ict, ajk, and gb regions are reported in appendix a. the binned scatter plots reported above indicate the lockdown policies induced heterogeneous regional effects on covid-19 outcomes. we further analyze the impact of lockdown policies on covid-19 outcomes systematically by using different regression techniques and estimate the following two equations. in the above equations ∑ 7 15 lr test is used for the evaluation of alpha. null hypothesis alpha =0 is rejected at 1% for both equations. and indicates poisson regressions had overdispersion (conditional variance exceeds conditional mean). hence, we use the output from negative binomial regressions for analyzing the effects of lockdown policies in table 4 . robust standard errors are in parentheses. ***p<0.1; **p<0.5; *p<0.1 regressions 1 while holding all other variables constant, the effect of daily tests performed is significant and positive on daily positive cases, however, the magnitude is very small (difference in logs of expected counts increases by 0.0002 in regression 1). next, we turn to main explanatory variables. in comparison to no lockdown, complete lockdown had a significant and negative discussion section 7, we explore the possible reasons leading to regional heterogeneity in the outcomes of lockdown policies. in this section we turn to another proxy for lockdown-the daily stringency score estimated by hale et al. (2020) . the score varies from zero to 100; a higher value indicates more stringent controls to contain the virus spread. the stringency score is based on the cumulative value of restrictions imposed on schools, workplaces, public events, social gatherings, public transport, stay home orders, domestic and international travel, public information campaign, testing policy, and contact tracing (hale et al., 2020) . essentially, lockdown and stringency measures are two different ways of quantifying restrictions in an economy. the stringency score by hale et al. (2020) is for the whole country, and resultantly, we are unable to do regional analysis using this score. therefore, we pool the regional data to obtain country-level data and subsequently perform analysis using daily stringency score as the main explanatory variable. the stringency score has 55 observations; its value ranges from 34 to 97, with a mean value of 86.29 and a standard deviation of 18.51. using the stringency score following two equations are estimated. negative binomial regression is used; the value of alpha is significant 17 , indicating poisson regression had over -dispersion. the regression output is reported in table 5. in regression 2 and 4, the variable for daily tests is excluded to check the robustness of the effect of the stringency score on the two outcome variables. this exclusion, however, does not alter the significance of the stringency variable. the effect of daily tests on daily deaths is insignificant in the main regression (1) level results show that stringency measures appear to be ineffective in the control of damage caused by covid-19 and in its spread as well. the regional results show heterogeneity in the effectiveness of lockdown measures while country-level results point towards the ineffectiveness of stringency measures. to reconcile the regional results with country-level results, we need to focus on the three important regions of punjab, sindh, and kpk. together these three regions account for 90% of the total positive cases and 96% of the total deaths during the time period considered in this study. as these three regions represent a huge share of covid-19 outcomes, they are playing a significant role in driving the country-level statistics. resultantly, the ineffectiveness of lockdown policies in these regions is reflected in the ineffectiveness of stringency measures at the country-level. as discussed earlier, the effect of regional lockdown policies on covid-19 outcomes is heterogeneous, with very few regions effectively using the lockdown policies to contain the spread of the disease. from a policy perspective, we identify here the factors that have contributed jointly to the ineffectiveness of lockdowns, specifically in the three largest regions of punjab, sindh, and kpk. the central government in pakistan has never been unified over the imposition of lockdown measures. the country's prime minister (pm) adamantly opposed lockdown fearing economic impacts on daily wagers that comprise a significant proportion of the country's labor force. on the other hand, several ministers in the pm's cabinet proposed strict lockdown measures to contain the virus. as a result of this confusion prevalent in the government circles, the potential risks of covid-19 were downplayed, the public did not observe the lockdown restrictions seriously, and resultantly the lockdown proved to be ineffective in three large provinces 18 . a significant proportion of pakistan's population inhibits in punjab (110 million), sindh (47.9 million) and kpk (30.5 million) regions (wazir & goujon, 2019) . together these three regions account for approximately 89% of the country's population, and a major proportion of this population resides in rural areas or slums in large cities (for example sindh's capital city karachi has the world's largest slum population approximated to be 2 million 19 ). in rural and specifically slum areas, social distancing or keeping one restricted to home are almost nonexistent, issues of cleanliness are acute, and poverty rates are high. all these factors, when combined together, provided an ideal habitat for the sharp spread of covid-19, even in the presence of lockdown measures. the informal labor force makes up 75% of the total labor force (48.75 million). about 40% of this informal labor force (19.5 million) is employed by the agriculture sector, while 60% (29.25 million) works for the industrial and service sector. 20 the majority of the informal labors are paid on a daily basis and unfortunately forced to leave homes in an attempt to earn money for food and subsequently violate and undermine the effectiveness of lockdown restrictions by serving as a potential source of virus spread within their workplace and residences. pakistan is a religiously homogeneous country with muslims making up 96.28% of the population. 21 in islam, daily five congregational prayers in the mosque are a vital part of worship. congregations and gatherings could be favorable grounds for viral transmission. in pakistan, the religious, as well as political leaders, were divided on the closing down of mosques. resultantly, government in coordination with religious leaders set up protocols for congregational prayers in mosques, however in most cases these protocols were not strictly followed, possibly leading to rapid transmission of virus even during the lockdown phases. 22 as an entirely unprecedented situation for masses, the heterogeneous behavioral response of the public to lockdown was evident. in the case of pakistan, poor handling of the situation by the government over using force to implement lockdown strategies in the big provinces led to fear in the minds and created a social stigma around covid-19. subsequently, people with symptoms kept on living with family members, and whole families got infected. these numbers eventually started showing up post lockdown in the largest regions. a lack of literacy and misinformation about the disease and its treatment further complicated the outcomes. on the contrary, in ajk and gb, where people were willing to observe lockdown, showed better outcomes. one reason why they showed this willingness is likely their high literacy rate than the national average rate. from a policy perspective, it is clear that lockdown effectively used by rich countries, including germany, japan, and usa, is to a large extent, ineffective in controlling the spread of virus in a poor country like pakistan. in fact, several researchers have already discussed the possibility of the lockdown being ineffective in poor countries (for example barnett-howell & mobarak, 2020; cash & patel, 2020) . the country-level results from this article support the predictions of these studies. we think contextualized strategies would be way more effective in the control of the virus in poor countries. in the case of pakistan, the socio-economic and political conditions and religious norms are some of the important contextual elements that should be considered while making future lockdown strategies. the purpose of the paper was to examine the impact of lockdown strategies in different regions ▪ federal and local governments should involve local religious scholars and community elders in teaching the public the importance of social distancing, hygiene, and prevention. they should also work on dispelling and addressing the stigma around covid-19 so that people can test themselves without anxiety and fear from society. ▪ government should allow shorter working hours, limit number of people at religious and social gatherings, and implement universal masking using cloth masks for the community. (1) (2) (3) robust standard errors are in parentheses. ***p<0.1; **p<0.5; *p<0.1 pakistan confirms first two cases of coronavirus, govt says 'no need to panic should low-income countries impose the same social distancing guidelines as europe and north america to halt the spread of covid-19? what japan can teach the world about the pandemic has covid-19 subverted global health? a practical introduction to regression discontinuity designs how does your kindergarten classroom affect your earnings? evidence from project star demographic science aids in understanding the spread and fatality rates of covid-19 did japan just beat the virus without lockdowns or mass testing? umer & khan 24 new zealand isn't just flattening the curve. it's squashing it variation in government responses to covid-19. blavatnik school of government working paper the curious case of south asia's 'low' coronavirus deaths covid-19 legislation and measures in pakistan sweden's coronavirus strategy will soon be the world's the coronavirus and pakistan: why people must immediately begin social distancing?" the national interest the impact of covid-19 mobility restrictions in india: comparing state and central responses assessing the 2017 census of pakistan using demographic analysis: a sub-national perspective countries around the world are reopening -here's our constantly updated list of how they're doing it and who remains under lockdown limiting the spread of covid-19 in africa: one size mitigation strategies do not fit all countries preparedness and proactive infection control measures of pakistan during covid-19 pandemic outbreak national action plan for corona virus disease (covid-19) pakistan lockdown of recovering italian town shows effectiveness of early action the global impact of covid-19 and strategies for mitigation and suppression key: cord-258879-dueab356 authors: imran, nazish; masood, hafiz muhammad umar; ayub, maryam; gondal, khalid masood title: psychological impact of covid-19 pandemic on postgraduate trainees: a cross-sectional survey date: 2020-08-25 journal: postgrad med j doi: 10.1136/postgradmedj-2020-138364 sha: doc_id: 258879 cord_uid: dueab356 background: the present study aimed to evaluate psychological impact of covid-19 outbreak on postgraduate trainees in pakistan by quantifying the symptoms of depression, anxiety and acute stress disorder and by analysing potential risk factors associated with these symptoms. methods: following institutional review board approval, a cross-sectional study was conducted among 10,178 postgraduate trainees following covid-19 outbreak through e-log system of college of physicians and surgeons of pakistan. the nine-item patient health questionnaire, seven-item generalised anxiety disorder scale and stanford acute stress reaction questionnaire were used to collect data. statistical analyses were conducted using spss.26. descriptive statistics, mann-whitney u test, the χ(2) test and logistic regression analysis were performed. the significance level was set at α=0.05. results: the prevalence of depressive symptoms, generalised anxiety disorder and acute stress disorder were 26.4%, 22.6% and 4.4%, respectively. female postgraduate trainees, senior trainees and front-line workers reported experiencing more anxiety, depression and acute stress symptoms (p value<0.001). logistic regression showed that being a front-line and senior staff member and female was associated with higher risk of experiencing symptoms of depression, anxiety and acute stress. conclusions: our study findings raise concerns about the psychological well-being of postgraduate trainees during the acute covid-19 outbreak in pakistan. it is necessary to employ strategies to minimise the psychological distress and provide adequate psychosocial support for postgraduate trainees during crisis situation such as covid-19 pandemic. the world health organization (who) identifies viral disease outbreaks like covid-19 pandemic as a serious threat to public health. 1 similar to previous outbreaks like severe acute respiratory syndrome-corona virus (sars-cov) and middle east respiratory syndrome, covid-19 outbreak has also raised various difficulties for healthcare workers (hcws) around the globe including increase workload, limited availability of personal protective equipment, scarcity of life-saving resource, frustration, isolation and 'fear of possible infection in themselves and their families'. 2 all these factors are likely to increase psychological distress among hcws. recent literature also suggests that hcws are very vulnerable to emotional distress during covid-19. [3] [4] [5] insufficient data are currently available from lowand middle-income countries (lmics) regarding changes in prevalence of depression during the pandemic. however, a recent study conducted in india found 32.6% of hcws having depression during covid-19 pandemic, which is much higher than the 10% prevalence for common mental disorders reported in its general population. 6 postgraduate trainees are among the most vulnerable hcws even in usual times with high prevalence of burnout and psychological morbidity. 7 previous studies report that junior doctors feel pressured and resentful that the primary care in acute situations is often left to them. 8 during covid-19 pandemic, postgraduate trainees are likely to be the main workforce to deal with the impending influx of patients with covid-19. mobilisation of postgraduate trainees to high demand departments, high likelihood of contacting suspected or confirmed cases with covid-19, making difficult ethical decisions, cancellation of teaching programmes, and study leaves, uncertainty regarding jobs and rotations are some of the concerns identified by junior doctors during covid-19 pandemic and are likely to adversely impact their mental and physical well-being. 9 similar views have been reported from pakistan. 10 a recent rapid review shows that presence on front lines, being younger and being more junior is associated with increased risk of psychological distress in hcws during viral outbreaks. 2 the psychological distress is associated with medical errors and lapses in professionalism as well as high risk of serious psychiatric problems including suicidal ideation. 11 12 although psychological distress is to be expected during covid-19 in lmics like pakistan, where postgraduate trainees in particular are under pressure to look after a large number of potentially infectious patients, institutions, supervisors and employers can help to mitigate this by implementation of several effective interventions. however, their psychological well-being has not been formally evaluated so far. to address this gap, the present study aimed to evaluate psychological impact of covid-19 outbreak on postgraduate trainees in pakistan by quantifying the symptoms of depression, anxiety and acute stress, and by analysing potential risk factors associated with these symptoms. this was a cross-sectional study conducted following covid-19 outbreak, through e-log system of college of physicians and surgeons (cpsp) from 15 april 2020 to may 2020. cpsp is the largest internationally recognised postgraduate medical institute in pakistan established in 1962 and is responsible for postgraduate medical training and research. it awards fellowships in 73 specialities/subspecialities and membership in 22 disciplines. all postgraduate trainees inducted from 2011 onwards in cpsp residency programmes have to make entries of all academic activities and work performed in mandatory e-logbook using their registration numbers and passwords. trainees are unable to enter activities that are more than 3 months old. supervisors verify the entries on a regular basis helping in monitoring the progress of trainees. currently, there are 24, 477 postgraduate trainees enrolled with cpsp. our study target population was postgraduate trainees who would access their e-logbook during the study duration from 15 april 2020 to may 2020. all trainees accessing e-portal were able to see the survey and answer the questionnaire by clicking on the relevant link. among the 11, 489 trainees, who accessed e-log portal during the study period, 10, 178 participated with a response rate of 88.6%. institutional review board approved the study. participation was voluntary; all study participants provided informed consent, and confidentiality of information was assured. demographic data collected from the participants included age, gender, marital status, speciality, year of residency, and medical and psychiatric history. residents who were directly involved in diagnosing, treating or providing care to patients with diagnosed or suspected patients with covid-19 on self-report were classified as frontline workers, while others were considered as second-line workers. furthermore, postgraduate trainees in the first 2 years of residency were classified as junior trainees and those in year 3 and year 4 were considered as senior residents. the questionnaire included three validated questionnaires in english language focusing on depression, anxiety and acute stress disorder. the nine-item patient health questionnaire (phq-9) was used to screen and measure the severity of symptoms of depression. 13 it has nine items, score of each item ranges from 0 to 3 with total score range being 0-27. the scores are interpreted as normal (0-4), mild (5-9), moderate (10) (11) (12) (13) (14) and severe (15-21) depression. as recommended, phq-9-total score of 8 points or greater was defined as the presence of depressive symptoms for the current study. 14 the seven-item generalised anxiety disorder (gad-7; range 0-21) was used to assess the severity of symptoms of anxiety. 15 the scores are interpreted as normal (0-4), mild (5-9), moderate (10) (11) (12) (13) (14) and severe (15) (16) (17) (18) (19) (20) (21) anxiety. stanford acute stress reaction questionnaire (sasrq; range 0-150) questionnaire was used to measure residents acute stress in accordance with diagnostic and statistical manual of mental disorders, fourth edition, criteria for acute stress disorder. 16 the sasrq is a six-point likert scale consisting of 30 items assessing dissociation, re-experiencing, avoidance, anxiety and hyperarousal. each item has a score of between 0 and 5, with a combined score ranging from 0 to 150, and a higher score indicating higher levels of self-reported stress. to meet acute stress disorder criteria, respondent had to indicate having at least three of five possible dissociation symptoms, and at least one symptom each of hyperarousal, anxiety, avoidance and reexperiencing of stressful event. information to access confidential psychological support was also provided during the study. data were analysed using spss version 26.0 (ibm corp., ny, usa). a descriptive analysis was conducted using numbers and percentages for categorical data and mean±sd for continuous data. medians with iqrs were reported for the skewed data values, mann-whitney u test was performed for comparison between the groups. data for each level for symptoms of depression, anxiety, and stress were presented as numbers and percentages. the significance level was set at α=0.05. qualitative variables were compared using χ 2 test. logistic regression analysis was performed to observe the potential risk factors for symptoms of depression, anxiety and acute stress in participants. factors with significant association (p<0.05) with the outcome variables at univariate analysis level were further included in the final multivariate analysis model. the associations between risk factors and outcomes are presented as ors and 95% cis, after adjustment for confounder variables. a total of 10, 178 postgraduate residents completed the survey with majority (56%) being female and belonging to surgery and allied speciality (55%). a total of 3767 (37%) were directly involved in diagnosing, treating or providing care to patients with diagnosed or suspected patients with covid-19 (frontline workers). table 1 gives further demographic details of the study participants (table 1) . the prevalence of depressive symptoms, gad and acute stress disorder was 26.4%, 22.6% and 4.4%, respectively (table 2) . the values for women were higher than those for man in all scales (p value<0.001). the median (iqr) scores on the phq-9 for depression, the gad-7 for anxiety and the sasrq for acute stress disorder for all respondents were 4.0 (1.0-9.0), 3.0 (0.0-7.0) and 11.0 (2.0-28.0), respectively. female residents, front-line workers and senior residents had higher scores in depression, anxiety and acute stress subscales compared with those men, second-line workers and junior staff (table 3, online supplemental table s1 ). all these three groups also reported experiencing more severe symptom levels on psychiatric outcome variables (table 4) . the associations of potential risk factors with depressive symptoms, gad and acute stress disorder during covid-19 outbreak are presented in table 5. in the logistic regression models, being female (or=1.48, 95% ci 1.35 to 1.63) and front-line worker during covid-19 (or=1.35, 95% ci 1.23 to 1.48) and senior resident (or=1.2, 95% ci 1.09 to 1.32) were significantly associated with depression in residents. similarly, being female, senior resident and front-line worker during covid-19 also appeared to be an independent risk factor for anxiety and acute stress symptoms after adjustment (table 5) . discussion covid-19 pandemic had a considerable impact on healthcare systems worldwide, and threaten not only the physical health but also psychological and social health of hcws including junior doctors. to our knowledge, this study is the first largescale national survey in pakistan to investigate the psychological impact of covid-19 pandemic on postgraduate trainees. this cross-sectional survey enrolled 10, 178 respondents, and overall, our findings raise concerns about the psychological well-being of postgraduate trainees involved in the acute covid-19 outbreak. even prior to pandemic, lmics have reported higher prevalence of depressive disorders and anxiety than the aggregate prevalence for very high human development index countries in the world. 17 18 people in lmics, including pakistan, are exposed to more stressors, which alongside greater stigma and social inequalities leads to less likelihood of accessing timely treatment. in the absence of any large population-based studies from pakistan looking at the relative change or increase in anxiety and depression during the covid-19 pandemic, we are unable to comment that symptoms observed in postgraduate trainees in our study differ from those of the general population. our study contributes to literature on prevalence of psychological symptoms in postgraduate trainees. prevalence of gad and depression as 22.6% and 26.4%, respectively, in our sample are in line with few recent studies of hcws during covid-19. zhu et al reported prevalence of anxiety symptoms as 24.1%, while in another web-based survey of hcws in china, 19.8% of hcws appeared to have depressive symptoms. 4 19 however, these results are in contrast with extremely high prevalence (35%-50%) of psychological morbidity in some reports from china, particularly in wuhan province and in neighbouring india. 3 4 6 similarly, prevalence of acute stress disorder as 4.4% in our sample, although closer to 5% observed in a study following sars outbreak in taiwan in 2004, is very low compared to 29.8% reported by zhu et al during current covid-19 outbreak. 19 20 this comparatively low psychological morbidity in our sample may partially be explained due to relatively lower (2.1%) covid-19 case fatality of pakistan as compared to usa (5.9%), italy (14.3%), uk (14.0%), iran (5.3%) and china (5.5%). 21 another reason may be the timings of the study, as it was conducted prior to the peak of the cov outbreak in pakistan, when healthcare system was coping well comparatively. the differences in the results between various studies in the literature can also be contributed to variability in study settings, methodologies, instruments used to assess the psychological morbidity and participants' backgrounds such as age and culture. previous small-scale studies done to assess psychological morbidity among postgraduate trainees in pakistan found that 14% had depression symptoms and 8% had moderate anxiety. 22 23 thus, although many other factors may have contributed, our results indicate that covid-19 outbreak perhaps led to increase in prevalence of depression and anxiety among postgraduate trainees in pakistan. increase workload, sleep deprivation, being junior resident and pay disparity were observed to be associated with depression in junior doctors in pakistan in literature. 22 these stressors are likely to be compounded by high risk of infection, inadequate safety equipment, social isolation-especially from family-and physical exhaustion leading to high psychological morbidity during these challenging times. 10 female postgraduate trainees in our sample had higher prevalence of psychological morbidity as well as more severe symptoms on all psychological measures. previous studies have also demonstrated that female gender is associated with increased vulnerability to psychological distress. 2 3 24 similar to recent literature, front-line workers and those directly exposed to patients with covid-19 in our sample had high risk of developing psychological symptoms. 2 3 24 this is understandable given that not only front-line postgraduate trainees are more exposed to the risk of covid-19 infection themselves but also have to deal with the sickest patients. our results of senior postgraduate trainees having significantly high psychological morbidity than year 1 and year 2 trainees are different from existing literature, in which less clinical experience has been linked with high adverse psychological outcome. 2 3 this could be explained by observed practice in hospitals in pakistan of senior postgraduate trainees being given more responsibility of looking after covid-19 units, intensive care units and high dependency units, thus perhaps being more exposed to patients at greatest risk of dying from the covid-19 illness. however, this finding warrants further research. although all the health resources of the country are currently deployed towards service provision for increasing number of patients with covid-19, the policy makers in teaching and training institutions need to make special efforts to promote the psychological well-being of post-graduate trainees. selfcare, need to maintain healthy balance lifestyle during residency training and in future careers and building skills in resilience should be emphasised in the training curriculum. adequate training around infectious diseases and provision of adequate personal protective equipment should be recommended to all institutions. the postgraduate trainees should have appropriate work shifts, regular breaks and guaranteed supplies. encouragement among peers, adequate supervision and access to psychological interventions should be guaranteed in order to deal with the psychological problems. 25 psychological first aid for front-line workers has also been recommended by who and includes the assessment of needs and concerns; practical care and support; basic needs provision; empathic listening; and access to information, services and social supports. these steps can allow postgraduate trainees to function at their best during this global health emergency. the study has some limitations. although all scales showed very good reliability (cronbach's alpha >0.9) in our sample, only phq-9 and gad-7 has been previously validated in pakistani population. as the study was cross sectional, we cannot evaluate the temporality and causality of the observed factors. psychological assessment in our study was based on self-report tools. the use of clinical interviews may help in a more comprehensive assessment. we also cannot exclude the possibility of a response bias. almost 47% of total enrolled residents in e-log portal (11 489/24 477) accessed it during the study period. it may be possible that many medical residents, who were directly participating in the care of patients with covid-19 and thus having increase likelihood of psychological morbidity, were too busy to log in during the study duration. also, residents who saw but did not responded to survey may have been too stressed out and overwhelmed to respond, thus skewing the results. alternatively, those who received the survey but did not reply may have had no distress and therefore were not interested in responding. furthermore, our study was conducted during a critical period of the covid-19 pandemic in pakistan when cases were still rising but prior to mid-june 2020 (the days that pakistan saw the peak of covid-19 cases and most likely high stressful time for hcws). longitudinal approach might help verifying whether long-term overload and distress develops as cases with covid-19 reach their peak in the country and whether psychiatric disorders, especially posttraumatic stress disorder, might occur with the covid-19 progression. despite the limitations, this study has significant strengths. to the best of our knowledge, this is the first national study to report the psychological symptoms among postgraduate trainees during the covid-19 pandemic. the data represented all four provinces and included trainees from multiple specialities. thus, the results of the study can be considered representative of postgraduate trainee doctors' psychological well-being during this outbreak. to conclude, the present study provides insight into the potential immediate psychological sequelae of covid-19 pandemic on postgraduate trainees in the resource-constrained setting of a lmic. our results show high levels of depression and anxiety experienced by trainees caring for patients with covid-19 in pakistan. female residents, those in the third and fourth year of residency and front-line workers experience more psychological distress. it is necessary to employ strategies to minimise the psychological distress and provide adequate psychosocial support for postgraduate trainees during a crisis situation such as covid-19. further research is needed to assess the long-term impact of this outbreak on trainee mental health as well as effectiveness of interventions to improve their psychological well-being. contributors ni and kmg conceived the idea of this study. ni, hmum and ma did literature review. ni, hmum and kmg collected and analysed data. ni and ma prepared tables and wrote the first draft of manuscript. hmum and kmg helped with writing-reviewing and editing. kmg was responsible for the supervision of this project. all authors approved the final version of this article. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests none declared. ethics approval approved by institutional review board and permission obtained from cpsp. provenance and peer review not commissioned; externally peer reviewed. data availability statement all data relevant to the study are included in the article or uploaded as supplementary information. supplemental material this content has been supplied by the author(s). it has not been vetted by bmj publishing group limited (bmj) and may not have been peerreviewed. any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by bmj. bmj disclaims all liability and responsibility arising from any reliance placed on the content. where the content includes any translated material, bmj does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/ or omissions arising from translation and adaptation or otherwise. this article is made freely available for use in accordance with bmj's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by bmj. you may use, download and print the article for any lawful, noncommercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained. ► high psychological distress among postgraduate trainees during covid-19 pandemic is reported in pakistan. ► female postgraduate trainees and those working as front-line healthcare workers reported experiencing more anxiety, depression and acute stress symptoms. ► senior postgraduate trainees reported more anxiety and depression symptoms. ► provision of adequate psychosocial support for postgraduate trainees during a crisis situation such as covid-19 outbreak is essential. ► studies outside pakistan, with larger sample size and similar/ uniform scales and cut-off points are needed for comparison. ► further research is needed to explore the reasons for senior residents having high prevalence of anxiety and depression. ► longitudinal studies with larger sample sizes are needed to understand the long-term mental health consequences of this devastating global pandemic on postgraduate trainees. ► qualitative research will also be helpful to gain insight into the impact of covid-19 pandemic on postgraduate trainees' psychological well-being. what is already known on the subject ► the unprecedented nature of the covid-19 pandemic challenges is likely to cause extreme psychological stress among the healthcare workers. orcid id nazish imran http://orcid.org/0000-0001-6857-5781 world health organization. current novel coronavirus (2019-ncov) outbreak. 2020b occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 generalized anxiety disorder, depressive symptoms and sleep quality during covid-19 outbreak in china: a web-based cross-sectional survey psychological status of medical workforce during the covid-19 pandemic: a cross-sectional study psychological impact of covid-19 on ophthalmologists-in-training and practicing ophthalmologists in india burnout in medical residents: a review the impact of severe acute respiratory syndrome on medical house staff: a qualitative study lostis e covid-19: junior doctors are worried about their physical and mental health mental health of medical workers in pakistan during the pandemic covid-19 outbreak association of resident fatigue and distress with perceived medical errors suicidal thoughts among medical residents with burnout the phq-9: validity of a brief depression severity measure optimal cut-off score for diagnosing depression with the patient health questionnaire (phq-9): a meta-analysis a brief measure for assessing generalized anxiety disorder: the gad-7 psychometric properties of the stanford acute stress reaction questionnaire (sasrq): a valid and reliable measure of acute stress prevalence of depression in the community from 30 countries between risk factors, prevalence, and treatment of anxiety and depressive disorders in pakistan: systematic review covid-19 in wuhan: immediate psychological impact on 5062 health workers survey of stress reactions among health care workers involved with the sars outbreak mortality analyses johns hopkins coronavirus resource center frequency of anxiety and depression among doctors at postgraduate resident level anxiety and depression in doctors undergoing postgraduate training courses at armed forces postgraduate medical institute rawalpindi mental health and psychosocial problems of medical health workers during the covid-19 epidemic in china facing sars: psychological impacts on sars team nurses and psychiatric services in a taiwan general hospital key: cord-267791-v10eh408 authors: chughtai, abrar ahmad; khan, wasiq title: use of personal protective equipment to protect against respiratory infections in pakistan: a systematic review date: 2019-02-07 journal: j infect public health doi: 10.1016/j.jiph.2019.01.064 sha: doc_id: 267791 cord_uid: v10eh408 like other low-income countries, limited data are available on the use of personal protective equipment (ppe) in pakistan. we conducted a systematic review of studies on ppe use for respiratory infections in healthcare settings in pakistan. medline, embase and goggle scholar were searched for clinical, epidemiological and laboratory-based studies in english, and 13 studies were included; all were observational/cross-sectional studies. the studies examined ppe use in hospital (n = 7), dental (n = 4) or laboratory (n = 2) settings. policies and practices on ppe use were inconsistent. face masks and gloves were the most commonly used ppe to protect from respiratory and other infections. ppe was not available in many facilities and its use was limited to high-risk situations. compliance with ppe use was low among healthcare workers, and reuse of ppe was reported. clear policies on the use of ppe and available ppe are needed to avoid inappropriate practices that could result in the spread of infection. large, multimethod studies are recommended on ppe use to inform national infection-control guidelines. healthcare workers are at the frontline when treating infectious disease cases and at high risk of acquiring influenza and other respiratory infections [1] [2] [3] . several outbreaks of new infectious diseases have occurred in recent decades, such as the outbreak of severe acute respiratory syndrome coronavirus (sars-cov) in 2002-2003 [4] , influenza pandemic (h1n1) in 2009 [5] , middle east respiratory syndrome coronavirus (mers-cov) in 2012 [6] and ebola virus diseases in 2014-2016 [7] . many healthcare workers were infected and died during these outbreaks because of a lack of infection control [4, 8, 9, 10] various infection control strategies are used to protect healthcare workers from respiratory and other infections in healthcare settings [11, 12] . these strategies can be broadly classified as administrative control measures, environmental control measures and the use of personal protective equipment (ppe). administrative control measures include developing policies and procedures, implementing triage protocols and providing health education and trainings. environmental control measures includes ensuring proper ventilation, establishing airborne infection isolation and negative pressure rooms, developing systems for cleaning and waste disposal. [13, 14] . ppe is commonly used in healthcare settings as standard or transmission based precaution to protect healthcare workers from infections and to prevent further spread to patients around them [14, 15] . ppe is generally ranked lowest in the infection control hierarchy due to less effectiveness compared to other control measures and high expenditure in the long run. therefore, most infection control guidelines recommend using ppe together with other administrative and environmental control measures. however, ppe is important during the early stage of an outbreak or a pandemic when drugs, a vaccine and other control measures are not available, or access is limited. commonly used ppe to protect from respiratory infectionsare; face masks, respirators, gloves, and goggles or face shields [16] . face masks (or medical masks) and respirators are the most commonly used ppe to protect from influenza and other respiratory infection in healthcare settings. however, these two products are not the same. face masks are not designed for respiratory protection and are used to avoid respiratory droplet and spray of body fluids on the face. they are also used by sick patients to prevent spread of pathogens to others (referred to as "source control"), or by surgeons in the operating theatre to maintain a sterile operating field. face masks are not fit to the face and have varying filtration capacities [17] . respirators ratory protection and are used to protect from respiratory aerosols [18] . a properly fitted respirator provides better protection again respiratory infections than a face mask. gloves are used to protect hands from blood and body fluids, including respiratory secretions. goggles and face shields are used to prevent transfer of respiratory pathogens into the eyes from contaminated hands and other sources. gowns, coveralls, surgical hoods and shoe covers can also be used where procedures on infectious patients generate aerosols or when a new respiratory virus has emerged [18] . there is an ongoing debate about the selection and use of various types of ppe in healthcare settings. this is mainly because of a lack of high quality studies on the use of ppe. most studies are observational and on the use of masks and/or respirators [18] . to date, only five randomized clinical trials have been conducted on use of ppe in hospital settings and all were on face masks/respirators [18] . moreover, most studies on ppe use were conducted in high/middle income countries and currently there are limited data from lowincome countries where the burden of infectious diseases is high. it is therefore important to examine the use of ppe in low resource countries to inform infection control policies. pakistan has a population of about 200 million. as a low-income country, its gross domestic product is low, as is its expenditure on health [19] . the country has one of highest rates of infant and maternal mortality in the south asia region. infectious diseases are still among the main causes of death, particularly in young children. health and surveillance systems are generally weak and limited data are available on infection prevention and control strategies. the aim of this study was to examine the use of ppe for respiratory infections in healthcare settings in pakistan. a systematic review was conducted using the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines. we searched for studies on the electronic databases medline and embase using selected key words. a combination of keywords were used including: 'face mask' or 'mask' or 'medical mask' or 'surgical mask' or 'cloth mask' or 'respirator' or 'gloves' or 'gowns' or 'coverall' or 'surgical cap/hood' or 'shoe/boot covers' or 'goggles' or 'face shield' or 'eye protection' and ' respiratory infection' or 'respiratory tract infection' or 'respiratory diseases', 'outbreaks' or 'infectious disease' or 'influenza' or 'pandemic influenza' or 'flu' or 'tuberculosis' or 'pneumonia' and 'pakistan' or 'punjab' or 'sindh' or 'balochistan' or 'khyber pakhtunkhwa'. we used an open date strategy up to december 2017. we anticipated that studies published in local journals might not be indexed on the medline or embase, therefore, an additional search was made on google scholar using the same keywords. we set a limit of 20 results per page on google scholar and first three pages were reviewed for each keyword search. after the initial search; we reviewed titles and abstracts and selected studies for full text review (fig. 1) . clinical, epidemiological and laboratory-based studies conducted in any part of pakistan and published in english were included in the review. the focus of this systematic review was on the use of ppe for prevention of respiratory infections. therefore, we only included those studies which examined the use of facemask and/or respirator in healthcare settings, with or without other ppe. we only included those studies where ppe was discussed for respiratory infections. studies where ppe was examined for general infection control were also included, given respiratory protective equipment (face masks and/or respirators) was mentioned. we excluded studies on the use of ppe only for bloodborne infections. conference abstracts and poster presentations were also excluded. a total of 137 studies were found in the initial search. after reviewing titles and abstracts, 46 studies were selected for full text review. finally, 13 articles were included in this review (table 1 ) [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] . we only found observational/cross-sectional studies on the use of ppe for infectious diseases in healthcare settings in pakistan. in all studies data were collected through questionnaires or interviews. no clinical trials or laboratory-based studies on the use of ppe in such settings were found. seven studies examined the use of ppe in hospital [20] [21] [22] [23] 25] and among those, two examined the ppe perceptions among medical students [24] or pharmacy students [32] . two studies were conducted in the laboratory settings [26, 27] while, four in dental settings [28] [29] [30] [31] two studies focused on the use of ppe for influenza [24, 32] , two were for tuberculosis [20, 25] and nine studies were on multiple respiratory diseases, including influenza [21, 22] or general infections [23, [26] [27] [28] [29] [30] [31] . only two studies examined the use of ppe alone [21, 22] , while other studies examined other infection control practices as well [20, [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] . guidelines and standard operating procedures on ppe do not exist in most of the hospitals [23] or laboratories [26, 27] in pakistan. two studies examined the guidelines and current practices on the use of face masks/respirators for influenza, tuberculosis and sars in pakistan [21, 22] . recommendations on the use of masks were reported to be inconsistent and different types of product were recommended and used in various healthcare settings [21, 22] . face masks were the most commonly used ppe to protect from respiratory infections in most hospitals in pakistan. medical masks were generally used to protect from influenza, tuberculosis and other respiratory infections, while the use of respirators was limited to high-risk situations [21, 22] . in a cross-sectional survey among final-year pharmacy students in seven universities of karachi, about 60% of 443 participants highlighted the need to cover the nose or mouth to protect from influenza and about 57% highlighted the use of face masks, gloves and other ppe [32] . laboratory coat and gloves were the most commonly used ppe in the laboratories in pakistan while face masks and eye covers were rarely used [26, 27] . a survey of dentists working in various settings (dental colleges, hospitals and private clinics) showed that face masks and gloves were also commonly used ppe [29] . the use of ppe was also reported to be low among health workers. according to a hospital-based survey, face masks are not provided to patients with tuberculosis and respirators are not provided to the healthcare workers [23] . another survey showed that 25% of participants used ppe for patients with suspected tuberculosis and 56% used ppe for patients with confirmed tuberculosis [25] . a study in a ward for patients with multidrug-resistant tuberculosis reported that 65% of the healthcare workers used n95 respirators and 58% were provided with a mask [20] . a study on 253 biosafety level (bsl) 2 laboratory workers showed that ppe was not used by about half of the staff (46.2%) [27] . a countrywide survey showed that almost one third (31.9%) of bsl-2 laboratory workers did not routinely use ppe [26] . both gloves and laboratory coats were used by only 26.7% of the personnel, while a laboratory coat or gloves alone were used by 30.4% and 8.1%, respectively. less than 1% of all the respondents across pakistan reported using eye covers [26] . in a survey of medical students during pandemic (h1n1) 2009, 75% said that they would use a face mask to protect from infection. students with less risk perception were more hesitant to use face masks [24] . the use of face masks was common in dental practice and according to various surveys, 68-100% of dentists wear masks during dental procedures [28] [29] [30] [31] . across all the studies in dental settings, more than 90% also used gloves. among the ppe, face masks were considered the most bothersome to use by wearers. reuse of ppe was also reported in many studies, mainly because of unavailability of ppe and lack of training. gowns are shared among the healthcare workers in hospital many times [23] . two surveys in dental clinics showed that more than half of the dentist reuse masks during routine work [28, 29] . the availability of ppe was generally low in all healthcare settings [21, 22, 28] and varied according to the type [23] ; gloves and masks were available while gowns and n95 respirators were not available in several wards [23] . a shortage of ppe was also reported during sars and pandemic (h1n1) 2009 [21, 22] . a lack of training was a common issue reported and most healthcare workers were not trained in the use of ppe. most of the studies (11/13) discussed other infection control practices as well, in addition to the use of ppe. other non-standard infection control practices included reuse of syringes, improper waste disposal, a lack of hand hygiene practices, non-isolation of infectious cases and low influenza vaccination among healthcare workers. we reviewed the use of ppe in various healthcare settings in pakistan. a lack of guidelines and standard operating procedures, inconsistent policies and practices, low compliance, and non-availability and reuse of ppe were the main issues highlighted in this study. evidence is lacking on the use of ppe in hospitals and other healthcare settings in pakistan and most studies are of low quality. clinical studies should be conducted to examine the effectiveness of ppe and improve the compliance. reuse of ppe may increase the risk of self-contamination to the wearer and this practice should be discontinued. there is a need to improve the availability of ppe and healthcare workers should be trained. ppe is generally considered lowest in the infection control hierarchy and is generally recommended in combination with other control measures. other infection control practices in such settings should also be examined. different types of ppe are used by healthcare workers in pakistan, which reflects a lack of standard policies and guidelines. the different policies and practices may be because of the different recommendations by the world health organization (who) and the united states (us) centers for disease control and prevention (cdc) [33, 34] . debate continues about the selection and use ppe for different infections, for example, face masks versus respirators, gowns versus coveralls, face shields versus goggles [7, 18, 34, 35] . selection of ppe mainly depends on mode of transmission, however, several individual and organizational factors also contribute the selection and use of ppe, such as risk perception, presence of adverse events, pre-existing medical illness, availability and cost [7] . respiratory infections are generally transmitted through contact, droplet and/or airborne routes. gloves should be used to protect from infections transmitted through contact (e.g. respiratory syncytial virus and adenovirus), face masks should be used for droplet infections (e.g. influenza and coronavirus) and a respirator should be used to protect form airborne infection (e.g. tuberculosis and measles). however, infection transmission is rarely by only one route and most infections are transmitted by more than one route [36] . for example, influenza and sars primarily transmit through droplet and contact routes, but airborne transmission has also been reported [37, 38] . similarly, ebola primarily transmits through direct contact with blood and body fluids [39] , but animal studies have shown that airborne transmission is also possible [7] . the risk of transmission further increases during aerosol-generating and other high-risk procedures [40, 41] . moreover, uncertainty exists about how pathogens transmit during outbreaks and pandemics [14, 34, 42, 43] . therefore, superior ppe should be used where the mode of transmission is uncertain, the case-fatality rate is high and pharmaceutical interventions are not available [7] . infection control guidelines in pakistan need to be updated urgently to reflect these recommendations. given that mers cov is circulating in the eastern mediterranean region (emr), policies and practices on the use of ppe in other countries of the region should also be examined. our study also reported low availability of ppe in hospital, dental and laboratory settings in pakistan. the availability of ppe is a challenge, not only in low-resource counties, but also in highincome countries, particularly during outbreaks and pandemics when the use of ppe greatly increases [46, 47] . this may result in non-standard practices such as reuse and extended use of ppe. shortages of ppe were even reported in many high-income countries during the 2009 influenza h1n1 pandemic and staff had to use various alternatives [46] [47] [48] . the availability of ppe is important to ensure proper use and compliance. low use of ppe among laboratory workers in pakistan may be due to non-availability and a lack of resources. for example, ppe use was relatively higher in laboratory workers in punjab, which is an affluent province, than other provinces [26] . moreover ppe use was reported more in the private sector in pakistan than the public sector which has fewer resources [27] . proper use of ppe depends on several factors such as availability, knowledge, training, risk perception and comfort [7, 44, 45] . this study showed the compliance with the use of ppe was generally low among healthcare workers and was mainly due to unavailability of ppe, discomfort and a lack of training. while the use ppe depends on many factors, a greater perception of risk was positively associated with compliance [24] . continuous use of face masks and respirators may have psychological and physiological effects on the wearer and result in more adverse events [49] [50] [51] . compliance with the use of face masks has been shown to be based on the nature of the disease, infectiousness of patients and the performance of high-risk procedures [52] . previous studies have tested the precede (predisposing, reinforcing and enabling) framework to examine healthcare workers' compliance with universal precautions [53] . the results showed that reinforcing factors, such as availability of ppe and less job hindrance, and enabling factors, such as safety climate and regular feedback, were significant predictors of compliance with ppe [53] . in addition, the health belief model [54] was also used to examine the compliance and use of face mask during the sars outbreak [55, 56] . perceived susceptibility (vulnerability to acquiring sars and close contact with case), perceived benefits (that face masks can prevent infection) and cues to action (someone asked them to use face masks) were significant predictors of protective behaviour and use of face masks [55] . our study showed that most healthcare workers were not trained on the use of ppe in pakistan. the risk of infection can be reduced with proper training and availability of policies and standard operating procedures [57] . however, regular monitoring is also required to make sure that healthcare workers are using ppe according to the protocols. a study in the us reported many deviations from the protocols even though all healthcare workers were trained [15] . this may result in self-contamination to the wearers and the spread of infection to others [58] . training programmes should be arranged for newly recruited staff and then annual refresher courses should be provided. our study had some limitations. the initial search was made on medline and embase but very few studies were retrieved because many papers are not indexed on these databases. therefore, we also searched google scholar but we only reviewed the first 3 pages after each search so some studies could have been missed. however, we checked the references lists of the relevant studies and could not find any other studies. our search was up to 2017 and studies in 2018 were not included. we only considered ppe in this study and did not examine other infection control practices. the use of ppe is generally recommended with other administrative and environmental control measures. the selection and use of ppe vary according to the type of healthcare worker and working environment. face masks and gloves were the most commonly used ppe to protect from respiratory and other infections. overall, compliance with the use of ppe was low, and non-availability and reuse of ppe were reported. most studies were observational and large-scale prospective studies are needed to collect more evidence about the use of ppe in healthcare settings in pakistan. no funding sources. aac tested the filtration of mask samples by 3 min in another study; 3m products were not used in this study. wk declares none. as this was a systematic review of published data, ethics approval was not required. aac devised the structure and topic areas for this review and made the initial search. wk and aac reviewed titles and abstracts and selected studies for full text review. aac prepared the first draft of manuscript and both authors contributed equally to the final manuscript. influenza and rhinovirus infections among health-care workers nosocomial transmission of measles among healthcare workers tuberculosis among health care workers emergencies preparedness, 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isolation precautions: preventing transmission of infectious agents in health care settings infection prevention and control of epidemic-and pandemic-prone acute respiratory infections in health care. who guidelines. geneva: world health organization assessment of healthcare worker protocol deviations and self-contamination during personal protective equipment donning and doffing guidance on personal protective equipment (ppe) to be used by healthcare workers during management of patients with confirmed ebola or persons under investigation (puis) for ebola who are clinically unstable or have bleeding, vomiting, or diarrhea in u.s. hospitals, including procedures for donning and doffing ppe protecting healthcare staff from severe acute respiratory syndrome: filtration capacity of multiple surgical masks face masks for the prevention of infection in healthcare and community settings infection control in hospitals managing drug-resistant tuberculosis in pakistan: how are we doing? infection control survey in the hospitals to examine the role of masks and respirators for the prevention of respiratory infections in hcws practices around the use of masks and respirators among hospital health care workers in 3 diverse populations infection control at a government hospital in pakistan medical students' knowledge, perceptions, and behavioral intentions towards the h1n1 influenza, swine flu, in pakistan: a brief report assessment of the protective measures taken in preventing nosocomial transmission of pulmonary tuberculosis among health-care workers biosafety perspective of clinical laboratory workers: a profile of pakistan practices and awareness regarding biosafety measures among laboratory technicians working in clinical laboratories in karachi cross infection control infection control practices across karachi: do dentists follow the recommendations? infection control practices among dental practitioners of lahore, pakistan knowledge attitude and practice of 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fit-tested and non-fit-tested n95 respirators to medical masks to prevent respiratory virus infection in health care workers physiologic and other effects and compliance with long-term respirator use among medical intensive care unit nurses discomfort and exertion associated with prolonged wear of respiratory protection in a health care setting the cookie monster muffler: perceptions and behaviours of hospital healthcare workers around the use of masks and respirators in the hospital setting behavioral-diagnostic analysis of compliance with universal precautions among nurses social learning theory and the health belief model factors influencing the wearing of face masks to prevent the severe acute respiratory syndrome among adult chinese in hong kong practice of habitual and volitional health behaviors to prevent severe acute respiratory syndrome among chinese adolescents in hong kong personal protective equipment for the ebola virus disease: a comparison of 2 training programs risk of self-contamination during doffing of personal protective equipment key: cord-305146-iprzeigk authors: chughtai, abrar ahmad; khan, wasiq title: use of personal protective equipment to protect against respiratory infections in pakistan: a systematic review date: 2020-03-04 journal: j infect public health doi: 10.1016/j.jiph.2020.02.032 sha: doc_id: 305146 cord_uid: iprzeigk like other low-income countries, limited data are available on the use of personal protective equipment (ppe) in pakistan. we conducted a systematic review of studies on ppe use for respiratory infections in healthcare settings in pakistan. medline, embase and goggle scholar were searched for clinical, epidemiological and laboratory-based studies in english, and 13 studies were included; all were observational/cross-sectional studies. the studies examined ppe use in hospital (n = 7), dental (n = 4) or laboratory (n = 2) settings. policies and practices on ppe use were inconsistent. face masks and gloves were the most commonly used ppe to protect from respiratory and other infections. ppe was not available in many facilities and its use was limited to high-risk situations. compliance with ppe use was low among healthcare workers, and reuse of ppe was reported. clear policies on the use of ppe and available ppe are needed to avoid inappropriate practices that could result in the spread of infection. large, multimethod studies are recommended on ppe use to inform national infection-control guidelines. healthcare workers are at the frontline when treating infectious disease cases and at high risk of acquiring influenza and other respiratory infections [1] [2] [3] . several outbreaks of new infectious diseases have occurred in recent decades, such as the outbreak of severe acute respiratory syndrome coronavirus (sars-cov) in 2002-2003 [4] , influenza pandemic (h1n1) in 2009 [5] , middle east respiratory syndrome coronavirus (mers-cov) in 2012 [6] and ebola virus diseases in 2014-2016 [7] . many healthcare workers were infected and died during these outbreaks because of a lack of infection control [4, 8, 9, 10] various infection control strategies are used to protect healthcare workers from respiratory and other infections in healthcare settings [11, 12] . these strategies can be broadly classified as administrative control measures, environmental control measures and the use of personal protective equipment (ppe). administrative control measures include developing policies and procedures, implementing triage protocols and providing health education and trainings. environmental control measures includes ensuring proper ventilation, establishing airborne infection isolation and negative pressure rooms, developing systems for cleaning and waste disposal. [13, 14] . ppe is commonly used in healthcare settings as standard or transmission based precaution to protect healthcare workers from infections and to prevent further spread to patients around them [14, 15] . ppe is generally ranked lowest in the infection control hierarchy due to less effectiveness compared to other control measures and high expenditure in the long run. therefore, most infection control guidelines recommend using ppe together with other administrative and environmental control measures. however, ppe is important during the early stage of an outbreak or a pandemic when drugs, a vaccine and other control measures are not available, or access is limited. commonly used ppe to protect from respiratory infectionsare; face masks, respirators, gloves, and goggles or face shields [16] . face masks (or medical masks) and respirators are the most commonly used ppe to protect from influenza and other respiratory infection in healthcare settings. however, these two products are not the same. face masks are not designed for respiratory protection and are used to avoid respiratory droplet and spray of body fluids on the face. they are also used by sick patients to prevent spread of pathogens to others (referred to as "source control"), or by surgeons in the operating theatre to maintain a sterile operating field. face masks are not fit to the face and have [17] . respirators are designed for respiratory protection and are used to protect from respiratory aerosols [18] . a properly fitted respirator provides better protection again respiratory infections than a face mask. gloves are used to protect hands from blood and body fluids, including respiratory secretions. goggles and face shields are used to prevent transfer of respiratory pathogens into the eyes from contaminated hands and other sources. gowns, coveralls, surgical hoods and shoe covers can also be used where procedures on infectious patients generate aerosols or when a new respiratory virus has emerged [18] . there is an ongoing debate about the selection and use of various types of ppe in healthcare settings. this is mainly because of a lack of high quality studies on the use of ppe. most studies are observational and on the use of masks and/or respirators [18] . to date, only five randomized clinical trials have been conducted on use of ppe in hospital settings and all were on face masks/respirators [18] . moreover, most studies on ppe use were conducted in high/middle income countries and currently there are limited data from lowincome countries where the burden of infectious diseases is high. it is therefore important to examine the use of ppe in low resource countries to inform infection control policies. pakistan has a population of about 200 million. as a low-income country, its gross domestic product is low, as is its expenditure on health [19] . the country has one of highest rates of infant and maternal mortality in the south asia region. infectious diseases are still among the main causes of death, particularly in young children. health and surveillance systems are generally weak and limited data are available on infection prevention and control strategies. the aim of this study was to examine the use of ppe for respiratory infections in healthcare settings in pakistan. a systematic review was conducted using the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines. we searched for studies on the electronic databases medline and embase using selected key words. a combination of keywords were used including: 'face mask' or 'mask' or 'medical mask' or 'surgical mask' or 'cloth mask' or 'respirator' or 'gloves' or 'gowns' or 'coverall' or 'surgical cap/hood' or 'shoe/boot covers' or 'goggles' or 'face shield' or 'eye protection' and ' respiratory infection' or 'respiratory tract infection' or 'respiratory diseases', 'outbreaks' or 'infectious disease' or 'influenza' or 'pandemic influenza' or 'flu' or 'tuberculosis' or 'pneumonia' and 'pakistan' or 'punjab' or 'sindh' or 'balochistan' or 'khyber pakhtunkhwa'. we used an open date strategy up to december 2017. we anticipated that studies published in local journals might not be indexed on the medline or embase, therefore, an additional search was made on google scholar using the same keywords. we set a limit of 20 results per page on google scholar and first three pages were reviewed for each keyword search. after the initial search; we reviewed titles and abstracts and selected studies for full text review (fig. 1) . clinical, epidemiological and laboratory-based studies conducted in any part of pakistan and published in english were included in the review. the focus of this systematic review was on the use of ppe for prevention of respiratory infections. therefore, we only included those studies which examined the use of facemask and/or respirator in healthcare settings, with or without other ppe. we only included those studies where ppe was discussed for respiratory infections. studies where ppe was examined for general infection control were also included, given respiratory protective equipment (face masks and/or respirators) was mentioned. we excluded studies on the use of ppe only for bloodborne infections. conference abstracts and poster presentations were also excluded. a total of 137 studies were found in the initial search. after reviewing titles and abstracts, 46 studies were selected for full text review. finally, 13 articles were included in this review (table 1 ) [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] . we only found observational/cross-sectional studies on the use of ppe for infectious diseases in healthcare settings in pakistan. in all studies data were collected through questionnaires or interviews. no clinical trials or laboratory-based studies on the use of ppe in such settings were found. seven studies examined the use of ppe in hospital [20] [21] [22] [23] 25] and among those, two examined the ppe perceptions among medical students [24] or pharmacy students [32] . two studies were conducted in the laboratory settings [26, 27] while, four in dental settings [28] [29] [30] [31] two studies focused on the use of ppe for influenza [24, 32] , two were for tuberculosis [20, 25] and nine studies were on multiple respiratory diseases, including influenza [21, 22] or general infections [23, [26] [27] [28] [29] [30] [31] . only two studies examined the use of ppe alone [21, 22] , while other studies examined other infection control practices as well [20, [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] . guidelines and standard operating procedures on ppe do not exist in most of the hospitals [23] or laboratories [26, 27] in pakistan. two studies examined the guidelines and current practices on the use of face masks/respirators for influenza, tuberculosis and sars in pakistan [21, 22] . recommendations on the use of masks were reported to be inconsistent and different types of product were recommended and used in various healthcare settings [21, 22] . face masks were the most commonly used ppe to protect from respiratory infections in most hospitals in pakistan. medical masks were generally used to protect from influenza, tuberculosis and other respiratory infections, while the use of respirators was limited to high-risk situations [21, 22] . in a cross-sectional survey among final-year pharmacy students in seven universities of karachi, about 60% of 443 participants highlighted the need to cover the nose or mouth to protect from influenza and about 57% highlighted the use of face masks, gloves and other ppe [32] . laboratory coat and gloves were the most commonly used ppe in the laboratories in pakistan while face masks and eye covers were rarely used [26, 27] . a survey of dentists working in various settings (dental colleges, hospitals and private clinics) showed that face masks and gloves were also commonly used ppe [29] . the use of ppe was also reported to be low among health workers. according to a hospital-based survey, face masks are not provided to patients with tuberculosis and respirators are not provided to the healthcare workers [23] . another survey showed that 25% of participants used ppe for patients with suspected tuberculosis and 56% used ppe for patients with confirmed tuberculosis [25] . a study in a ward for patients with multidrug-resistant tuberculosis reported that 65% of the healthcare workers used n95 respirators and 58% were provided with a mask [20] . a study on 253 biosafety level (bsl) 2 laboratory workers showed that ppe was not used by about half of the staff (46.2%) [27] . a countrywide survey showed that almost one third (31.9%) of bsl-2 laboratory workers did not routinely use ppe [26] . both gloves and laboratory coats were used by only 26.7% of the personnel, while a laboratory coat or gloves alone were used by 30.4% and 8.1%, respectively. less than 1% of all the respondents across pakistan reported using eye covers [26] . in a survey of medical students during pandemic (h1n1) 2009, 75% said that they would use a face mask to protect from infection. students with less risk perception were more hesitant to use face masks [24] . the use of face masks was common in dental practice and according to various surveys, 68-100% of dentists wear masks during dental procedures [28] [29] [30] [31] . across all the studies in dental settings, more than 90% also used gloves. among the ppe, face masks were considered the most bothersome to use by wearers. reuse of ppe was also reported in many studies, mainly because of unavailability of ppe and lack of training. gowns are shared among the healthcare workers in hospital many times [23] . two surveys in dental clinics showed that more than half of the dentist reuse masks during routine work [28, 29] . the availability of ppe was generally low in all healthcare settings [21, 22, 28] and varied according to the type [23] ; gloves and masks were available while gowns and n95 respirators were not available in several wards [23] . a shortage of ppe was also reported during sars and pandemic (h1n1) 2009 [21, 22] . a lack of training was a common issue reported and most healthcare workers were not trained in the use of ppe. most of the studies (11/13) discussed other infection control practices as well, in addition to the use of ppe. other non-standard infection control practices included reuse of syringes, improper waste disposal, a lack of hand hygiene practices, non-isolation of infectious cases and low influenza vaccination among healthcare workers. we reviewed the use of ppe in various healthcare settings in pakistan. a lack of guidelines and standard operating procedures, inconsistent policies and practices, low compliance, and non-availability and reuse of ppe were the main issues highlighted in this study. evidence is lacking on the use of ppe in hospitals and other healthcare settings in pakistan and most studies are of low quality. clinical studies should be conducted to examine the effectiveness of ppe and improve the compliance. reuse of ppe may increase the risk of self-contamination to the wearer and this practice should be discontinued. there is a need to improve the availability of ppe and healthcare workers should be trained. ppe is generally considered lowest in the infection control hierarchy and is generally recommended in combination with other control measures. other infection control practices in such settings should also be examined. different types of ppe are used by healthcare workers in pakistan, which reflects a lack of standard policies and guidelines. the different policies and practices may be because of the different recommendations by the world health organization (who) and the united states (us) centers for disease control and prevention (cdc) [33, 34] . debate continues about the selection and use ppe for different infections, for example, face masks versus respirators, gowns versus coveralls, face shields versus goggles [7, 18, 34, 35] . selection of ppe mainly depends on mode of transmission, however, several individual and organizational factors also contribute the selection and use of ppe, such as risk perception, presence of adverse events, pre-existing medical illness, availability and cost [7] . respiratory infections are generally transmitted through contact, droplet and/or airborne routes. gloves should be used to protect from infections transmitted through contact (e.g. respiratory syncytial virus and adenovirus), face masks should be used for droplet infections (e.g. influenza and coronavirus) and a respirator should be used to protect form airborne infection (e.g. tuberculosis and measles). however, infection transmission is rarely by only one route and most infections are transmitted by more than one route [36] . for example, influenza and sars primarily transmit through droplet and contact routes, but airborne transmission has also been reported [37, 38] . similarly, ebola primarily transmits through direct contact with blood and body fluids [39] , but animal studies have shown that airborne transmission is also possible [7] . the risk of transmission further increases during aerosol-generating and other high-risk procedures [40, 41] . moreover, uncertainty exists about how pathogens transmit during outbreaks and pandemics [14, 34, 42, 43] . therefore, superior ppe should be used where the mode of transmission is uncertain, the case-fatality rate is high and pharmaceutical interventions are not available [7] . infection control guidelines in pakistan need to be updated urgently to reflect these recommendations. given that mers cov is circulating in the eastern mediterranean region (emr), policies and practices on the use of ppe in other countries of the region should also be examined. our study also reported low availability of ppe in hospital, dental and laboratory settings in pakistan. the availability of ppe is a challenge, not only in low-resource counties, but also in highincome countries, particularly during outbreaks and pandemics when the use of ppe greatly increases [46, 47] . this may result in non-standard practices such as reuse and extended use of ppe. shortages of ppe were even reported in many high-income countries during the 2009 influenza h1n1 pandemic and staff had to use various alternatives [46] [47] [48] . the availability of ppe is important to ensure proper use and compliance. low use of ppe among laboratory workers in pakistan may be due to non-availability and a lack of resources. for example, ppe use was relatively higher in laboratory workers in punjab, which is an affluent province, than other provinces [26] . moreover ppe use was reported more in the private sector in pakistan than the public sector which has fewer resources [27] . proper use of ppe depends on several factors such as availability, knowledge, training, risk perception and comfort [7, 44, 45] . this study showed the compliance with the use of ppe was generally low among healthcare workers and was mainly due to unavailability of ppe, discomfort and a lack of training. while the use ppe depends on many factors, a greater perception of risk was positively associated with compliance [24] . continuous use of face masks and respirators may have psychological and physiological effects on the wearer and result in more adverse events [49] [50] [51] . compliance with the use of face masks has been shown to be based on the nature of the disease, infectiousness of patients and the performance of high-risk procedures [52] . previous studies have tested the precede (predisposing, reinforcing and enabling) framework to examine healthcare workers' compliance with universal precautions [53] . the results showed that reinforcing factors, such as availability of ppe and less job hindrance, and enabling factors, such as safety climate and regular feedback, were significant predictors of compliance with ppe [53] . in addition, the health belief model [54] was also used to examine the compliance and use of face mask during the sars outbreak [55, 56] . perceived susceptibility (vulnerability to acquiring sars and close contact with case), perceived benefits (that face masks can prevent infection) and cues to action (someone asked them to use face masks) were significant predictors of protective behaviour and use of face masks [55] . our study showed that most healthcare workers were not trained on the use of ppe in pakistan. the risk of infection can be reduced with proper training and availability of policies and standard operating procedures [57] . however, regular monitoring is also required to make sure that healthcare workers are using ppe according to the protocols. a study in the us reported many deviations from the protocols even though all healthcare workers were trained [15] . this may result in self-contamination to the wearers and the spread of infection to others [58] . training programmes should be arranged for newly recruited staff and then annual refresher courses should be provided. our study had some limitations. the initial search was made on medline and embase but very few studies were retrieved because many papers are not indexed on these databases. therefore, we also searched google scholar but we only reviewed the first 3 pages after each search so some studies could have been missed. however, we checked the references lists of the relevant studies and could not find any other studies. our search was up to 2017 and studies in 2018 were not included. we only considered ppe in this study and did not examine other infection control practices. the use of ppe is generally recommended with other administrative and environmental control measures. the selection and use of ppe vary according to the type of healthcare worker and working environment. face masks and gloves were the most commonly used ppe to protect from respiratory and other infections. overall, compliance with the use of ppe was low, and non-availability and reuse of ppe were reported. most studies were observational and large-scale prospective studies are needed to collect more evidence about the use of ppe in healthcare settings in pakistan. no funding sources. aac tested the filtration of mask samples by 3 min in another study; 3m products were not used in this study. wk declares none. as this was a systematic review of published data, ethics approval was not required. aac devised the structure and topic areas for this review and made the initial search. wk and aac reviewed titles and abstracts and selected studies for full text review. aac prepared the first draft of manuscript and both authors contributed equally to the final manuscript. influenza and rhinovirus infections among health-care workers nosocomial transmission of measles among healthcare workers tuberculosis among health care workers emergencies preparedness, 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self-contamination during doffing of personal protective equipment key: cord-318240-wxtktbfa authors: salman, muhammad; mustafa, zia ul; khan, tahir mehmood; shehzadi, naureen; hussain, khalid title: how prepared was pakistan for the covid-19 outbreak? date: 2020-07-14 journal: disaster medicine and public health preparedness doi: 10.1017/dmp.2020.247 sha: doc_id: 318240 cord_uid: wxtktbfa nan t he newly emerged coronavirus, severe acute respiratory syndrome coronavirus 2 (sars-cov-2), now a pandemic, is spreading far more rapidly than the earlier coronaviruses, as well as other infectious disease outbreaks of the recent past. as effective preparedness is pivotal to significantly minimize damage from imminent and unexpected disaster, here, we critically analyzed pakistan's preparedness for the coronavirus disease (covid-19). china is located northeast of pakistan and both countries share more than a 500-kilometer border. the people of both these countries travel frequently due to multiple economic ties, technical assistance of the china pakistan economic corridor, studies, and tourism. hence, the likelihood of a covid-19 outbreak in pakistan was immensely high. in late january 2020, according to the news, 5 individuals (1 pakistani and 1 chinese in multan and 3 chinese in lahore) who recently came from china were suspected of covid-19 and hospitalized. this led to fear and chaos in the public. the national institute of health, pakistan, issued an advisory (f.1-22/advisory/fedsd/ 2020) regarding the disease, which was endorsed by the director of general health, and an alert was issued (443-523/pa/dghs) to all the hospitals of punjab province asking staff members to remain vigilant about any suspected cases. however, this alone was not enough to effectively tackle the impending sars-cov-2 attack in pakistan. in our opinion, the following measures should have been implemented by the health regulators. unfortunately, the health regulators were slow to act on covid-19. it was taken seriously for the first time toward the end of january 2020, and screenings were started at major airports. 1 however, screening at all border entry points were not initiated until after the first 2 positive-tested patients (february 26, 2020) came from iran -pakistan's neighbor to the west, one of the most severely affected countries with covid-19. this led to thousands of pilgrims coming from iran to be quarantined at camps without proper arrangements (no real housing, poor sanitation, lack of basic preventive measures, lack of proper testing and medical facilities), making the matter worse. 2 due to the failure of border quarantines, provinces were compelled to prepare their own quarantine facilities to house the pilgrims, which did not work out well either and so local viral transmissions began. soon, owing to the insufficient provision of personal protective equipment, pakistani health professionals started protesting, even going on a hunger strike and threatening to quit work. [3] [4] [5] furthermore, awareness campaigns in the country commenced late (march 13, 2020). the vague policies resulted in an alarming high rate of disease spread until june 8, 2020; there were 103 671 covid-19 cases in the country (67 249 active cases, 2067 deaths, and 34 355 recoveries). 6 in conclusion, pakistan's preparedness for covid-19 was far from satisfactory. the health regulators still need to devise and implement a clear policy to effectively combat covid-19. the guardian. pakistan coronavirus camp: "no facilities, no humanity doctors on hunger strike over lack of ppe. anadolu agency pakistan arrests doctors protesting for coronavirus medical gear. aljazeera medics, health workers protest "non-provision" of ppe in lahore covid-19 dashboard the authors have no conflicts of interest to declare. key: cord-278145-3tfcxbfz authors: ahmed, sibtain; jafri, lena; majid, hafsa; khan, aysha habib; ghani, farooq; siddiqui, imran title: challenges amid covid-19 times review of the changing practices in a clinical chemistry laboratory from a developing country date: 2020-06-06 journal: ann med surg (lond) doi: 10.1016/j.amsu.2020.06.004 sha: doc_id: 278145 cord_uid: 3tfcxbfz corona virus disease 2019 (covid-19) pandemic is the defining global health crisis of our time. compared with its neighbors china and iran, which were rated as epi-centers of the outbreak, pakistan has lower standards of health care, unstable economy and dearth of financial resources to tackle the outbreak. like other institutes and industries in the country, clinical laboratories were succumbed to a variety of challenges. this article is based on the experience and adapted workflow measures from the clinical chemistry laboratory at the aga khan university hospital (akuh), karachi, which serves as a national referral center with its widespread network of satellite laboratories and phlebotomy centers across the country. it highlights the challenges faced and the appropriate responses to ensure the provision of diagnostic facilities during the covid-19 outbreak. furthermore, the lessons acquired and necessary preparations for the post crisis situation are also incorporated. the marks of the coronavirus disease 2019 (covid-19) outbreak trace back to 31 st december 2019, when a pneumonia of unknown etiology was informed to the world health organization (who) in wuhan, china [1] . since then the outbreak termed as a 'pandemic', declared by who on 11 th march 2020, has continued to cause severe morbidity and mortality in most countries globally with devastating implications [2] . pakistan reported its first confirmed case in the metropolis of karachi on 26 th february 2020, in an iran returned traveler [3] . a point of concern for the country, was frequent exchange of travelers; with iran and china, main reason being religious pilgrimages and business activities respectively. consequently, by mid-march the pandemic, initially seen only in travelers coming from abroad was confirmed to have spread throughout the country with cases of local transmission and the first death on 20 th march 2020 [4] . compared with its bordering neighbors china and iran, which were rated as the initial epi-centers of the outbreak, pakistan has lower standards of health care, unstable economy and dearth of resources to tackle the outbreak [5] . most of the cities including the major economical hubs i.e. karachi, lahore and islamabad were put on a lock down in fourth week of march to prevent the local spread with negative impact on the financial outcomes and revenue generation of most entities [6] . health care facilities, especially tertiary care setup like the aga khan university hospital (akuh), karachi, pakistan, catering to covid-19 cases, were the ones which sustained more serious blows [7] . routine patient inflow was significantly reduced owing to the imposed lock down and psychological insecurities of visiting a facility testing and housing covid-19 patients. laboratories have a critical role to play during the pandemic right form diagnosis till surveillance, with the laboratory professionals as the front-line warriors [8, 9] . however, unlike most laboratories in the developed countries with the essential infrastructure and financial resources, the current situation poses enormous challenges for the laboratories based in the developing world [10] . the clinical chemistry laboratory at the akuh, serves as a referral center, and caters to on an average 16000 routine and specialized tests requests per day from all the provinces owing to its network of more than 250 phlebotomy stations spread across pakistan. the laboratory was the first to be accredited by joint commission international accreditation (jcia) and the only with college of american pathologist (cap) accreditation in pakistan. from an organizational perspective, laboratory is considered a critical service in a tertiary care hospital and is expected to continue 24/7 operations even during an infectious pandemic [11] . this is also vital for the individual patient, who expects the provision of diagnostic services not to be disrupted. to ensure such continuity of services, the aim of this review is to highlight the challenges faced by a clinical https://doi.org/10.1016/j.amsu.2020.06.004 received 6 may 2020; received in revised form 1 june 2020; accepted 1 june 2020 chemistry laboratory in a developing country amid the covid-19 crisis, the challenges, implementing changes and the lessons learnt. 1.1. day to day challenges faced the financial ramifications of the covid crisis were significant. owing to the lock down across the country and social distancing campaigns, during the initial phase of the outbreak the testing volumes decreased significantly by approximately 52% of the baseline compared to pre-covid months. this led to substantial financial decline and the revenue generation targets suffered enormously. the major reasons identified were a smaller number of subjects visiting outreach phlebotomy centers across the country, cessation of outpatient clinics and postponement of all non-emergency surgeries causing limited flow of patients to the tertiary care hospital, with which the laboratory is associated. to cope up with the situation, free of cost home sample collection was started with the aid of outreach phlebotomy centers [12] . the hospital initiated tele clinics for outpatients and door step sample collection for required diagnostic work up was propagated [13, 14] . following these measures and due to the ease in lockdown, a steady increment in volume of approximately 5% was noted at the time of publication. the clinical chemistry faculties were divided into teams (e.g. teams 1 and 2). this is so that, if one team needs to be quarantined, the other team could provide continuity of service [15, 16] . each team lead by a team leader consisted of three specialist pathologists and one post graduate trainee. the second team was made to work from home via microsoft teams and was connected with the team present in the section via sectional whatsapp group. within the workplace, the teams had dedicated workspaces and a distance of at least 2 m was practiced. all the essential meetings were converted to virtual meetings via microsoft teams and zoom to ensure continuity of services and plans as laid down at the beginning of the year by the management [17, 18] . in the beginning few issues pertaining to low bandwidth connection at home and lack of working knowledge of online platforms posed challenges but gradually improved. the technical staff working at the bench side were also limited to minimize exposure. furthermore, the staff was offered to avail their paid leaves during the outbreak. however, this does not lead to any ease for the section as majority of the staff were reluctant to go on annual earned leaves. the major reasons communicated were an apparent fear of losing the job amid the financial crisis and hindrances in execution of vacation plans which were normally considered to be undertaken during the leaves. moreover, pakistan, being a developing country has substantially compromised living conditions. not unusual to find large households with an average of six to seven persons living together [19] . many considered staying at work as a better and safer alternate than being lock downed at home. however, the staff was counselled to abide by the situation and physical presence of the staff at the laboratory was reduced by approximately 30% compared to normal by aid of modifications in duty rosters. as a measure to ease fixed costs and stave off job losses salaries of mid-level and senior level staff were revised with no annual increases, and pay cuts ranging from 10 to 30% were implemented. however, salaries of approximately 73% of the total staff including most junior staff and trainees was preserved to save them from excess economic burden. furthermore, all travel, new projects and hiring were put on hold. additionally, it was announced that the staff will further have no appraisals as scheduled for the fiscal year. adequate supply of personal protective equipment (ppe) as an essential requirement was ensured with the assistance of the purchase department. staff was counselled to practice judicious use of ppe and sanitizers. bench in charges were reinforced to re-visit their inventory requirements owing to the expected delays in shipment due to the air space closure, to maintain demand-supply chain. despite the reduction in overall test volumes, a few tests e.g. albumin, troponin-i (trop-i) and c -reactive protein (crp) exhibited more than usual demands as they were being used for covid-19 cases in supplementation to the molecular diagnosis and later for prognosis. furthermore, due to rapid influx of inpatients with covid-19 to the hospital to which the laboratory serves, there was a surge in demand of point of care tests (poct) including arterial blood gases and glucose. to meet the increasing poct workload, additional instruments, were procured and installed on an urgent basis. alongside the poct operator trainings were conducted on ad hoc basis and validation requirements were also fulfilled in a timely manner by the poct team. on the other hand, the laboratory also had to cope with the shortage of trop-i kit, a vital biomarker, due to shipment delay and a few kits were borrowed from other sources until the receipt of the next shipment. furthermore, the lab had to discontinue provision of another special biochemistry test, immunoglobulin g4 (igg4), due to the shortage because of delays in production and shipment of supplies from the manufacturer in united kingdom, one of the countries hardest hit by the covid-19 crisis. 1.1.5. impact on external quality assurance and accreditation requirements due to airspace closure due to logistic challenges proficiency testing surveys from cap were also not able to meet the timelines and the cap directed the participating labs to perform and document alternate assessment testing by either split sample analysis, clinical correlation studies or direct observation of technique dependent tests as appropriate [20] . the quality assurance group in liaison with the sectional chemical pathologists came up with a plan swiftly and it was implemented to ensure the lab continues to deliver the highest standards of quality. furthermore, the european research network for evaluation and improvement of screening, diagnosis and treatment of inherited disorders of metabolism (erndim), an external quality assurance scheme for the biochemical genetics laboratory also extended their dates of result submission, amid the airspace closure, which further eased the path for maintaining compliance with this scheme. at this instant, again having the privilege of having a virtual quality control platform in shape of bio-rad unity real time, which allows for external peer group analysis in a networkable quality control program proved to be beneficial for the laboratory and was utilized efficiently. due to limited availability of testing kits and consumables, scheduled method validation/verification activities were also disrupted. the laboratory was preparing for an upcoming accreditation compliance audit by cap in the later part of 2020, however as most audits, most of which requires physical presence of inspectors were called off by cap due to the covid-19 crisis, the status of the upcoming event also became uncertain. in order to ensure continuous growth, our lab core group plans introduction of new tests into the system keeping in sight the productivity, demand and regulatory approvals after appropriate protocols. for the current year, the laboratory had completed the required task associated with the new tests it was bound to offer including anti-phospholipase a2 receptor antibodies (pla2r) and acylcarnitine on its newly acquired tandem mass spectrometry platform. however, due to logistic issues the supply of reagents and consumables was either slowed down or halted. this further negatively impacted the anticipated revenue growth. as the laboratory caters to both outpatients and inpatients, a noteworthy threat was the local spread of infection from un-screened patients and attendant visiting the facility for diagnostic workup [21, 22] . a special counter was set up with appropriate safety protocol outside the main lab premises for screening using a standard questionnaire. suspected covid-19 cases were refrained from entering the laboratory premises and were diverted to the hospital's specially designated area for screening and management of such cases with appropriate protocol. as covid-19 is transmitted by droplets and close contacts, patients, staffs and visitors to the laboratory had to wear mandatory masks and were provided with hand sanitizers at the counter and movement in common corridors were restricted. all healthcare professionals serving in the laboratory were strictly made to wear surgical masks and gloves as per the safety guidelines and safety officers were held responsible to ensure compliance [23] . staff who developed symptoms were asked to report immediately and were given medical consultation within the hospital staff clinic. this enabled symptomatic staff to be identified promptly. furthermore, the organization announced that all staff and their dependents, in case, if tested positive, their complete care will be fully covered financially by the hospital. this was re-assuring and taken positively by all the staff. additionally, refresher training on the use of ppe was also conducted. following good laboratory practices, all samples received at the section of clinical chemistry were regarded as infectious whether or not coming from suspected or confirmed cases and hazardous risk was minimized by reducing aerosolization, spill prevention and reducing unnecessary sample handling and movement. a fume hood, on war footing, was added to the processing bench to avoid aerosol and droplet spread specially for fecal samples. for provocative tests e.g. sweat chloride test and hydrogen breath test the technical staff was required to wear n95 mask, face shields, gowns (with sleeves) and gloves. following sample collection, the procedure room was disinfected with hypochlorite and left vacant for at least 60 min for air changes before the next procedure. housekeeping cleaning schedules were re-defined and high exposure areas like the toilets, lifts, desks, tables were cleaned and wiped down several times a day with 5% hypochlorite and alcohol-based sanitizers as appropriate. the premises were mopped three times a day with disinfectant. discarded ppe and other clinical waste were collected in biohazard bags and disposed in a proper manner. the sectional safety officer was assigned the task of compliance monitoring. an integral component of our daily work-based learning is dissemination of new knowledge via one to one lecture by faculty and senior managers for technologists, post graduate trainees and trainee technologists, case-based discussion, instrumentation module for resident and journal clubs. to foster teaching and learning environment and continue the routine teaching-learning activities the section transitioned from face to face teaching sessions to online teaching activities. virtual learning environments were explored by the faculty and all live lectures and journal clubs were being conducted via microsoft teams for synchronous teaching with the provision of recording for those who miss it. after getting familiar with microsoft teams. the section has been conducting all administrative and educational meetings on microsoft teams or even zoom since the crisis started. the faculty was formally trained to operate these software's by the information technology department and further utilized as trainers for residents and other staff. feedback from the residents and technologists on the use of virtual podiums was positive as they can efficiently participate from their desk via their cell phones alongside the performance of other tasks assigned rather than scheduled events requiring their physical presence. most of the staff were demoralized by the pay cut and abandonment of appraisals, however they were encouraged by the leadership that the positive aspect is their jobs are maintained with provision of free health care amid the times of the crisis. cookies with a thank you note were distributed to the staff to create recognition. furthermore, the management was reinforced to ensure easily accessible channels for staff feedback and concerns. this covid pandemic is generating significant stress and anxiety in our laboratory personnel particularly in those with existing mental health problems, in those with elderly or infants at home and in those with chronic disease. it was essential for all laboratory personnel, seniors and junior staff, to remain connected throughout this crisis. one of the main reasons for stress came from a feeling of uncertainty. as fear and uncertainty continued, the only key was to spread positivity by staying connected [24, 25] . an important stress releaser activity at workplace is social networking with peers especially during intervals and time offs. initially our dedicated dining room's seating arrangements were not in compliance as adequate distance was not maintained. however, to keep the staff connected and ensure relaxation time temporary arrangements were made to split the seating and staff's interval schedules were redefined to ensure compliance with social distancing. most organization worldwide, including the pakistani masses were not prepared to face a looming threat of a covid-19 pandemic. the preparations for such a crisis never existed in the books of laboratories especially for resource constrained setups in developing world where most focus is on cost savings and revenue enhancement. while one cannot predict when the next major pandemic will occur. however, the results of the timely measures highlighted above will be more accurately evident in the times to come, a substantial success was achieved in terms of infection control as of today, and none of our staff was tested positive during the outbreak, despite handling covid positive samples. a few staff members were quarantined as part of the internal surveillance measures due to clinical suspicion or contact but their tests also turned negative and they resumed work after appropriate interval. a few salient lessons learnt from the crisis, which will enlighten the pathway for adequate workflow of the laboratory in the post covid-19 world are summarized as follows. â�¢ in times of such crisis, follow a proactive approach in anticipating and planning for the impact. crisis response teams should be part of the regular laboratory groups with appropriate training. if need arises, prior standard operating procedures addressing the challenges the lab faced during the pandemic should be in place for immediate referral. â�¢ the management, faculty and key stake holder should engage and coordinate formulating policies to tackle such emergency situations. the sectional leadership should pay special attention in identifying the "bottlenecks" in their respective domains for appropriate alternate plans. â�¢ decrease workload where possible in anticipation of depletion of resources. built infrastructure for home phlebotomy and sample collection to facilitate the patients in lock downs and prevent unnecessary movement and reduce probability of exposure in the laboratory phlebotomy stations. â�¢ establish staff segregation either spatially or temporally, work from s. ahmed, et al. annals of medicine and surgery 55 (2020) 300-304 teams to be encouraged in order to have a few back up personnel if the front liners are exposed and need to be isolated. â�¢ staff training on the use of virtual connectivity podiums e.g. microsoft teams and zoom should be part of the regular training regimen at the entry level. â�¢ it may be wise for educational institutes to encourage faculty to spend some of their time teaching online to gain experience and prepare themselves. â�¢ as lack of human interaction will be the new norm in the post pandemic scenario, work culture will need modification on the grounds of social distancing. all meetings and consultations are to be conducted online with maximum participation. social activities at the workplace including celebration parties, leisure breaks are to be halted. â�¢ rescheduling the tea and meal breaks for the staff in shifts, segregating the employs meal area with provision of limited seating and facility of prepacked meals ensured safety precautions are compliant. â�¢ salary cuts, postponed appraisals and the looming threat of losing their jobs created a negative impact on already disturbed mental status for most employs faced with painstaking objectors potentially risking the lives of their families when undertaking duties in a contagious outbreak. the lack of social activities further overburdened the scenario. managers as effective counsellors should play a role and keep the morale high for effective functioning. furthermore, the budget allocation should be diverted as such to ensure better incentives and remuneration; and may be fairer to give preference to groups that are more vulnerable. â�¢ post pandemic world with the anticipated overwhelming financial crisis, will require major resource allocation decisions for inventory management and prioritizing needs for new developments and projects. the post covid lab functioning was evidently different from the normal scenario. even though, the lab continued to serve 24/7, in all three shifts as prior; but the number of staff was reduced to minimize exposure. a significant time of the daily work place activities of clinical chemistry faculty and managerial staff is spent in quality control & quality assurance activities, administrative meetings, internal and external audits, teaching sessions, grand rounds, journal clubs etc. requiring physical interaction and interventions. however, amid the social distancing measures all such activities were transformed to virtual sessions, including a few temporary postponements. additionally, most of the staff were trained on using virtual platforms using self-directed learning, which is the new norm and essential skill for the post covid era. additionally, a literature review of approaches adopted by clinical laboratories worldwide during the pandemic, revealed a report from a united states of america based cytology laboratory, which implemented likewise measures specifically pertaining to social distancing, revision of certain policies, safety measures, re-evaluation of staffing needs, online meetings and virtual academic activities [26] . taken together, many questions remain for this emerging infection, the take home message derived is that a few of yesterday's practices and policies may be too old or irrelevant in the post covid-19 laboratory. as social distancing will be the new normal, a potential impact may be seen in an intensification of digital infrastructure of the laboratories, to allow few of the stakeholders to effectively function remotely in compliance with the regulatory and accreditation requirements [27] . new ways of ensuring cost cuttings and reaching a break-even point at minimum has to be formulated, keeping the interests and security of your frontline warriors in sight. with the current state of local spread in the country and amid the high chances of contracting covid-19, it is inevitable that the clinical laboratories take drastic measures and succumb to acceptable alternate plans for ensuring the safety and interests of its valuable employs alongside continuousness of provision of diagnostic services for better health outcomes, in times of the pandemic. we must be prepared to adapt to the constantly evolving phases and emergent scenarios during the pandemic with a proactive approach. we hope that other clinical chemistry laboratories globally will benefit from our experience in dealing with the covid-19 crisis. in 2020, we woke up in a different world, with different set of rules; for work environment, financial priorities and social norms, both at home and workplace. the earlier we adapt and embrace the change, the earlier we will be able to create a safe, workable, financial, social, environment for ourselves, our colleagues and families. not commissioned, externally peer reviewed. not required as it is a narrative review and does not include any human data or intervention. none. sa performed the majority of the writing work in the first draft. lj helped in designing the outline and the writing work. hm helped with references search and retrieval and gave suggestions to improve the first draft. ahk and fg did the critically revisions of the manuscript. is conceived the idea and coordinated the writing of the paper and reviewed the final draft. all authors have reviewed the final draft and agreed upon. not required. name of the registry: not requiredunique identifying number or registration id: not requiredhyperlink to your specific registration (must be publicly accessible and will be checked): who coronavirus disease (covid-19) situation report world health organization declares global emergency: a review of the s is pakistan prepared to tackle the coronavirus epidemic? review of covid-19 related deaths and recoveries for identification of suitable measures as alternative of partial lockdown is pakistan prepared for the covid-19 epidemic? a questionnaire-based survey pakistan's response to covid-19 pandemic and efficacy of quarantine and partial lockdown: a review what will be the economic impact of covid-19 in the us? rough estimates of disease scenarios the critical role of laboratory medicine during coronavirus disease 2019 (covid-19) and other viral outbreaks ascp-laboratories on the front lines: battling covid-19 report pathology services in developing countries: a challenge laboratory medicine resilience during coronavirus disease 2019 (covid-19) pandemic, ahead-of-print improved participation for blood lead screening with in-home phlebotomy remote treatment delivery in response to the covid-19 pandemic virtually perfect? telemedicine for covid-19 radiology department preparedness for covid-19: radiology scientific expert panel navigating the challenges of the covid-19 outbreak: perspectives from the radiation oncology service in singapore zoom: an innovative solution for the live-online virtual classroom meetings in teams, mastering microsoft teams building a foundation: poverty, development, and housing in pakistan inspections update are we ready for controlling community transmission of covid 19 in india? e-issn: 2455-7048 presumed asymptomatic carrier transmission of covid-19 world health organization, laboratory biosafety guidance related to coronavirus disease 2019 (covid-19): interim guidance managing mental health challenges faced by healthcare workers during covid-19 pandemic hopelessness, helplessness and resilience: the importance of safeguarding our trainees' mental wellbeing during the covid-19 pandemic the covid-19 pandemic: implications for the cytology laboratory the covid-19 pandemic in the usa: what might we expect? key: cord-315059-l6guql8q authors: mubarak, naeem title: corona and clergy: the missing link for an effective social distancing in pakistan. time for some unpopular decisions date: 2020-04-30 journal: int j infect dis doi: 10.1016/j.ijid.2020.04.067 sha: doc_id: 315059 cord_uid: l6guql8q nan countries. to begin with, more than half of the covid-19 cases in malaysia received virus 11 in a congregation of 16000 believers from 30 countries. [1] in iran, for weeks clergy repudiated 12 to ban gatherings of pilgrims in holy shrines till virus crossed the borders of neighbouring 13 countries. [2] tableeghi ijtima (annual, international muslim missionary gathering) in raiwind, 14 pakistan was a super-spreader of the virus due to "stubbornness of the clergy" that opposed 15 closing of the congregation, however, agreed to curtail. later, when the cases surged in the 16 attendees of this congregation, raiwind was completely sealed and declared a hotspot. more 17 than half of the cases in punjab (the mostly affected province) were emanated from raiwind 18 congregation (table 1) pakistan's case is of concern due to a fragile healthcare system, poor hygiene practices, 20 limited access to healthcare, and steep rise in the number of local cases in a population bigger 21 than italy and iran combined. evidence supports the substantial impact of social distancing as 22 a viable practice to contain the spread of the virus. [4] however, successful implementation of 23 any social practice requires public support. in pakistan, the practice of social distancing 24 an evaluation version of novapdf was used to create this pdf file. purchase a license to generate pdf files without this notice. author has no conflict of interest and source of funding to disclose for this manuscript. email: naeem.mubarak@lmdc.edu.pk tel: 00-92-42-37392215 muslim world, and cancelled umrah (pilgrimage). in kuwait, adhan (call for prayer)-an 41 unalterable element in islam since centuries-witnessed a slight change; instead of "hayya 42 alas-salah" (come to prayer), muezzins tweaked, "as-salatu fi buyutikum" (pray in your 43 homes). [6] 44 as who has warned worst is yet ahead [of] us", coming days would be more challenging 45 for pakistan to implement social distancing in the holy month of ramadan (26 th april) when 46 influx in mosques increases many-fold for daily prayers and tarawih (an additional prayer in 47 author has no conflict of interest and source of funding to disclose for this manuscript. email: naeem.mubarak@lmdc.edu.pk tel: 00-92-42-37392215 79 80 none of us have a fear of corona': the faithful at an 57 the new york times. accessed on 25 th sacred ignorance': covid-19 reveals iran split 3-government of pakistan, online covid-19 dashboard interventions to mitigate 66 early spread of sars-cov-2 in singapore : a modelling study covid-19: pakistan to allow mosques prayers in 70 how prayer is changing as a result of covid-19 key: cord-307697-ds4uw7y1 authors: ahmed, jawad; malik, farheen; bin arif, taha; majid, zainab; chaudhary, muhammad a; ahmad, junaid; malik, mehreen; khan, taj m; khalid, muhammad title: availability of personal protective equipment (ppe) among us and pakistani doctors in covid-19 pandemic date: 2020-06-10 journal: cureus doi: 10.7759/cureus.8550 sha: doc_id: 307697 cord_uid: ds4uw7y1 background the coronavirus disease (covid-19) pandemic has put an excessive strain on healthcare systems across the globe, causing a shortage of personal protective equipment (ppe). ppe is a precious commodity for health personnel to protect them against infections. we investigated the availability of ppe among doctors in the united states (us) and pakistan. methods a cross-sectional study, including doctors from the us and pakistan, was carried out from april 8 to may 5, 2020. an online self-administered questionnaire was distributed to doctors working in hospitals in the us and pakistan after a small pilot study. all analysis was done using statistical package for social science (spss) version 23.0 (ibm corp., armonk, ny). results after informed consent, 574 doctors (60.6% from pakistan and 39.4% from the us) were included in the analysis. the majority of the participants were females (53.3%), and the mean age of the participants was 35.3 ± 10.3 years. most doctors (47.7%) were from medicine and allied fields. among the participants, 87.6% of doctors from the us reported having access to masks/n95 respirators, 79.6% to gloves, 77.9% to face-shields or goggles, and 50.4% to full-suit/gown. whereas, doctors in pakistan reported to have poor availability of ppe with only 37.4% having access to masks/n95 respirator, 34.5% to gloves, 13.8% to face-shields or goggles, and 12.9% to full-suit/gown. the reuse of ppe was reported by 80.5% and 60.3% physicians from the us and pakistan, respectively. more doctors from pakistan (50.6%) reported that they had been forced to work without ppe compared to doctors in the us (7.1%). conclusion there is a lack of different forms of ppe in the us and pakistan. doctors from both countries reported that they had been forced to work without ppe. compared to the us, more doctors from pakistan reported having faced discrimination in receiving ppe. after informed consent, 574 doctors (60.6% from pakistan and 39.4% from the us) were included in the analysis. the majority of the participants were females (53.3%), and the mean age of the participants was 35.3 ± 10.3 years. most doctors (47.7%) were from medicine and allied fields. among the participants, 87.6% of doctors from the us reported having access to masks/n95 respirators, 79.6% to gloves, 77.9% to face-shields or goggles, and 50.4% to fullsuit/gown. whereas, doctors in pakistan reported to have poor availability of ppe with only 37.4% having access to masks/n95 respirator, 34.5% to gloves, 13.8% to face-shields or goggles, and 12.9% to full-suit/gown. the reuse of ppe was reported by 80.5% and 60.3% physicians from the us and pakistan, respectively. more doctors from pakistan (50.6%) reported that they had been forced to work without ppe compared to doctors in the us (7.1%). there is a lack of different forms of ppe in the us and pakistan. doctors from both countries reported that they had been forced to work without ppe. compared to the us, more doctors from pakistan reported having faced discrimination in receiving ppe. the novel coronavirus, initially originating from the hubei province of china, has spread to nearly every continent, overwhelming and straining even the most sophisticated healthcare systems [1] . the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is transmitted through inhalation or contact with infectious droplets. it may be asymptomatic early on in the course or present with mild respiratory symptoms, headache, fever, fatigue, nausea, vomiting, in addition to some reports describing hematological and cardiac involvement [2] . healthcare workers (hcws) or individuals who tend to coronavirus disease patients are at highest risk of contracting the infection. the prevention of the spread of infection to and from medical personnel solely lies in the effective use of personal protective equipment (ppe), including gloves, face masks, airpurifying respirators, goggles, face shields, respirators, and gowns. the rampant nature of covid-19 has created a shortage of ppe in high demand areas. the abrupt increase in the demand for ppe has to be met with an accelerated manufacturing and supply of ppe. many healthcare systems are failing to provide ppe due to financial or time constraints. there have been multiple reports of hcws protesting about the lack of appropriate ppe, and instances of doctors and other healthcare staff being forced into working without this precious commodity [3, 4] . the healthcare system of the united states (us) is known all over the world for its innovative and highly specialized patient care. the us spends a significant amount (17.1%) of the country's gross domestic product (gdp) on health care, which is far more on health care as a percentage of its economy than any other developed nation [5] . nonetheless, the us has the highest number of cases (1,432,265 cases and 87,180 deaths; may 18, 2020) of covid-19, and despite being the pinnacle of modern medicine, the healthcare system is strained and stretched to its very limits [6] . as expected, the situation in developing countries, with weaker healthcare infrastructure, is even direr. the covid-19 pandemic was confirmed to have reached pakistan on february 26, 2020 [6] . in pakistan, 42,125 cases have been reported with 903 deaths till may 18, 2020 [6] . consequently, the already struggling health care system of pakistan is not equipped for large pouring in of potentially infectious patients seeking testing and care [7] . resources are stretched thin, and the number of hcws being infected is rising every day. in this context, we sought to examine the availability of ppe in pakistan (a resource-constraint country) and the us (resource-rich country) as well as draw a comparison between the two in terms of availability, discrimination in distribution and perceived reasons for the shortage of ppe. a cross-sectional study was carried out among doctors in the us and pakistan using convenience sampling. the study duration was from april 8 to may 5, 2020. a self-administered questionnaire was made using google forms and was distributed to doctors in the us and pakistan via emails and social media platforms. the bias of receiving irrelevant (non-doctors) responses was reduced by posting the questionnaire on doctor/physician-only groups. the credibility of social media groups was ensured that they only admit licensed doctors after confirming their registration numbers and affiliations. the inclusion criteria consisted of three points, (1) a practicing doctor, (2) work in a hospital, and (3) currently working in pakistan or the us. responses of doctors working in private clinics were excluded from the study. explanation of the study's aim, as well as the informed consent form was present at the start of the questionnaire, permitting us to collect the data. a structured questionnaire consisting of four major parts was designed by authors (see appendices section). the initial draft of the questionnaire was sent to multiple senior doctors for evaluation, and all appropriate suggestions were incorporated in the questionnaire. the first part consisted of a brief explanation of the study, informed consent statement, and demographic variables such as country name, age, gender, the specialty of work, and hospital type (private or public). the second part consisted of questions to assess the availability of different forms of ppe, including n95 respirator, masks, gloves, eye protection (goggles or face shield), and full-suit/gown. the third part consisted of questions to assess any discrimination in ppe distribution, perceived reasons for its shortage, the extent of reuse of ppe, and to identify if doctors had been forced to work without ppe. the last part consisted of questions about the likelihood of quitting the job if adequate ppe was not provided and feelings of doctors working in the pandemic situation. in total, the questionnaire consisted of 33 items. a small pilot study was carried out among 10 doctors from each country (pakistan and the us) to ensure that no ambiguity exists in the questionnaire. recent contact with covid-19 patients was defined as a contact within the last three days of filling the questionnaire. all the data were entered and analyzed through statistical package for the social sciences software (spss version 23.0; ibm corporation, armonk, ny, us). results were drawn through descriptive statistics, and means with standard deviation were presented for continuous variables such as age and amount of money spent on purchasing ppe. categorical variables were reported as frequencies with percentages. chi-squared and independent sample t-tests were used to find statistical significance, and a p-value of <0.05 was considered significant for all analyses. a total of 574 doctors (268; 46.7% males) from both countries (60.6%; n = 348 from pakistan and 39.4%; n = 226 from the us) were included in the analysis. the mean age of participants was 35.3 ± 10.3 years, and most of the respondents (47.7%; n = 274) were from medicine and allied fields. the demographics of the participants are noted in table 1 ppe availability was reported significantly more (p < 0.001) among doctors in the us than doctors in pakistan. in the us, 53.1% (n = 120) doctors reported having access to all forms of ppes (including n95 respirators/masks, gloves, gowns/full-suits, and face-shields or goggles) in their hospitals, whereas only 12.6% (n = 44) of doctors in pakistan reported having this privilege. among the participants, 87.6% (n = 198) of doctors from the us reported having access to masks/n95 respirator, 79.6% (n = 180) to gloves, 77.9% (n = 176) to face-shields or goggles, and 50.4% (n = 114) to full-suit/gown. in contrast, doctors in pakistan reported to have poor availability of ppe with only 37.4% (n = 130) having access to masks/n95 respirator, 34.5% (n = 120) to gloves, 13.8% (n = 48) to face-shields or goggles, and 12.9% (n = 44) to full-suit/gown. more than half (58.4%; n = 132) of n95 respirator users in the us reported to have size-fitted masks, whereas only a quarter (25.9%; n = 90) of participants from pakistan reported sizefitting for their n95 respirator in pakistan. in our analysis, 80.5% (n = 182) and 60.3% (n = 210) doctors from the us and pakistan reported reusing ppe, respectively. the details of the frequency of reusing ppe for the us and pakistan are graphically presented in figure 1 . chi-squared test and independent sample t-test were used to find statistical significance between the variables. in the absence of ppe, significantly higher (p < 0.001) number of doctors in pakistan (81.0%; n = 282) reported to have kept working in contrast to doctors form the us (14.2%; n = 32). moreover, a significantly higher (p < 0.001) number of doctors from pakistan (49.4%; n = 172) reported that they had been "bullied into working" without ppe as opposed to the us doctors (7.1%; n = 16). shortage of supply (68.3%; n = 392) and inadequate/poor distribution management (41.1%; n = 236) were reported as the most common reasons for the lack of ppe ( table 2 ). other reasons reported by doctors from the us and pakistan are given in figure 2 . a total of 140 (24.4%) doctors, with 98 (28.2%) from pakistan and 42 (18.6%) from the us reported that they would "likely quit" their job and 32 (5.6%) doctors (the us = 8; pakistan = 24) proclaimed that they would "definitely quit" if they do not receive proper ppe in the future ( table 2) . almost three-fourth (73%; n = 254) doctors from pakistan and 58.4% (n = 132) from the us reported that hcws in their hospitals had been infected by covid-19. half of the respondents from the us (50.4%; n = 114) and pakistan (50.0%; n = 174) expressed that they felt scared working in a pandemic situation ( table 2) . almost one-third (31.6%; n = 110) doctors from pakistan and one-fourth (23%; n = 52) doctors from the us reported that they felt purposeful and proud of themselves for working in the pandemic (figure 3 ). the summarized results of the study and responses of doctors from both countries are presented in table 2 and table 3 . chi-squared test and independent sample t-test were used to find statistical significance between the variables. one of the most substantial strategies to protect both patients and hcws from transmittable pathogens is the adequate use of ppe. in our study, the availability of ppe was reported to be better among the us doctors as compared to pakistani doctors. more doctors in pakistan faced discrimination in receiving ppe, and the reuse of ppe was reported by the doctors from both countries. according to the world health organization (who), the essential supplies of ppe include gowns, gloves, masks or respirators, goggles, face shields, head cover, and rubber boots. since covid-19 is primarily transmitted by contact or droplet and its definite cure has not been discovered yet, the only significant and emotive subject for the hcws is ppe. the types of protection required to combat the specific mode of transmission include (1) gloves and aprons as contact precautions, (2) gloves, aprons, fluid-resistant surgical masks with or without eye protection (goggles or a visor) for droplet transmissions, and (3) gloves, fluid repellant longsleeved gowns, eye protection, and filtering facepiece 2/3 (ffp2/3) mask or n95 respirator during aerosol-generating procedures [8] . our study population comprised of doctors from two countries having a vastly different landscape of healthcare and helped us in comparing the difficulties faced by both countries in the face of a pandemic. a comparison of ppe availability in the us and pakistan with reports from the uk is shown in table 4 . our results are consistent with reports from the uk that some protective equipment such as gowns/full-suits and eye protection are scarce [4] . almost three-quarters of the doctors from pakistan reported that they were not size fitted for their n95 respirator. these results are alarming as the improper fitting of the n95 respirator reduces its efficacy and can make doctors susceptible to infection [9] . in our study, doctors from the us reported to have comparatively better access to ppes, however, they too, are struggling to maintain adequate ppe supply in light of the overwhelming influx of cases, and are not out of danger to get infected. for the worst-hit cities like new york and san francisco, donations were called for from the locals, to ease the state of desperation [1] . the strategic national stockpile (sns), which was responsible for making ppes available during epidemics of ebola virus and h1n1 influenza, is currently making an effort to balance between a quick distribution and restocking [1] . part of the problem could be attributed to the unpreparedness of the authorities despite multiple warnings of a possible influenza pandemic in the near future [10] . furthermore, the us had decreased its production of masks, gowns, and gloves and hugely relied on imports from countries like china [10] . in our study, more than one-third of the doctors from pakistan (35%) reported reusing one ppe for more than one week, while most of the doctors in the us (44%) reported reusing one ppe for two days. in times of extreme shortages and the rapidly increasing cases, the health and safety executive (hse) recently issued guidance that recommended reusing ppes, which followed a skeptical response by the hcws of england [11] . the guidance stated reusing water-resistant equipment and promoted the use of sealable bags for storage, whereas washable gowns or similar long-sleeved articles of clothing were advised as replacements for medical gowns [11] . in literature, several methods of disinfection have been described, which include the use of hydrogen peroxide vapors, ultraviolet (uv) radiation, moist heat, dry heat, and ozone gas, with hydrogen peroxide vapors being the most widely suggested technique [12] . reuse of ffp after appropriate measures has been considered a suitable alternative; however, it is uncertain to state the same for surgical masks [12] . although our study reported that a large majority of physicians from the us and pakistan reusing their pieces of equipment, the exact method of decontamination being administered is beyond the scope of this study and needs further evaluation. the dire shortage of protective gear does not seem to be the only concern of hcws worldwide as the biased distribution and supply further add to the trouble. analysis of our data showed that doctors from pakistan faced greater discrimination in receiving ppe, with one of the main reasons being lack of seniority in position, which is surprising since a large workforce in tertiary care hospitals comprises of junior training doctors. our study showed that 49.4% and 7.1% of doctors from pakistan and the us, respectively, were forced to work without ppe. when compared to the reports from the uk, where 56% of doctors felt pressurized to work despite inadequate ppe, our figures are lower, but they cannot be ignored [4] . news of doctor being arrested for demanding ppe in pakistan has also been reported [13] . several factors have contributed to the shortage of ppes on a global scale. one reason is the psychological 'fear of uncertainty' among masses, giving rise to panic buying and hoarding of masks and gloves along with other essential products. in the current era of globalization, the supply of any product is dependent on its demand; however, with the advent of this sudden calamity, the demand has escalated multiple folds in a short duration, leaving the suppliers struggling to keep up. disruption in the supply and demand graph has resulted in a higher equilibrium price, and certain opportunists are trading the life-saving essentials at staggering rates. another major aspect contributing to the crisis is the travel/export restrictions halting china's trade, which produces and supplies nearly 50% of the worldwide face masks along with other types of safety equipment [14] . the shortage of supplies on a global scale has not only rendered several nations to improvise and innovate but also highlighted the significance of national self-dependency. who, at the beginning of march 2020, advised the relevant industries and governments to ramp up the manufacturing of ppes by 40% to curb the ever-increasing demand [15] . regardless of the efforts of several non-governmental organizations (ngos) in pakistan to distribute ppes among doctors and donation of supplies from china as a gesture of goodwill, the level of protection of pakistan's hcws is nowhere near satisfactory. in the us, however, the role of ngos in contributing to ppe supply or healthcare system is limited, the reason being the notable difference in the socioeconomic status and spendings of both countries on their respective health budgets. even before the pandemic, the government-run tertiary-care hospitals of pakistan highly relied on the interventions from ngos and overseas donors, with the dependency increasing now more than ever. the majority of doctors in our study reported being scared of the current situation and feared that they might transmit the infection to their loved ones. the feeling is synchronous among doctors globally, particularly emergency room physicians, working in direct contact with the infected patients, and performing the intubation [16] . the fear of infecting loved ones was responded positively by the vast majority of both pakistani and the us doctors, with 98.9% and 97.3% responses, respectively. the figure is comparatively greater than that found in a survey performed by royal college of physicians (rcp), stating that 61% of respondents worrying about spreading the disease to family members [17] . almost 50% of participants of our study, from the us and pakistan, described feeling scared while working in a global pandemic. the study from rcp reported similar data, with 48% of their respondents feeling concerned about working in the current situation [17] . the fear among hcws is real and justified as the infectivity and mortality due to covid-19 is increasing every day. similarly, a study on the effect of the sars outbreak (2002-2009) on hcws described a significant sense of threat to life, vulnerability, along with the somatic and cognitive impact [18] . in our study, about 160 (46%) pakistani participants felt like quitting their job due to lack of ppe, which was higher than the response from the us doctors, 72 (31.9%) of which responded affirmatively. however, this figure is not in line with a study from greece published during the a/h1n1 influenza pandemic in 2009, where only 4.3% of hcws reported opting for leave to avoid contracting the virus [19] . even a recent article from the same country (greece) reported the willingness of hcws to work during the current pandemic to be unaffected [20] . the readiness to work, in turn, may be dependent on the socioeconomic status of a state, the trust of its service workers on government, and the severity of the situation. other factors may include but are not limited to gender, childcare responsibilities, personal safety, and protective measures [21] . in our study, 73% of doctors from pakistan and 58.4% from the us reported that hcws in their hospitals had been infected with covid-19. in china, an estimated 3,300 hcws were infected, and 22 expired due to "insufficient protective equipment" [22] . these statistics are alarming, for the war against covid-19 is yet to be over. as the number of infected/dead hcw rises, the anxiety and reluctance of other hcws to work will also increase [23] . the general public should be made aware of the fact that ppe is crucial for hcws on the frontline and n95 respirators, full-suits/gowns or eye protection are not required for daily life uses. it is suggested to introduce a proper surveillance system for the distribution of ppe among doctors in a healthcare setting. social media spreading unauthentic information and promoting black marketing to escalate prices should be banned. the shortage of ppe can cripple the healthcare system. as more healthcare personnel will get infected with covid-19, the workforce fighting against pandemic will decrease. a recent study conducted in a resourcelimited setting found that ward assistants have not been adequately educated about hygiene protocols [24] . educating ward assistants is equally important regarding the proper use of hand disinfectants and ppe, so they do not act as a vector for transmitting infections to healthy patients in this time of covid-19 pandemic. alternative methods for the conservation of these limited and indispensable commodities need to be employed. at present, some healthcare systems are disinfecting or reprocessing ppes using appropriate techniques reported by who or using telemedicine tools for performing medical exams as a form of electronic-ppe [25, 26] . furthermore, recommendations of reprocessing n95 respirators using hydrogen peroxide vapors or uv light have surfaced. although resourceful, these methods lack standardized protocols, and the efficacy of the disinfection process is still uncertain [25] . our study is limited by its online-survey nature, small sample size, and reporting bias, as some responses may be driven by personal emotions of doctors. to conclude, there is a shortage of ppe in hospitals of the us and pakistan due to covid-19 and doctors are feeling scared working without adequate protection in the pandemic situation. some doctors even reported that they are likely to quit their job if they do not receive proper ppe in the future. adequate ppe is crucial in the battle against covid-19, and radical steps need to be taken by hospital administrations and governments to make ppe more accessible to doctors and other hcws. there is a need to educate the general population regarding ppe usage and make them realize that doctors and other hcws are the ones that need them the most. further research is required on this topic that includes other healthcare personnel, and a need to study the opinion of the general population regarding ppe usage is suggested. availability of personal protective equipment (ppe) is a pressing issue for doctors working in covid-19 pandemic. the study aims to assess the availability of ppe to all doctors currently working. the data will be kept confidential and no names and institution details are required. if you meet the following criteria, only then please fill the form (1) are a practicing doctor, (2) work in a hospital (if you work in a private clinic you are ineligible to fill the questionnaire), and (3) working in pakistan or united states. by filling the questionnaire you agree to be part of the study and agree to provide information to the best of your knowledge. the study data will be used for publication in any journal. thank you for taking part in the study. your response has been recorded. human subjects: consent was obtained by all participants in this study. animal subjects: all authors have confirmed that this study did not involve animal subjects or tissue. conflicts of interest: in compliance with the icmje uniform disclosure form, all authors declare the following: payment/services info: all authors have declared that no financial support was received from any organization for the submitted work. financial relationships: all authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. other relationships: all authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. covid-19: the crisis of personal protective equipment in the us cardiac manifestations of coronavirus disease 2019 (covid-19): a comprehensive review. cureus. 2020 healthcare workers protest for vital protection equipment doctors lacking ppe "bullied" into treating covid-19 patients world health organization: united states of america world health organization: novel coronavirus (covid-19) situation reports drugs ther perspect. 2020 personal protective equipment during the covid-19 pandemic -a narrative review comparing the protective performances of 3 types of n95 filtering facepiece respirators during chest compressions: a randomized simulation study why america ran out of protective masks -and what can be done about it rimmer a: covid-19: experts question guidance to reuse ppe disposable masks: disinfection and sterilization for reuse, and non-certified manufacturing, in the face of shortages during the covid-19 pandemic pakistan doctors beaten by police as they despair of 'untreatable' pandemic china makes them, but has been hoarding them world health organization: shortage of personal protective equipment endangering health workers worldwide as coronavirus spreads, doctors fear for themselves -and their families nearly half of doctors fear for their health -survey psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital general hospital staff worries, perceived sufficiency of information and associated psychological distress during the a/h1n1 influenza pandemic covid-19 pandemic and its impact on mental health of healthcare professionals healthcare workers' willingness to work during an influenza pandemic: a systematic review and meta-analysis. influenza other respir viruses what hospitals and health care workers need to fight coronavirus protecting health care workers during the covid-19 outbreak: lessons from taiwan's sars response (epub only) compliance and knowledge of healthcare workers regarding hand hygiene and use of disinfectants: a study based in karachi world health organization: rational use of personal protective equipment for coronavirus disease ( covid-19) and considerations during severe shortages electronic personal protective equipment: a strategy to protect emergency department providers in the age of covid-19 key: cord-302842-idbmh1uo authors: raza, ali; khan, muhammad tariq iqbal; ali, qamar; hussain, tanveer; narjis, saadia title: association between meteorological indicators and covid-19 pandemic in pakistan date: 2020-10-14 journal: environ sci pollut res int doi: 10.1007/s11356-020-11203-2 sha: doc_id: 302842 cord_uid: idbmh1uo this study was designed to investigate the impact of meteorological indicators (temperature, rainfall, and humidity) on total covid-19 cases in pakistan, its provinces, and administrative units from march 10, 2020, to august 25, 2020. the correlation analysis showed that covid-19 cases and temperature showed a positive correlation. it implies that the increase in covid-19 cases was reported due to an increase in the temperature in pakistan, its provinces, and administrative units. the generalized poisson regression showed that the rise in the expected log count of covid-19 cases was 0.024 times for a 1 °c rise in the average temperature in pakistan. second, the correlation between rainfall and covid-19 cases was negative in pakistan. however, the regression coefficient between the expected log count of covid-19 cases and rainfall was insignificant in pakistan. third, the correlation between humidity and the total covid-19 cases was negative, which implies that the increase in humidity is beneficial to stop the transmission of covid-19 in pakistan, its provinces, and administrative units. the reduction in the expected log count of covid-19 cases was 0.008 times for a 1% increase in the humidity per day in pakistan. however, humidity and covid-19 cases were positively correlated in sindh province. it is required to create awareness among the general population, and the government should include the causes, symptoms, and precautions in the educational syllabus. moreover, people should adopt the habit of hand wash, social distancing, personal hygiene, mask-wearing, and the use of hand sanitizers to control the covid-19. the public health and global economy faced difficulties due to the outbreak of novel severe acute respiratory syndrome coronavirus 2 (sars-cov-2), which is responsible for coronavirus disease (covid-19) (briz-redón and serrano-aroca covid-19 spread . in china, both relative humidity and temperature significantly influenced the transmission of covid-19 (wang et al. 2020a) . sajadi et al. (2020) also mentioned the nexus between temperature, humidity, and respiratory viruses. the variations in the temperature and humidity also influenced the covid-19 mortality . prata et al. (2020) stated that it is hypothesized that variations in average temperature could significantly affect the covid-19. jahangiri et al. (2020) wrote that ambient temperature could be a crucial transmissibility factor behind covid-19. tosepu et al. (2020) explored the correlation between the covid-19 pandemic and weather indicators (minimum temperature, maximum temperature, average temperature, and rainfall) in jakarta, indonesia. spearman-rank correlation confirmed a significant correlation between covid-19 and temperature. in korea, the transmission of influenza was associated with relative humidity and low temperature. studies also highlighted that covid-19 was linked with meteorological factors . şahin (2020) explored the linkages between covid-19, population, and meteorological indicators (temperature, wind speed, dew point, and humidity) in turkey. the spearman's correlation confirmed the highest correlations score for population, temperature, and wind speed. bashir et al. (2020) revealed the link among climate indicators (average temperature, average humidity, rainfall, air quality, and wind speed) and covid-19 in new york, usa. correlation statistics confirmed a significant link between climate conditions and covid-19. however, no study explored the association between meteorological indicators and covid-19 in pakistan. the contribution of this study is (a) it first time examined the relationship between meteorological indicators and covid-19 in pakistan, (b) it first time examined the relationship between meteorological indicators and covid-19 in four provinces and three administrative units in pakistan, and (c) it used the generalized models to investigate the impact of average temperature, rainfall, and humidity on covid-19 cases. therefore, this study explored the impact of meteorological variables (temperature, average rainfall, and humidity) on coid-19 cases and infection rate. this study was designed to examine the link between meteorological variables and covid-19 cases in pakistan. pakistan ranked among top 20 countries, which were affected by the covid-19. pakistan is the 6th most populated country and ranked 36th according to the area in the world. pakistan is an agriculture-based developing country, having 1629 usd per capita income per annum (hussain et al. 2018) . pakistan is situated between longitudes 60°e-75°e and latitudes 24°n-37°n (ali 2018) . pakistan has four provinces such as punjab, sind, khyber pakhtunkhwa, and baluchistan; and three administrative units such as gilgit-baltistan, islamabad capital territory, and azad jammu and kashmir. pakistan has 2.08 (hussain et al. 2018) . pakistani climate shows regional diversity from arid to humid. pakistan is blessed with the monsoon rainfall in summer and western systems rainfall in winter. the climate of pakistan showed variations in the temperature (ali 2018 ). this study used covid-19 data (government of pakistan (gop) 2020a) in the case of pakistan from march 10, 2020, to august 25, 2020. the data of meteorological indicators like temperature (°c) and rainfall (mm) was obtained from the pakistan meteorological department (government of pakistan (gop) 2020b). the humidity (%) data was obtained from world weather online (world weather online 2020). the infection rate shows the speed of the covid-19 transmission, which was calculated as (ahmadi et al. 2020 data analysis the non-parametric tests (spearman's and kendall's rank correlations) were used to investigate the association between two variables. these tests were computed on ranks and depicted a monotonic association (hamadeh et al. 2017 ). spearman's rank correlation coefficient was used to investigate the correlation between meteorological variables and covid-19 cases and infection rate. it used a monotonic function to analyze the association between two variables. spearman's rank correlation coefficient is estimated as (şahin 2020): where n shows the number of alternatives, and d i shows the gap among ranks of two parameters. the coefficient of kendall's rank correlation (τ) was estimated as (kocsis and anda 2018) : where s shows trend and d shows data pairs using n members of dataset (kocsis and anda 2018) : regression analysis a generalized linear model was found useful to assess the link between covid-19 cases and different factors (prata et al. 2020) . the generalized additive model (gam) established a univariate response variable y, to predictor variables xi. the exponential family of distribution was specified for y like poisson, normal, and binomial (goswami et al. 2020) . the relationship between meteorological variables and covid-19 cases was explored using gam, to fit equations and splines. the gam fitted for parametric and nonparametric regression and smoothing. it was used to estimate the linear and nonlinear association between meteorological factors and health indicators ). an additive and semiparametric polynomial model was expressed as (prata et al. 2020) : where y shows the covid-19 cases in pakistan, its provinces, and administrative units on day t, β 0 represents the intercept, s(•) shows a spline function with two degrees of freedom to control over-fitting wang et al. 2018) , β shows the parameter of x, and x shows the days since the first outbreak, at represents average daily temperature (°c), rf shows the average rainfall (mm), and hum shows the average humidity per day (%). the explanatory variables were controlled for confounding using expression s(•). the smoothing spline function could control the effects of confounding factors . ma et al. (2020) used gam to explore the relationship between meteorological variables (temperature and humidity) and covid-19 death in china. the gam model used both linear and nonparametric trends to optimize the linear model. however, prata et al. (2020) mentioned the statistical significance of a linear association between meteorological variables and covid-19, which was expressed as (prata et al. 2020) : a dose-response function f connected several explanatory variables (dose x), with a probability of infection (response f(x)) (brouwer et al. 2017) . the dose-response association was normally expressed graphically and showed different mathematical distributions to express a clear relationship (sullivan et al. 2005) . mathematically, a dose-response relationship showed the expectation of potential loss as a function of different environmental indicators (ye et al. 2020) . chuang et al. (2016) used gam to explore the dose-response association between the daptomycin dose and mortality. in the present study, the gam was applied to establish a dose-response function, which connected different dose variables (outbreak days, average temperature, rainfall, and humidity), with a probability of covid-19 infection (response variable). li et al. (2019) used the poisson model to explore the association between total cases and meteorological variables. poisson regression is a commonly used classical model, which was based upon the classical assumptions. it was further assumed that the dependent variable had poisson distribution, as the random variable showed a value 0, 1, 2, 3, … n. it explained the distribution of y i or the expected value y i by the explanatory variables x i , as expressed below (cupal et al. 2015) : the count data models assumed that the count variable y i for given x i had a poisson distribution. where y! shows y factorial. substituting the appropriate functional form for λ i produced expressions for the probabilities used to construct the log-likelihood function for this model, called the poisson regression model. the generalized poisson regression was capable to explain the count data with any type of dispersion. it incorporated both positive and negative correlation between response variables (consul and famoye 1992; famoye 2014) . the generalized poisson regression was beneficial in the presence of over-dispersion (var(y i ) > e(y i )) and under-dispersion (var(y i ) < e(y i )). according to the generalized poisson distribution, the probability density function of y i was expressed as (famoye 1993; maxwell et al. 2018) : where x i shows a (k-1) dimensional vector of covariates such as driving habits, demographic factors, and medication use, and β shows (k-1) dimensional vector of regression parameters. it assumed that: the generalization of standard poisson regression was called generalized poisson regression (maxwell et al. 2018 ). this study also used generalized poisson regression to assess the link between meteorological variables and covid-19 cases. the empirical analysis was performed using r software, stata 15, and eviews 10. the trend of covid-19 and meteorological indicators in pakistan figures 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11 show the trend of meteorological indicators (temperature, rainfall, and humidity), day-wise covid-19 cases, and total covid-19 cases in pakistan from march 10, 2020, to august 25, 2020. figure 2 shows that the day-wise trend showed a continuous increase in pakistan up to june 13, 2020. after that, the reduction in the day-wise covid-19 cases was reported in pakistan. the covid-19 cases were 482 on august 25, 2020. however, there were some fluctuations in the day-wise confirmed cases. figure 3 shows the daywise cases in provinces and administrative areas. it was cleared that the day-wise increase was more in punjab and sindh provinces. it might be due to the higher population and population density in punjab and sindh. figure 4 shows the trend of total covid-19 cases in pakistan. it showed a rapid increase in the total covid-19 cases from march 10, 2020, to june 13, 2020. after that, covid-19 cases were increased at a decreasing rate. figure 5 shows total covid-19 cases in provinces and administrative areas. it is cleared that the total covid-19 cases were higher in sindh province followed by punjab, khyber pakhtunkhwa, islamabad capital territory, baluchistan, gilgit-baltistan, and azad jammu and kashmir. it was cleared that punjab and sindh provinces were mostly affected by the covid-19. figure 6 shows the trend of average temperature in pakistan. there are fluctuations in average temperature in pakistan. however, there was an increasing trend in average temperature from march 10, 2020, to may 27, 2020. after that, there was no significant increase in temperature, but it shows fluctuation in average temperature. figure 7 shows the average temperature in provinces and administrative areas. the average temperature was higher in sindh province followed by punjab, baluchistan, islamabad capital t e r r i t o r y , a z a d j a m m u a n d k a s h m i r , k h y b e r pakhtunkhwa, and gilgit-baltistan. the average temperature also showed fluctuations in provinces and administrative units. figure 8 shows the trend of average rainfall per day in pakistan. there was no specific trend in the rainfall per day in pakistan due to the presence of fluctuations between march 10, 2020, and august 25, 2020. figure 9 shows the average rainfall per day in provinces and administrative units. average rainfall per day also showed fluctuations in all provinces and administrative units. however, average rainfall per day showed upward spikes after the covid-19 outbreak in pakistan. the trend of humidity (fig. 10) shows a decreasing trend from march 10, 2020, to june 17, 2020. after that, there was an increasing trend of humidity in pakistan. figure 11 shows the humidity in provinces and administrative units. the humidity also showed fluctuations in all provinces and administrative units between march 10, 2020, and august 25, 2020. an increasing trend of humidity was found in sindh province. however, other provinces and administrative units showed a minor reduction in humidity up to the first week of june 2020. after that, the increasing trend of humidity was observed in provinces and administrative units. however, fluctuations in humidity were also observed in provinces and administrative units. tables 2 and 3 show the spearman's and kendall's rank correlation analysis. the five meteorological variables like temperature (minimum, maximum, average), rainfall, and humidity were used in correlation analysis with total covid-19 cases (table 2) and covid-19 infection rate (table 3) . both spearman's and kendall's rank correlation shows the same direction between selected variables. tosepu et al. (2020) used weather-related indicators in the case of jakarta. but this study used these variables for the country level (pakistan) as well as provincial l e v e l ( p u n j a b , s i n d h , b a l u c h i s t a n , k h y b e r pakhtunkhwa, islamabad capital territory, gilgit-baltistan, and azad jammu and kashmir). the results showed that temperature (minimum, maximum, and average) has highest correlation coefficient. therefore, average temperature is closely linked with the covid-19 cases. it implies that the covid-19 cases increased in pakistan due to an increase in average temperature, which was in line with the results of tosepu et al. (2020) in the case of jakarta, indonesia. a positive correlation was also observed between total cases and average temperature in new york, usa, which was badly a f f e c t e d b y c o v i d -1 9 ( b a s h i r e t a l . 2 0 2 0 ) . temperature is an environmental factor behind covid-19 spread in china . contrarily, şahin (2020) reported an increase in covid-19 cases due to a reduction in average temperature in turkey. sobral et al. (2020) also reported a reduction in infections due to an increase in temperature. in past studies, bi et al. (2007) also reported an inverse correlation between sars cases and temperature in beijing and hong kong. the diversified results between temperature and covid-19 cases were due to the fact that the impact of temperature on human health may vary between different regions or countries (hajat and kosatky 2010; sobral et al. (2020) . the literature highlighted that influenza and sars-cov viruses survived only under specific climatic conditions and their transmission rate was sensitive to increasing temperature (chan et al. 2011; jaakkola et al. 2014) . second, correlation between average rainfall and covid-19 cases was negative and significant in pakistan, which implies the reduction in covid-19 cases due to rainfall in pakistan. however, those findings were not in line with findings of tosepu et al. (2020) in the case of jakarta, indonesia. it seems that weather and covid-19 behavior was different in pakistan and indonesia. another study (bashir et al. 2020) showed an insignificant correlation between rainfall and covid-19 cases in new york, usa. contrarily to tosepu et al. (2020) , correlation between humidity and the total covid-19 cases was negative in pakistan, which implies the reduction in covid-19 cases due to an increase in the level of humidity in pakistan. the reduction in covid-19 cases due to a rise in the level of humidity was also reported in turkey (şahin 2020) . it means that pakistan and turkey showed similarities with respect to covid-19 and humidity. it was also noted that the absolute value of negative correlation between humidity and covid-19 cases was higher in pakistan (0.742) as compared to turkey (0.317) (şahin 2020). moreover, ma et al. (2020) also indicated a reduction in covid-19 cases due to higher humidity in china. chan et al. (2011) pointed out that higher relative humidity eliminated the virus viability, which supported the findings of the present research. along with environmental factors, population (zu et al. 2020) , population density, medical care (wang et al. 2020b ), people's endurance, social distancing, and health facilities (bashir et al. 2020) were also possible reasons behind spread or control of covid-19. a higher correlation coefficient was observed between temperature (minimum, maximum, and fig. 11 humidity in provinces and administrative areas environ sci pollut res average) and covid-19 cases for all provinces and administrative units (punjab, sindh, baluchistan, khyber pakhtunkhwa, islamabad capital territory, gilgit-baltistan, and azad jammu and kashmir). the correlation between rainfall and covid-19 cases was significant and negative in the case of khyber pakhtunkhwa and baluchistan. it implies that the increase in rainfall was linked with a reduction in covid-19 cases. a positive correlation was reported between rainfall and covid-19 cases in gilgit-baltistan. in general, humidity had a negative correlation with covid-19 cases in punjab, baluchistan, khyber pakhtunkhwa, islamabad capital territory, gilgit-baltistan, and azad jammu and kashmir. however, sindh province showed different behavior due to a positive correlation between humidity and covid-19 cases. to control the covid-19, it is required to reduce the infection. the results (table 3) showed that temperature (minimum, maximum, and average) has highest correlation coefficient. therefore, average temperature was linked with the infection rate. it implies that the covid-19 infection increased due to an increase in average temperature. second, correlation between average rainfall and the covid-19 infection rate was negative in pakistan. a negative correlation was observed between humidity and covid-19 infection rate. this study also explored the correlation between meteorological indicators and the covid-19 infection rate in the case of provinces. the positive correlation coefficient was observed between temperature (minimum, maximum, and average) and covid-19 infection for all provinces and administrative units. the correlation between rainfall and the covid-19 infection rate was significant in sindh and azad jammu and kashmir. in general, humidity had a negative correlation with covid-19 cases the gam explored the association between meteorological variables (temperature, rainfall, and humidity) and the covid-19 cases in pakistan, its provinces, and administrative units. figure 12 explains the dose-response link between average temperature and covid-19 cases using the gam. initially, there was a direct association between temperature and covid-19 cases, but the curve showed a flatter shape when average temperature lies between 25 and 30°c. the rise in the covid-19 cases was also observed when average temperature was more than 30°c. the temperature was positively linked with the covid-19 cases in jakarta, indonesia (tosepu et al. 2020) , and new york, usa (bashir et al. 2020) . in punjab, the covid-19-temperature curve showed a positive slope initially, but it was flattered when average temperature was more than 23°c. there was an inverse link between covid-19 and temperature in gilgit-baltistan, and azad jammu and kashmir. temperature and the covid-19 cases were positively associated in sindh and baluchistan. in khyber pakhtunkhwa and islamabad capital territory, the covid-19 cases increased when the temperature was low, but there was a reduction in the covid-19 cases when the temperature was higher. figure 13 explains the dose-response link between rainfall and covid-19 cases per day, showed an increase in covid-19 cases due to rainfall initially, but the curve was flattered when the rainfall was more than 20 mm per day. an insignificant association between rainfall and covid-19 cases was reported in jakarta, indonesia (tosepu et al. 2020) and new york, usa (bashir et al. 2020) . the dose-response curve between covid-19 and rainfall was positively sloped in sindh, baluchistan, and khyber pakhtunkhwa, but it was not much steeper. the curve between covid-19 cases and rainfall seemed like a flatter curve in islamabad capital territory, gilgit-baltistan, and azad jammu and kashmir. figure 14 explains the presence of an inverse dose-response curve between humidity and covid-19 cases in pakistan. the curve was steeper when humidity was more than 70%. the inverse relationship between covid-19 cases and humidity was also reported in turkey (şahin 2020) and china ) because higher relative humidity eliminated the virus viability (chan et al. 2011) . the dose-response curve showed a reduction in covid-19 cases due to a rise in humidity in islamabad capital territory, gilgit-baltistan, and azad jammu and kashmir. the curve was downward sloped between covid-19 and humidity in punjab, baluchistan, and khyber pakhtunkhwa, but it showed a positive trend in the presence of a higher level of humidity. table 4 shows the impact of average temperature, rainfall per day, and humidity using time-series generalized poisson regression in pakistan, its provinces, and administrative units. yuan et al. (2006) also used regression analysis to reveal the impact of temperature, wind speed, and relative humidity on sars transmission. temperature and humidity were significant factors in the seasonal spread of coronaviruses (sajadi et al. 2020) . results showed that the increase in the expected log count of covid-19 cases was 0.024 times for a 1°c rise in average temperature in pakistan. it implies that the increase in temperature was favorable to control the covid-19 in pakistan. the regression analysis of provincial and administrative units showed that the increase in expected log count of covid-19 cases was 0.086 times in sindh, 0.095 times in khyber pakhtunkhwa, and 0.156 times in baluchistan for 1°c rise in average temperature. the rise in the covid-19 cases due to an increase in average temperature was also reported in jakarta, indonesia (tosepu et al. 2020) , and new york, usa (bashir et al. 2020) . xie and zhu (2020) also considered that temperature was a factor in covid-19 transmission. wu et al. (2020) described that the increase in new cases was 3.08% for a 1°c rise in temperature. however, coefficient of average temperature was insignificant in punjab, azad jammu and kashmir, islamabad capital territory, and gilgit-baltistan. the impact of rainfall on covid-19 cases was insignificant in pakistan. it implies that the increase in rainfall per day was not a significant factor behind the covid-19 transmission in pakistan. the increase in expected log count of covid-19 cases was 0.019 times in punjab and 0.020 times in khyber pakhtunkhwa for 1mm increase in rainfall per day. however, coefficient of rainfall was insignificant in sindh, baluchistan, azad jammu and kashmir, islamabad capital territory, and gilgit-baltistan. on the other hand, a reduction in the expected log count of covid-19 cases was 0.008 times for a 1% increase in humidity per day in pakistan. it implies that the increase in humidity was beneficial to stop covid-19 transmission in pakistan. the provincial and administrative units also showed that the reduction in expected log count of total covid-19 cases was 0.015 times in punjab, 0.018 in islamabad capital territory, and 0.027 times in azad jammu and kashmir for 1% increase in humidity. however, an insignificant link between covid-19 cases and humidity was observed in sindh, baluchistan, khyber pakhtunkhwa, and gilgit-baltistan. wu et al. (2020) described 0.85% reduction in covid-19 cases for a 1% increase in relative humidity. chan et al. (2011) pointed out that the higher relative humidity eliminated the virus viability, which supported the empirical results. however, some other meteorological indicators (air quality and wind speed) could also affect the transmission of infectious diseases ). public health and the global economy faced huge problems due to covid-19. this study was designed to investigate the impact of meteorological indicators (temperature, rainfall, and humidity) on total covid-19 cases and covid-19 infection rate in pakistan from march 10, 2020, to august 25, 2020. the correlation analysis implies that the covid-19 cases increased due fig. 12 the dose-response curves between average temperature and covid-19 cases to a rise in average temperature in pakistan, its provinces, and administrative units. the dose-response relationship showed a direct association between temperature and covid-19 cases but the curve was flattered when average temperature lies between 25 and 30°c in pakistan. the increase in covid-19 cases was also observed when average temperature was more than 30°c in pakistan. the results of generalized poisson regression showed that the increase in the expected log count of covid-19 cases was 0.024 times for a 1°c rise in average temperature in pakistan. second, correlation between average rainfall and covid-19 cases was negative in pakistan. the dose-response curve showed an increase in covid-19 cases due to rainfall initially but the curve was flattered when the rainfall was more than 20 mm per day. third, correlation between humidity and the total fig. 13 the dose-response curves between rainfall and covid-19 cases covid-19 cases implies the reduction in covid-19 cases due to an increase in humidity in pakistan. the dose-response curve between humidity and covid-19 cases showed the presence of an inverse relationship between humidity and covid-19 cases in pakistan. the downward slope curve becomes steeper when humidity was more than 70%. the reduction in the expected log count of covid-19 cases was 0.008 times for a 1% increase in humidity in pakistan. it implies that the increase in humidity was beneficial to stop the covid-19 transmission. this study also had some limitations like (a) total covid-19 cases also included those pakistani citizens, which were affected abroad and moved to pakistan with covid-19 symptoms, (b) it is also important to include some other factors like virus resistance, population mobility, and immunity, (c) the spread of covid-19 also depends upon some precautionary measures such as hand wash habits, social funding this research has no funding from any organization. availability of data and material data will be available on request. conflicts of interest the authors declare that they have no conflict of interest. ethical approval this article does not contain any studies with human participants or animals performed by any of the authors. consent to publish not applicable investigation of effective climatology 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from china quantifying livestock vulnerability to snow disasters in the tibetan plateau: comparing different modeling techniques for prediction a climatologic investigation of the sars-cov outbreak in beijing, china association between ambient temperature and covid-19 infection in 122 cities from china coronavirus disease 2019 (covid-19): a perspective from china publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-285223-07o9irev authors: malik, usman rashid; atif, naveel; hashmi, furqan khurshid; saleem, fahad; saeed, hamid; islam, muhammad; jiang, minghuan; zhao, mingyue; yang, caijun; fang, yu title: knowledge, attitude, and practices of healthcare professionals on covid-19 and risk assessment to prevent the epidemic spread: a multicenter cross-sectional study from punjab, pakistan date: 2020-09-02 journal: int j environ res public health doi: 10.3390/ijerph17176395 sha: doc_id: 285223 cord_uid: 07o9irev in the current outbreak of novel coronavirus (covid-19), healthcare professionals (hcps) have a primary role in combating the epidemic threat. hcps are at high risk of not only contracting the infection but also spreading it unknowingly. it is of utmost importance to evaluate their knowledge, attitudes, and practices (kap) and the ability to assess the risks associated with the outbreak. a cross-sectional online survey involving physicians, pharmacists, and nurses was conducted. a 39-itemed questionnaire based on the world health organization (who)covid-19 risk assessment tool was shared with healthcare professionals in three purposively selected key divisions of punjab province. out of 500 healthcare professionals, 385 responded to the survey. the majority (70%) were aged 22–29 years; 144 (37.4%) physicians, 113 (29.4%) nurses, and 128 (33.2%) pharmacists completed the survey. overall, 94.8% of healthcare professionals scored adequately (>14) for covid-19-related knowledge; 97.9% displayed an optimistic attitude (>42) and 94.5% had an adequate practice score (>28). kruskal–wallis and jonckheere–terpstra tests showed significant differences (p < 0.05) in kap and risk assessment scores among groups; physicians and nurses scored higher as compared to pharmacists. further research and follow-up investigations on disaster management and risk assessment can help policy-makers better tackle future epidemics. the first-ever cases of novel coronavirus were reported by the world health organization (who) regional office in beijing, china, on 31 december 2019, when a few patients were diagnosed with pneumonia in the city of wuhan in china [1] . the wuhan institute of virology declared a new strain of coronavirus as a causative agent of this new deadly pneumonia and listed it as a novel coronavirus disease (ncov-2019) [2] . later, the disease was officially named as covid-19 by the who [3] . initially reported in china, the disease started being reported in nearby neighboring countries, and until 20 january 2020, new cases were also confirmed in thailand, japan, and south korea. the first situation report by who issued on 21 january 2020 on the novel coronavirus reported 282 confirmed cases of the disease in china and other affected neighboring countries [4] . since then, the disease transmitted to various parts of the world, and on 30 january 2020, the who declared the novel coronavirus disease to be a public health emergency of international concern. soon after, the disease became a global threat to public health and economies, finally transforming into a pandemic disease. on 11 march 2020, the who officially declared covid-19 as a pandemic disease due to the alarming levels of an upsurge in the spread and severity of the disease [5] . the disease spread rampantly, and according to who reports, by 19 july 2020 the disease had shown its notorious presence in around 213 countries with more than 14 million confirmed covid-19 cases and nearly 0.6 million deaths worldwide [6] . healthcare workers have a critical role in lowering morbidity and mortality but in doing so they are directly exposed to patients and the causative agents. preventing nosocomial infections and protecting healthcare workers posed great challenges to the healthcare system during the initial covid-19 outbreak in china [7] . healthcare professionals (hcps) are at a high risk of infection from the patients if they do not have ample knowledge and awareness about the disease or if they do not take adequate precautionary measures. in china, 2050 cases of covid-19 were reported in healthcare workers as of 20 february 2020; the majority of the cases were due to lower awareness and experience of handling the disease [8] . avoiding cross-infection from patients along with effective care delivery can be achieved if the healthcare professionals, including physicians, pharmacists, nurses, and other medical staff, have sufficient knowledge, a positive attitude, and better practices about covid-19. in addition, better preventive policies and risk assessment of healthcare teams are crucial for an effective response to new emerging pandemics such as covid-19 [9] . in pakistan, the incidence of coronavirus disease was initially reported on 26 february 2020 in two persons who returned from the epidemic-affected region of iran [10] . until 14 march 2020, there were only 31 confirmed covid-19 cases. however, afterwards, a dramatic escalation was observed, and the number of cases rose stupendously. by 21 june 2020, the confirmed cases in pakistan had crossed a figure of 174,200 and the new cases were gaining momentum [11] . deaths of healthcare professionals as a result of exposure to covid-19 patients have been reported in countries including the usa, the uk, china, and italy [12, 13] . a recent study reported the deficiencies in the awareness and preparedness of medical professionals regarding covid-19 in pakistan and demonstrated that frontline health workers were not well-prepared to prevent and control the infection [14] . keeping in view the severity of the outbreak and the importance of healthcare professionals working with scarce resources to combat covid-19, it was pertinent to evaluate their knowledge, attitude, practices, and risk assessment skills. a cross-sectional study to examine the knowledge, attitude, practices, and risk assessment of hcps regarding coronavirus and its associated disease (covid-19) was conducted. these data were collected from 21 march 2020 after the covid-19 cases began increasing in pakistan, and were completed on 20 april 2020. pakistan is composed of five provinces, with punjab being the most populous province of pakistan (hosting >50% of total population) having a population of about 110 million [15] . out of nine administrative divisions in the punjab province, three key divisions (lahore, multan, and rawalpindi, representing the north-east, southern, and northern parts of punjab province, respectively) were purposively selected. healthcare professionals working in tertiary and secondary hospitals along with nearby located community pharmacies were chosen as the target population, thus covering both public and private sector hcps (figure 1 ). respectively) were purposively selected. healthcare professionals working in tertiary and secondary hospitals along with nearby located community pharmacies were chosen as the target population, thus covering both public and private sector hcps ( figure 1 ). the study was conducted on doctors (general physicians), hospital and community pharmacists, and nurses who dealt with management and control of the covid-19 disease. these participants included hcps working in various private and public sector (secondary and tertiary care) hospitals and those working at community pharmacies located close to the hospitals. all registered hcps with their respective councils (pakistan medical and dental council, pakistan nursing council, and pharmacy council of pakistan) who were dealing with covid-19 cases, regardless of their experience, age, gender, and socioeconomic status, were included in the study. unregistered hcps and those returning incomplete surveys were excluded during the data analysis phase. participation in the survey was purely on a voluntary basis, and the participants could choose to quit the survey at any stage. in order to obtain robust and complete information, we requested that the participants responded to all questions of the survey. there are 107,112 physicians (including the general physicians and specialists) [16] , 64,846 nurses [17] , and 21,954 pharmacists in punjab province, thus totaling to a population size of 193,912 [18] . raosoft sample size calculator was used to select the sample size with a 95% confidence level, 5% margin of error, and a population size of 193,912. the resultant sample size of 384 was calculated to be a representative of the health care professional population in punjab province. keeping in mind a 20% dropout, in order to achieve an optimal response rate, a total of 500 healthcare professionals were approached online through the whatsapp© application (copyright 2020 whatsapp inc., menlo park, ca, usa) and cellular phone calls by using the purposive sampling method. the questionnaire was designed based on the latest who risk assessment and management of healthcare workers in the context of covid-19 tool [19] and published literature on previously spread viral epidemics in various parts of the world [20, 21] . initially, the questionnaire consisted of the study was conducted on doctors (general physicians), hospital and community pharmacists, and nurses who dealt with management and control of the covid-19 disease. these participants included hcps working in various private and public sector (secondary and tertiary care) hospitals and those working at community pharmacies located close to the hospitals. all registered hcps with their respective councils (pakistan medical and dental council, pakistan nursing council, and pharmacy council of pakistan) who were dealing with covid-19 cases, regardless of their experience, age, gender, and socioeconomic status, were included in the study. unregistered hcps and those returning incomplete surveys were excluded during the data analysis phase. participation in the survey was purely on a voluntary basis, and the participants could choose to quit the survey at any stage. in order to obtain robust and complete information, we requested that the participants responded to all questions of the survey. there are 107,112 physicians (including the general physicians and specialists) [16] , 64,846 nurses [17] , and 21,954 pharmacists in punjab province, thus totaling to a population size of 193,912 [18] . raosoft sample size calculator was used to select the sample size with a 95% confidence level, 5% margin of error, and a population size of 193,912. the resultant sample size of 384 was calculated to be a representative of the health care professional population in punjab province. keeping in mind a 20% dropout, in order to achieve an optimal response rate, a total of 500 healthcare professionals were approached online through the whatsapp© application (copyright 2020 whatsapp inc., menlo park, ca, usa) and cellular phone calls by using the purposive sampling method. the questionnaire was designed based on the latest who risk assessment and management of healthcare workers in the context of covid-19 tool [19] and published literature on previously spread viral epidemics in various parts of the world [20, 21] . initially, the questionnaire consisted of 60 questions on knowledge, attitude, practices, and risk assessment. however, after content and face validity by five experts in clinical practice, pharmacy, and academia (two classified physicians, two pharmacists, and one professor of pharmacy practice), the questionnaire was reduced to 39 questions/items (see supplementary file). initially, a pilot study was conducted and data of 50 participants were used to determine the internal consistency of the questionnaire by calculating the cronbach's alpha value. the cronbach's alpha value of the questionnaire was calculated to be 0.74, which indicated an acceptable level of internal consistency. the final questionnaire had four sections with 39 questions/items. the basic information from all the participants regarding their age, gender, marital status, level of education, occupation, and type of organization was obtained in the demographics section. the second section contained 19 questions about the basic knowledge of coronavirus disease with three options ("yes", "no", and "do not know"). the knowledge was assessed by giving the value 1 to a correct answer and 0 to the wrong answer. the "do not know" response was also processed as 0. the scale measured knowledge score from a maximum of 19 to minimum of 0. scores <9 were taken as poor, 9-14 average, and >14 as adequate knowledge of covid-19. the third section constituted 12 questions on the attitude of healthcare professionals and was rated using a 5-point likert scale varying from "strongly disagree" to "strongly agree". the attitude was assessed by giving value 1 to "strongly disagree" and 5 to the "strongly agree" response. reversed scoring was utilized for negative questions. the scale measuring attitudes ranged from 12 to 60. scores ≤42 were taken as negative while >42 were taken as a positive attitude towards covid-19. the fourth section had 8 questions on covid-19-related practices and risk assessment (4 on practices and 4 on risk assessment) rated on a 5-point likert scale: "always", "mostly", "sometimes", "rarely", and "never". this scale measured practices and risk assessment from a maximum score of 40 to a minimum of 8. scores ≤28 were taken as poor practices while >28 were taken as good practices towards covid-19. keeping in mind the lockdown situation, for the purpose of study, we developed an online google form of the questionnaire that we shared with healthcare professionals. the google form was shared with the participants through the whatsapp platform and the participants were requested via cellular phone calls to fill the online survey. continuous weekly reminders were given both through cellular phone calls and whatsapp to ensure optimal participation. participants were also guided about the aims and objectives of the study and informed consent was obtained verbally to make sure they understand each aspect of the study before filling the survey form. ethical approval was obtained from the human ethics committee at the university college of pharmacy, university of the punjab, lahore, pakistan, no. d/hec/112/ucp2340 and the biomedical ethics committee at xi'an jiaotong university, xi'an, china. the data from the google forms was imported to spss (version 22.0, ibm, chicago, il, usa) and analyzed. descriptive statistics were performed by calculating the frequencies and proportions. the scores on knowledge, attitude, and practices & risk assessment were calculated from a total of 19, 60, and 40 points, respectively. the correct responses for all the questions were determined from the guidelines developed by the who for general public and healthcare workers. data were checked for normality by the kolmogorov-smirnov test and shapiro-wilk's test. these tests indicated that the data were not normally distributed, with a p-value < 0.05 and skewness of −0.702(standard error (s.e.) = 0.124), −0.317 (s.e. = 0.124), and −1.405 (s.e. = 0.124) for scores on knowledge, attitude, and practices, respectively. the kruskal-wallis test was used to evaluate the significant differences among physicians, pharmacists, and nurses and their scores on knowledge, attitude, practices, and risk assessment. the jonckheere-terpstra test was used to confirm the trend of association. out of a total 500 healthcare professionals approached, 385 completed the online survey. the response rate of the survey was 77%. the ages of health care professionals ranged from 22 to 68 years, with a mean age of 28.73 ± 6.31 years. a majority of the participants (69.4%) belonged to the age range of 22-29 years. out of the 385, 144 (37.4%) were physicians, 113 (29.4%) were nurses, and 128 (33.2%) were pharmacists. overall, 53% of all the participants were females. around 51% of participants were from the public sector while 49% came from the private sector. a majority of the participants (88%) belonged to urban regions of punjab province. table 1 shows the baseline characteristics of the respondents. among the 385 participants, 94.8% partakers scored >14, and the average knowledge score of participants was 17.31 ± 1.40. in the current cohort, all of the participants were aware that the disease was a viral infection and were also familiar with the most commonly observed symptoms of covid-19. among them, 99.0% knew that the disease could be transmitted through infected humans and animals; 80% knew that the covid-19 virus is a virus that is related to the severe acute respiratory syndrome coronavirus-2 (sars-cov) and middle east respiratory syndrome coronavirus-2 (mers-cov) family; and 95.8% were aware of the asymptomatic presence of covid-19 in people who recently visited virus-affected areas, with this being a potential source of disease spread. however, 42.1% believed that the disease could be transmitted through contaminated food and 17.9% believed that covid-19 was similar to the normal flu or cold. almost, 37% of healthcare workers believed that antibiotics could be useful in the treatment of covid-19 (see table 2 ). about 96.0% were aware of the fact that virus could survive on different objects such as doors, windows, beds, and tables; 99.7% knew that isolation of the infected patients is a necessity to avoid or prevent disease transfer to other people; and 97.4% knew that the incubation period for symptoms to appear ranges from 1 to 2 weeks. about 97% knew that patients with comorbidities are at a higher risk of getting infected, and 99.7% knew that immune-compromised, old age people, and healthcare professionals working closely with infected people were at increased risk of infection. a total of 84.7% of healthcare professionals believed that they were well prepared to deal with covid-19 in the case of an outbreak in the country (see table 2 ). overall, 97.9% participants scored >42, showing a positive attitude, with a mean score of 50.69 ± 3.96. the majority of the participants (>97%) agreed that the disease could be transmitted by coughing and sneezing and that regular hand washing and the use of sanitizer would help prevent the spread of infection. moreover, around 94% agreed that wearing masks can help prevent covid-19 transmission to other people and 97.6% agreed that isolating infected patients could be beneficial in reducing the risk of cross-infection. more than 98.0% agreed that avoiding frequent touching of the nose, mouth, and eyes could reduce the risk of infection, and 92.2% of participants also agreed that avoiding contact with doors, furniture, and other objects significantly reduce the risk of infection. out of the remaining 7.8%, only 1.1% disagreed on the possibility of transmission through objects, while 6.7% stayed neutral (see table 3 ). more than 92.0% of subjects also expressed that if a vaccine is developed against covid-19, it can significantly prevent the epidemic spread. however, a mixed response was observed for the use of antibiotics in the prevention of the infection. about 39.0% of healthcare professionals agreed antibiotics could be useful in preventing the covid-19 infection, while 7.5% remained neutral and 53.5% disagreed with the statement (see table 3 ). about 94.5% of healthcare professionals scored >28 and showed better practices towards disease management with a mean score of 35.97 ± 4.15. about 93.0% of participants almost always advised their patients to eat properly cooked food and 96.9% advised using soaps and sanitizer for regular hand and face washing. moreover, more than 93% of healthcare professionals in most interactions with people advise them to keep themselves warm and hydrated, and 89% advise avoiding close contact with people with cough and flu-like symptoms. out of remaining population, 5.5% sometimes advised and 2.9% rarely advised patients to avoid close contact with people with flu and cold-like symptoms. the risk assessment revealed that more than 92.0% of healthcare workers almost always preferred to use personal protective equipment (ppe) during interaction with covid-19-suspected patients. more than 91% almost always perform a hand hygiene and washing procedure before or after any medical intervention or procedures. about 89% of participants, in a majority of interactions, perform hand hygiene after touching a patients' surroundings such as beds, doors, tables, and almost 86% of healthcare staff observe social distancing in a majority of interactions and avoid unnecessary contact with the patients. from the remaining 14.0%, 7.0% sometimes avoid unnecessary contact while the other 7.0% rarely or never observe social distancing as it is difficult for them to do so because of the continuous exposure to patients (see table 4 ). the kruskal-wallis test demonstrated significant differences (p-value < 0.05) in the scores on knowledge, attitude, practices, and risk assessment of different healthcare professionals (table 5) . overall, the physicians achieved significantly higher scores on knowledge and attitude as compared to pharmacists and nurses. no significant difference was observed on knowledge and attitude scores between pharmacists and nurses. however, the scores on practices and risk assessment demonstrated that the nurses and physicians scored significantly higher as compared to pharmacists (see figure 2 ). the jonckheere-terpstra test confirmed that knowledge and attitude towards covid-19 were significantly associated (p < 0.001) with occupation. a positive trend was further reported, whereby physicians had more knowledge and carried a positive attitude towards covid-19 as compared to nurses and pharmacists (τ = 0.411 and 0.398, respectively) (see table 6 ). the jonckheere-terpstra test confirmed that knowledge and attitude towards covid-19 were significantly associated (p < 0.001) with occupation. a positive trend was further reported, whereby physicians had more knowledge and carried a positive attitude towards covid-19 as compared to nurses and pharmacists (τ = 0.411 and 0.398, respectively) (see table 6 ). this study exclusively targeted the healthcare staff that would be directly or indirectly in contact with suspected or confirmed covid-19 patients. in current study, more than 94% of hcps had adequate knowledge about covid-19, which is relatively better than earlier reported studies conducted in other countries including egypt, iran, and greece [22] [23] [24] . the clinical symptoms most commonly observed in covid-19 patients in a recent study were fever, cough, fatigue, or myalgia and dyspnea [25, 26] . all of the respondents were well aware of most common symptoms, which showed a considerate level of understanding. moreover, the awareness about the effectiveness of hygienic principles such as regular hand washing, sanitizer usage, isolation of patients, and self-confinement at homes for the prevention of covid-19 is a positive sign. the basic health measures such as washing hands regularly, staying at home, maintaining social distancing, and covering the mouth and nose during coughing and sneezing were effective in controlling and preventing a previously unfolded sars epidemic in china [27] . moreover, these measures have proved to be effective in preventing covid-19 virus transmission [28] . approximately 90% of participants in our study exhibited better practices of hygiene and handwashing before and after interacting with the patients, which is quite high as compared to the findings of a study conducted in greece where only 1 in 4 hcps had a hand-washing routine before and after the patient interaction [23] . dissimilarity was observed between the knowledge, attitude, and practices of healthcare professionals. physicians and nurses, in particular, had significantly higher scores as compared to pharmacists, reflecting a need for improvements in terms of practices and disaster responsiveness. this kind of variation among healthcare workers was also reported in saudi arabia after the outbreak of mers disease in 2016 [20] . however, our findings with pharmacists lacking in covid-19-related knowledge and apt practices were contrary to a recent survey reported from pakistan in which the pharmacists demonstrated better practices as compared to other healthcare colleagues [29] . the respondents' mixed responses about the risk of transmission of the disease through virus-contaminated food and the beneficial and effective role of antibiotics for the treatments of covid-19 reflects uncertainty and misperception among healthcare workers. analytically speaking, until now, no evidence has yet reported the risk of transfer of covid-19 virus to healthy people through contaminated food. the foodborne gastrointestinal viruses often lead to transmission of the virus through food, but covid-19 mainly transmits from person to person, and transmission through food has not been reported from any part of the world [30, 31] . a few antiviral, antimalarial, and anti-inflammatory drugs have shown some benefits in terms of therapy. however, the usefulness of antibiotics as a therapy for covid-19 is still unclear. the footprints of ambiguity about antibiotics were clearly visible in our study, however, a high number of hcps (60.5%) believed that antibiotics are not useful therapy for covid-19, a reasonably high percentage as compared to findings from a study in egypt where only 38% of participants believed so [22] . a few recent studies suggested a supportive and symptomatic treatment approach for disease management and treating secondary bacterial infections [26, 32] . however, antibiotics do not work against any viruses and are only recommended against bacterial infections arising from covid-19 and not as a preventive measure or a treatment for coronavirus infection [33] . following the rumors about the possible use of azithromycin in combination with hydroxychloroquine, the already existing debate about the role of antibiotics in covid-19 escalated [34] . a randomized controlled trial conducted recently has shown that the use of azithromycin in combination with hydroxychloroquine may be effective in eliminating covid-19. however, the trial involved fewer patients [35] and warrants further research to collect evidence on the effectiveness of azithromycin and/or hydroxychloroquine to treat/prevent a viral disease [36] . the current study had certain limitations. the study was conducted in three key divisions of one province and thus the results may not be generalizable to the rest of country. secondly, most of the healthcare professionals came from urban areas. rural areas were not easily accessible during the pandemic outbreak, and therefore not enough responses were achieved from rural parts of punjab. thirdly, healthcare staff other than physicians, nurses, and pharmacists were not involved in the study and their practices went unreported. fourth, the survey was conducted online using whatsapp and, therefore, many of the hcps were not able to be contacted for participation. fifth, the hcps were inquired about their earlier experiences with covid-19 patients, which may have led to recall bias. finally, owing to the exploratory nature of the study, the inherent selection bias cannot be overruled. participants' age may also be one of the potential confounding factors. the study revealed that most of the participants were well primed to deal with the pandemic. pharmacists exhibited relatively lower levels of knowledge and their practices indicated that they were at a higher risk of contracting infections as compared to physicians and nurses. interestingly, due to a lack of evidence, the healthcare professionals were not certain about use of antibiotics to treat or prevent covid-19. it is suggested that the government should take necessary measures to train all healthcare stakeholders for the emergency preparedness and any other environmental or health-related calamity. further research and follow-up investigations are needed to evaluate the readiness of hcps in terms of disaster management and risk assessment to avert future public health crises. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/17/6395/s1, questionnaire, table s1 : section ii-knowledge, table s2 : section iii-attitudes, table s3 : section iv-practices and risk assessment. funding: this research was funded by "young talent support program" of health science center, xi'an jiaotong university. coronavirus infections-more than just the common cold a pneumonia outbreak associated with a new coronavirus of probable bat origin world health organization (who) novel coronavirus situation report-1. 2020 covid-19 a pandemic novel coronavirus situation report-181 clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in report of the who-china joint mission on coronavirus disease 2019 (covid-19) characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china. summary of a report of 72314 cases from the chinese center for disease control and prevention coronavirus cases in pakistan ministry of national health services regulation and coordination, g.o.p. covid-19 pakistan death from covid-19 of 23 health care workers in china italian doctors call for protecting healthcare workers and boosting community surveillance during covid-19 outbreak is pakistan prepared for the covid-19 epidemic? a questionnaire-based survey government of pakistan census registered physicians in punjab punjab public health agency. nurses and midwifery in punjab registered pharmacists in punjab risk assessment and management of exposure of health care workers in the context of covid-19 knowledge and attitudes towards middle east respiratory syndrome-coronavirus (mers-cov) among health care workers in south-western saudi arabia bin saeed, a. knowledge, attitude and practice of secondary schools and university students toward middle east respiratory syndrome epidemic in saudi arabia: a cross-sectional study assessment of knowledge, attitudes, and perception of health care workers regarding covid-19, a cross-sectional study from egypt assessment of knowledge, attitudes, and practices towards new coronavirus (sars-cov-2) of health care professionals in greece before the outbreak period covid-19 and iranian medical students; a survey on their related-knowledge, preventive behaviors and risk perception covid-19-new insights on a rapidly changing epidemic clinical features of patients infected with 2019 novel coronavirus in novel coronavirus-important information for clinicians use of antiviral drugs to reduce covid-19 transmission knowledge, attitude, practice and perceived barriers among healthcare workers regarding covid-19: a cross-sectional survey from pakistan food safety and coronavirus disease covid-19 and food safety: guidance for food businesses review of the clinical characteristics of coronavirus disease 2019 (covid-19) world health organization (who) early treatment of covid-19 patients with hydroxychloroquine and azithromycin: a retrospective analysis of 1061 cases in marseille, france hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial no evidence of rapid antiviral clearance or clinical benefit with the combination of hydroxychloroquine and azithromycin in patients with severe covid-19 infection we express gratitude and appreciation to all healthcare professionals who participated in the survey. we are thankful to zineb riboua (mccourt school of public policy, georgetown university, washington dc, usa) for rendering her professional services in terms of editing and proofreading the manuscript. the authors declare no conflict of interest. key: cord-311085-jmuyi53x authors: saqlain, muhammad; munir, muhammad muddasir; ahmed, ali; tahir, azhar hussain; kamran, sohail title: is pakistan prepared to tackle the coronavirus epidemic? date: 2020-03-20 journal: drugs ther perspect doi: 10.1007/s40267-020-00721-1 sha: doc_id: 311085 cord_uid: jmuyi53x nan the world health organization (who) has classified the coronavirus epidemic as a global public health emergency of international concern [1]. on 11 february 2020, the virus was named by the who as 'severe acute respiratory tract coronavirus-2' (sars-cov-2; also referred to as 2019-ncov), and the disease it causes as 'covid-19' [1]. on 26 february 2020, for the first time, the number of new cases outside china was higher than the number of new cases inside china (427 vs. 411 new cases) [2] . by 11 march 2020, the virus had spread to 113 countries and territories, with the number of registered cases reaching 118,162 and the number of deaths reaching 4290 (mortality rate 3.63%) [3] . the who states that the covid-19 outbreak is now categorized as a pandemic, with the number of cases increasing by 13-fold in 2 weeks [4] , and has issued alerts to countries at risk of getting covid-19 [5] . also on 26 february 2020, the pakistan federal health minister confirmed the first two cases of covid-19 in karachi and islamabad [2, 6] . within 15 days (12 march), the total number of positive covid-19 tests reached 20, with 14 cases in sindh province, 5 in gilgit baltistan and 1 in a 12-year-old child in baluchistan) [7] . all cases had a history of a recent visit to iran, syria or london. to 12 march 2020, a total of 471 suspected samples had been tested, 20 (4.25%) of which were found to be positive [7] . pakistan borders countries infected with covid-19, including china, an epicenter of the disease that currently has the highest number of deaths attributed to covid-19 (n = 3162), to the north, and iran, a country with the third highest number of covid-19-associated mortalities (n = 291), to the west; italy has the second highest number of deaths [3] . this geographical location, as well as a continual increase in the number of confirmed cases, demands a high level of preparedness and requires actions to be taken promptly before the situation becomes worse [8] . the who states that countries should take steps to prevent and limit further spread of the virus, including active surveillance, early detection, quarantine, clinical management, and tracing of close contacts [5] . after declaration of the covid-19 epidemic, the pakistan government took several measures to cope with this zoonotic illness. first, the federal government, in collaboration with the civil aviation authority, established a system to screen every passenger who had traveled directly or indirectly from china and other infected countries, including south korea, japan, and thailand [8] . after the importation of covid-19 from iran, pakistan also started closed monitoring and more active screening of passengers travelling from iran [9] . media reports highlighted that, although a screening system was established, lapses have been seen in detection, which required a more effective system to be installed [7] . the pakistani national institute of health (nih) has played a pivotal role in devising and circulating protocols regarding covid-19 prevention, transmission and defection, as well as launching public awareness campaigns. these relate to the use of personal protective equipment and facemasks, the handling of suspected cases, sample collection and transport through virus transport medium, and adequate hand and general body hygiene, etc. [10]. the federal nih also provides support to all pakistani provinces for establishing provincial surveillance units [8] . during the early days of covid-19, pakistan lacked any diagnostic facilities, and suspected samples were sent to foreign laboratories. pakistan later received test kits from china and primers from japan. currently, pakistan is capable of testing samples from suspected cases within the country at the main diagnostic laboratory at the nih [11] , and also at who-designated covid-19 test centers in seven hospitals countrywide (two centers each in karachi and quetta, and one center each in peshawar, islamabad and lahore) [12] . only a few specific quarantine centers are currently established in pakistan. there is a single modern quarantine center with 300 beds in islamabad [13] , and, in baluchistan, a province that borders iran, a quarantine center for 2000 people has been prepared, but the center has run out of room and lacks standard screening and protective equipment [14] . apart from these specific facilities, the government has established isolation wards and quarantine areas in teaching hospitals; however, media reports have highlighted that most of these hospitals violate covid-19 preparedness guidelines and, despite establishing new standardized isolation areas, isolation nets previously used during dengue fever outbreaks are now being used for covid-19 patients [15] . pakistan had enough facemasks to fulfil its local needs; however, due to increased demand and export to china [16] , facemasks became scarce in local pakistani markets, resulting in a sudden increase in prices. to cope with the situation, the national disaster management authority asked the government to ban the export of facemasks and other relevant materials. the drug regulatory authority of pakistan has also taken actions against illegal stockists and profiteers, and the situation is now under control [16] . unfortunately, pakistan is located between two main coronavirus centers, i.e. china and iran, with considerable traffic to and from these countries. compared with china and iran, pakistan has a lower standard of health care and facilities, and a government that is less strong. due to its social and political structure, the pakistani government will not be able to take actions against covid-19 such as those shown in china and iran, and can never use the religious references that have been used by the governments of saudi arabia and the united arab emirates. therefore, the only way pakistan can avoid disaster is to have everyone-from the prime minister to the ordinary pakistani-to work together to prevent this outbreak from spreading. until the danger has been overcome, muslim scholars continue to mention the covid-19 outbreak in every friday sermon, and have also requested that it be mentioned in every prayer. • the current coronavirus situation is in check in pakistan. • experts recommend that, given this developing country's history of dealing with other disease outbreaks and its fragile fragmented healthcare system and poor health literacy, the government and all relevant institutes should be on high alert and well prepared to tackle any unusual situation. author contributions all authors contributed to the preparation of this commentary. pakistan confirms first two cases of coronavirus, govt says covid-19) situation 2020 mar 11. https :// exper ience .arcgi s.com/exper ience /685d0 ace52 1648f 8a5be eeee1 b9125 cd who director-general's opening remarks at the media briefing on covid-19 covid-19 strategic preparedness and response plan for the novel coronavirus covid-19 live dashboard pakistan 'concerned' over iran coronavirus outbreak, closes border pakistan now equipped to test for novel coronavirus, says pm's aide these are the 7 who designated coronavirus test centers in pakistan coronavirus quarantine centre at pak-iran border runs out of space total chaos: hospitals in pak lack facilities to treat corona patients govt warns stern actions against traders who raise face mask price: nausheen hamid funding no funding was received for this commentary.conflict of interest none declared. key: cord-292293-tko186lh authors: javed, w.; baqar, j. b.; abidi, s. h. b.; farooq, w. title: sero-prevalence findings from metropoles in pakistan: implications for assessing covid-19 prevalence and case-fatality within a dense, urban working population date: 2020-08-14 journal: nan doi: 10.1101/2020.08.13.20173914 sha: doc_id: 292293 cord_uid: tko186lh population-level serologic testing has demonstrated groundbreaking results in monitoring the prevalence and case-fatality of covid-19 within a population. in pakistan, getz pharma conducted a sero-prevalence survey on a sample of 24,210 individuals using the igg/igm test kit (colloidal gold) with follow-up and sequential testing after every 15-20 days on a sub-sample. this is the first of its kind, large scale census conducted on a dense, urban, working population in pakistan. the study results reveal that from 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 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, which is 17.7 times higher than the current number of 231,818 symptom-based pcr cases reported by the government which exclude asymptomatic cases. serologic tests are based on the qualitative detection of igm and igg generated by the body in response to a sars-cov-2 infection. 1 igm is the first antibody type generated by the body in response to a covid-19 infection, followed by igg which replaces igm as the predominant antibody in the blood. 1 given that pakistan is facing an issue of limited testing capacity focused exclusively on symptom-based pcr tests, there is a need to conduct sero-prevalence studies to determine the true extent of the disease via serologic tests. 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. 2 although literature indicates that asymptomatic infections within a population may be many folds higher than the number of pcr reported cases, 3, 4 large-scale, sero-prevalence studies within low-risk populations have not yet been conducted in pakistan. hence, in order to expand the database of covid-19 infections in the country, getz pharma conducted a random testing (census) of 24,210 individuals from various workplaces in metropoles of pakistan, using usfda eua and ce approved serologic test kits. the kits are currently being used in 38 countries globally, as they have a sensitivity of 95.3% and specificity of 98.7% for igg, and a sensitivity of 86.48% and specificity of 95.18% for igm, 5 with a false positive rate ranging from 2% to a maximum of 7%, 3 due to nonspecific immunity and nonspecific protection to covid-19. hence, serologic testing kits can be used as cost-effective measures for conducting mass screening amongst asymptomatic individuals, who would otherwise not present at a government-approved pcr testing facility. consequently, the official number of confirmed cases severely under-represent the full extent of covid-19, as they fail to capture the proportion of the population who are asymptomatic carriers and are actively spreading the infection to more vulnerable members of society. getz pharma conducted a 100% census sero-prevalence study on a sample of 24,210 individuals using the igg/igm test kit (colloidal gold) with follow-up and sequential testing after every 15-20 days. the sample size included an adult, working population aged 18-65 years, recruited from dense, urban workplaces including factories, corporates, restaurants, media houses, schools, banks, healthcare providers in hospitals, and families of positive cases in various metropoles of pakistan (karachi, lahore, multan, peshawar and quetta). this was a large-scale, cross-sectional study conducted amongst the general, low-risk population. while extrapolating the study findings to the general population of 220 million people in pakistan, 53% of the population which is under 18 years of age and 4.5% above 65 years needs to be stratified and excluded, thus restricting the universe to 93 million. similarly, the urban population setting of this census excludes 64 percent of the rural population of pakistan, thus reducing the universe to 33 million individuals from the urban, adult working population. it must be noted that the infectivity quotient (r0) of covid-19 is very different between densely urban and less crowded, rural populations ranging from 1.4 to 3.9. 6,7 the study results revealed a total of 17.5% covid-19 positive cases from a sample size of 24,210 individuals. most of these were ongoing infections at 11.5%, while 6% had recovered. from the 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 exposed, unaware and spreading infection to people around them. 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 8 within this age range, 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 with covid-19 as of 6 th july, 2020. 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 and print media, we can extrapolate that 4,297 individuals from the media industry of pakistan are currently exposed to covid-19. amongst 3,120 healthcare workers including doctors and paramedics from different metropoles in pakistan, 17% tested positive, with 4.1% currently infected and 4.6% igg positive which means that they had been infected in the past and have now recovered. taking a base population of 313,457 healthcare workers 9 across pakistan as per who emro, we can extrapolate that 53,248 healthcare workers are currently exposed to covid-19. 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% with both. with 231,818 pcr cases being reported as of 6 th july, 2020 10 and taking an average pakistani household size of 6.7 11 , 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. 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 10 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, with a 30% prevalence of test positivity amongst individuals who have symptoms, at least 426,187 people currently have covid-19 in pakistan. 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 cases that the official figures of pakistan are quoting. 10 (table 1 ) getz pharma's sero-prevalence study revealed that 90% of the population who tested covid-19 positive (screened via serologic tests) were asymptomatic carriers of the disease, who would otherwise have not presented at a pcr testing facility. this is the first of its kind, large scale census conducted on the general, urban population of pakistan, which indicates the total number of covid-19 positive cases is 17.7 times higher than symptom-based pcr reported figures. while the study showed sero-prevalence of 17.5% at workplaces, the newly emergent cases at 6 weeks had an incidence rate of 7%, which reveal groundbreaking findings in the context of the evolving covid-19 situation in pakistan. although the study results are restricted to pakistan's how do the covid-19 coronavirus tests work detection of sars-cov-2 in different types of clinical specimens covid-19 antibody seroprevalence seroprevalence of covid-19 virus infection in guilan province serum 2019 new coronavirus igm and igg antibodies jointly detect the diagnostic value of the new coronavirus infection early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia pattern of early human-to-human transmission of wuhan how can we protect contract and informal workers in pakistan? who emro | health service delivery covid-19 health advisory platform by ministry of national health services regulations and coordination characteristics of households and respondents. pakistan demographic and health survey key: cord-279395-qfb06csa authors: khan, samea; khan, mahjabeen; maqsood, khizra; hussain, tanveer; noor‐ul‐huda,; zeeshan, muhammad title: is pakistan prepared for the covid‐19 epidemic? a questionnaire‐based survey date: 2020-04-10 journal: j med virol doi: 10.1002/jmv.25814 sha: doc_id: 279395 cord_uid: qfb06csa covid‐19 is a pandemic that began in china in december 2019. world health organization (who) has expressed fears that pakistan might emerge as the next epicenter of this pandemic. we hypothesize that at present the pakistani masses are not prepared to face any threat of a looming epidemic. the main aim of this study was to evaluate the basic knowledge of educational and health care workers (hcws) regarding covid‐19, its control, and prevention. knowledge about origin, symptoms, and spread of viral infection was assessed. in this cross‐sectional survey, a self‐designed questionnaire was distributed among 302 hcws including physicians (10.9%), nurses (1.32%), lab staff (1.65%), and academic individuals including faculty and students (86.42%) of different organizations. results were analyzed using the χ (2) test. obtained results validate our null hypothesis that pakistani masses are not well aware of the covid‐19 and strategies for the prevention and control of infection. the study concluded that individuals belonging to the front‐line workers and high literacy groups are not prepared for the alarming situation in the country. effectual implementation of infection control programs should be practiced, and it depends on awareness, training, and cooperation of individuals. covid-19 has been first reported as a cluster of pneumonia cases of unknown etiology from wuhan, hubei, mainland china on 8th december 2019. 1 this novel coronavirus outbreak is believed to be originated from an animal source in individuals who visited the local seafood and animal market in wuhan, after which community transmission led to the initial endemic turning into a pandemic. 2, 3 travel associated cases of covid-19 infection have been reported by different countries. [4] [5] [6] at present as the world health organization (who) has declared the covid-19 as a pandemic, pakistan is facing a critical situation and strict measures need to be taken to avert the threat of a national health crisis. who has expressed its fears that pakistan is facing a major covid-19 challenge. they mentioned that if effective measurements are not taken pakistan might emerge as the next epicenter of this pandemic. [7] [8] [9] it is believed that insufficient consideration is given to the basic infection control protocols including hand washing and personal protective equipment use in the educational and health care institutes of the country. the ministry of health, pakistan has declared new guidelines for infection control which are based on the who recommendations. 10 however, the implementation of the basic infection control protocols is possible only when people and employees are made aware of the introduced policies by giving them clear guidelines. awareness level and compliance of the educational and healthcare workers play an important role in the effective and timely prevention and control of a public health crisis. 11 to formulate a healthy policy, the multi-disciplinary teams including key front-line workers should be a part of the policy planning to ensure that these policies function effectively. 12 pakistan faces many specific challenges about infection control that must be met by devising national policies. our null hypothesis states that "pakistani masses are not prepared to face a looming threat of a covid-19 epidemic." the main aim of the present questionnaire-based analysis was to check the awareness level among the employees at educational institutes and the health care workers (hcws) in various organizations across pakistan. questionnaires were filled by diverse groups of faculty, students, hcws (physicians, nurses and lab staff). these questionnaires addressed access to information, training, confidence in the ability of faculty and hcws to implement the introduced policies at their workplaces and asses the main threats which could lead to a possible public health crisis. these forms also evaluated the level of preparedness that any institute had to deal with a covid-19 outbreak. a total of 303 individuals were included in this study. these include students and faculty (261) and hcws (41) of which 32 physicians, 4 nurses and 5 laboratory staff in public and private sector educational and health institutes across pakistan filled a questionnaire. view of students, faculty and hcws from educational and health institutes regarding the recent public health emergency of the pandemic covid-19 was collected by filling in a standardized questionnaire. questionnaires were distributed using the quick mode of communications including facebook, emails, and whatsapp. anonymous responses were recorded and no ethical approval was required for this survey. feedback was taken based on their knowledge about covid-19, its spread, and prevention and control measures implemented at their organizations. the questionnaire contained 21 different questions on basic knowledge of the infection, personal attitudes, and common practices during infection outbreak, control programs and policies, training and orientation conducted to bring awareness on origin, a common mode of transmission, signs, and symptoms. the participants were asked to either choose from given options or write their own opinion. please access the manuscript at: https://forms.gle/r2smqa4besb3qnjq6. all the data were analyzed with computer software spss version 21. the χ 2 test was applied and p value .1 or less was considered significant. level of significance was measured to evaluate the difference in proportion among different respondent groups (hcw and professionals from educational institutes). in total 303 individuals including students and faculty (86.42%) and hcws (13.56%) of which 10.59% physicians, 1.32% nurses and 1.65% laboratory staff in public and private sector educational and health institutes across pakistan submitted their responses to the questionnaire. figure 1 summarizes the characteristics of the study groups in terms of age, gender and organization (educational and health care). out of these respondents, 50.99% were aged less than 25 years, 48.66% between 25 and 50 years, and 0.33% above 50 years comprising of 28.47% males and 71.52% females. a total of 12.58% of the respondents were from government hospitals, 7.61% were from private hospitals and 79.8% were from the educational institutes. responses to questions were compared among subjects from educational institutes, physicians, nurses, and lab staff. response percentage in each group and their p values which were obtained using the χ 2 test are summarized in table 1 . the responses to questions regarding basic knowledge, that is name, origin, common signs and symptoms, sources of infection of covid-19 and awareness of any other pandemic viral infection in the past varied greatly. in response to a query regarding the name of the virus 95.36%, individuals responded that they were aware and 2.32% responded that they did not know the name of the virus. a p value of .85 suggests that results were insignificant and the variables (profession and awareness regarding the name of the virus were not related). the second question posed was regarding the origin of covid-19, 82.45% of respondents said that they were aware of its origin, while 8.94% said that they did not know its origin, 8.61% of respondents were not sure whether they knew or not the origin of covid-19. the highest uncertainty (50) about the origin of covid-19 was found among the nurses. based on professional awareness it was seen that 93.75% of physicians, 25% nurses, 100% lab technicians, and 81.61% f i g u r e 1 visual representation of demographic characteristics of study group. a total of 28.74% (blue males and 71.52% (red) females participated in the study. a total of 50.99% of participants were below the age of 25 years, 48.66% were between ages 25 to 50 years and 0.33% belonged to the age group above 50 years. a total of 86.42% of participants belonged to the educational institutes, and 13.56% were health care workers. a total of 79.8% of respondents belonged to the educational institutes and 20.19% belonged to the health care workers (hcws) for the query about sources of information regarding covid-19, the internet, and social media remained at the highest level while the newspaper is considered as the third source of information in all professions however most prominent trend was noticed in academic subjects ( figure 2 ). organization wise distribution of the responses is shown in table 2 . results are presented in terms of several respondents and percentages; the p value is also recorded for each response. the table 3 about the previous pandemics, a high level of awareness was found in all organizations. a similar pattern of responses was noticed in a query about the spread of infection in pakistan. it is clear from the data presented in when we look at the response of people about the latest update about covid-19, most people rely on getting information from the internet followed by social media (figure 3 ). male and female distribution across different professions was significantly varied ( χ 2 9.818; p value .001; table 2 ). physicians, nursing and laboratory staff were less likely to be male and female than expected, while the other was significantly more likely to be female and less likely to be male as compared to the expected. according to the profession, the distribution of responses to the questions was varied, so we checked whether gender has any impact on responses. however, both male and female response distribution is very much similar. (table 2) . also, concerning the organization, there is a significant variation in the distribution of age groups ( χ 2 33.036; p value .001). it was mainly observed that in government and private hospital participants were more likely falling in 25-to 50-year group that is below 25 years were lesser than expected, whereas educational institute participants were more likely to be falling in below 25 years than expected as compared to the 25-to 50-year group where the ratio of expected is higher than the observed. the outcome of this questionnaire suggests that pakistan faces a unique challenge related to public health, which majorly is the peo to avert the threat of an epidemic, it is significant that public knowledge, attitude, and behavior towards covid-19 response is prompt. however, the results of our study reveal that the masses of pakistan are not aware of the gravity of the situation. moreover, front-line workers are not prepared to face the challenge. it is a matter of urgency that awareness at all levels is promoted. characteristics of and public health responses to the coronavirus disease 2019 outbreak in china coronavirus disease 2019 (covid-19): a perspective from china a new emerging zoonotic virus of concern: the 2019 novel coronavirus (covid-19) the novel coronavirus originating in wuhan, china: challenges for global health governance assessing the impact of reduced travel on exportation dynamics of novel coronavirus infection (covid-19) covid-19 outbreak on the diamond princess cruise ship: estimating the epidemic potential and effectiveness of public health countermeasures pakistan facing major covid-19 challenge. who; 2020. 8. 52 new coronavirus cases push pakistan's tally to 237 number of covid-19 cases in pakistan surpasses 100 ministry of health p. national action plan for corona virus disease (covid-19) pakistan core components for effective infection prevention and control programmes: new who evidence-based recommendations is pakistan prepared for the covid-19 epidemic? a questionnaire-based survey the authors declare that there are no conflict of interests. sk and mz designed the study and compiled the manuscript, mk and km performed the statistical analysis, nh compiled the statistical results, th carried out the final formatting and manuscript proofread.all authors have read the manuscript and agree to the submission. http://orcid.org/0000-0002-9909-4726 f i g u r e 3 bar chart for distribution of responses according to organization. this figure represents the various sources used by the people to gather knowledge about covid-19. light blue bar represents all organizations, orange bar stands for educational institutes, gray bar represents government institute, the yellow bar represents private institute key: cord-290952-tbsccwgx authors: ullah, saif; khan, muhammad altaf title: modeling the impact of non-pharmaceutical interventions on the dynamics of novel coronavirus with optimal control analysis with a case study date: 2020-07-03 journal: chaos solitons fractals doi: 10.1016/j.chaos.2020.110075 sha: doc_id: 290952 cord_uid: tbsccwgx coronavirus disease (covid-19) is the biggest public health challenge the world is facing in recent days. since there is no effective vaccine and treatment for this virus, therefore, the only way to mitigate this infection is the implementation of non-pharmaceutical interventions such as social-distancing, community lockdown, quarantine, hospitalization or self-isolation and contact-tracing. in this paper, we develop a mathematical model to explore the transmission dynamics and possible control of the covid-19 pandemic in pakistan, one of the asian countries with a high burden of disease with more than 100,000 confirmed infected cases so far. initially, a mathematical model without optimal control is formulated and some of the basic necessary analysis of the model, including stability results of the disease-free equilibrium is presented. it is found that the model is stable around the disease-free equilibrium both locally and globally when the basic reproduction number is less than unity. despite the basic analysis of the model, we further consider the confirmed infected covid-19 cases documented in pakistan from march 1 till may 28, 2020 and estimate the model parameters using the least square fitting tools from statistics and probability theory. the results show that the model output is in good agreement with the reported covid-19 infected cases. the approximate value of the basic reproductive number based on the estimated parameters is [formula: see text]. the effect of low (or mild), moderate, and comparatively strict control interventions like social-distancing, quarantine rate, (or contact-tracing of suspected people) and hospitalization (or self-isolation) of testing positive covid-19 cases are shown graphically. it is observed that the most effective strategy to minimize the disease burden is the implementation of maintaining a strict social-distancing and contact-tracing to quarantine the exposed people. furthermore, we carried out the global sensitivity analysis of the most crucial parameter known as the basic reproduction number using the latin hypercube sampling (lhs) and the partial rank correlation coefficient (prcc) techniques. the proposed model is then reformulated by adding the time-dependent control variables u(1)(t) for quarantine and u(2)(t) for the hospitalization interventions and present the necessary optimality conditions using the optimal control theory and pontryagin’s maximum principle. finally, the impact of constant and optimal control interventions on infected individuals is compared graphically. modeling the impact of non-pharmaceutical interventions on the dynamics of novel coronavirus with optimal control analysis with a case study coronavirus disease is the biggest public health challenge the world is facing in recent days. since there is no effective vaccine and treatment for this virus, therefore, the only way to mitigate this infection is the implementation of non-pharmaceutical interventions such as social-distancing, community lockdown, quarantine, hospitalization or self-isolation and contact-tracing. in this paper, we develop a mathematical model to explore the transmission dynamics and possible control of the covid-19 pandemic in pakistan, one of the asian countries with a high burden of disease with more than 100,000 confirmed infected cases so far. initially, a mathematical model without optimal control is formulated and some of the basic necessary analysis of the model, including stability results of the disease-free equilibrium is presented. it is found that the model is stable around the disease-free equilibrium both locally and globally when the basic reproduction number is less than unity. despite the basic analysis of the model, we further consider the confirmed infected covid-19 cases documented in pakistan from march 1 till may 28, 2020 and estimate the model parameters using the least square fitting tools from statistics and probability theory. the results show that the model output is in good agreement with the reported covid-19 infected cases. the approximate value of the basic reproductive number based on the estimated parameters is r 0 ≈ 1.87. the effect of low (or mild), moderate, and comparatively strict control interventions like social-distancing, quarantine rate, (or contact-tracing of suspected people) and hospitalization (or self-isolation) of testing positive covid-19 cases are shown graphically. it is observed that the most effective strategy to minimize the disease burden is the implementation of maintaining a strict social-distancing and contact-tracing to quarantine the exposed people. furthermore, we carried out the global sensitivity analysis of the most crucial parameter known as the basic reproduction number using the latin hypercube sampling (lhs) and the partial rank correlation coefficient (prcc) techniques. the proposed model is then reformulated by the novel coronavirus infectious disease, caused by the coronavirus is commonly known as covid19 . it has become the greatest challenge the history has ever seen. started from wuhan city of china earlier this year, it spread to the rest of the world in a few months and was declared a pandemic by the un. it has paralyzed life across the globe. the main cause of the virus is yet to be discovered, but it is presumed that it has emerged in one the biggest animal market in the chinese city of wuhan [1, 2, 3] . so far, it has engulfed more than 210 countries of the world and according to who statistics, the virus has affected around 6 million people across the world and more than 300 thousand people have died so far [1, 2, 3] . the recovery rate is higher than the mortality rate. however, the ratio varies from country to country and region to region. usa is the most affected country which is the epicenter of the virus followed by europe [2] . scientists are struggling to discover or invent a vaccine for the treatment, but it is yet to be discovered. the question, how long it will last? is on everyone's lips. although research is in a very early stage and with the passage of time things will unfold. the scientists are trying to dig out the main symptoms and causes of transmission. however, according to the information available the main symptoms are high fever, severe chest pain, continuous dry coughing, body aches, headache and difficulty in the respiratory system. the spread, according to available information, is droplets, produced by an infected person during coughing and sneezing and physical contacts, etc. [4] . covid-19 pandemic has caused great damage not only to human lives and health it has multidimensional effects. it not only exposed the weak health infrastructure even in the most advanced countries of the world, but also badly affected the world economy. almost the entire world is on lockdown and all the economic and business activities are halted. it has shocked the largest economies of the world, i.e. china and usa where the economic slowdown is observed since the outbreak of coronavirus. the third world countries, particularly pakistan, are the prime targets of the economic devastation. millions of people have lost their jobs in the past few months. poor countries are unable to repay their debts. they are even unable to support poor citizens who cannot earn their livelihood. the social and political lives of the nations are affected badly. people across the world have severed social relations. they avoid meeting each other even in the gravest times. governments of all the countries have diverted their attention and resources to cope with the challenge of this mysterious disease and thus no political activity is visible. like other countries in the world, covid-19 pandemic poses a huge threat to both humans health and economy in pakistan. this infection is even more devastating in pakistan because the implementation of non-pharmaceutical interventions i.e., make social-distancing and community lockdowns are certainly very tough for a society like pakistan. the government is unable to afford a strict nationwide lockdown. the covid-19 first case was reported on 26 february 2020 in karachi which was a student come back from iran. later, only within three weeks, the infection spread in all four provinces, gilgit-baltistan, azad jammu and kashmir, and the federal territory of islamabad. the total number of confirmed infected cases raised to 2291 across the nation and 252 new cases were reported on 1 april. due to the rapid growth of infected people across the country the government of pakistan decided to put the whole nation under strict lockdown and later extended twice until 9 may, due to a worse situation. currently, the situation in pakistan is worse and the number of confirmed cases crossed the cases reported in mainland china. pakistan is placed 17th in the list of highly reported infected cases and deaths by countries, territories, or areas [5, 6] with a total of more than 100,000 confirmed covid-19 cases. about 31,000 patients are fully recovered and 1900 people lost their lives due to this deadly infection [7, 8] . mathematical models are very useful in helping us to understand the transmission dynamics and control of emerging and re-emerging communicable diseases. one of the main challenges that mankind is facing nowadays is predicting the severity and suggest suitable public health intervention strategies to curtail the covid-19 pandemic. recently, a number of mathematical models have been proposed to explore the transmission patterns of covid-19 pandemic. in [9] , the authors formulated a deterministic model to explore the impact of various public interventions on the dynamic and mitigation covid-19 in ontario, canada. in [10] , a mathematical model based on nonlinear differential equations is presented to study the dynamics of covid-19 infection in highly affected countries that are china, italy, and france. a fractional-order covid-19 model with the atangana-bleanu-caputo operator is proposed by khan and atangana [11] and implemented the model to analyze the infection in wuhan. the role of lockdown in the absence of effective vaccines and treatment in order to mitigate the covid-19 pandemic is analyzed in [12] . the author has used the novel fractional-fractal operators to formulate the proposed mathematical model [12] . in [13] , a transmission model is formulated to predict the cumulative covid-19 cases in italy, uk, and usa. the transmission dynamics of covid-19 in mexico are studied using mathematical and computational models in [14] . the influence of non-pharmaceutical controls, including quarantine, hospitalization or self-isolation, contact-tracing, and the use of a face mask on the dynamics of covid-19 pandemic in the population of new york state and the entire usa is studied in detail in [15] . the present study proposes a new transmission model to analyze the dynamics and impact of non-pharmaceutical interventions on the covid-19 in pakistan. initially, we develop the model without optimal control variables and provide a good fit to the reported cases and then estimate the model parameters using a nonlinear least square curve fitting approach. further, the model is reformulated by adding two times dependent control variables. the rest of the manuscript is organized as: the mathematical formulation of the covid-19 model is presented in section 2. basic mathematical analysis, including stability results of disease-free equilibrium is explored in section 3. the model fitting to reported cases and estimation of parameters is done in section 4. the simulation results of without optimal control model are shown in section 5. the global sensitivity analysis and its graphical interpretation are depicted in section 6. the optimal control problem and its analysis of the covid-19 infection is presented in 7. finally, a brief concluding remarks are given section in 8. this section presents a brief description of the proposed model to study the dynamics and possible control of the covid-19 pandemic. the model is developed by dividing the whole human population at any time t, denoted by n (t) into eight mutually exclusive sub-groups depending on the disease status. these sub-groups are susceptible s(t), exposed or latent e(t), infected with the disease symptoms (or symptomatically infectious) i(t), asymptotically infectious having no clinical symptoms i a (t), quarantined q(t), hospitalized i h (t), critically infected (or intensive care) patients i c (t) and the recovered/removed individuals r(t), so that the infected individuals showing mild symptoms of the disease are also placed in the epidemiological class i a (t). the quarantine and isolation should be either at home or the specific centers or hospitals designated by the government. further, the group i h stand for the patients admitted into hospital also contains those with clinical symptoms of the disease who are self-isolating at home. we further assume that hospitalized people may also transmit the infection after interacting with susceptible people. the transmission dynamics of the covid-19 disease is expressed through the following system of the nonlinear differential equation: (1) the corresponding initial conditions are the birth rate is denoted by λ and the natural mortality rate in all groups is denoted by µ. the susceptible people acquired covid-19 infection when they interact with the infected people in i, i a and i h compartments. the force of infection is where the parameter β shows the effective contact rate, i.e., contacts capable of leading to infection transmission and the parameter 0 ≤ ψ ≤ 1 accounts for the assumed reduction in disease transmissibility of asymptomatic infected individuals in comparison to symptomatic one. similarly, ν is used for the infectiousness rate due to hospitalized covid-19 patients. it is noticed from the transmission patron of covid-19 that the asymptomatic individuals are comparatively dangerous relative to the individuals in the i h class because they are not aware of the infection and are capable to transmit the infection. the latent individuals develop an infection after completion of incubation period and become infected at the rate ω and a fraction denoted by ρ enters to the symptomatic class after showing disease symptoms and the remanding with no (or mild) symptoms join the asymptomatic compartment i a (t). the exposed individuals who have interaction with covid-19 infected patients are detected (via contact-tracing) and placed in quarantine at the rate κ which further moves to hospitalized class if they are tested positive with covid-19 infection. the symptomatically-infectious people are hospitalized at the rate η which further moves to critically-infected class i c at the rate φ if they are serious and need critical care. the parameters ζ 1 and ζ 2 represent the recovery rates in i and i a groups respectively. further, the recovery rates of quarantined, hospitalized and critically infected classes are shown by φ 1 , φ 2 and φ 3 respectively. finally, the covid-19 induced mortality for individuals in the i, i h and i c classes are respectively shown by ξ 1 , ξ 2 and ξ 3 . for simplicity, let us denote then, the above model (1) can be written as we present some basic and necessary analytical results of the covid-19 model (3) lemma 1. let p(0) ≥ 0 denotes the initial data and p(t) = (s, e, i, i a , q, i h , i c , r) are the model variables, then all solutions of the model (3) will be non-negative for all t > 0. (3): it can be further written as hence, the solution of (5) can found as below following a similar procedure, it can be shown that p(t) > 0, ∀ t > 0. in order to prove the second part we have 0 < p(0) ≤ n (t), and then the addition of all equations of the covid-19 model (3) we have the dynamics of the covid-19 mathematical model (3) will be studied in the following closed and biologically feasible region. the region defined in the closed set ∆ ⊂ r 8 + , is positively invariant for the model (3) with non-negative initial conditions in r 8 + . proof. as in lemma 1, it follows from the summation of all equation of the covid-19 model (3), it is clear that the solution of and (6) is given in the following inequality, in particular, n (t) ≤ λ/µ, if n (0) ≤ λ/µ. therefore, the region ∆ is positively invariant as will as attracts all the possible solution trajectories in r 8 + . the propose model (3) has a disease free equilibrium (df e), given by next, we investigate the most important and crucial threshold quantity known as the basic reproduction number and generally denoted by r 0 . this parameter measures the average number of new covid-19 infected cases generated by a typical infected individual when introduced into a completely susceptible population. the most common approach used to obtain r 0 is the next-generation method presented in [16] . the next generation matrices obtained from the model (3) are given as follows: the corresponding jacobian matrices f and v evaluated at df e is given as below: hence, utilizing the definition r 0 = ρ(f v −1 ) (where ρ(.) represents the spectral radius), we derived the following expression for the basic reproduction number: interpretation of r 0 in order to interpret the basic reproductive quantity we split the expression for r 0 as follows: where, the first term r 0i in (7) shows the average number of new covid-19 infections generated by symptomatically-infectious individuals in the i class. this term contains the product of the infection rate in the i class (the disease transmission rate), β, the fraction of exposed people that completed the incubation period and move to the symptomatic stage ( ρω k 1 ) and the average period spend in the i compartment ( 1 k 2 ). the second constituent reproduction number r 0a represents the number of new covid-19 infection cases generated by asymptomatically-infectious individuals in class i a . it is the product of infectious rate due to asymptomatic coivd-19 individuals (βψ), the fraction of latent people that completed the incubation period and move to the asymptomatic stage ( ρ(1−ω) k 1 ) and the average period spent in the asymptomatic class ( 1 k 3 ). similarly, the third constituent reproduction number r 0h expresses the new covid-19 infection cases generated by hospitalized/isolated individuals. in particular, the first term in r 0h represents the contribution into the hospitalized class by symptomatic infectious individuals (in class i). it is the product of infectious rate due to hospitalized individuals (βν), the fraction of latent individuals that completed the incubation period and move to the asymptomatic stage ( ρ(1−ω) k 1 ), the portion of individuals that left the symptomatic class i and move to the hospitalized class i h ( η k 2 ), and the average duration in the hospitalized class ( 1 k 5 ). finally, the second term in r 0h expresses the contribution of quarantined individuals into the hospitalized class. in this part, we will prove the local and global stability of the model around the df e. the epidemiological implication of the stability result of df e case is that a small influx of covid-19 infections cases will not generate a covid-19 outbreak if r 0 < 1. (3) is locally asymptotically stable if r 0 < 1 and unstable otherwise. proof. the jacobian matrix j w 0 obtained at the dfe w 0 is as follows: clearly, from the above jacobian matrix j w 0 , the eigenvalues −µ, −µ and −k 6 have negative real part. there remanning eigenvalues can be obtained through the equations given below: the coefficients involved in (8) are as follow: where, clearly, c j for j = 1..., 5 are all positive if r 0 < 1. further, it is easy to show the remaining routh-hurtwiz condition for the fifth order polynomial (8) . thus, the df e is locally asymptotically stable if r 0 < 1. the global dynamics of df e, w 0 of the covid-19 transmission model is studied in the following result. theorem 2. the system (3) at w 0 is globally asymptotically stable if r 0 <1, and unstable for r 0 >1. proof. let we consider the following lyapunov function, in order to prove the required result: where b i , for i = 1, 2, · · · , 5, used for some unknown positive constants. differentiating the function z(t) with respect to t and using the solutions of system (3), we obtain: we obtained after some simplification hence, it is obvious that if r 0 < 1 then dz(t) dt < 0. therefore, the largest compact invariant set in ∆ is the singleton set w 0 and using the lasalle's invariant principle [17] , w 0 is globally asymptotically stable in ∆. the present section investigates the data fitting using model (3) to the confirmed reported covid-19 infected cases in pakistan. the disease situation in pakistan is becoming worse day by day and currently, the cumulative reported cases are higher than china. in this study we consider the covid-19 confirmed cases from march 01, 2020, till may 28, 2020, reported in pakistan. the data is obtained from [7, 8] . in order to parameterize the model, we utilized two approaches: some of the demographic parameters are estimated from the literature. we assume the time unit is days and the estimation procedure of the parameters is as follows: • the birth rate λ: the total population of pakistan estimated by un for the year 2020 is about n (0)=220,309,834 [18], therefore, the parameter λ is obtained from λ/µ = n (0), and it is assumed that this is the limiting population in the disease absence, so that λ = 8939 per day. • mortality rate due to coronavirus ξ 1 : the death rate due to this novel infection in pakistan is 2.2% so far [8] , therefore the covid-19 induced mortality rate is estimated as ξ 1 = 0.022. the remaining biological parameters are fitted from the reported infected cases plotted in figure 1 . to do this we used the non-linear least-square curve fitting technique followed in [19, 20] . we briefly present the main steps in this statistical technique. in order to present the main theme of the algorithm, firstly, the model (3) can be comprehensively expressed as the function f depends on time t, the vectors of dependent or state variables y and unknown parameters θ to be estimated. the purpose of using the least square technique is to estimate the best values of model parameter which is obtain by minimizing the error between the reported data pointsỹ t l and the solution of the model y t l associated with the model parameters θ. the objective function used in the minimization procedure is given asθ where n denotes the available actual data points. to obtain the model parameters, we aimed to minimize the following objective function minθ subject to eq.(10). for more detail about this technique please see [21, 19] and reference therein. we investigate the proposed model fit to the reported covid-19 infected cases in pakistan using the above approach. the reported cases are shown in figure 1 . the model is solved using ode45 (rk4 technique) package which is a solver for the initial value problem in matlab. then, we implemented the lsqcurvefit package to fit the model to real data and to estimate the parameters. the best fit to the reported data via our model is depicted in figure 2 . it can be seen that the model simulation is in good agreement with the real data. the estimated and fitted parameters are given in this section is devoted to perform the simulation results of the covid-19 transmission model (3) . the model is solved numerically using fd45 package in matlab which is base on the range-kutta fourth-order method. the estimated parameter values given in table 1 are utilized in the simulation process in order to study the impact of various possible non-pharmaceutical interventions against the spread of covid-19 in pakistan. in the graphical results, the various non-pharmaceutical control parameters are taken at their baseline values given in table 1 (unless otherwise stated in captions). the effect of parameter β that represents the impact of effective contacts is shown in figure 3 . we have analyzed the impact of baseline social-distancing, mild social-distancing (10% reduction in β), moderate social-distancing (30% reduction in β) and comparatively strict socialdistancing (35% reduction in β) on the disease transmission. it is observed from figure 3 that the enhancement in social-distancing significantly reduced the burden of cumulative new infected cases. it is further observed that the implementation of a highly-effective social-distancing strategy (i.e., at least 35% reduction in β) dramatically reduces the cumulative new infected cases. thus, this graphical interpretation suggests that strict socialdistancing measures that reduces the contacts between people including staying 2 meters apart or more preferably staying at home should be implemented by the government. the impact of parameter ψ representing the infectiousness rate due to asymptomaticallyinfected individuals is depicted in figure 4 . it can be seen that the reduction in ψ also significantly reduces the cumulative number of newly confirmed covid-19 infected cases. this interpretation shows that the people who do not even know that they are infected (i.e., those with mild or no symptoms), are significantly contributing the disease burden. further, the influence of parameter ν the infectiousness rate due to covid-19 patient admitted in the hospital are depicted in figure 5 . it is observed that the reduction in this parameter has no reasonable impact on disease transmission. obviously, the hospitalized covid-19 patients are isolated and no one is allowed to meet him. the health care facilities are also supposed to follow strict standard operating procedure (sop) during the treatment and look after of hospitalized patients. therefore, these infected individuals do not contribute greatly to the disease burden. we further simulate the covid-19 model (3) by using the baseline parameter tabulated in table 1 and various of κ by increasing with different level i.e, mild, moderate, and strict rates. the resulting behavior is depicted in figure 6 showing that a strict quarantine or contact-tracing policy (up to 70% enhancement to its baseline) is needed to reduce the disease burden in pakistan. finally, the impact of hospitalization or selfisolation of tested positive cases (η) is plotted in figure 7 . it is observed that this strategy is comparatively less effective than social-distancing and quarantine interventions. these graphical interpretations emphasize that once a covid-19 infected case is diagnosed via testing, that case must be rapidly isolated and his/her contacts quickly traced (via effective contact-tracing) and placed in quarantine. global sensitivity analysis is one of the important aspects of mathematical modeling not only for epidemic models but in all sciences. the global sensitivity analysis of the threshold quantity r 0 is used to measure the effect of changes in the dominant factors of the model and to point out the most influential parameters of the model that greatly influence the prevalence of infection. furthermore, the sensitivity results provide a pathway to set effective and suitable control strategies to curtail the disease in a community. more specifically, this analysis is helpful to explore how the initial inputs to the model contribute to the system outputs. a latin-hypercube sampling approach (lhs) coupled with the partial rank correlation coefficient (prcc) is commonly used for this purpose [22] . this technique provides prcc and the corresponding p-values for each parameter the use of which can help estimate the level of uncertainty in an epidemic model. the higher prcc and smaller p-value of a parameter indicating that it has a substantial effect on simulation behavior. the graphical prcc results of the covid-19 model associated parameters taken in this analysis are shown in figure 8 , while the numerical values of prcc and corresponding p-values are placed in table 2 . it is observed from table 2 and figure 8 that β is considered to be the most sensitive parameter with high prcc value with a positive sign followed by ψ, ν, and ω. moreover, µ and κ, ξ 1 and η have competitively high prcc with negative sign and zero p-values. previously, we analyzed the impact of non-pharmaceutical interventions with constant rates. in this section we formulate an optimal control problem for covid-19 with the inclusion of two time dependent controls in the model (3). the resulting control problem is presented in (13) . these controls are chosen on the basis of global sensitivity results. the control variable u 1 (t) is used for the enhancement of effective contact-tracing policy to quarantine the exposed individuals which was previously taken as a constant parameter. the time dependent control variable u 2 (t) is used to enhance the hospitalization or selfisolation of diagnosed covid-19 infected cases (following testing). thus, the resulting control model after incorporating the aforementioned control variables is formulated via the following system: subject to the non-negative initial conditions. in order to minimize this covid-19 infection, we are aimed to minimize the cost function given as: where the expressions a i for i = 1, 2, · · · , 5, are the constants and representing the balancing cost factors while t f represents the final time. we consider the quadratic objective functional because the intervention is nonlinear, for more details see the work and references therein [23, 24, 20, 25] . onward our main objective is to investigate an optimal controls u * 1 , u * 2 for quarantine and hospitalization respectively such that the associated control set is given by the lagrangian and hamiltonian for the above optimal control system is defined by and where λ j , for j = 1, 2 · · · , 8, are the adjoint variables. we use the pontryagin's maximum principle [26] in order to solve the covid-19 optimal control problem (13) . to do this, let u * 1 , u * 2 are the desired optimal solution then, the corresponding conditions of pontryagin's maximum principle used in solution process are as follows: utilizing the conditions mentioned above (17), we present the solution of optimality system in the following theorem. theorem 3. the optimal controls u * 1 , u * 2 and the solutions s * , e * , i * , i * a , q * , i * h , i * c and r * of the corresponding control system (13) that minimize the objective functional j(u 1 , u 2 ) over ω. there exists adjoint variables λ i , where i = 1, 2, · · · , 8, along with transversality conditions λ i (t f ) = 0 such that furthermore, the associated optimal controls u * 1 and u * 2 are given by proof. the desired results (18) and the transversality conditions are obtained by utilizing the conditions specified in (17) for the hamiltonian function given (16) and with the settings s = s * , e = e * , i = i * , i a = i * a , q = q * , i h = i * h , i c = i * c and r = r * . further, to obtain the equations (19) for the control characterization, we use the condition ∂h(t,u j * ,λ j ) ∂u j = 0 given in (17) for j = 1, 2, and the equations (19) are presented. we present and discuss the graphical results of the covid-19 model (3) with constant quarantine and hospitalization/isolation control measures and the model (13) with time dependent control interventions and compared both results. to perform the simulations, both models are solved numerically using the rk4 technique. the estimated and fitted parameters given in table 2 are used in the simulation results. the time level is considered up to 150 units (days). the weight and balancing constants are chosen as a 1 = 0.001, a 2 = 0.01, a 3 = 0.001, a 4 = 300, and a 5 = 200. it should be noticed that the weights constant values taken in the simulations are theoretical as they were chosen only to carried out the control strategies developed in this study. in figure 9 (a-d), we have depicted the impact of hospitalization control only and keeping the quarantine or case tracing control inactive (i.e., u 1 = 0 and u 2 = 0). the control profile for this strategy is shown in 9 (e). it is observed that although the control u 2 is kept 100% for the first 70 days, but still it has no significant impact on the different infected individuals as seen 9 (a-d). thus, only the hospitalization or self-isolation intervention is not enough for the control of covid-19 pandemic in pakistan. the impact of only quarantine optimal control by keeping the hospitalization control zero (i.e., u 1 = 0 and u 2 = 0) is shown in 10 (a-d). the corresponding control profile for this case is depicted in 10 (e). it can be seen that by maintaining a strict quarantine control is very effective in minimizing the spread of the covid-19 infection. finally, the impact of both optimal controls on the dynamics of covid-19 burden is analyzed. the graphical results are depicted in figure 10 (a-d) , while the control profile is shown in 10 (e). it can be observed from 10 (a-d) that the number of exposed, symptomatically-infected, asymptomatically-infected, and critically-infected individuals are decreasing very significant when the optimal quarantined and hospitalization controls are applied rather than the constant case. the effectiveness can be viewed from the difference between the peaks of the two graphs. from the control profile depicted in figure 10 (e), it can be seen that the control u 1 is kept initially at 100% for 140 days and gradually reduces towards the end of the intervention, while the control u 2 is set to 55% and then immediately increases to 90% in the initial days and then gradually reduced during the rest of the intervention. the covid-19 pandemic has rapidly spread out to most of the regions of the world and has severe public health and socio-economic burden in developed and devolving countries including pakistan. the number of reported cases in pakistan is increasing and more than 100,000 confirmed cases have been reported till 05 june 2020. in the absence of a safe and effective vaccine or antiviral, the whole human's community is being focused on the use of non-pharmaceutical interventions against the covid-19 pandemic. in this study, we formulated a mathematical model in order to study the dynamics of covid-19 pandemic in pakistan, and used it to assess the community-wide impact of the various control and mitigation strategies. initially, we developed the model and presented some mathematical analysis, including positivity and stability results of the disease-free equilibrium. it is proven that the disease-free equilibrium is stable both locally and globally when r 0 < 1. the model is parameterized from the covid-19 confirmed cases reported till may 28, 2020 in pakistan while some parameters are estimated from literature. the findings show that the model predicted infected curve is in good agreement to the real infected cases. the estimated numerical value of the basic reproduction is obtained as r 0 ≈ 1.87 showing the alarming situation of the pandemic in pakistan. the control and mitigation strategies should be implemented to bring the threshold quantity r 0 to a value less than unity. after the estimation of model parameters, we simulated the model to explore the effectiveness of various control strategies implemented in pakistan. firstly, we presented the impact of three effectiveness levels (i.e., low or mild, moderate and strict) of social-distancing in curtailing the burden of covid-19. the simulation results revealed that although the implementation of mild social-distancing decreased the covid-19 burden significantly (as measured in terms of shifting and lowering the peak of daily infected cases), still a strict social-distancing measures should be implemented and maintained for an extended period of time to avoid a significant outbreak in pakistan. further, we simulated the model to assess the effect of various levels of quarantine and hospitalization or self-isolation interventions. with a highly-effective quarantine intervention (enhanced by 70% to its baseline value) a dramatic reduction in the pandemic peak was observed. on the other hand increase of hospitalization intervention of confirmed cases had no significant influence on the pandemic burden. finally, the proposed covid-19 model is reformulated by the inclusion of two time-dependent control variables in order to assess the impact of optimal control measures on disease dynamics. we simulated the control model and compared the effect of constant and optimal time-dependent control measures on disease burden. it is observed from the simulation results of the control covid-19 model that the infected individuals significantly decrease with the implementation of both time-dependent control measures. although it is impressive that pakistan ramps up daily diagnostic covid-19 testing and contact tracing to have a realistic measure of the burden of the nationwide pandemic and emphasize personal hygiene and hand washing, physical-distancing, wearing face masks in public. still, this study suggests that the implementation of basic non-pharmaceutical interventions, particularly social-distancing, quarantine (or self-isolation or stay at home) should be strictly observed in the future to avoid the worse scenario in pakistan. it is also believed that the present study will be beneficial to the decision-making in combating the disease. in the near future, we will extend the present model by introducing the fractional operators with local and nonlocal kernel to gain more insights about the dynamics of covid-19 pandemic. an interactive web-based dashboard to track covid-19 in real time. the lancet infectious diseases world health organization coronavirus disease (covid-19) situation reports presumed asymptomatic carrier transmission of covid-19 covid-19 coronavirus pandemic world health organization coronavirus disease (covid-19) situation reports covid-19 coronavirus pandemic covid-19 coronavirus pandemic in pakistan quantifying the role of social distancing, personal protection and case detection in mitigating covid-19 outbreak in ontario analysis and forecast of covid-19 spreading in china, italy and france modeling the dynamics of novel coronavirus (2019-ncov) with fractional derivative modelling the spread of covid-19 with new fractal-fractional operators: can the lockdown save mankind before vaccination? forecasting the cumulative number of confirmed cases of covid-19 in italy, uk and usa using fractional nonlinear grey bernoulli model modeling and prediction of covid-19 in mexico applying mathematical and computational models mathematical assessment of the impact of non-pharmaceutical interventions on curtailing the 2019 novel coronavirus reproduction numbers and subthreshold endemic equilibria for compartmental models of disease transmission the stability of dynamical systems modeling the transmission dynamics of tuberculosis in khyber pakhtunkhwa pakistan optimal control strategies for dengue transmission in pakistan parameter estimation in nonlinear dynamical systems a methodology for performing global uncertainty and sensitivity analysis in systems biology optimal isolation control strategies and cost-effectiveness analysis of a two-strain avian influenza model media coverage campaign in hepatitis b transmission model mathematical formulation of hepatitis b virus with optimal control analysis the maximum principle. the mathematical theory of optimal processes no conflict of interest exists regarding the publications of this paper. the authors declare that there is no conflict of interests regarding the publications of this work. key: cord-348521-ai7d634u authors: atif, muhammad; malik, iram title: covid-19 and community pharmacy services in pakistan: challenges, barriers and solution for progress date: 2020-06-15 journal: j pharm policy pract doi: 10.1186/s40545-020-00240-4 sha: doc_id: 348521 cord_uid: ai7d634u in the wake of atrocious rise in covid-19 cases, developed countries are leveraging a range of community pharmacy services with the goal of improving access to essential medication and healthcare services. while in the developing nations, including pakistan, pharmacists are unable to perform covid-19 containment roles in community, since presence of pharmacists at community pharmacy settings and delivery of pharmacy services have historically been plagued by shortcomings at various levels. in this document, we identified these shortcomings which need to be resolved on many fronts. broadly, a number of intertwined government related, public related, academic curricula and pharmacist related, and drug retailers’ related factors refrain community pharmacists from performing and facilitating pakistan’s fragile public and healthcare system in the midst of covid-19 pandemic. government led multifaceted approaches are urgently needed to strengthen this unrecognized domain and thereby effectively combat covid-19 by utilizing community pharmacy services, as evidenced in the developed world. [note: part of this article is published in pakistan observer newspaper; dated 17 may 2020). covid-19 has put unprecedented pressure on healthcare systems of every nation [1] . specifically, owing to a number of voids in their healthcare system, the developing nations are unable to meet the healthcare needs of the population and adopt the recommended covid-19 response strategies to flatten the contagion curve. to this end, there is emerging recognition across the globe that community pharmacists are in a unique position to provide medicines, therapeutics, vaccines and essential healthcare services in the wake of atrocious rise in covid-19 cases [2] . many countries across the globe are leveraging a range of community pharmacy services with the goal of improving access to essential medication and healthcare services. as a result, community pharmacists in developed nations, such as china, australia, canada, the united states (us) and the united kingdom (uk) have acted swiftly and are offering a broad range of the quality pharmaceutical service [3] [4] [5] [6] [7] . these include, drug review and monitoring, clinical consultation and treatment, medication therapy management, pertinent drug information, assessment of patients and their treatment outcomes, and mitigation of drug shortages through various strategies etc. these evidences from developed countries provides insight to the resource-deprived nationswith fragmented health care systemsfor planning and operating pharmacy services to combat current and future epidemics. in pakistan, community pharmacy services are highly warranted as the devastating covid-19 pandemic is swiftly spreading and the country does not have the capacity to meet the international standards of care due to a number of public health and healthcare system related vulnerabilities. despite being described under the drug regulatory authority of pakistan (drap) act 2012, a majority of pharmacy services don't exist in the country and only a few core services [8] , such as dispensing, storage, distribution and management of therapeutic goods are available at drug retail outlets. however, there is a mounting list of previously known threats to the optimal use of medicines (e.g., adverse drug reactions, medication errors, misuse of controlled substances and excessive) [9] and medicinerelated practices (e.g., inappropriate use of medicines, especially antibiotics, formulation issues, over-the-counter (otc) availability of prescription medicines, unsafe storage and disposal of medicines, and poor availability of medicines) that demand advanced community pharmacy services in the patient's welfare [10] [11] [12] [13] [14] [15] . whilst, in the current situation, when healthcare system is buckled under the burden of public health crisis and the country is attempting to adhere to the recommended preventive measures against covid-19, full-blown community pharmacy services are urgently needed. the importance of community pharmacy services during covid-19 havoc could be gauged by the fact that many developed nations have amended pharmaceutical policies, introduced reimbursement schemes and released new instructions for community pharmacies to expand pharmacy services [3] [4] [5] [6] [7] . for pakistan, however, this may not be easy, since both the presence of pharmacist and provision of patient centered pharmacy services at community settings have historically been plagued by shortcomings at various levels. therefore, pharmacists are currently not able to perform covid-19 control roles in public. this commentary highlights a set of factors that refrain community pharmacists from performing and facilitating pakistan's fragile public health and healthcare system in the midst of covid-19. in response to ongoing public health crisis, regulatory authorities throughout the world have been found to play a key role in ensuring the delivery of essential patient care services through utilization of community pharmacy services [3] [4] [5] [6] [7] . however, the community pharmacy services are inadequately provided in pakistan mainly due to lack of attention at government level [8] . healthcare regulators in pakistan regulate community pharmacies as ordinary commercial entities rather than considering these as healthcare settings and pharmacists as promising healthcare professionals. though, rules and regulations in the form of drugs act, 1976, pharmacy act, 1967 and punjab drug rules 2007 are in place, but partially implemented specifically in terms of assurance of qualified persons' presence at the community pharmacy settings [16] [17] [18] . recently, atif and colleagues revealed that there is an excessive breach of existing rules in the country; such as the owners of drug retail outlets do not mandate availability of pharmacist at their premises, and pharmacists rent out their pharmacy license in lieu of small sum of money and this is even without assuring their presence on the premises [8] . besides regulatory loopholes, the government resists underwriting facilities for community pharmacy proprietors, such as fair profit margins (difference between retail and trade price), low cost electricity and non-profit loans. analogous to previous patterns, pakistani healthcare regulators have not yet announced any sort of support to this sector despite the covid-19 triggered a high need for community pharmacy services. the other factors that place the establishment of community pharmacy services at stake are relevant to the general public or patients. the majority of the pakistani population has low rates of health literacy [19] . as a result, pharmacy customers rarely seek and acknowledge pharmacy services. moreover, massive proportions of people in pakistan only recognize physicians as qualified and capable healthcare practitioners [20] , while regard pharmacists as purveyor of medicines. this in effect reduces the demand of pharmacists at these settings. in brief, pharmacist's identity in community pharmacy is questioned. their abilities are marked unreliable, and are regarded as pre-packaged drug dispensers. however, as a result of reduced public enthusiasm for visiting hospitals due to fear of catching covid-19, community pharmacists around the globe have a great opportunity to gain recognition as competent healthcare practitioners. the demand of telepharmacy and home delivery of medication and services has grown globally along with other key services. the patients in need of these services are interacting and acknowledging the full potential of community pharmacists. the same could happen in pakistan if government supports pharmacists and pharmacy proprietor in offering a set of advanced pharmacy services. considering the rapid spread of covid-19 and the limited frontline healthcare personnel and diagnostic facilities, healthcare regulators are looking for strategies to meet the healthcare needs of massive population. there are growing discussions about engagement of community pharmacists in different patient-centered activities. aside from previously recognized advanced patient care services, community pharmacists are anticipated to be tasked with testing, treatment and immunization of communities. however, aspect that may negatively affects the adoption of these much needed envisaged community pharmacy services in pakistan is the lack of expertise of pharmacists resulting from deficits in academic curricula and other pharmacist related factors [19, 21] . although, a transition from the four-years b. pharm program to the five-year pharm-d program has been observed in pakistan [22] , the content of pharmacy curriculum does not comply with the needs of advanced pharmacy services [8] . moreover, clinical sessions and clinical research at under-graduate stage are introduced only as a formality. pharmacy students, therefore, lack the necessary knowledge and competence regarding advanced pharmacy services [23] . this in turn impacts self-confidence of pharmacists and ultimately the standard of even core pharmacy services, including patient counseling skills [19] . fresh graduates are also reluctant to acquire professional skills at community pharmacies owing to lack of recognition and low remuneration. in this episode of covid-19, this attitude of pakistani pharmacists refrains them from possible interaction with the public and patients. furthermore, a large number of pharmacy graduates in pakistan are female, however, due to socio cultural barriers and traditional orthodox society their presence at the community pharmacies is sparse [24] . therefore, the low uptake of community pharmacy services in the country during covid-19 is highly related to this gender imbalance driven low availability of experienced community pharmacists. in the wake of covid-19, nations are facing a huge challenge associated with access to essential medicines. in order to mitigate medication disruption, community pharmacies in the presence of pharmacists have been temporarily authorized to offer additional services, such as medicines compounding, re-packaging of nonprescription medicines, digital image prescriptions and continued dispensing of essential prescription only medicine without a prescription. nevertheless, authorizations for these services in pakistan will be curtailed due to unavailability of pharmacists at community settings, which is fuelled by a range of aspects at pharmacy proprietor level. first, fully compliant drug store proprietors are earning less owing to low profit margin in medicines and related products. as a result, they cannot fulfill even reasonable salary demands of pharmacists, which is one of the key factors why pharmacists in pakistan are unwilling to opt this profession as a fulltime job. second, the proprietors tend to sale "prescription only" and "controlled drugs" easily in the absence of a qualified pharmacist. therefore, most of pharmacy owners infringe the regulation and avoid recruiting pharmacists at their premises. third, proprietors do not want to pay fresh pharmacists merely because of their qualification. this is because fresh pharmacists have minimal competency to fill the prescriptions and counsel patients. on the other hand, pharmacists have low demand from the pharmacy customers. pharmacists on the other hand find it humiliating to work as a sale staff (i.e., prescription filling without patient counseling) after studying a nerve racking five-year professional course. given the foregoing reasons, it is very difficult not only for community pharmacists to integrate themselves in the community pharmacy settings during covid-19, but also for pharmacy owners to satisfy the expectations of pharmacists. there are a number of intertwined government, public, academia, curriculum, pharmacist and drug retailers related factors in pakistan which are hindering the establishment of community pharmacy services regardless of covid-19 driven high demand for such services. government led multifaceted approaches are urgently needed to strengthen this unrecognized domain. the existence of a multi-stakeholder committee led by pharmaceutical regulators and foreign experts appears to be essential in tackling these challenges. the government level initiatives are urgently required to attract and encourage pharmacists to perform their role in community pharmacies during ongoing pandemic. the government should consider the provision of sufficient interest free loans to the pharmacy graduates which will enable them to open their own pharmacies. on the other hand, the government should urgently consider increasing profit margins for the proprietors (i.e., increase in the difference between trade and sale price) and later emphasizing them to ensure the presence of pharmacists at their setting. the pharmacy council of pakistan has a crucial obligation to act progressively to overhaul and synchronize pharmacy education and practices. not only do pharmacists need to work closely to deal with the continuing challenge of covid-19, they do need to understand that their strength lies in the acquisition of identification rather than authority. how will country-based mitigation measures influence the course of the covid-19 epidemic? on the frontline against covid-19: community pharmacists' contribution during a public health crisis. res social adm pharm recommendations and guidance for providing pharmaceutical care services during covid-19 pandemic: a china perspective summary of covid-19 regulatory changes from regulatory flexibility to reimbursement changes, how canadian regulators and payers are managing the covid-19 crisis update on new legislation relating to controlled drugs during the covid-19 pandemic pharmacy developments related to covid-19 resting and compounding of critical drugs pharmacy services beyond the basics: a qualitative study to explore perspectives of pharmacists towards basic and enhanced pharmacy services in pakistan drug safety in pakistan factors affecting patients' knowledge about dispensed medicines: a qualitative study of healthcare professionals and patients in pakistan factors associated with inappropriate dispensing of antibiotics among non-pharmacist pharmacy workers community pharmacists as antibiotic stewards: a qualitative study exploring the current status of antibiotic stewardship program in bahawalpur, pakistan what drives inappropriate use of antibiotics? a mixed methods study from bahawalpur pediatric antibiotic pack size compliance with the dosage regimen: a descriptive study global menace of superbugs: time to consider a "pharmacist led one health approach" to counteract the crisis pharmaceutical policy in countries with developing healthcare systems punjab drug rules a qualitative study exploring perceptions of policymakers about community pharmacy practice and extended pharmacy services in lahore medication related knowledge and practices among patients attending pharmacies in bahawalpur. pakistan: a cross-sectional study medicines shortages in pakistan: a qualitative study to explore current situation, reasons and possible solutions to overcome the barriers pakistan's national university of pharmaceutical sciences social pharmacy strengthening clinical pharmacy: why pharmaceutical policy research is needed in pakistan? a qualitative study exploring perceptions and attitudes of community pharmacists about extended pharmacy services in lahore lack of female pharmacist leadership and struggling pharmacy profession: a call to action publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations none. both authors made equal contributions in writing this commentary. no funding sources.availability of data and materials not applicable.ethics approval and consent to participate not applicable. not applicable. the authors declare that they have no competing interests.received: 2 june 2020 accepted: 11 june 2020 key: cord-255376-nqq5ieyg authors: safdar, muhammad; yasmin, musarat title: covid‐19: a threat to educated muslim women's negotiated identity in pakistan date: 2020-05-08 journal: gend work organ doi: 10.1111/gwao.12457 sha: doc_id: 255376 cord_uid: nqq5ieyg this study attempts to explore how the lockdown/containment measures taken by the government during the covid‐19 pandemic have threatened educated muslim women's negotiated identity regarding wifehood and motherhood in urban pakistan and how they struggle to reposition to reconstruct it. through semi‐structured interviews, making an in‐depth comparative study of three differently situated cases (muslim women), this study argues that the abnormal situation that has ensued from the pandemic has reinforced the vulnerability of women's nascent negotiated identity by landing them in a space where they are supposed by the normative structures to step back to carrying out their traditional responsibilities as ‘good’ wife and mother during the crisis. it has found that the pandemic has similarity in its impacts for the women in their familial lives, despite their being variously situated and resistive, due to the general religio‐culturally defined patriarchal social behaviour of the place (pakistan) toward women and lack of action on the part of the state for implementing its laws of women's empowerment. this study attempts to explore how the lockdown/containment measures taken by the government during the covid-19 pandemic have threatened educated muslim women's negotiated identity regarding wifehood and motherhood in urban pakistan and how they struggle to reposition to reconstruct it. through semi-structured interviews, making an in-depth comparative study of three differently situated cases (muslim women), this study argues that the abnormal situation that has ensued from the pandemic has reinforced the vulnerability of women's nascent negotiated identity by landing them in a space where they are supposed by the normative structures to step back to carrying out their traditional responsibilities as 'good' wife and mother during the crisis. it has found that the pandemic has similarity in its impacts for the women in their familial lives, despite their being variously situated and resistive, due to the general religio-culturally defined patriarchal social behaviour of the place (pakistan) toward women and lack of action on the part of the state for implementing its laws of women's empowerment. covid-19, identity, motherhood, muslim women, pakistan, wifehood the world has scrambled to deal with the multidimensional impacts of the cataclysmic covid-19 pandemic which first erupted in wuhan, china in december 2019 and spread across the world within weeks (at the time of writing in the last week of march 2020 the virus has claimed about 30,000 lives and has infected hundreds of thousands of people across the globe; the virus is still spreading and casualties multiplying with no medicine to cure it so far). though statistics reported in the media have shown men in greater number as victims of the pandemic, the effects of the virus cannot be taken as limited to just physical illness or mortality. there is a need to study the outbreak with reference to its impact on women in terms of increased aggravation of unpaid labour, domestic and sexual violence, reproductive health, issues of pregnancy and maternity, and economic burden. there is hardly any published academic research on the impact of covid-19 on women regarding how it has worsened gender issues. pandemics like covid-19 can have severe and long-term gender impacts for women, especially in religio-culturally inspired patriarchal societies like pakistan. informed by the little feminist research focused on the impacts of the zika and ebola epidemics (the diseases that struck south and north america and africa during [2013] [2014] [2015] [2016] , this study, from the feminist perspective, attempts to explore the impact of the covid-19 pandemic on muslim women in pakistan. ebola in africa resulted in long-term destructive consequences for women by affecting their life chances as many of them had to drop out of school; teenage-pregnancy rates increased, domestic and sexual violence grew, women's health deteriorated and the rate of women dying due to obstetric complications rose (farmer, 2014; lewis, 2020; marindo, 2017) . zika epidemics, in latin america, were exacerbated due to the lack of reproductive rights of women in that patriarchal society which had deep structural economic inequalities for its women (velez & diniz, 2016) . to contain the spread of the highly contagious covid-19 virus, pakistan's federal and provincial governments closed down all schools, colleges and universities across the country from 11 march 2020 to 31 may 2020. all types of international, national, inter-city and intra-city travel were banned; shopping malls, businesses and all types of public gatherings were prohibited; along with other law enforcement agencies, the army was deployed to force people to stay at home. the lockdown period was extended to 7 april 2020, which could further be increased in view of the spread of the virus. muslim women in pakistan have long struggled to negotiate their gender identity in the religiously inspired patriarchal sociocultural structures of the postcolonial globalized nation state that came into existence (in 1947) in the name of islam (details in the following section). this study attempts to explore how the lockdown/containment measures taken by the government during the covid-19 pandemic have threatened educated muslim women's negotiated identity regarding wifehood and motherhood in urban pakistan and how they struggle to reposition to reconstruct it. through semi-structured interviews, making an in-depth comparative study of three differently situated cases (muslim women), this study argues that the abnormal situation resulting from the pandemic has reinforced the vulnerability of the women's nascent negotiated identity by landing them in a space where they are supposed by the normative structures to step back to carrying out their traditional responsibilities as 'good' wife and mother during the crisis. it has been found that the pandemic has similarity in its impacts for the women in their familial lives, despite their being variously situated and resistive, due to the general religio-culturally defined patriarchal social behaviour of the place (pakistan) toward women and lack of will and action on the part of the state for implementing its laws of women's empowerment. the pandemic for the women has resulted in the form of increased burden of unrecognized unpaid domestic labour and domestic violence which, as a result, has caused them mental stress and apprehension regarding the loss of the identity that they had long negotiated their religio-traditional structures to achieve. within the framework of the case study methodology, the data from the interviews is properly coded and categorized for their thematic analysis. though gender-defining intersectional factors like social status, class, education, economic independence, locality, interpretation of religion and physical beauty usually intervene to influence a woman's empowerment in the family, this study finds that, in addition to the influence of these factors, the general dominant social behaviour toward women and the lack of will and action/infrastructure on the part of the government to ensure women's empowerment are major factors which even worsen their condition during a crisis like covid-19. muslim women in pakistan have never been able to get rid of being viewed as symbols of the religiously rooted national and postcolonial culture in which they have to embody and enact the modest and pious muslim lady as a daughter, sister, mother and wife. they are supposed by the nationalist and dominant social discourse to look 'muslim' and not 'western'; westernization is deemed as being vulgar and obscene. social, political, cultural, religious and economic structures of pakistan see its women as caregivers at home and have deep gender disparities. however, cultural and economic globalization and increasing geographic and non-geographic physical and intellectual mobility of women can also be felt through its effects on changing lifestyles and social spaces (safdar & ghani, 2018) . though a number of factors like class, region, locality, ethnicity, social status, age and historical specificity have intersected to define and position gender of muslim women in pakistan, the intervention of religion and state discourses has always had, throughout the country's history, a major influence on the construction of the perceptions and expectations associated with gender (jafar, 2005; jamal, 2006; julia, 2013; mumtaz & shaheed, 1987; shaheed, 2010; yasmin, naseem & sohail, 2019; yasmin, naseem & raza, 2018; zia, 2018) . religious and state discourses, though varied across various government configurations (democratic and dictatorial), have been key to forming general social behaviour and the state's policy toward determining female spaces. the moderate social space women gained through their active participation in the struggle for independence of the nation during the 1940s reduced after independence in 1947 and then was drastically curtailed in the name of islam by the dictatorship of general zial-ul-haq in the 1980s (saigol, 2016; suleri, 1992) . the state promulgated such legislations (including zina and hodood ordinances) and initiated such public discourses (people could act as vigilantes to judge and police the character of women) that have continued to victimize women. women action forum (waf), led by upper-class women following the politics of secular feminism, protested against the regime of zia for its women-biased public discourse and policies, and demanded equality of women. waf, though struggled hard for the democratic rights of women and other suppressed communities, failed to attract common women largely due to the dominant religiously inspired social behaviour toward women. its problems in forwarding its agenda multiplied in the aftermath of 9/11, when it became usual in pakistan to label secular feminist struggles with the stigma of westernization of the society. feminism, having been ambivalently interpreted by the majority of people in the country, has been in retreat; instead, a third space enabling women to negotiate the oppressive indigenous religio-cultural patriarchal structures and western notions of women's equality has increasingly opened for women to negotiate their space (akhtar, 2014; mansoor, 2014; safdar & ghani, 2018; zubair & zubair, 2017) . as a reaction to secular perceptions of gender, religion-based struggle for women's rights has been advocated by academics as the alternative indigenous agency that does not necessarily mean to subvert patriarchy in the sense that secular feminism means (iqtidar, 2011; mahmood, 2005; syed, 2010) . the pre-and post-zia era state policies exploited relatively moderate versions of religious interpretations to forward their political and economic agendas. general pervez musharraf's regime (1999) (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) (2008) included religious political parties in the coalition government and advocated cultural enlightenment and women's rights. successive governments after musharraf have also introduced several women-friendly legal measures. however, the recently reignited discursive conflict between secular and religious viewpoints about muslim women's gender roles and rights in pakistan by the marvi sarmad (a pakistani feminist activist) and khalil ur rehaman (a playwright) episode (dawn, 2020a (dawn, , 2020b has revealed that the majority of people in pakistan view gender of muslim women through the perspectives of their religion and local culture rather than secularism. women's visibility and mobility have been growing across the country, and as a result, their intellectual mobility as well in the form of an increasing sense of reasoning and critical thinking. however, they mostly seek their agency from interpretations of religion, especially in the case of middle-class women (khurshid, 2015) . the state, in the last two decades, has also passed a number of pro-women legislations to punish the perpetrators of honour killings, domestic violence and sexual harassment, and to empower women in matters related to divorce and marriage (dawn, 2016; mirza, 2011) . however, what is missing is the will, readiness, proper training and consistency in action on the part of the state institutions to implement these laws (dawn, 2020a (dawn, , 2020b . it has resulted in scattered, disorganized and haphazard growth in social behaviours towards gender in the contemporary pakistan which is globalized and also always mindful of the reason of its being (that is, religion). the covid-19 pandemic and the asymmetric condition of gender in hardcore patriarchal societies like pakistan form the background of this study. the study conducts purposive sampling to explore the impact of the pandemic on the familial life of those pakistani muslim (single parent and double parent) women who are highly educated, comparatively less educated (grade 10-12), economically independent/dependent and located in urban areas in pakistan. it is generally assumed that educated and economically independent women located in urban areas exercise comparatively greater agency than uneducated and economically dependent women who are located in rural/remote areas. this is why this study attempts to explore the experience of the educated and economically independent (and dependent as well) women who are located in urban areas to understand how the women have to struggle to maintain their relatively better position regarding their rights/agency in the times of pandemics like covid-19. all the three cases selected for this study are from sialkot. sialkot is an industrial city located in the province of punjab in pakistan; after the metropolises: karachi, lahore and faisalabad, it is the forth city in the country that has high per capita income. case study methodology, as explained in hood (2009) , provides a useful entry point to explore the experiences of the women through their personal narratives; narratives constitute and can help understand one's identity (neitz, 2004; wuthnow, 2011) . since the authors are also married and going through similar experiences as the cases are in their familial life during the containment measures, self-reflexivity as a method, which is often employed by feminist research (alldred, 1998; birch, 1998; parr, 1998; zubair, 2005; zubair & zubair, 2017) , is also used to feel a connection with the research participants and to research with rather than on them. as typical with linguistics and discourse studies, language is constitutive and expressive of one's identity; this study therefore attempts to investigate and capture the lived experiences of the muslim women through their talks. the following prompt was used to initiate the semi-structured individual interviews which lasted over an hour each and also included informal irrelevant exchanges of ideas and gossip: how are you doing during these lockdown/containment measures by the government? since the interviews were recorded, the relevant material was later noted down and transcribed for the study. two of the cases (both of them women and coded as nisa and rida) and the authors have been serving as colleagues in the same university in sialkot for several years, and have visited each other's families many times. therefore, the authors position themselves with respect to the two participants as colleagues and friends who have a deep understanding of each other's familial situations and can share their experiences confiding in each other. the third case (also a woman coded as nayab) for this study is a relative of ours with whom also we can position ourselves in a situation where there is mutual confidence and trust and deep knowledge of each other's familial experiences. though the authors' positionalities with the participants are such that they have mutual confidence, trust and deep knowledge of each other's familial and personal lives, the first author, being a male, may have to be more reflective and empathetic to understand the women participants' sensibilities. however, this sexual opposition of the author enables him to be more interested and curious to explore the experiences of the women. the second author, being a woman, can better feel with the women participants and helps the first author to feel the same by explaining to him the situations of the participants. rida is a single parent, parenting her five-year-old daughter after her divorce two years ago. she is in her thirties, living with her parents in their own home after her divorce. she is the only daughter of her parents and has no siblings. her parents are over 60 years of age and need someone to take care of them. her family environment is not that strict in religious matters like dress and rituals, etc. she wears cultural (shalwar qameez) and modern dress also (like pants and loose shirts). however, she wears a scarf which is a symbol of modesty and piety in pakistan. being a senior management officer, her monthly salary is sufficient to lead a respectable middle-class life. her father's retirement pension also adds a considerable amount to her monthly budget. for household chores like cooking, washing and cleaning, she has a female servant. during workdays, she spends nine hours a day at the university campus, and back at her home the servant takes care of her household chores and parents; her daughter is dropped off and picked up from school by the school van. during the covid-19 outbreak, she has spent all of her time at home looking after her daughter and parents. as culturally and religiously expected, she personally takes care of most of the services of her parents and daughter even when the servant is also available. nisa is a double parent having three sons and no daughter. she is in her forties and lives with her husband, father-inlaw and mother-in-law. she is highly educated (18 years of education) but the level of her husband's education (14 years education) is lower than hers. being a university lecturer she is financially independent; her husband also runs his own small private business. she belongs to the middle class. her eldest son is 20 years old and the youngest 16; all three of them are students at different levels and can travel to and back home from their schools on their own. her family environment is religiously and culturally fundamentalist. with the purpose of avoiding obscenity and irreligiousness, they do not even have a television at home. though she is allowed to travel alone to the university campus, which is only a mile away from her home, she first used to wear a full head-to-toe veil (abaya), however, latter, for a few years she has negotiated her veil and now wears a complete head scarf instead of the head-to-toe veil. the authors have never seen her wearing pants and shirts; she dresses according to religious and cultural norms. for household chores, she has a female servant. during workdays, she usually spends five to six hours a day at the university campus and the rest of the time she spends with her family at home. during the covid-19 pandemic, she has had to spend all of her time at home with her family. the third case coded as nayab is a woman in her thirties with two children (a five-year-old daughter and a two-yearold son). she is comparatively less educated (she has ten years of schooling) than the other two cases in this study and is not financially independent. she is a housewife. however, her husband is highly educated (he has 18 years of education) and has a job as a senior management officer in a local private organization. her family environment is not culturally and religiously fundamental, however, she has always been seen wearing culturally appropriate clothing and is traditional in her views about lifestyle. she does all the household chores herself, however, during the last few weeks of her pregnancy and the initial weeks after giving birth to her two children, she hired a female servant for the household chores. during the covid-19 pandemic, her husband spends most of his time at home doing his professional work online through internet and mobile phone services. to study the experiences of the participants, the authors have come from the position of moderate, educated pakistani muslims who believe in the progressively negotiated identity of muslim women that resists universalist as well as indigenous traditional oppressions. in the following sections, major themes that were identified through regressive and recursive readings of the transcripts are analysed. our analysis is informed by the feminist assumption that the non-traditional agency of women, like the one that comes from their mobility and economic independence, in patriarchal societies, easily falls vulnerable to curtailment during moments of national crisis, and they are mostly supposed to step back to their conventional gender roles. one of the major themes that transpired from the data is the compromised identity and frequent mental stress that all the three cases under study have experienced in their respective familial environments during the lockdown period. doing jobs, nisa and rida had become accustomed to such an environment which they considered was professional and in which they used to think and act professionally as useful and empowered persons of the society. but the lockdown shut them in homes rendering them traditional mothers and caregivers while facing harsh behaviours of their male life-partners which added to the mental stress they were already suffering from because of the widespread fear of the pandemic. nisa says: it is signified by the above excerpt that though nisa has multiple coexisting positions and identities as an educated, economically independent, professional muslim married woman, what ultimately dominates her, during these times of national calamity, is her identity as a 'good' wife and mother; the rest have to be compromised and even suppressed, at least for the time being. though the educated, professional and economically empowered positionalities and identities enable her to discern the patriarchal suppression and negotiate the religioculturally defined 'pari likhi' (educated) wife and mother makes her behave patiently and modestly, corresponding with the findings of khurshid (2015) about educated muslim women in an ethnographic study in pakistan. being an educated muslim woman in pakistan implies a privileged social position entitled to claiming power in decision-making in familial matters, but these educated women feel greater social pressure to abide by the islamic morality and struggle within rather than without the institutions of family, culture and religion (khurshid, 2015) . zubair and zubair (2017) argue through personal narratives of their research participants (muslim women educated in english literature in pakistan) that multiple positionalities and identities, like the one seen in nisa, enable women to negotiate in the third space by being resistive to the local religioculturally defined patriarchal structures and the western concepts of women's autonomy. however, the situation wherein nisa is operating is unusual which has triggered reinforcement of traditional norms in familial environments which expect her to conform rather than to resist or negotiate. people have turned more religious, intended to please god to forgive them and end his wrath that has struck them in the form of the pandemic; this general behaviour of the society also makes its imprint on familial environments. being a 'bad' wife or mother by resisting her traditional normative duties may not be afforded in these times of hyperreligiosity of the society. fighting against and suppressing her identity as an empowered and intellectually mobile woman while embodying like a good wife and mother has created unusual psychological pressure for her. similarly, rida says: rida, though a single parent who divorced her husband years ago and has only one daughter and parents to take care of, has started feeling like the traditional woman who is just supposed to stay at home and look after familial domestic matters. she feels that the identity that she had negotiated for herself as an independent professional woman has come under threat through the containment/lockdown measures. i feel as if this disease is the new super authoritarian man that has been fast rendering me powerless and reduced to femininity. i do try to find some time to read books, and to answer the queries of my students who keep sending me messages through whatsapp about their studies. however, you really have to grapple to find some time for such things. nisa personifies covid-19 as the super authoritarian man that has continuously been rendering her deprived of her power to negotiate the traditional patriarchal norms and assert herself. she has to continuously remind herself to situate her thinking, feelings and actions within the sociocultural structures of her family which are hyper-conservative. her mobility for her paid job does not mean that the social and familial norms have undergone some drastic and established change. though cultural fluidity giving rise to women's mobility and less conservative social spaces in the contemporary globalized pakistan cannot be denied, its effects are still restricted mostly to the private lives of people rather than seen generally in the society (safdar & ghani, 2018) . despite shifts in their identity due to their multiple social positions, women in pakistan have to embody traditional gender perceptions while in public spaces. the identity of these women is precarious and vulnerable to challenges due to their being in multiple social positions, locations and roles that are contradictory. as mouffe (1993) notes: the identity of such a multiple and contradictory subject is therefore always contingent and precarious, temporarily fixed at the intersection of those positions and dependent on specific forms of identification. it is therefore impossible to speak of the social agent as if we were dealing with a unified, homogeneous entity. we have rather to approach it as a plurality, dependent on the various subject positions through which it is constituted within various discursive formations. (p. 77) zubair and zubair (2017) call it frontstage and backstage identities when educated muslim women in pakistan have to behave and act differently in their public and private lives and/or while in different social spaces. but being at frontstage and backstage is not devoid of mental stress, at least in the cases of nisa and rida who, after having learnt to think critically and negotiate their identity, have to step back and dormant their faculties of reasoning and negotiating just to conform to the traditional and dogmatic normative structures. nayab's situation, however, is pretty different from nisa and rida. being an average educated housewife with a husband who is more interested and involved in his professional matters than those of home, she is happy performing her household responsibilities regarding looking after and feeding her two children, and cooking, washing and cleansing. she has negotiated her position as a responsible wife and mother and therefore claims a considerable decisive power in household matters. this negotiated position comes under threat when her husband has to stay at home all the time due to the lockdown/containment measures of the government. before the covid-19 pandemic, nayab used to use her ability and skills of taking care of her home, husband and children as her agency to negotiate and resist the domineering influence and superiority of her husband's education and provision of financial resources. with a few exceptions, her husband too regarded her for her skills as a good caregiver. however, the newly emerged situation in which they have to live together inside the home for weeks has made her husband even question her very ability that had enabled her to negotiate her identity. all the three women, though situated differently and having different positionalities and identities, have similarity in the perceived threats to the identity that they had taken years to develop; and these perceived threats are a cause of their mental stress. however, they do not simply submit as a way of surrendering, rather they reposition themselves and re-resist through various changed tactics. understanding the sensitivity of the unusual circumstances under the pandemic lockdown and taking her husband's stay at home as just temporary, nayab uses her silence, submission and even greater consciousness of her wifely and motherly duties as a wilful strategy to counter the domineering behaviour of her husband. her silence is not a helpless or unthoughtful surrender but a strategy to pull herself off the conflict and prove through her behaviour and action that she is more in control of her temperament, behaviour and treatment to others. however, she does feel the pain her husband's growing misbehaviour has caused her. nayab says: worsen. my silence silences him. though i feel upset but i mind my own business even more carefully. the use of silence by nayab to silence her raging husband is strategic, agentive and resistive. it is in correspondence with the findings of bartkowski and read (2003) about wifely submission of christian female participants; it is also resonant of the findings of zubair and zubair (2017) regarding agentive silence of muslim women to their husbands in the patriarchal religio-cultural society of pakistan. if not discursively, psychologically and behaviourally she resists the patriarchal oppressive measures of her husband. perhaps due to being positioned in the financially and socially disadvantaged position, nayab (as she is economically dependent on her husband and is less educated) makes comparatively greater use of silence as agency than nisa and rida. they have been found using their knowledge and information of the updated developments in pakistan and across the world regarding the pandemic as a strategy to negotiate and resist the sudden patriarchal clampdown on them. though nisa endeavours to comply with the heightened religio-cultural traditional responsibilities of her as a wife and mother, she, as a way to be agentive, finds time to take part in informative discussions with her husband, sons and in-laws. rida also often keeps updating her parents of the latest impacts of the pandemic and what the government is doing as a result. it enables them to resist against the patriarchal structures that have pushed to narrow their gender space. they discursively open and expand a space for them in which they have power in the form of information, knowledge and critical thinking which agentively repositions them against the traditional expectations of the patriarchy. being situated in a socially advantageous position (highly educated and economically independent), nisa and rida are agentive not only psychologically but also discursively, through silence as well as discourse. further, nisa being the mother of three sons (giving birth to a son in a patriarchal society empowers the mother by enhancing her respect and value in her family and society) possesses another point of leverage. on the one hand, her religio-culturally fundamentalist family environment curtails many of her human rights; on the other hand, she, being very knowledgeable in islamic teachings about muslim women's rights, embeds her agency in religion. she resists her husband's oppressive manoeuvres through silence as well as discourse that are supported by her stance in religion. her agency is neither of the type that mahmood's (2005) women exercise through their piety, nor is it of the type of islamic feminism which reinterprets quranic text from a feminine perspective (barlas, 2013) . rida's comparatively less conservative environment than that of nisa and her having no husband to domineer her also enables her to easily create a space for herself. however, being a divorced middle-aged woman she also has to be careful regarding her modesty and piety in society as she is more likely to be seen by others to be having an illicit relationship. nayab's domestic environment is also not conservative; also, she is not in a socially disadvantageous position regarding the sex of her children as she has given birth to a daughter and a son. however, perhaps what makes her seek recourse to silence rather than to discourse is her being comparatively less well equipped with knowledge that could have empowered her in discourse as well. the identity of each of these three women is contingent on the conjuncture of a number of intersecting factors defining their gender. being (re)situated in their respective historical specificities, they appropriate and reconstruct their religious, cultural and feminist ideals to negotiate their gender space. nisa supposes men, the state and the dominant social behaviour toward women as being in connivance with each other in the form of a nexus to ensure enforcement of patriarchal power structures. though by her religious and cultural orientation she does not consider it appropriate for a muslim woman in pakistan to complain to state institutions against her own husband for minor abuse or torture, she highlights the need for the availability of and ease of access to such state institutions whom a woman can conveniently approach for justice if she feels she is being seriously tormented by her husband or in-laws. despite being highly educated and being in professional jobs, both nisa and rida do not know the existence of any state institution or even a helpline in their city that is especially available to rescue a woman if she is under threat of any kind. it corresponds with the observations of dawn (2020a dawn ( , 2020b that the state has introduced several legislations over the previous two decades to protect women's rights. however, due to the lack of proper planning and allocation of resources for the implementation of these legislations, the condition of women has not changed much; even a dominant majority of women is unaware of these laws. it seems the patriarchal core of the nature of the state institutions has not changed; consistent implementation, training of state institutions and change in social behaviours are still things a long way off. the pakistani state being actively involved in defining and shaping the gender of its muslim women became glaringly obvious during general zia's regime, whose impact can still be felt in its various forms including extremist religious ideologies regarding muslim women's identity in public spaces (jamal, 2006 (jamal, , 2009 rouse, 2004; saigol, 2016; suleri, 1992; zia, 2018) . in the last few decades, the state has passed several such legislations (perhaps under the pressure of its western donors that want to see gender equality) that are pro-women, but lack of coherence in their implementation indicates the level of seriousness on the part of the state. even in normal situations in the country, the appropriated and reconstructed identity of educated, working, mobile muslim women remains vulnerable to the patriarchy's whims; abnormal situations like covid-19 just add to its vulnerability in which women find no option other than to succumb and/or reposition themselves depending on their own specific situations. in a society where there does not exist in normal conditions the generally accepted social practice to approach the state for matters like domestic violence, women perhaps cannot even imagine doing so during the pandemic-like national crisis which traditionally demands them to be more 'cooperative' to their men. it is good that there should be some institution to complain; at least we are also human beings. i've heard about some women who were even killed by their husbands and in-laws. when asked if she would complain against her husband, she says: no, not at all. i do not mean to complain against my own husband when i talk about these laws. i was just talking about them, not meaning to actually approach them. it is not fair. i can't even imagine it. it's not a practice here in our society. these are hard times on us. doing so will be highly unfair. though nayab is aware of her rights as a human being and is worried about the mental torture given to her by her husband's growingly oppressive and insulting behaviour, she does not think it appropriate to complain about it to the state because doing so is socially unacceptable. like most other states, the pakistani state has also played a major role in shaping the social behaviour of its people; in pakistan, patriarchal interpretations of religion and culture have greatly inspired the state's policies focused to regulate social behaviours. nayab's predicament can be described as a typical example of many of those muslim women in her situation who are conscious of their oppression but are unarmed and revert back (by the overtly/covertly state-supported social behaviours) to their traditional strategies of resistance that are silence and psychological agency, rather than 'rhetorical agency' which is seen on the part of nisa and rida to re-construct new subject positions for them (sinha, 1999, p. 208) . this study reveals that the chances of vulnerability of the negotiated identity and social space of middle-class educated muslim women in urban pakistan get heightened in situations like covid-19 mainly due to the religiously inspired dominant patriarchal social behaviours and the state's inability to practically empower its women during normal conditions. though neither the abnormal pandemic conditions are to stay as permanent, nor the women in these situations, what gets exposed is the nascence of their negotiated identities and social spaces which are contingent on the intersectional social structures and conditions. the psychological scars of nayab and nisa due to their husbands' oppressive and even insulting behaviour may get stored in their unconscious and not be healed for a long time, and can also leave a long-lasting impression on their children's psyche and behaviour as well. given the dominant general social behaviour towards the state's treatment of gender, what is considered of paramount importance by all the three women, during the abnormal pandemic circumstances, is to conform to the normative structures while innovating new forms of re-positioning and re-negotiating their identity in their respective contexts. gendered social behaviour, the state's policies and women's identity are interlinked. the study also reveals that awareness, education, mobility, religiosity and economic self-dependence intersect (variously according to their contextual setups) to re-enable the women to re-negotiate their traditional gender identity as wife and mother, re-position and reconstruct their subjectivities even during the stressful times. they take care of their families and perform their wifely and motherly duties as well as innovate ways to re-position themselves to seek agency. this study indicates that if educated urban women feel the social pressure to step back to their traditional patriarchal roles while bearing domestic violence as well, the situation of those living in remote/rural areas or less empowered women could be much worse. the nexus of religiously inspired patriarchal social behaviour and the state's callousness regarding implementation of its laws renders women suppressed. given the religiously disguised violent reaction of the local patriarchal elements to feminist voices in pakistan, the authors, throughout this study have felt the normative pressure not to speak about the issues related to the women participants' sexuality which are cultural taboos. the findings and conclusion of this study enable the first author, whose gendered perspective repeatedly intervened to demand closer insights and empathy in order to feel and understand the participants' situations, to get insight into the underlying religio-culturally disguised patriarchal oppressions of which he himself, consciously or unconsciously, at least partly, had been a part. however, the author has progressively been moderate, advocated and voiced for the rights of muslim women in pakistan. the authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article. https://orcid.org/0000-0002-3927-3781 musarat yasmin https://orcid.org/0000-0002-0571-7575 we were muslims but we didn't know islam': migration, pakistani muslim women and changing religious practices in the uk. women's studies international forum ethnography and discourse analysis: dilemmas in representing the voices of children does the qur'an support gender equality? or, do i have the autonomy to answer this question veiled submission: gender, power and identity among evangelical and muslim women in the us re/constructing research narratives: self and sociological identity in alternative settings pakistan passes anti-honor killings and anti-rape bills khalil ur rehman, please sit march 8). violence against women the largest ever epidemic of ebola case study 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service foundation feminism, citizenship and radical democratic politics women of pakistan, two steps forward, one step back? gender and culture: challenges to the sociology of religion theoretical voices and women's own voices shifting body politics: gender, nation, state in pakistan (feminist fine print) gender in hamid's fiction: a reflection on cultural paradigm shift brewing among pakistani women feminism and the women's movement in pakistan contested identities: gendered politics, gendered religion in pakistan the lineage off the indian modern: rhetoric, agency and the sarda act late colonial india woman skin deep: feminism and the postcolonial condition an historical perspective on islamic modesty and its implications for female employment. equality inequality, zika epidemics, and the lack of reproductive rights in latin america. reproductive health matters taking talk seriously: religious discourse as social practice thespians in print: gender portrayal in pakistani english print media religious and socio-cultural influences on the pakistani wedding invitation. open linguistics creative marginalization of gender: a discourse analysis of advertisements in pakistani newspapers faith and feminism in pakistan: religious agency or secular autonomy? just a time-pass: acknowledgement/denial (?) of sexual harassment in young women's discourse situating islamic feminism(s): lived religion, negotiation of identity and assertion of third space by muslim women in pakistan. women's studies international forum he graduated from pakistan, the united kingdom and the united states. his research areas include gender and sexuality, identity, displacement, cultural hybridity, postcoloniality and english language teaching.his research has been published in peer-reviewed international journals which have impact factor since 2014, she has been an assistant professor with the university of gujrat, pakistan. she has the highest impact factor(thomson reuters) in the field of english language in pakistan. she has authored more than 16 peer-reviewed international journal papers with an h-index 8. her research interests include discourse analysis, language, education and adult education. she serves as a co-editor of hayatian journal of linguistics and literature(hjll) key: cord-275445-d3i12m3l authors: hashmi, madiha; taqi, arshad; memon, muhammad i.; ali, syed muneeb; khaskheli, saleh; sheharyar, muhammad; hayat, muhammad; shiekh, mohiuddin; kodippily, chamira; gamage, dilanthi; dondorp, arjen m.; haniffa, rashan; beane, abi title: a national survey of critical care services in hospitals accredited for training in a lower-middle income country: pakistan date: 2020-08-21 journal: j crit care doi: 10.1016/j.jcrc.2020.08.017 sha: doc_id: 275445 cord_uid: d3i12m3l purpose: to describe the extent and variation of critical care services in pakistan. materials and methods: a cross-sectional survey was conducted in all intensive care units (icus) recognised for postgraduate training to determine administration, infrastructure, equipment, staffing, and training. results: there were 151 hospitals recognised for training, providing 2166 icu beds and 1473 ventilators. regional distribution of icu beds per 100,000 population ranged from 1.0 in sindh to none in gilgit baltistan (median 0.7). a senior clinician trained in critical care was available in 19 (12.1%) of units. one to one nurse to bed ratio during the day was available in 84 (53.5%) of units, dropping to 75 (47.8%) at night. availability of 1:1 nursing also varied between provinces, ranging from 56.5% in punjab compared to 0% in azad jamu kashmir. similarly there was disparity in availability of ventilators between provinces. all icus had basic infrastructure (electricity, running water, piped oxygen) and basic equipment (electronic monitoring and infusion pumps). conclusion: pakistan, a lower middle-income country, has an established network of critical care facilities with access to basic equipment, but inequalities in its distribution. investment in critical care training for doctors and nurses is needed. baltistan (median 0.7). a senior clinician trained in critical care was available in 19 (12.1%) of units. one to one nurse to bed ratio during the day was available in 84 (53.5%) of units, dropping to 75 (47.8%) at night. availability of 1:1 nursing also varied between provinces, ranging from 56.5% in punjab compared to 0% in azad jamu kashmir. similarly there was disparity in availability of ventilators between provinces. all icus had basic infrastructure (electricity, running water, piped oxygen) and basic equipment (electronic monitoring and infusion pumps). conclusion: pakistan, a lower middle-income country, has an established network of critical care facilities with access to basic equipment, but inequalities in its distribution. investment in critical care training for doctors and nurses is needed. keywords: critical care resources; critical care services; critical care staffing; lower middle-income country. demand for critical care services continues to grow internationally. resources remain limited, most notably in low and lower-middle income countries (llmics). in south asia, overall improved public health and primary healthcare services in the region, the growing burden of noncommunicable disease, and with it a demand for surgical and trauma care has resulted in a shift in health systems priorities [1, 2] . there is thus an increasing demand for critical care services, and the associated human resources, infrastructure and equipment requirements in llmics. understanding the landscape of existing infrastructure, equipment and staffing both between and within countries provides valuable information for those seeking to strengthen critical care services and inform disaster and pandemic planning; including during the current global spread of covid-19. furthermore, mapping critical care services to the clinical characteristics of the patient it serves is a fundamental step in evaluating quality of existing service provision and to identify priorities for research and quality improvement. sri lanka was the first country in south asia to undertake a comprehensive national survey of critical care services [3] . since then, regional efforts to map critical care services in asia have contributed valuable information regarding intensive care unit (icu) bed availability in the region [9] . however, information regarding skills, training and organisational processes (essential to developing strategies for improving the quality of care) remains absent. the pakistan registry of intensive care (price) [5] , a cloud-based surveillance platform, currently supports a network of 43 icus in pakistan recording over 2000 monthly critical care admissions. price provides near real-time reporting on the epidemiology, severity of illness, treatment, microbiology and outcomes of icu patients, alongside information regarding work force, unit occupancy, unit acuity, and resource utilisation. this information is used to drive local service evaluation and quality improvement interventions. price is a founding member of the recently established wellcome-moru-crit care asia (cca). this paper details a national survey of critical care services in pakistan including organisational structures, equipment, infrastructure and training capacity. an icu was defined as a clinical area (excluding operating theatres) which had the ability to provide organ support for in-patients, including mechanical ventilation. all hospitals recognised by the pakistan medical and dental council (pmdc) for internship training or the college of physicians and surgeons pakistan (cpsp) for postgraduate residency training in anaesthesia, internal medicine, general surgery, cardiac surgery, pulmonology, nephrology, cardiology or critical care medicine were contacted by telephone by mh. all such hospitals were invited to participate in the survey if they reported the presence of at least one adult icu. eligible hospitals were asked for the number of adult icus, number of ventilators and asked to nominate a senior icu doctor or sister in charge to respond to the survey questions. if a nominated contact was unavailable, at least one follow-up call was made for each icu. the surveys (supplementary file 1) were administered by telephone or online between february 2017 and december 2018. all responses were included in the analysis. the survey instrument including characteristics and organizational structure, infrastructure and human resources was based on the tool pioneered in south asia by our group [5] . population per region was obtained from the government census up to january 2018 from publicly available sources [4] . icus were defined as open, in which the primary specialty had primary responsibility for admission, treatment, and discharge decisions with optional consultative input from an intensivist, or closed, in which the intensivist had primary responsibility or there was a shared model of care between primary specialty and the intensive care team [6] . one hundred and fifty-one hospitals were identified, of which 30 did not have a icu and were therefore excluded. all 121 eligible hospitals reported their icu bed and ventilatory capacity. two hundred and twenty icus were identified in these hospitals providing 2166 critical beds and 1473 ventilators. of these 220 icus, 157 (71.4%) units containing a total of 1566 beds completed the full survey of organisational structure, infrastructure, equipment and human resources. of the 63 remaining icus, 60 icus had no designated in charge and a further 3 were not available for interview ( figure 1 ). table 1 summarizes the main characteristics of the hospitals surveyed. the density and distribution of icu beds within teaching institutions (total and per 100 000 population) by administrative regions is described in table 2 access and organisational structure average beds within teaching institutions per 100,000 population was 0.7 (total number of icu beds in participating institutions divided by the total population of pakistan), ranging from 0 in gilgit baltistan to 1.0 in sindh. the median number of critical care beds per unit was 9 (7, 12) . a total of 58 (47.9%) icus were managed directly by the government and 42 (34.7%) of units were managed by the private sector, with the remainder being administered by not-for-profit organisations (17.4%). fifty-seven (36.3%) of the icus surveyed reported a 'closed' model of care. unrestricted visiting for families was practiced in 40 (25.5%) of units (table 3) . ventilator to bed ratio of 1:1 was observed in 82 (52.2%) of the icus (table 4) , with punjab province having the greatest number 49 (59.8%) and azad jamu kashmir the lowest 0. all 157 icus had a telephone line, however, only 52.2% had access to the internet. table 5 summarises the availability of equipment to monitor critically ill patients. almost all icus (95.5%) had access to 1:1 non-invasive j o u r n a l p r e -p r o o f multiparameter monitoring. invasive arterial monitoring and capnography was available in 69 (44.0%) and 9 (5.7%) icus respectively. in addition, 51 (32.5%) and 39 (24.8%) units had access to point-of-care haemoglobin and lactate measurement respectively. isolation rooms essential for management of infectious diseases, including severe acute respiratory infections, were available in 45 (28.7%) icus, 24 (53.3%) of which were in private institutions. human resources, team structure and training opportunities table 6 summarises the human resources, team structure and training opportunities. a senior clinician (in charge) trained in critical care was available in only 19 (12.1%) of units surveyed. the majority of units (86, 54.8%) were overseen by a consultant anaesthetist (defined as an anaesthetist who has completed higher training in their speciality). in the remainder, 38.8% were overseen by a consultant internal medicine physician and 6.4% by a consultant surgeon. a non-consultant doctor was assigned to icu round-the-clock with no other work commitments in 140 (89.1%) of icus. of the 121 institutions surveyed, 101 (83.5%) were recognised by the college of physicians and surgeons for speciality training (residency training). critical care medicine (ccm) fellowship training was offered by 6 (4.9%) of institutions. the majority of intensive care units were managed by registered nurses with general training 149 (94.9%), with the remaining 8 (5.1%) being managed by technicians trained in anaesthesia or critical care. one to one nurse to bed ratio during the day for ventilated patients was available in 84 (53.5%) of units, and in 19 (12.1%) of units for self-ventilated patients. at night this availability dropped to 75 (47.8%) and 14 (8.9%) respectively. availability of 1:1 nursing also varied between provinces, ranging from 56.5% having a 1:1 availability in the punjab compared to 0% in azad jamu kashmir. similarly, availability of 2:1 nursing, already limited during the day, further reduced at night (table 6 ). microbiologists and haematologists were accessible in 96 (61.1%) and 103 (65.6%) of units respectively. health care assistants or trained technicians were part of the care provision team in 94 (59.9%) of icus. radiology technicians were available in 150 (95.5%) units and a further 128 (81.5%) icus had access to physiotherapy services. this national survey from pakistan reports very limited critical care bed availability but where available icus are well resourced with basic equipment for invasive ventilation and monitoring. it further highlights the lack of critical care trained staff and the need for urgent investment in critical care services to address this gap in training capacity if care is to be improved. the number of critical care beds in llmics are known to be lower when compared to higher-income countries [7, 8] , this disparity is pronounced in pakistan in comparison to neighbouring countries: at 0.71 per 100 000 population, it is lower than sri lanka (2.3 critical care beds per 100,000), nepal (2.8) and india (2.3) [9] . the survey further identified a wide disparity in access to critical care beds between the provinces (figure 2, lower panel) . punjab, whilst being the most densely populated province of the country, has lower availability of critical care beds than neighbouring sindh. similar disparity exists between major cities in each province ( table 2) . as urbanisation and migration to cities for employment continues in pakistan, and as the burden of non-communicable disease rises -including road traffic j o u r n a l p r e -p r o o f accidents and multimorbidities, it is a national priority to address the disparity in access to critical care services [2] . icus in both public and private sector institutions (including not-for-profit) had the basic infrastructure (electricity and a backup generator, piped oxygen, medical air and suction, infusion and syringe pumps), and basic monitoring (non-invasive multiparameter monitor, mercury thermometer, and manual cvp measurement). overall ventilator to bed ratio was 1:1.3, meaning 3 out of every 4 icu beds have the facility to mechanically ventilate. availability of these resources is reassuring, and suggests that the provision of the mainstays of critical care organ support-ventilation therapy, basic cardiovascular monitoring and support, and delivery of fluids is possible. however as with access to icu beds, availability of ventilators is not uniformly available within each region (supplementary file 2) . the safe and effective delivery of these therapies, however, relies not only on the availability of equipment, but on specialist trained staff with the skills to instigate, titrate and troubleshoot treatment. in contrast to the specific resources of critical care described above, sinks for hand washing were absent in 29.3% of icus and access to isolation rooms or cubicles to control cross infection with negative/positive air exchange mechanism was available in just 28.7% of icus, the majority of which were private sector tertiary care hospitals in the major cities. addressing the absence of facilities for infection control is perhaps a key priority for those seeking to improve critical care services in the country, given the increasingly important role critical care plays in the preparation and management of seasonal epidemics (including severe acute respiratory infections-sari) and in the rising burden of drug resistant infections. furthermore, access to point-of-care (poc) measurements including lactate haemoglobin, and availability of invasive haemodynamic monitoring, which are increasingly seen as essential resources for the management of critical illness, is lacking [10, 11] . only 39 (24.8%) of units had access to poc lactate and just 14 (8.9%) could invasively monitor haemodynamics. as pakistan seeks to improve diagnosis and management of critically ill patients with sari, sepsis and following trauma, better access to poc services and invasive monitoring, along with specially trained staff to interpret and respond to this information, is essential. just 19 of the icus surveyed had trained intensivists. critical care has been a recognised speciality in pakistan with a structured training programme since 2004, however, at the time of this survey, only six institutions out of 121 teaching institutions (excluding military sites) were recognized by the college of physicians and surgeons of pakistan for critical care medicine training [12] . these figures are much lower than estimates from south asia, latin and north america [13] [14] [15] . to date, just twenty-seven fellows have obtained the fellowship from the college in critical care medicine [16] . many currently practising intensivists in icus still have to travel outside of pakistan for their higher training fellowships. low intensivist to patient ratios (< 1:14) in academic medical icus have been cited as a barrier to delivery of quality of care and having a detrimental effect on staff well-being, specifically to the quality of professional mentorship available for rotating trainees, who may consider specialising in ccm [17] . lack of specialist training opportunities may be perpetuating the low numbers of designated critical care doctors on-call in icus and the low percentage of icus which are led by a trained intensivist. lack of training opportunities extends beyond doctors, with only 40.1% of nurses in charge of icus having j o u r n a l p r e -p r o o f received any formal training in intensive, critical or cardiac care. access to microbiologists, specialists who are increasingly considered fundamental to the interdisciplinary management of critically ill patients, was limited (61.1%). whilst there is growing evidence to support that intensivist-led patient management is associated with better patient outcomes and greater compliance with broadly accepted indicators of critical care quality [18] , a closed model was uncommon in the icus surveyed (36.3%). furthermore of those icus reporting a closed structure, only 17 had a trained intensivist as their clinical lead. investment in the reorganisation of critical care services to improve operational efficiency and patient outcomes (length of stay, duration of mechanical ventilation) in icus has resulted in a shift toward closed organisational structures whereby admission to and management of patients within the icu is coordinated by designated critical care clinicians [18] . given the paucity of critical care services in pakistan, such a model of management may promote effective resource utilisation. however, such models require national level investment in specialist training, and institution level investment in hiring and retaining such a specialist workforce. other settings have demonstrated how investment in critical care trained clinician staff to lead units and investment in training for nurses working in critical care has positively impacted on safety within icus and outcomes for critical care patients. without this investment, efforts to strengthen specialist capacity and improve quality of critical care services through research and implementation will be hindered. this survey only approached institutions recognised for specialist teaching. consequently. the number of icu beds per 100,000 population is underestimated. a recent multicountry snapshot of critical care bed availability [9] , to which pakistan contributed, reported a national average in pakistan of 1.3 beds per 100,000 population. however, such estimates included units which may have no recognised affiliation with critical care training and no support from critical care societies. whether considering the numbers reported here, or the estimates from those with broader inclusion, icu bed availability and trained, skilled staff is still lower than neighbouring countries. pakistan has no central register or standard definition for icus and as such units may be operating without the support of trained intensivists. this survey provides a detailed landscape of critical care resources and training institutions recognised by the pmdc and cpsp in pakistan. pakistan has an established network of critical care facilities with access to basic equipment but inequalities in access within and between provinces is prominent. investment in critical care training for doctors and nurses is a key priority for the country. investment in training for health care staff will likely enable efforts to improve safety within icus, accelerate opportunities for research and quality improvement. â�¢ critical care services are well established in pakistan. â�¢ all intensive care units have access to basic equipment for essential critical care. â�¢ inequity exists in access to critical care within and between regions. â�¢ investment in specialist training for doctors and nurses is an urgent priority. j o u r n a l p r e -p r o o f j o u r n a l p r e -p r o o f intensive care unit capacity in low-income countries: a systematic review health systems and services: the role of acute care pakistan registry of intensive care (price): expanding a lower middle-income, clinician-designed critical care registry in south asia a cross-sectional survey of critical care services in sri lanka: a lower middle-income country physician staffing pattern in intensive care units: have we cracked the code? the variability of critical care bed numbers in europe trends in critical care beds and use among population groups and medicare and medicaid beneficiaries in the united states critical care bed capacity in asian countries and regions sepsis and septic shock the european guideline on management of major bleeding and coagulopathy following trauma: fifth edition accredited institutions. college of physicians and surgeons pakistan n intensivists in u.s. acute care hospitals structure, organization, and delivery of critical care in asian icus organizational issues, structure, and processes of care in 257 icus in latin america: a study from the latin america intensive care network list of good standing fellows. college of physicians and surgeons pakistan 2020 intensivist/patient ratios in closed icus: a statement from the society of critical care medicine taskforce on icu staffing a framework to enhance clinical operations, development of institutional policies, and further research the authors would like to thank all members of the critical care community in pakistan who contributed to this work with the shared goal of improving critical care services in the country. we would also like to thank dr t tolppa for his support with manuscript preparation, and mr t rashan for support with figures. the authors declare that they have no competing interests. key: cord-030959-olcz7g19 authors: hussain, ejaz; rao, muhammad furqan title: china–pakistan economic cooperation: the case of special economic zones (sezs) date: 2020-08-28 journal: fudan j doi: 10.1007/s40647-020-00292-5 sha: doc_id: 30959 cord_uid: olcz7g19 this article attempts to underscore the extraordinary significance of special economic zones (sezs) in the industrialization and economic growth of pakistan as well as the development and consolidation of china–pakistan economic corridor (cpec)—which is a core component of the belt and road initiative (bri). though pakistan has previously experimented with sezs, its scale, outreach and impact on the country’s economy and society remained very limited. thus, the proposed sezs under the cpec offer new opportunities for mutual economic cooperation, investment, human resource development, sustained industrialization and, above all, the consolidation of cpec. nevertheless, there are several challenges ranging from structural issues to security problems that the proposed sezs, in particular, and cpec, in general, face. the article, thus, provides a comprehensive set of strategies to convert challenges into capabilities. pakistan experienced slow growth rate ranging from 0.4% in 2008-2009 to 4.24% in 2014-2015. 1 nevertheless, owing to certain strategic and economic developments that include the construction of china-pakistan economic corridor (cpec), the country's economy reflected positive trends in all major sectors of the economy during 2014-2018. therefore, the gdp growth rate stood at 5.2% (revised) in 2018. 2 though the global donors and ratings institutions are pinning hope on the country's economic potential to rise as a fast-growing and promising regional economy, pakistan, due to prevailing structural constrains, is still struggling with its stated economic goals that include around 8% annual growth rate. 3 in addition, during the first quarter of fiscal year 2018-2019, the gdp growth rate has dropped from 5.2 percent to 3.8 percent. 4 importantly, owing to covid-19, the country's gdp growth rate for 2020-2021 has been projected negatively. 5 in the wake of sustained economic growth regionally if not globally, it is pertinent for pakistan to revisit its economic policy for the country possesses certain infrastructural, demographic and human resource potential that can play a pivotal role in shaping the socioeconomic profile of the country in an unprecedented manner. for instance, during the past four decades, pakistan's manufacturing sector registered an average annual rate of around 7% despite a slowdown in recent years. this marks resilience of the pakistani industries and entrepreneurs, which is very crucial for sustained economic growth. 6 in order to achieve the stated annual growth rate, realize full potential of its natural and human resources, improve upon its agriculture and manufacturing sector and, overall, rise as a stable regional economy, pakistan has already taken certain concrete measures. in this respect, the launch in 2015, of the landmark project of coordination and cooperation between china and pakistan, namely the china-pakistan economic corridor (cpec), has emerged as an icon for fast-tracked industrial development and dissemination. thus, in the context of cpec, pakistan aims to establish financially vibrant, socially visible and potentially productive industries to initiate a new era of industrialization that includes high-end textiles, telecom, engineering, knowledge-based manufacturing, sea products and sophisticated storage facilities for fruits and vegetables, jointly or separately with chinese companies to be based in special economic zones (sezs). "while embarking on the [new] phase of industrialization, pakistan faces a number of issues that have so far restricted industries to realize their growth potential. these include, low investment, dispersal of industries across country, weak institutions, low quality human resources, shallow tooling skills owing to lack of depth in vocational expertise, lack of modern technology, high business cost, brain-drain, low quality hard and soft infrastructure, etc." argued mahmood. 7 expectedly, the sezs under cpec offer lifetime opportunity for pakistani companies to work in tandem with their chinese counterparts for the development of export-oriented manufacturing industries, while striving to overcome the abovementioned issues with the assistance of reformed public sector institutions. the sezs with new business models are likely to generate reasonable jobs, develop industrial and business infrastructures and establish domestic value chains connected regionally and extra-regionally. thus, the special economic zones are expected to provide much needed impetus to stimulate economic activities across the country. 8 moreover, given the relatively successful record of china in constructing and running several sezs, pakistan finds an opportunity to capitalize on the chinese experiences and, importantly, investment, human resources and technology in establishing china-led industrial parks. in this new phase of industrialization under the framework of china-pakistan economic corridor, pakistan is expected to have a number of opportunities to capitalize on. nevertheless, the country's leadership, both civil and the military, would also face multiple challenges at the policy and operational level. in order to turn cpec into a success story for bilateral economic confidence and, overall, for the positive projection of the belt and road initiative (bri), the construction of special economic zones, thus, assumes extraordinary significance. in view of the foregoing, this article, therefore, is an attempt to underscore the overwhelming significance of special economic zones for the expansion and consolidation of china-pakistan economic corridor-which is a core component of the belt and road initiative. in doing so, the article attempts to address the following questions: did pakistan ever venture in sezs pre-cpec? what are the nature, character, geographic scale and socioeconomic outreach of the proposed sezs under cpec? what type of challenges the proposed sezs, especially the rashakai special economic zone-which is prioritized in terms of construction by the two governments on april 29, 2019-face? are there any solutions to the identified set of challenges? this article, in the following sections, addresses these questions empirically. in this respect, qualitative method is employed, while data include both primary and secondary sources. 9 nonetheless, before so doing, it is prudent to review the major works on sezs in order to draw cross-regional insights that would be useful for the identification of challenges and the formulation and implementation of strategies. human beings, since antiquity, are instinctively inclined toward socialization which gradually generated a sense of commodity exchange. the structural transformation from the paleolithic period to the neolithic era marked the differentiated primacy of agrarian relations cross-regionally. 10 the early civilizations enriched human organization culturally, artistically and intellectually. the advent of "common era" witnessed the feudalization of, for instance, the european society where the means of production-essentially agrarian in nature and character-were controlled by the higher echelon of the empire-state. in the middle medieval to the late medieval period in world economic history, the contribution of the non-western world was remarkable in terms of proto-trade of, for example, silk, gunpowder and paper technology from china. 11 thus, the antecedents of modern "industrialization" could be observed in the sustained exchange relations among the ottoman empire, the qing dynasty and various european dynasties. while the asian empire-states could not pursue industrialization on account of strategic and political calculations, the europeans, especially the british, took lead in setting up a variety of industrial units across the country in the thirteenth century onwards. 12 such institutional changes, thus, brought forth structural transformation of the market relations from feudalism to capitalism. moreover, it also had a bearing on the nature of political relations that, on account of the european revolutions, i.e., 1688, culminated into the formation of the nation-state post-french revolution. ironically, however, the modern nation-states of europe and later north america adopted a contradictory approach by extracting raw material from the non-western world in order to sustain industrialization at home. this process of structural exploitation ultimately resulted into colonialism of the asian and african societies and markets from the nineteenth to the mid-twentieth century. 13 nonetheless, the capitalist colonial hegemony was challenged by mostly socialist forces during the first world war, i.e., the russian revolution (1917), onwards till the final phase of decolonization in the 1960s. 14 in the post-second world war period, the united states emerged as the leader of the capitalist bloc, whereas the ussr and the people's republic of china, as it emerged as a sovereign nation-state in 1949, represented the socialist model of governance and economy. it is in this context of the cold war geoeconomics that the western world, in order to expand its industrial production, invested innovatively in finding new means for enhancing its manufacturing sector and broadening the export base. the british, again, took lead, in this respect, by establishing the first modern export processing zone (epz) in ireland in 1959. 15 the following decade witnessed the establishment of epzs in barcelona (spain) and puerto rico (usa). in asia, india became the first country to conceptualize epz and, consequently, established its first epz in kandla (gujarat) in 1965. [t]he development of free trade zones got a significant boost in the 1960s and 1970s because growing international specialization, global production relocation by transnational corporations and an increasing orientation by host countries towards exports necessitated the development of special economic zones. in this respect, one of the most startling success stories of sezs comes from china. the country adopted the free zone policy later than india and it only embraced the concept of sezs in the late 1970s. the first wave of sezs was established in china in 1980. since then, sezs have become a spectacular success and have emerged as a major driver of growth and exports in china. 17 as the preceding indicate, china has, in the last forty years, emerged as the world's second largest economy. importantly, it has lifted around 800 million people from abject poverty since 1979 as a result of its "reform and opening up" policy which underscored the importance of special industrial zones, particularly in the shenzhen region, 18 to realize industrial growth. 19 besides india and china, in asia quite a number of developing countries such as bangladesh-with currently high gdp growth rate after india in south asia 20 -the asean nations and other "emerging countries" are accruing economic dividends from effective operationalization of sezs. 21 in addition, russia, in recent times, has also ventured in industrial "clusters" to diversify its industrial production and alleviate regional economic disparity in the wake of the 2008 global financial crisis. 22 last but not least, the african countries-in order to achieve economic growth through promotion of their exports-are also engaged, in certain cases with the chinese collaboration, in the construction of special economic zones. 24 the popularity of sezs has, thus, increased in last two decades. for example, there were around 176 sezs in 47 countries in 1986, whereas, as per the international labor office's estimation in 2006, the number stood at 35,00 in 130 countries in 2006. 25 in addition, based on various studies, the word bank, in 2017, put the number of sezs approximately at 43,00, globally. 26 according to a study published, in 2019, by the united nations conference on trade and development (unctad) "there are nearly 5400 sezs today, more than 1000 of which were established in the last five years. at least 500 more zones (approximately 10 per cent of the current total) have been announced and are expected to open in the coming years." 27 as far as pakistan is concerned, in the pre-cpec period (pre-2013), it had already experimented in export processing zones and, importantly, the country hosted certain number of sezs at various locations. this is further discussed in the following section. historically, almost every district of pakistan had an sez with proper infrastructure and various incentives for local and international investors (see table 1 ). for example, punjab, the population-wise largest province, hosts around twenty sezs, whereas sindh, balochistan and khyber-pakhtunkhwa (kp) carry thirty, seven and twelve sezs, respectively. out of the above-mentioned, certain such zones were successful in terms of established industry and generation of employment and capital; there are failed cases, too. the failure of such industrial parks can be ascribed to their remoteness from the major urban and industrial areas. for example, the rashakai economic zone is located some 70 km away from peshawar-which is the provincial capital of kp and major urban hub from a commercial perspective. similarly, khairpur economic zone is established some 30 km away from khairpur city. moreover, certain major cities of pakistan also host certain industrial clusters (small industrial units which are not part of an sez) because of their added strength in skilled workforce, availability of raw material, supporting institutions and strong historical linkages with the local and global supply chains. for instance, such clusters include sports and surgical clusters in sialkot, textiles cluster in faisalabad, fan cluster in gujarat and engineering cluster in gujranwala-all these cities are located at considerable distance in punjab. in addition, there are certain industrial parks (specialized industrial units which formally are not part of an sez) in pakistan which include rachna industrial park (lahore), marble city (lahore) and textile city (port qasim, karachi). the distance between lahore and karachi is around 1200 km. some of the newly established industrial estates consist of value addition city (sheikhupura-faisalabad expressway), m-3 industrial city (faisalabad) and quaid-i-azam apparel park (m-2 lahore). 28 china and pakistan signed the memorandum of understanding (mou) in 2013 that served as the cornerstone of the china-pakistan economic corridor. the 2015 visit of pakistan by the chinese president xi jinping formalized cpec in terms of allocation of 46 billion us$. 29 by the end of 2017, the sum total of loans and investment under cpec has crossed 60 billion us$. significantly, the early harvest projects under cpec have already been operationalized and scores of projects in port, energy, railways, roads, etc., are currently underway. 30 to consolidate cpec and enhance bilateral economic cooperation, the chinese and pakistani governments concluded, in the sixth joint cooperation committee (jcc) held in december 2016, to establish special economic zones. 31 the total number of such sezs varied from initially over hundred to gradually reduced to forty-six. 32 however, later, the pakistani authorities, in particular, the ministry of planning, development & reform and the board of investment (that works under the prime minister secretariat) proposed the construction of nine industrial zones in different parts of pakistan. its outline is given in table 2. as the table above rashakai economic zone (kp) and dhabeji (sindh). 33 most recently, however, pakistan's prime minister imran khan-during the course of participation in china's second belt & road forum (brf) of the bri-has signed various agreements with his chinese counterparts. importantly, one of the agreements was related to the construction of rashakai economic zone as a topmost priority. 34 importantly, as per official updates, groundbreaking of rashakai economic zone is expected in 2020. 35 the feasibility work on remaining sezs is underway in accordance with the second phase of cpec. 36 the proposed sezs offer multiple opportunities to both the chinese and pakistani government, firms and people. the following section of the article discusses it in detail. pakistan requires a developed industrial sector to lay a solid foundation for its economic recovery and revival; the special economic zones are supposed to provide a wide range of opportunities to sustain enhanced industrialization. through industrial zone production and export hubs of high-quality manufactured goods, pakistan is likely to be favorably positioned in the regional and international market. whereas cpec is expected to enhance investment and infrastructure in pakistan and the western part of china, the construction and optimization of the proposed sezs are likely to boost up industrial growth and economic activity not only within pakistan but also between china and pakistan. the following opportunities are expected to come with the establishment of the sezs. to begin with, the proposed special economic zones are expected to work as a strong economic incentive for pakistani authorities to introduce reforms in order to improve upon domestic business environment, governing behavior, productive capacity, export base and enhance commercial attractiveness for further foreign investments. furthermore, industrialization with a new face is likely to create jobs for the country's large but underemployed population. the intended industrial activity under sezs in general and cpec in particular would expectedly generate employment for the growing educated workforce. in addition, capacity-building efforts through vocational and technical training would also help local workforce to catch up in quality skills. 37 secondly, the sezs offer an opportunity to attract pakistani diaspora with their skills and knowledge along with their accumulated capital for more profitable prospects in the country. the sezs can enable firms to agglomerate and get benefits of external economies and will thus provide opportunity to put domestic industries on a higher path of the learning curve. thirdly, trade generation opportunities are likely to induce both the states improve and strengthen bilateral trade regime. moreover, within sezs, pakistani companies either competing or complementing chinese companies would learn latest business and trade techniques from their chinese counterparts. in addition, the global firms that are overwhelmingly organizing their production and trade in increasingly complex global value and supply chains-and are, thus, looking for the least costly locations-special economic zones can provide a platform to reap the benefits of such opportunities that are literally ignored by the pakistani authorities. 38 fourthly, the agreed upon sezs offer an opportunity to strengthen technology cooperation between chinese and pakistani companies. moreover, the sezs provide with opportunity to manage labor pooling, thus cutting down search cost and reducing unemployment of skilled labor. besides, while working within a sez, there could be a strong possibility of nourishing innovative ideas that can be disseminated across companies and corporations. lastly, the proposed sezs, which would be operationalized in the second phase of china-pakistan economic corridor (2020-2025), carry the potential to establish linkages with the huge chinese market; and the chinese sezs, in this respect, may create a strong and sustainable business integration through trade and investment. nonetheless, these potential set of opportunities is prone to multiple challenges which are indicated in the following section. indubitably, china-pakistan economic corridor is a well-thought-out long-term project aiming at bilateral trade and commercial cooperation. 39 though the cpec is at its initial phase, some of its early harvest projects have already been completed and the second phase kick-started in 2020. 40 however, there are voices from within, if not outside, pakistan that approached the corridor extremely critically. regardless, the pakistani government held its ground and the project is now entering into its next phase where special economic zones are supposed to act as an economic pillar of cpec. however, the construction and function of the sezs are likely to face a set of challenges, which are categorized, in the following, as structural, political and security challenges. one of the major structural challenges pertains to the location of a special economic zone. as will be discussed in the next section, politics, at all level, does influence public policy in pakistan. therefore, each of the four provincial governments, the local and provincial political parties and regional stakeholders differ over the 38 "pakistan, china jointly working for establishment of special economic zones," the nation, 7 january, 2018. https ://natio n.com.pk/07-jan-2018/pakis tan-china -joint ly-worki ng-for-estab lishm ent-of-speci al-indus trial -zones (accessed on 23 april 2019). 39 site of a sez and present(ed) a respective province and/or region such as gilgit-baltistan as a perfect natural location-which might not be the case in pure economic terms. moreover, pakistan's human resources are not attuned to the proposed sez requirements. neither they are proficient enough to operate chinese technological tools and machines. this will be a major challenge for the government to fully benefit from employment opportunity offered by the sezs. 41 access to finance could be termed as equally important impediment for the growth of industries. such a problem doubles in magnitude with reduction in size of a firm. pakistani governmental bodies generally lack experience and knowledge in sezs management, i.e., doing business with foreign investors. it may seriously hinder the implementation capacity of the government institutions. therefore, the challenge posed is to develop requisite capacity of public sector institutions. furthermore, the creation of environment for fast and effective dissemination of technology is necessary. ensuring adequate number and size of allied and supplier firms and locating them in sezs to draw benefits of external economies will be a major challenge, too. similarly, local connectivity, inter-zonal liaison and provision of utilities would be a structural impediment to be taken care of. besides, the incidence of financial corruption is a serious challenge in so far as transparency of various cpec projects is concerned. 42 by and large, structural challenges point to consistency in economic policies, avoidance of sudden policy reversal, transparency in decision-making, eradication of corruption and expansion of financial markets to provide enough finance to industries, availability of qualified manpower through vocational training and conducive business environment including effective property rights protection and fair and speedy dispute resolution mechanism. 43 one of the main political challenges relates to due share in cpec and the sezs on the behalf of provincial governments, regional and local stakeholders. in 2015, when the chinese president xi jinping formally launched cpec, the khyber-pakhtunkhwa and balochistan government and the regional political parties differed, for example, over "cpec routes." the so-called route controversy 44 was blamed on the punjab (and the federal) government which were held partisan by the opposition political parties such as pakistan tehreek-e-insaf (pti) and pakistan people's party (ppp). importantly, political parties based in non-punjab provinces, especially balochistan that hosts gwadar port, raised questions on the feasibility, outreach, functions and strategic implications of the china-pakistan economic corridor. in a similar vein, local politicians and rights activists from, for example, gilgit-baltistan highlighted the potential risk for physical environment owing to cpec traffic chains. 45 in order to address the grievances of the smaller provinces, the federal government of pakistan led by pakistan muslim league-nawaz (pml-n) held a series of meetings with key leaders of provincial governments, regional dispensation and proclimate change associations. particularly, the sharif government (2013-2017) 46 was able to organized all parties conference on cpec more than twice. consequently, the mainstream and regional political parties and groups in general and the federal and provincial governments in particular achieved consensus on the nature and character of china-pakistan economic corridor. thus, the "route controversy" was amicably resolved with due share of roads and railways provided to different provinces and regions. 47 the foregoing, however, did not result into silencing the debate over cpec. little wonder, senator mir hasil bizenjo, 48 who was federal minister for ports and shipping, argued on the floor of the country's senate that "91 per cent of the revenues to be generated from the gwadar port as part of the china-pakistan economic corridor (cpec) would go to china, while the gwadar port authority would get 9pc share in the income for the next 40 years." 49 in addition, the cpec long term plan (ltp) has invited concerns and questions from stakeholders and analysts alike. by and large, the political elite and public at large from smaller provinces demanded more transparency and fair play in terms of detailing publicly the pros and cons of different agreements reached between chinese and pakistani authorities. indeed, the current pakistan tehreek insaf (pti) government led by prime minister imran khan initially viewed certain cpec projects skeptically. 50 this means that though cpec has been successful in terms of acceptability as a mega economic project between china and pakistan, it still requires further fine-tuning at the popular level. 51 if one goes by the foregoing, it is speculated that the construction of the special economic zones would not be free of political challenges emanating 45 lan jiang, "impact of local politics on cpec: research focusing on several energy programs" (paper presented at the international academic seminar on industrial cooperation and construction of industrial zones, cpec, peking university, beijing, 2018). 46 nawaz sharif was disqualified by the county's supreme court on 28 july 2017. the term sharif government refers to the period during which he served as pakistan's prime minister (july 2013 to july 2017). 47 ahmad noorani, "cpec route controversy routed," january 16, 2016. https ://www.thene ws.com.pk/ print /90708 -cpec-route -contr overs y-route d (accessed on 2 january 2019). 48 mir hasil bizenjo was the president of national party (np) that is nationalist in nature. 49 primarily from non-punjab provinces and autonomous regions. already there has been considerable debate registered on the location, size and number of special economic zones by the kp and balochistan, if not sindh, based nationalist political parties such as pakhtunkhwa milli awami party (pkmap), awami national party (anp) and the national party (np). little wonder, in initial meetings between the federal and provincial government, the number of sezs was reduced from hundred plus to forty-six whereby each government strove to host maximum number of sezs in order to uplift a respective province from poverty, economic slowdown and unemployment. 52 however, further negotiations among the regional, provincial and federal stakeholders brought the proposed number of sezs down to nine whereby each province, islamabad capital territory (ict), and region host one each. apparently, this seems a fair start in terms of equitable distribution numerically; however, issues and concerns regarding the size (the largest size sez is proposed for punjab) and economic competitiveness, industrial base of a province/region and overall economic indicators of an area may pop up in the following years if not months. as per the political culture of pakistan, political parties and politicians, at all level, see to their petty interest and that too at the expense of national interest. thus, it is very likely that sezs are further highlighted on partisan lines where each stakeholder tends to get the lion's share. political disagreements and tussles, thus, amount to serious political challenges that demand serious and steady debate, negotiations and conflict resolution mechanism. pakistan is facing serious threats in the form of religious extremism and terrorism. modern terrorism that pakistani society and state is suffering from is essentially post-9/11. when the pakistani military regime led by general pervez musharraf (1999) (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) decided to support the usa-led war on terror against the taliban and al-qaeda, the latter, in reaction, took on pakistan by invoking (suicide) terrorism as a strategic weapon. consequently, around thirty thousand pakistanis, both civil and law enforcement, have lost their lives in multiple incidences of terrorism from 2003 till 2019. though the number of civilian and security personnel fatalities has comparatively gone down since 2014 due largely to the various military operations, the phenomenon of terrorism has yet not been wiped out completely. for example, during 2013-2019, 6528 civilians and 2312 security personal lost their lives in (suicide) terrorism. 53 in addition, by august 21, 2020, 28 civilians and 125 security personnel lost their lives in 112 incidences of terrorism in pakistan. 54 given opportunity, a terrorist organization such as tehreek taliban pakistan (ttp) and/or jamaat-ul-ahrar (jua) strikes mostly on the country's minorities, i.e., christians, in mostly far flung areas such as quetta; the latter witnessed, on april 12, 2019, another deadly terror attack on its hazara minority that lost 20 lives, whereas 48 people were injured. 55 here, it is pertinent to mention that a chinese couple was initially kidnaped and ultimately killed in quetta in 2017 by a terrorist organization. 56 moreover, the chinese consulate in karachi was attacked by terrorists belonging to balochistan liberation army (bla); the attack was foiled by pakistani security forces with the loss of two policemen. 57 anti-pakistan terrorist networks work in tandem with regional proxies and powers such as india whose intelligence operator, kulbhushan jadhav, was arrested near iran-pakistan border by pakistan's security forces. 58 it is no secret that the current indian prime minister, narendra modi, had talked publicly against china-pakistan economic corridor. 59 in the context of domestic and regional security threats to its sovereignty, in general, and cpec, in particular, the pakistan state has taken due measures that include pooling up a special armed force, 60 consisting of military and the civil law enforcement institutions, for the protection of cpec projects and personnel. thus, china-pakistan economic corridor has, so far, survived major terrorist attack on its infrastructure, equipment and workforce. however, potential security threats ought not to be ignored. this then raises security concerns for second phase of cpec whereby special economic zones are accorded top priory by the chinese and pakistani government. will the local, provincial or federal government provide security to the sezs at, for example, different stages of construction? if it is a joint venture of, for instance, provincial and federal government, which government will call the shots? who will bear the financial and logistical cost? if it is the sole responsibility of the provincial government, will a province be able to manage a sez's security on its own? overall, will the chinese companies and workforce be satisfied with the security arrangements provided by the pakistani authorities? the foregoing has, thus, highlighted major security challenges to the sezs, in particular, and, cpec, in general. the next section of the paper attempts to provide a set of strategies vis-à-vis the posed challenges whose solutions will ensure the safety of not only the special economic zones but also that of pakistan's society and economy. the following are certain strategies to tackle structural, political and security challenges. these strategies, it is posited, can deliver tangible results if implemented in letter and spirit. pakistan has to take a number of steps in close collaboration with china to transform the highlighted challenges into capabilities. as far as structural challenges are concerned, the fundamental principle that pakistani government ought to abide by is the economic competitiveness of the area where a special economic zone is proposed. it is important that during consultation on site selection, all the concerned stakeholders be on board. second, the pakistani authorities need to initiate policies in coordination with pakistani and chinese companies. the pakistani firms should learn from the chinese experiences for effective policy implementation. in this respect, it is advisable to implement the special economize zone act 2012 (revised) that was promulgated before the launch of cpec so that economic aspirations of both the chinese and pakistani investors are realized. moreover, to train the sezoriented workforce, it is pertinent to establish modern vocational and technology institutions while taking inference from the chinese vocational education and technology know-how since they are comparatively state of the art in terms of innovation and dissemination of skills. 61 in order to make sezs an effective strategy and specimen for industrial growth, its financial side cannot be ignored. in this respect, the pakistani and chinese governments ought to work in tandem to devise a policy to provide adequate funds to small-to medium-size firms that lack indigenous financially stability. nevertheless, such financials should be firm-friendly to attract further investment nationally and (extra-)regionally. here, the role of pakistani diaspora could be very handy since they deposit, on average, around 10 billion us$ in remittances per annum. 62 furthermore, it is essential for pakistani and chinese authorities to make special economic zones a part of global supply chain and global value chain by increasing the competitiveness of supplier firms with improved reliability and efficiency. this can be achieved by introducing business supporting policies, modernizing trade facilitation system and infrastructure, devising a special cadre of customs officials and staff, cutting on delays, bureaucratic hurdles and, importantly, eradication of financial corruption. in addition, there is a need to promote sezs as enclaves of good practices and self-containment, supported by sound infrastructure and service provider firms. ideally, the pakistani government should engage a private firm to develop and manage the sezs, while the government should be an active player in provision of transport, electricity, water, telecommunications, waste disposal and other infrastructures to link sezs with global and local supply chains. 63 besides, the pakistani government ought to accord complete and secured property rights protection to ensure sustainability and attract chinese firms. in this respect, market access is to be ensured through efficient transportation system. 64 such measures will help improve transportation of much needed raw materials and finished goods. last but not least, pakistan ought to negotiate with chinese government to secure duty-free status to exports originating from the sezs. to realize it, pakistani authorities should promptly conclude special trade agreement for sezs in addition to the existing bilateral free trade agreement. since china has already effectively positioned its sezs to establish linkages with allied and supplier industries, pakistan should act fast to capitalize on the chinese experiences. in this respect, it is suggestive to create complementarity between pakistani and chinese sezs for mutual advantage and connectivity. as discussed earlier in the paper, politics affects policy and in the pakistani case, it did affect (economic) policies for the country's history is replete with cases where long-term economic plans suffered from political instability. 65 therefore, to make cpec a success story, pakistani politicians and political parties have their work cut out. in this respect, it is urgently required on the part of the federal government to engage regional and nationalist political parties in debate and discussion on the pros and cons of cpec in general and sezs, in particular. perhaps there is no harm in gradually increasing the equitable number and size of industrial zones in different parts of pakistan. such a policy measure will help generate political confidence and economic collaboration among the four provinces, regions and the federal government. more sezs mean more local and regional participation in cpec and economic growth and social progress of the country. moreover, the expansion of further sezs in close partnership with local and provincial authorities is likely to assuage local and regional socioeconomic grievances by engaging local skilled manpower of, for example, gilgit-baltistan and balochistan in the sezs in particular and cpec in general. 66 to realize the foregoing, it is suggested that the federal government does not ignore local and regional political aspirations. importantly, the mainstream political parties, which are major stakeholders of cpec, ought not to sideline nationalist political parties of kp, sindh and balochistan. thus, there is need of developing an effective mechanism for inter-parties coordination and policy formulation. at the moment, the federal government conducts all parties conference (apc) to discuss serious policy issues of national magnitude. this, in my view, is a ad hoc measure. a long-term institutional solution lays in the establishment of a permanent interparties coordination body responsible for holding meetings, generating consensus on policy issues and, overall, ensuring participation and policy role of smaller political parties. as already discussed in the preceding sections, pakistan is mired in multiple problems of which bad governance and insecurity are quite alarming for without orderly rule; it is impossible to achieve economic growth and societal development. since cpec is a joint venture, it is equally essential to ensure safety of the (non-) cpec workforce and logistics along with heavily invested corridor infrastructure. to begin with, china-pakistan relations have achieved "a factor of durability". 67 what this implies in strategic and military terms is that both the countries amicably resolved potential areas of conflict, i.e., broader management, and, importantly, consolidated bilateral relations since the mid-1960s. consequently, since 2015, china-pakistan relations have taken a new turn where geoeconomics is predicated on geopolitics in terms of formalization of cpec. a considerable section of the chinese workforce is engaged in gwadar, balochistan, where more than fifty major projects in infrastructure and energy are underway. 68 the pakistani authorities, being aware of restive security situation particularly in balochistan and generally in the rest of the country, established a security regime to safeguard the chinese labor from mostly internal threats. 69 in october 2019, the special security division (ssd) has been expanded in terms of establishment of its "southern" command that would exclusively ensure safety of the chinese executives and workers in balochistan and karachi. 70 though the kidnapers in balochistan killed two chinese nationals in 2017, the overall safety of the chinese workers has been duly ensured by the government of pakistan. moreover, recently there have been reports of some chinese nationals having been involved in the so-called marriages scandal; their cases are being invested by the country's law enforcement as per the law. 71 nevertheless, the chinese citizens working in pakistan have overwhelmingly demonstrated goodwill and good conduct. at the moment, the majority of pakistanis perceive them friendly people from a friendly country. nevertheless, given the chaotic security situation in parts of pakistan, public safety remains a big challenge for pakistani law enforcement which, as mentioned above, is taking due measures to enhance security. in addition, in order to improve cpec security in general and that of sezs in particular, pakistani authorities would have to tackle terrorism on multiple levels. strategically, pakistan needs to engage with its neighbors meaningfully. here, china can play a role by encouraging regional cooperation and peace. indeed, the quadrilateral afghan peace process is a step in the right direction. moreover, china-iran-pakistan trilateral engagement carries the potential to devise a collective response to anti-peace elements in the south asian region. in this respect, the visit, on april 21, 2019, of pakistani prime minister imran khan to iran was very crucial given growing strategic uncertainty in the south asian region. 72 khan paid another visit to tehran on october 13, 2019, in order to "mediate" between iran and saudi arabia. 73 if this materializes, it will carry positive implications for cpec in particular and the belt and road initiative in general. importantly, china may also convince the usa-another major stakeholder in the region-to engage pakistan, afghanistan and india in a manner that reduces strategic uncertainty. politically, pakistani government should strive to negotiate with the locally active extremist and insurgent groups. ideologically, there is a growing need to conceive and implement a pluralist narrative to counter hate mongers in pakistani society. above all, china and pakistan would have to play a central role by reinforcing the importance of peace and stability locally, nationally and transregionally. the former must understand the precarious security situation pakistan is facing where it lost around 30,000 thousand civilians and security personnel in past nineteen years. 74 nevertheless, pakistan must revisit its policies that might have provided an enabling environment to anti-humanity forces. the latter though have been militarily neutralized by the law enforcement of pakistan, certain militant organizations such as jamat-ul-ahrar and ttp, whose captive spokesperson ehsanullah ehsan escaped from detention in pakistan in february 2020, 75 still pose security challenge. such organizations are always in search of soft targets to destabilize pakistani state, society and economy. last but not least, for effective cpec security, pakistan has to take certain extraordinary measures. on the one hand, there is need to devise a strategy to have local and provincial law enforcement apparatuses, i.e., police, frontier constabulary, on board while enhancing policy and operational capacity of civil law enforcement along with improving human intelligence of strategic locations along cpec including the special economic zones. on the other hand, the local, provincial and federal governments ought to chalk out a policy framework under which the country's armed law enforcement could work effectively. the recently established cpec authority seems a step in the right direction. 76 moreover, during the visit of pakistani civil-military leadership to china in october 2019, the two sides reiterated bilateral commitment to expand cpec and speed up work on the sezs. 77 lastly, for effective surveillance of sezs and gwadar port, the chinese government can be helpful in terms of provision of sophisticated gadgets to enhance physical and infrastructural security of the enclave. within the gwadar enclave, the chinese may, in consultation with pakistani authorities, operate on its own. nonetheless, handing over of overall security of gwadar and sezs to chinese companies, both public and private, would not be suitable idea and practice given pakistan's bad experiences with american cia and blackwater. 78 since 9/11, pakistanis are overwhelming anti-usa, whereas china's perception at the popular level is, overall, positive. 79 the chinese authorities should stay mindful of popular perception. 20 killed, 48 injured in attack targeting hazara community in quetta islamabad confirms death of chinese couple abducted from quetta terror attack on chinese consulate foiled; 3 terrorists killed who is kulbhushan jadhav? pm modi raises india's concern over cpec which runs through pok cpec: governance and security challenges-implications for the belt and road initiative a historical analysis cpec projects cpec: governance and security challenges-implications for the belt and road initiative iqrar ul hassan of sar e aam exposed pak china marriages prime minister imran khan reaches iran for 2-day official visit khan leaves for tehran to mitigate tensions between iran and saudi arabia fatalities in terrorist violence in pakistan taliban militant flees prison, claiming deal with pakistani security forces post-9/11, both the countries started exploring new angles to enhance strategic cooperative partnership. with the launch of china's belt and road initiative in 2013, the china-pakistan economic corridor-as a core component of the bri-was formalized in 2015. the corridor adds not only economic dimension to bilateral relations but also serves as a catalyst for the consolidation of mutual trust and the realization of economic development of pakistan whose economy is currently underperforming. at the core of cpec lies the concept of special economic zones whose proposed number stands at nine of which, initially, four were selected for early construction pakistan establishes cpec authority china resolve to strengthen strategic partnership as pm imran concludes visit china-pakistan economic corridor after years of tension, anti-american sentiment ebbs in pakistan the remaining sezs would be established and made operational in the ongoing second phase (2020-2025) of china-pakistan economic corridor. indubitably, special economic zones offer a set of opportunities to both china and pakistan-ranging from infrastructural development to industrial cooperation. nonetheless, the sezs are prone to multiple challenges including security problems in addition, he has contributed to peer-reviewed journals such as armed forces & society and chinese political science review. dr hussain has been a visiting fellow at fudan university. he is daad, fddi and fulbright fellow. moreover, he taught at comsats university, islamabad, fc college university, lahore, and shanghai international studies university (sisu) he received certification in new media and communication from renmin university of china in 2015 key: cord-337155-e4gn4fo1 authors: ullah, atta; pinglu, chen; ullah, saif; zaman, mubasher; hashmi, shujahat haider title: the nexus between capital structure, firm-specific factors, macroeconomic factors and financial performance in the textile sector of pakistan date: 2020-08-31 journal: heliyon doi: 10.1016/j.heliyon.2020.e04741 sha: doc_id: 337155 cord_uid: e4gn4fo1 the study aimed to analyse the role of the capital structure in the financial performance of 90 textile firms listed in pakistan stock exchange (psx) during the period 2008–2017. the dependent variable was return on equity as a proxy for financial performance. the independent variables were the debt to equity, total debt to total assets, asset turnover ratios, sales growth, taxation, and export growth, while the firm size was taken as a control variable. the panel regression estimation technique was employed for analysis purposes, and both cross-sectional and time-series data were collected for this study. this study used the random-effect regression estimation model based on the hausman diagnostic test statistics. the results indicate that the capital structure debt to equity variable has a negative and significant relationship with financial performance while the asset turnover ratio and firm performance showed a negative and statistically insignificant relationship. export growth and sales growth have a considerable positive connection with financial performance; however, firm size has a negative and significant impact on firm performance, in favour of our alternative research hypothesis. the remaining variables include tax payable and the total debt to total assets ratio, which have an insignificant connection with financial performance (roe) and validate the agency theory. with better corporate governance by putting more pressure on managers or increasing managerial ownership, institutional investors can reduce the capital, leverage risk and the overall firm capital cost that help to improve the firm's financial performance and economic stability. the capital structure of a firm represents an amalgam of the sources through which it is financed. it is one of the first important decisions of a business because of its association with the risk and reward. long-term liabilities and stockholders' equity sum or the financial structure of a company minus its current liabilities are related to the capital structure (nieh and lou, 2005; yung-chieh, 2013) . according to damodaran (2001) and pais (2017) , the capital structure is a combination of the equity and debt capital that a firm uses for its financing. if the financial manager makes any irrational decisions to raise funds through debt financing, it could be costly for the firm as the cost of capital could increase, which could eventually reduce the firm's value. therefore, the financial manager's irrational financing decisions could affect the business's stability and survival. pinto et al. (2017) stated that the capital structure decision is vital to deal with the competitive environment because of the need to maximize the returns and because such decision has an impact on the financial condition and firm's stability. financial performance is a particular measure of how effectively a firm uses its resources and assets to maximize its profitability. erasmus (2008) expressed that financial performance, liquidity, and profitability are essential tools for stakeholders and firms' current position and stated that financial performance depends on many factors, including, among many other variables, the structure of capital and macroeconomic factors. the financing or capital structure decision is a management choice, as it influences the investors' return. the capital structure choice is additionally controlled by the market -firms need a capital structure fundamentally for their advancement. therefore, regardless of whether the assets must increase, a capital structure choice is necessary. an interest in the finances raised entails an essential examination that produces another capital structure (nirajini and priya, 2013; ruzben, 2003) . the capital structure modern theory was proposed by modigliani and miller and states that, under the ideal capital market hypothesis, the association's esteem is autonomous with the construction of capital. in this era of globalization, every country seeks to increase its exports since they are the engine of economic growth and enable it to accelerate the development process. in the area of exports, local firms can achieve economies of scale and profitability as well as internationalization and globalization. the escalation in the exporting of products can enhance earnings in foreign currencies and enable the country to import raw materials and meet its development needs. a country's focus on exports enables it to acquire greater economic efficiency and growth because of modern technology, competition, and learning (abbas et al., 2015; sheikh et al., 2017) . liu and ge (2018) reported concern about the benefits of the policy of export tax rebates. they asserted that export tax rebates' effects on producers at the domestic level depend on the relative magnitude of the import demand elasticity and export supply. to earn higher profits and enhance the income of exporting firms, an export tax rebate is implemented because the reduced-form elasticity indicates that value-added tax lowers the number of exports and raises the export price. developing countries have a long history of providing incentives to reduce the overall tax burden on export incomes. most developing countries provide incentives by enabling exporters to lower their prices without reducing their net profits as well as offering tax exemptions, export finance schemes, and other measures to facilitate exports. in recent years, to promote export growth, export promotion has been the hallmark of most south asian economies' trade policies. in competition with other countries in the same market, export incentives have become more complicated and countries aim to offer a wider range of export incentives than their rivals. however, this exerts a positive impact on exports while simultaneously causing the government to lose revenue by increasing the incentives to promote and compete. during and after the beginning of the financial and electricity shortfall crisis, pakistan's textile industry shifted to india and bangladesh, the main reason being the latter's relatively liberal export incentive schemes (ahmad et al., 2012; salim, 2018) . according to the world bank, the share of pakistani exports declined to 0.13% from 0.18% in the world. however, the share of bangladesh's exports increased to 0.19% from 0.06% in the world. vietnam's share increased to 1.17% from 0.14%, and india's share increased to 1.65% from 0.61%. in pakistan, since the financial year 1981-82, the largest decline in exports recorded in a single year, 13%, occurred in the financial year 2015-16 (state bank of pakistan, 2017). the trend of pakistan's exports is shown below in figure 1 . the most complex and imperative issue in corporate finance is whether an ideal capital structure exists. the current study thus contributes to the existing literature by highlighting the firm-specific factors that affect the performance of the textile sector firms that are listed on the pakistan stock exchange (psx) concerning capital structure choices. in financial year (fy) july 2018, exports of readymade production increased from 22.708 to 25.621 million units, worth us$1695.557 million, compared with us$1499.472 million in the fy july 2017 (economic survey of pakistan, 2017-18). the textile sector of pakistan is one of the largest sectors and contributes 67% of exports, 10.2% of the gross domestic product (gdp), and 46% of the total manufacturing, and it employs 40% of the labour force. hence, it is the best growing industry in pakistan, which makes exploring this industry essential. regarding quantity, the pakistani textile sector exports achieved a positive trend of 13.08% in terms of value at the end of fy-2018 while it was 12.83% in fy-2017 (safeer et al., 2019) . thus, this sector is considered to be the best sector in terms of job creation and economic growth. the influence of firms' financial performance and capital structure has been perceived in a few experimental investigations in developed countries (see figures. 2 and 3 ). in pakistan, few studies have been conducted on the textile industry. memon et al. (2012) explored the capital structure and financial performance; however, they used the proxy of the roa from 2004 to 2009. awan (2016) studied the determinants of the capital structure in the textile sector of pakistan, but the study was limited to only eight firms from 2009 to 2013. ullah et al. (2017) explored the capital structure and financial performance but overlooked certain factors, especially export growth and the tax rate variable. safeer et al.'s (2019) study only focused on the challenges facing the textile sector and the potential solutions for improving export competitiveness. ahmed and siddiqui (2019) studied the impact of debt financing on performance and variables, including political uncertainty, capital expenditure (debt to total assets), and financial performance through the roa from 2010 to 2015. the relationship of firms' financing choice based on the capital structure, export growth, taxation, and financial performance (roe) is a new variable in this particular study based on the textile sector. in the last decade, many textile firms have closed in pakistan as a result of financial issues. however, in the past year, pakistan's textile industry has attracted increased attention. it is imperative to study the capital structure as debt has become a burden during the crisis. in this situation, the inclusion of taxation and export variables in the traditional role of the capital structure in financial performance makes this a novel study. furthermore, vijayakumaran (2018) asserted that the capital structure is relevant to the performance of a firm because of market imperfections such as information asymmetry, taxes, and agency problems. moreover, ullah et al. (2017) emphasized that firms' choice of capital structure is an issue to take into consideration and requires a focus on the textile sector due to its situation as a crucial competitive environment in recent times. therefore, it is essential to understand how firms' choice, exports, and taxation rebates affect their financial performance. this study was conducted to shed light on the role of the capital structure in firms' financial performance in the textile sector of pakistan. the remainder of the study is organized as follows. a brief literature review on developed and developing countries is reported, establishing the theoretical and empirical association between the determinants of the capital structure and the financial performance. this is followed by a discussion on the data, variables, and selection of the model and estimation procedure and an explanation of the results obtained. the last section draws conclusions, makes recommendations, and presents the practical implications of the study. there are two sorts of money, specifically obligation capital and value capital. alfred (2007) stated that a company's aggregate capital structure infers the level of obligation and value. firms broadly utilize the common and preferred stock capital structure to acquire the necessary assets; the strategy of the capital structure seeks an exchange between the expected return and the risk. a proper capital structure is an essential part of the decision making for any business. the common contention was provided by modigliani and miller (1958) initially by expressing that an ideal structure of capital aims to adjust the bankruptcy risk with the obligation of saving tax. the foundation of this capital structure should give a higher return to an investor from the more significant part of a firm's value (memon et al., 2012) . the other segments are incorporated into the capital structure, such as preference shares, common stockholder equity, profitability, leverage, gearing, return on investment, and return on assets (abor, 2007; hull and dawar, 2014) . gearing is the level of an organization's financial leverage and expresses the degree to which its activities are subsidized by investors and lenders comprehensively (akintoye, 2008; okoye, 2019) . there are many theories that explain how investors can build the best "capital structure", which improves the firm's market value by selecting the best mixture of equity financing and debt financing (brigham and gapenski, 1996) , and theories on capital structure. various studies have been conducted on the capital structure in developed countries and a few have been performed in developing countries. logically, most of the authors have found a positive relationship while others have found a negative association between capital structure and firm performance. in developed countries, hadlock and james (2002) studied 48 us firms from 1981 to 1990 and found a positive relationship between capital structure and profitability. champion (1999), ghosh et al. (2000) , and hull and dawar (2014) reported that firms that use more debt earn more profit. margaritis and psillaki (2010) found a significant progressive relationship between debt and the performance of the organization. they used data from french organizations from 2003 to 2005 as a sample. contrary to these studies, rajan and zingales (1995) conducted thorough research in the us that indicated that the link between profitability and debt is negative. this relationship will be more definite if the observed organization is more prominent. in turkey, nassar (2016) studied the relationship between fixed capital and financial performance. he found a significant negative relationship between capital structure and firm performance. gleason et al. (2000) found that leverage at a higher level in the capital structure, to some extent, becomes the cause of decreased performance of organizations. fama and french (2002) reported two findings: first, a negative connection of debt in performance matrixes; and second, a negative association between capital structure and performance. they concluded that high-profit firms with a low amount of risk of debt payment and less leverage pressure are linked with trade-off theory. titman and wessels (1988) reported on the influence of the capital structure on firms' financial performance in developed and developing countries' markets. he determined that the capital structure negatively affected the performance of firms in china, whereas germany and sweden's relationship was positive. the recent contribution by vijayakumaran (2018) expressed concern over the corporate structure decisions and corporate performance of listed companies in china using 4181 firm-year observations. he found a positive relationship between firm performance and leverage. the findings indicate that large firms enjoy economies of scale and have a significant relationship. he concluded that financing through debt is one of the mechanisms of governance suggested by agency theory to mitigate equity capital agency costs and enhance firm performance. in developing countries, gill and mathur (2011) assessed the components that influence the impact of the organizations and the information utilized separately for the 166 organizations recorded on the toronto stock exchange from 2008 to 2012. the final product allowed them to realize that the leverage impact positively affects the business in the administration division while it is adversely connected with the activity in the assembly division. the relationship between capital structure and firm performance was investigated by salim and yadav (2012), and their findings describe a negative relationship between firm performance and leverage. an examination in india by goyal (2013) uncovered a positive relationship between a transient obligation and its benefit, while on the contrary it found a connection between gainfulness and long-haul necessity. seyed and pejman (2013) reported on the capital structure link with firm performance on the tehran stock exchange and established a positive relationship between the two. pinto et al. (2017) expressed the relationship between capital structure and firm performance from 2011 to 2015 in india by using regression analysis. the measurement variables were the debt to total assets and debt to equity leverage ratios and the return on capital employed (roce). they found a significant relationship between capital structure and firm performance. sheikh and wang (2010) examined the financing behaviour of textile companies in pakistan. the regression model was used to analyse the data of 75 textile companies listed from 2002 to 2007, and the results indicate a negative impact of debt on profitability in the capital structure. a primary survey conducted in the building division of pakistan reported that the roe is adversely influenced by the obligations at all levels (khan, 2012) . mirza and javed (2013) examined the determinants of money-related outcomes in pakistan. the examination of the settled impacts was connected to the information on 60 organizations from 2007 to 2011, and the outcomes demonstrated that the execution of the organization (re) is decidedly influenced by the debt to equity ratio and contrarily influenced by the short term debt to total assets (stdta) divided by long term debt to total assets (ltdta). hijazi and tariq (2006) described the capital structure determinants of pakistan's real business. the result demonstrates that the benefit and the measure of the board have a negative link with leverage, while there is a noteworthy association with incarnations, development, and exploitations. the overview by amara and aziz (2014) expressed concerns about the spread of the converse relationship with the return on equity by the level of obligation of the capital structure in the sustenance segment of pakistan. the volume of debt in the capital structure of organizations has a reverse association with their performance (hasan et al., 2014) . in the pakistani textile sector, ullah et al. (2017) found a positive relationship between the ratio of debt to equity (de) and the roe at the 10% confidence interval while the asset turnover ratio is inversely associated with the roe. moreover, there is a negative relationship between firm size and roe. rahman et al. (2019) explored the effect of the capital structure on the profitability of publicly traded manufacturing firms in bangladesh. they took a sample of 50 observations of 10 selected manufacturing companies listed on the dhaka stock exchange from 2013 to 2017. the fixed-effect regression technique was applied to the data to determine the correlation between the independent variables (debt ratio, equity ratio, and debt to equity ratio) and the dependent variable (the roe). the results showed that the debt ratio and equity ratio have a significant positive effect. the equity ratio has a significant positive relationship with the roe, but the debt to equity ratio has a significant negative impact on the roe. chang et al. (2019) conducted a study to identify the impact of the capital structure on profitability. this study was conducted on four asian economies, and the researchers applied correlation and regression analysis to the data from 2013 to 2016. the study found that leverage and profitability have a significant negative relationship, whereas there are significant positive relationships between growth and leverage in korea, taiwan, and hong kong. further, the study identified a significantly positive relationship between size and leverage in each country. nguyen and nguyen (2020) examined the relationship between the capital structure and the profitability of non-financial companies listed on the vietnam stock exchange. panel data on 488 listed companies were employed, and the data were taken from 2013 to 2018. the capital structure was represented by the ratios of short-and long-term liabilities, total liabilities to total assets, and profitability measured by the roe. the generalized least square technique was applied, and the results suggest that the capital structure of vietnamese listed non-financial companies is negatively related to their performance. moreover, vu et al. (2020) examined the impact of the capital structure on the performance of construction companies listed on the vietnam stock exchange. the sample consisted of 59 listed companies, and data were taken from 3 years (177 observations). a linear regression model and correlation analysis were applied, and the results show that debt/equity has a robust positive effect on the roe. the factor of total fixed assets to total assets yielded a positive and significant effect on the roe. putri and rahyuda (2020) examined the impact of the capital structure on the debt to equity ratio proxy, sales growth with sales growth proxy, and profitability. the sample consisted of annual reports of 51 industrial consumer goods companies listed on the indonesian stock exchange, and the data set was from 2013 to 2018. the results show that the debt to equity ratio proxy has a significant negative impact on profitability. sales growth has a significant positive impact on profitability. chen et al. (2006) investigated the effect of tax rebates and export performance in china for the period of 1985-2002 and concluded that, when the rate of an export rebate is raised by the government, it leads to a decrease in the output and profitability of foreign competitors and an increase in the output of finished goods and profitability of domestic firms. a comparison study of pakistan, india, and bangladesh was conducted by ahmad (2015) on the value of export incentives for 2001-2011. the comparative analysis findings indicate that, due to having the highest export incentives, bangladesh's textile sector is more export oriented than those of india and pakistan. chung et al. (2018) found a positive relationship between the performance of strategic exports and the financial export performance in the korean clothing and textile sector. many positive external sources of exports are factors such as job creation, improved production chains, creativity, innovation, and competitiveness; in addition, for developing countries, the export performance of local companies is critical. pakistan has focused on increasing its exports but has failed to gain a significant share in the global market for multiple reasons, for instance lower exports of semimanufactured goods and the narrow base of its exports, technology and obsolete machinery, devaluation and increasing industrial units 'patents, technical obstacles, and instability in the political structure. unfortunately, due to the above factors, pakistan's exports are undesirable. pakistan, as a developing country, faces many economic challenges. export growth is the best strategy to overcome weak economic growth. to achieve this, the country must accelerate its export performance (abbas et al., 2015) . safeer et al. (2019) expressed concern over the textile industry of pakistan and reported that the firm strategy, structure, and export-oriented rivalry are the critical factors because of the demand in the local market as well as competition in international exports. the above literature outcomes provided us with the foundation on which to develop the methodology, and the following research hypotheses could be formed. h1. there is a decisive role of the asset turnover ratio in the financial performance in the pakistani textile sector. h2. there is a significant role of the debt to equity ratio in the financial performance in the textile sector of pakistan. h3. there is a significant role of tax payable in the financial performance in the pakistani textile sector. h4. there is a decisive role of export growth in the financial performance in the pakistani textile sector. h5. there is a specific negative impact of firm size on the financial performance in the pakistani textile sector. h6. there is a significant role of the ratio of sales growth in the financial performance in the pakistani textile sector. h7. there is a significant role of the total debt to total assets ratio in the financial performance in the pakistani textile sector. this study aimed to determine the impact of the capital structure, exports, and macroeconomic factors on firms' performance. the study scope was the pakistani textile sector in the period 2008-2017. the proxy used for the capital structure was two independent variables, debt to equity and total debt to total assets. in comparison, the two microeconomic variables were asset turnover and growth (sales) and the two macroeconomic variables were export growth and taxation. the return on equity (roe) was used as a proxy variable for measuring financial performance as a dependent variable, and the control variable was firm size. the roe measures the overall profitability and is a combination of the net profit after tax and shareholders' equity, and it can best interpret the results. the return on equity (roe) helps investors to gauge how their investments are generating income. moreover, the roa and nim are also options to measure financial performance. the roa measures the comprehensive ability to utilize assets, and tobin's q measures the market value. the studies by ahmed and siddiqui (2019) and memon et al. (2012) on the textile sector of pakistan were based on the roa (financial performance proxy) and the debt to total assets ratio (capital structure proxy). however, this study was limited to the return on equity (roe) as a measure of overall profitability and the capital structure in the view of debt and shareholders' equity is a better measure of textile sector firms listed on the pakistan stock exchange. these variables are the most appropriate for testing the hypotheses, questioning, and analysing the pakistani textile sector's financial performance. moreover, the study was limited to the textile sector firms listed on the pakistan stock exchange. in the textile sector of pakistan, the selected variables in the current study are more rational and appropriate. panel data spanning ten years were used for the analysis in the current study, and both cross-sectional and time series data were collected. this study consisted of 90 well-known textile companies listed on the pakistan stock exchange (psx) (see appendix 1). the data of the textile companies were collected from annual reports, in which the individual was the company and the period was annual data, and our study was balanced as all the entities were observed for an equal period from 2008 to 2017. the total number of textile firms listed on the psx was 153, which can be divided into 3 different groupsspinning, weaving, and textile compositewhich have a ratio of 83, 14, and 56 companies, respectively. in this study, we selected a sample of 90 firms, almost 60% of the population based on data availability criteria, and all the firms remained listed throughout the period 2008-2017. the variables for this study were selected by comprehensively examining the earlier work undertaken in this area. the variables that are stated below were used to test the hypotheses of our research (see table 1 ). initially, a redundant fixed-effect test was performed, but it indicated that a common panel should be utilized as the p value was insignificant (0.0882), with a coefficient value of 1.22. a random-or fixed-effect model was employed based on the hausman diagnostic test results. therefore, in accordance with the initial results of the quantitative model for these panel data, we used the random-effect model. the randomeffect model specifies the constant coefficient; the assumption of the cross-sectional data is as follows: where roe represents the dependent variable, return on equity, ato represent the asset turnover, gr represents growth, td represents the total debt to total assets, ex represents exports, tr represents the tax rate, siz represents the size of the firm, β 0 represents the intercept, β1 represents the explanatory variable, i represents a cross-sectional variable, t represents the time series variable, and μ represents the error term. the presentation and discussion of the results consist of two parts: i) a descriptive analysis and ii) an inferential analysis. the descriptive study involved a complete sample of independent variables and a dependent variable for the sample period of ten years. to conduct the statistical analysis of the data, the panel data regression estimation analysis model was employed. the study mean value explains the measure of central tendency, and the jarque-bera test suggests the normal distribution of the data. skewness explains the lack of symmetry; that is, concerning the central point, the left and right sides of the curve are unequal. meanwhile, kurtosis indicates the degree of tailedness in the frequency distribution. the standard deviation, minimum, and maximum explain the variability or flexibility and range of the data. the detailed results are shown in table 2 . the relationship between the dependent variable and the independent variable was assessed through a correlation matrix. each variable has a correlation of 1 with itself. a higher value highlights a higher correlation, while a lower value indicates a weaker relationship. the results in table 3 show that the asset turnover ratio (2.3%), ebit to tax (0.02%), export growth (6.2%), and sales growth (1%) have a significant and positive relationship with the roe. the debt to equity (de) ratio and firm size are negatively correlated with the roe with 4.3% and 1.3%, respectively. the financial performance related to the roe is positively debt to equity long-term debt þ short-term debt/total shareholder equity. asset turnover net sales/total assets growth it is used as a proxy for growth opportunities. zeitun and tian (2007) used this variable in their study (growth ¼ variation in the natural logarithm of sales) and reported that a growth firm refers to the capability of maximizing the profit from the investment. sheikh and wang (2010) also used this variable and method. total debt to total assets (total debt/total assets) is used as a proxy for leverage. tax rate ¼ income tax expenses/income earned before taxes. memon et al. (2012) also used this in their study. this is used as a proxy for export growth in the textile sector. exports ¼ variation in the natural logarithm of total exports (textile sector). firm size (size) ebaid (2009) used firm size. firm size was assessed by taking the logarithm of aggregate resources of firms recorded on the psx. the logarithm of the total assets of a firm. a. ullah et al. heliyon 6 (2020) e04741 correlated with the total debt and will bring a positive change. detailed correlation results are presented in table 3 . in table 4 , the summary results of the unit root test are presented. the panel unit root test was conducted to check the stationarity of the data. we used exogenous variables and individual effects with user-specified lag effect 1. we used newey-west automatic bandwidth selection and the bartlett kernel on balanced observations for each test. it indicated that the variables fit the model to run the panel regression analysis. the p-value is less than 0.05, so that variable was added to the model to run the panel regression analysis, and our result indicates the goodness of fit for all the variables and growth sales at the first difference. thus, the growth variable was taken at the first difference. the hausman t-statistic test was conducted to determine whether the fixedor the random-effect model should be selected to run the regression analysis. according to this test's results, the random-effect regression estimation technique is appropriate because the p-value is insignificant (0.2795). table 5 presents the random-effect regression model, which examines the impact of the capital structure and its determinants to establish the financial performance by using panel data of 891 observations. the dependent variables could be affected by unobserved financial, economic, or region factors and relate positively with the error term (μ it ). to resolve the endogeneity issue, the iv method was applied to classify the actual results of the independent variables on the dependent variables. to account for the chances of bias in the simultaneous equation in the case of panel least squares estimation, the akaike information criterion, schwarz information criterion, hannan-quinn information criterion, durbin-watson statistic, and wu-hausman test were performed and the statistics indicate the model's appropriateness. the constant value is statistically positive and significantly related to the roe. the t-statistic does not reject the proposed hypothesis used as a diagnostic test for the iv's relationship with the error term and over-identification of the iv, respectively. the iv's validity was confirmed, and the results are shown at the end of the respective table 5 . the study accepted that the randomeffect regression model is intercepted and sloped based on the hausman test statistic, which is equal in production and years. the results in table 5 indicate that the f-statistic value is 22.20 with a p-value of 0.00, which highlights the fitness of the model, and the adjusted r square value, which is 0.70, demonstrates the effectiveness of the model. the results in table 5 highlight a negative and statistically insignificant impact of the asset turnover ratio on firm performance due to the tstatistic value of a 22% significance level with p-values of 0.82 and -0.08. the regression results of the hypothesis, that is, the asset turnover and statistics, led to the acceptance of the null hypothesis. this shows that converting assets into quick cash or selling the goods in stock quickly has no significant impact on firms' performance at the financial level. the second hypothesis on the debt to equity ratio has a decisive negative impact on the return on equity with a negative t-statistic value of 42.94 and a p-value of 0.00. therefore, we accepted the alternative hypothesis, as proposed in the study literature. between the debt to equity and firms' performance, the p-value of 0.00 indicates that those firms that used debt finance to purchase their assets experience a negative relationship with or impact on their financial performance. similar findings were reported by putri and rahyuda (2020) based on a capital structure debt to equity ratio proxy and profitability (roe), in which the sample comprised 51 indonesian firms from 2013 to 2018. our statistical findings based on the capital structure and roe are in line with nguyen and nguyen's (2020) study in vietnam. rahman et al.'s (2019) debt to equity ratio findings show a significant negative impact on the roe in bangladesh and are in line with the current study's outcomes. furthermore, our results on the capital structure variables are in line with the findings of nassar's (2016) study as he identified a negative relationship between capital structure and firm performance in turkey. in pakistan's textile sector, sheikh and wang (2010) examined the financing behaviour through a regression model from 2002 to 2007 for 75 firms and found a negative impact of debt and financial performance. therefore, our study's findings are consistent with the previous findings. moreover, amara and aziz (2014) and hasan et al. (2014) reported a reverse association between firms' performance and their capital structure. our results also validate gleason et al.'s (2000) concluding remarks that high-level leverage in a firm's capital structure, to some extent, becomes the cause of decreased financial performance. the results for the hypothesis on tax payable indicates that the t-value is 0.14. however, the p-value is 0.89, which is not less than 0.05; it has a statistically insignificant effect on the firm's performance and led to the acceptance of the null hypothesis. it validates the idea that firms that pay a moderate rate of tax perform well regarding profit. the trade-off theory suggests a significant relationship between profitability and the effective tax rate because it decreases the possible debt costs. however, the lower tax rate increases the debt costs, as occurs in the pakistani textile sector. therefore, an increase in the tax rate increases the tax advantage of debt financing and emphasizes the old theory of deangelo and masulis (1980) that there is a significant relationship between tax rates and profitability. the findings support chen's (2006) concluding remarks that, when the rate of export rebates is raised by the government, there will be a decrease in foreign competitors' output and an increase in domestic firms' output of finish goods and profitability. the results on exports and firm financial performance (roe) show a tvalue of 2.33 and a p-value of 0.02, supporting the acceptance of the alternative hypothesis. export growth is statistically significant and positively related to firms' performance (roe). it explains that those firms that have high exports have a high profitability percentage, meaning that their performance is continuously improving. our results are in line with the findings of chung et al. (2018) , who found a positive relationship between exports and financial performance in the korean clothing and textile sector. this establishes that, in developing countries, textile sector exports play a decisive role in a high return on equity. firm size has a statistically insignificant and adverse relationship with financial performance. the results support the acceptance of the alternative hypothesis in favour of the research hypothesis on firm size and firm financial performance, and the profitability is irrelevant to the firm; therefore, our firm size hypothesis results are in line with the study by masnoon and saeed (2014) . they also reported a negative relationship between firm financial performance and size. sales growth has a statistically significant relationship with the tvalue, which is 0.85, with a p-value of 0.04, showing that there is a positive impact of sales growth on profitability, and the alternative hypothesis can be accepted. the results are in line with chang et al.'s (2019) study based on the capital structure and profitability in the asian economies, i.e., korea, taiwan, and hong kong, from 2013 to 2016. furthermore, putri and rahyuda (2020) found that sales growth had a significant positive impact on profitability in indonesian firms from 2013 to 2018. hence, our hypothesis (h 0 ) can be rejected. the hypothesis of total debt to total assets and firm financial performance (roe) indicates that the t-value is -1.11 with a p-value of 0.26 and a coefficient value of -0.16, rejecting the alternative hypothesis, so there is an insignificant relationship between the total debt to total assets ratio and the financial performance. it shows that debts that are financed by assets have no impact on financial performance. our study findings regarding the hypothesis on debt and financial performance are in line with the observations of fama and french (2002) . our study findings on the negative link between the total debt to total assets ratio and the firm financial performance are the same as hijazi and tariq (2006) study's account of the capital structure determinants of real business of pakistan. salim and yadav's (2012) study supported the negative relationship findings on leverage and firm performance. the detailed results are presented in table 5 . the current study aimed to highlight the relationship between the determinants of the capital structure and its impact on firm financial performance in the textile sector of pakistan. it also considered the macroeconomic variable of industry exports and taxation. the independent variables were the debt to equity ratio (de), total debt to total assets ratio, asset turnover (ast), sales growth, taxation, and export growth. the dependent variable was the return on equity (roe), and one control variable was firm size. the random-effect regression model was employed based on the hausman t-statistic result by considering panel data for the analysis, which consider both cross-sectional and time series dimensions. the results can be categorized into two phases. first, it was statistically proven that the variables have either a positive or a negative relationship with the dependent variable and exert an impact on the textile sector. the results of the random-effect method highlight the fitness and effectiveness of the model. the findings led to the conclusion that the debt to equity (de) ratio, tax payable, sales growth, and export growth variables have a significant relationship with the return on equity. the variable total debt to total assets ratio and asset turnover (ast) has an insignificant relationship with the roe. these findings of our study are consistent with the trade-off theory. according to the pecking order theory, the debt ratio has a negative correlation with firm size, and, in pakistan, firm size and debt are negatively associated according to our findings. our results will aid decide making about the capital structure and support the argument of the trade-off theory that firms should increase their debt ratio on an individual level in the capital structure, which, in turn, helps to improve their performance. however, this study was limited to the textile sector of pakistan and firms listed on the pakistan stock exchange. the pakistani textile sector has improved considerably but previously suffered greatly from an electricity shortfall, and the study highlights that there is still a need for second-generation textile sector reforms. gdp growth is linked to profitability and financial performance; therefore, booming textile companies should protect themselves at the time of decline so that hostile/default situations do not affect them and pakistan's economy severely. therefore, firms' management should not only focus on profitability but also manage advancements in technology and risks at the internal and external levels. there is a need to practise better governance (capital structure and corporate governance policy) for firms through many other reforms, like the debt-equity structure, director remunerations, hiring criteria, and other related party transaction regulations. in addition, by enhancing corporate governance by putting more pressure on managers or increasing managerial ownership, institutional investors can reduce the risk and the overall firm capital cost as well as improving the firm financial performance and stability in the pakistani economy. the latest revised corporate governance code of 2017 in pakistan should be implemented to improve information transparency and the regulatory framework by considering the human development system to enable firms to develop their human capital and stability. internationally, many positive external sources are supported by factors such as job creation, improved production chains, invention, innovation, and competitiveness. for developing countries like pakistan, the export performance of local companies is critical. furthermore, export growth is the best strategy for pakistan to overcome weak economic growth by utilizing useful projects like cpec; accordingly, pakistan must accelerate its export performance. china's back-up plan at the time of the covid-19 crisis is supported by a massive public-private partnership share, which has been planned and implemented for a longer, concentrated duration. therefore, pakistan can learn from china's experience by taking advantage of the one belt one road project initiative of the china-pakistan economic corridor. it is hoped that future research could draw on cross-country comparisons and the effectiveness of the silk road project. in addition, future studies can investigate, among other issues, expanding the data of all sectors with the fintech effect. author contribution statement firm size, exchange rate, and exports performance: a firm-level study of pakistani manufacturing sector debt policy & performance of smes: evidence from ghanaian and south africa firms the value of export incentives capital structure effect on firms' performance: focusing on consumers and industrials sectors on malaysian firms impact of debt financing on performance: evidence from the textile sector of pakistan the sensitivity of performance to capital structure corporate finance issues investigations. innovations and application (2nded) impact of capital structure on firm performance: analysis of food sector listed on karachi stock exchange determinants of capital structure of textile industry in pakistan financial management. the dryden press relationship between capital structure and profitability: evidence from four asian tigers the effect of export tax rebates on export performance: theory and evidence from china relationships between the capabilities and export performance of korean clothing and textiles smes and the moderating effects of export mode on these relationships corporate finance theory and practice the optimal capital structure under corporate and personal taxation the impact of capital-structure choice on firm performance: empirical evidence from egypt evaluating value-based financial performance measures testing trade-off and pecking order predictions about dividends and debt the pricing of seasoned equity offerings: evidence from reit's. r. estate econ board size, ceo duality, and the value of canadian manufacturing firms the interrelationship between culture, capital structure, and performance: evidence from european retailers impact of capital structure on performance of listed public sector banks in india do banks provide financial stack? influence of capital structure on firm performance: evidence from bangladesh determinants of capital structure: a case for the pakistani cement industry agency theory, capital structure, and firm performance: some indian evidence the relationship of capital structure decisions with firm performance: a study of the engineering sector of pakistan who benefits from the export tax rebate policy? evidence from the chinese fishery sector capital structure, equity ownership, and firm performance capital structure determinants on kse listed automobile companies capital structure and firm performance: a case of textile sector of pakistan determinants of financial performance of a firm: case of pakistani stock market the cost of capital, corporation finance, and the theory of investment the impact of capital structure on the financial performance of the firms: evidence from borsa istanbul capital structure and firm performance of non-financial listed companies: cross-sector empirical evidences from vietnam introduction to securities investment and financial analysis impact of capital structure on financial performance of the listed trading companies in sri lanka financial leverage and profitability performance of financial institutions in nigeria do managers herd when choosing the firm's capital structure? evidence from a small european economy capital structure and financial performance effect of capital structure and sales growth on firm value with profitability as mediation the impact of capital structure on the profitability of publicly traded manufacturing firms in bangladesh the great reversals. the politics of financial developments in the 20th century capital structure and financial performance: evidence from selected business companies in colombo stock exchange sri lanka diagnostics of the challenges and potential solutions to improve export competitiveness in international markets: the case of pakistani readymade garments industry capacity realization and productivity growth in a developing country: has economic reform had impact? routledge capital structure and firm performance: evidence from malaysian listed companies the growth of e-marketing in the businessto-business industry and its effect on the performance of businesses in pakistan: marketing success financing behavior of textile firms in pakistan the relationship between capital structure decisions with firm performance: comparison between big and small industries in firms listed at tehran stock exchange the determinants of capital structure choice impact of capital structure on financial performance of textile sector in pakistan capital structure decisions and corporate performance: evidence from chinese listed industrial firms the impact of capital structure on the performance of construction companies: a study from vietnam stock exchanges the effects of capital structure on the corporate performance of taiwan-listed photovoltaic companies: a moderator of corporate innovation activities capital structure and corporate performance: evidence from jordan the authors declare no conflict of interest. no additional information is available for this paper. key: cord-303102-ap1dzbp9 authors: iqbal, sajid; bilal, ahmad raza; nurunnabi, mohammad; iqbal, wasim; alfakhri, yazeed; iqbal, nadeem title: it is time to control the worst: testing covid-19 outbreak, energy consumption and co(2) emission date: 2020-11-12 journal: environ sci pollut res int doi: 10.1007/s11356-020-11462-z sha: doc_id: 303102 cord_uid: ap1dzbp9 during the covid-19 outbreak, managing energy consumption and co(2) emission remained a serious problem. the previous literature rarely solved this real-time issue, and there is a lack of public research proposing an effective way forward on it. however, the study examines the impact of the covid-19 outbreak on energy consumption and co(2) emission. the design of the study is quantitative, and the data is acquired from different online databases. the model of the study is inferred by using panel unit root test and ardl test. the robustness of study findings was checked through panel quantile regression. the findings highlighted that the covid-19 outbreak is negatively significant with energy consumption and co(2) emission. the study suggested revising the energy consumption patterns by developing and implementing the national action plan for energy consumption and environmental protection. the study also contributed in knowledge by suggesting the novel insight into co(2) emission and energy consumption patterns during covid-19 pandemic and recommended to consider renewable energy transition methods as an opportunity for the society. for a more effective management of energy consumption and environmental pollution, country-specific measures are suggested to be taken, and the national government should support the concerned public departments, ministries and private organizations on it. to the best of our study, this is one of the pioneer studies studying this novel link and suggesting the way forward on recent topicality. the world economy is facing two major problems: the spread of the new covid-19 outbreak and the current plunge in oil prices. the amalgamation of these two issues will probably trigger a long-term monetary slump and push the world economy into a subsequent downturn (baker et al. 2020a ). the covid-19 outbreak continues to spread widely in the united states (usa), italy, china, iran and other countries, especially in europe, which has triggered special effects of stock market impulse and economic policy uncertainty. the recent stock market volatility level has exceeded from the levels of the stock market crashes in october 1987 and december 2008 and 1929 . during the same period, the uncertainty of the us economic policy indicated that by 24 march 2020, this number had jumped from 100 to 400 (disemadi and shaleh 2020) . similarly, the impact of the pandemic, such as the covid-19 outbreak commonly referred to as the coronavirus, has severely affected pakistan's energy sector. the petroleum and natural gas authority (ogra) of pakistan is committed to strengthening the national energy system and avoiding energy shortages not only due to local economic impacts but also due to international impacts. (chakraborty and thomas 2020) . likewise, it is widely accepted that the impact of the covid-19 outbreak is very big and structural in all the domains of life including the energy sector (nicola et al. 2020) . humans are the core regulator of society, and their health is the foremost important consideration for thriving in a productive and strong society. while, due to covid-19 outbreak, several health issues have been raised and such issues are becoming serious days by day, more specifically in frugal economies like pakistan, this impact is very critical, and now, an economic shock is being perceived; lockdown is being extended continuously; and by the effect of lockdown fuel consumption, co 2 emission, energy demand and supply declined and market mechanism is altered very speedily. thus, to understand and identify the novel impact of covid-19 outbreak on co 2 emission and energy consumption, the recent study is intended to investigate (solangi et al. 2019b; hou et al. 2019) . this is the motivation of a recent study. deciding how much the impact of covid-19 is important, especially in the recent conditions, where many countries like the usa, china, italy, spain, iran, and india are facing 'pandemic effect' at large. by the fact, the covid-19 outbreak affected the energy sector of the world as a whole, and eventually, the demand graph of oil supplies have become bearish; oil market prices faced a decline; and big economies like the usa are bidding the oil-free of cost (malamud and núñez 2020) . according to bloomberg, a sudden decline has been observed in the oil and gas industry during march 2020, and its future is still in an unpredictable state. importantly, the failure of opec negotiations is also the reason for the decline in oil prices and the covid-19 outbreak, which has expanded the greater impact on the energy industry of pakistan (solangi et al. 2019a ). this is a very big impact with which existing theoretical propositions, assumptions, methods and models have not kept the pace. this is one of the big limitations and failures of previous literature. therefore, novel exertions are prerequisites to present advancement in the literature, empirical modelling and operational research by addressing the contemporary problem of the covid-19 outbreak (halkos and tsirivis 2019) . our study attempts to investigate this critical issue by testing the effect of covid-19 outbreak on the energy sector. more specifically, we inferred the effect of covid-19 outbreak on co 2 emission and energy consumption. we incorporated the theory of economic efficiency to validate the association between co 2 emission, energy consumption and the covid-19 outbreak. by considering the law of diminishing economic return due to the covid-19 outbreak, we authenticated the connection of the covid-19 outbreak with energy consumption and co 2 emission (correia et al. 2020) . we test the inherent assumptions of economic efficiency theory and then validate an empirical model that forecasts the optimal points of energy consumption and co 2 emission in pandemic where greater advantages are been achieved with the intent to sustain energy efficiency. we inquired the question how the covid-19 outbreak can reduce co 2 emission and energy consumption (goodell 2020) . a better understanding of this question is the need of the time for academia, practitioners and regulators. in the energy sector, several energy consumptions and co 2 emissionoriented frameworks, efficiency management policies and performance management mechanisms were presented. ironically, these policy frameworks and ways forward often increase energy demand and challenge the capacity of the energy sector to stay committed but not provide the way forward to adjust with the structurally imposed challenges, such as the covid-19 outbreak (department of economic and social affairs 2020). therefore, inquiries should give additional attention to understanding how structural changes like the covid-19 outbreak affect co 2 emission and energy consumption (öncü 2020) . in line with the concept of energy efficiency, we consider energy consumption as a contextual and market process that signals the expectation of an energy market (iqbal et al. 2019b) . a so-called energy management system of ogra pakistan is expected to do this effectually but not essentially: recent declines in the local energy market of pakistan are big examples to support this argument. however, a policy way forward to manage the energy consumption and co 2 emission is important (baloch et al. 2020) . and it is further important to give an alternative strategy in managing energy consumption by reducing the co 2 emission in the pakistani context by taking the covid-19 outbreak as an opportunity. the objective of the current study is to investigate the impact of covid-19 outbreak on energy consumption and co 2 emission, a way forward for sustainable energy markets. further, the study contributes to energy consumption patterns by suggesting how to cope and put up with the energy sector from the novel effect of the covid-19 outbreak. we propose sector-wide planning and administration in managing energy shortfalls and redressing the energy consumption habits. this is the first contribution. secondly, a recent study contributes to the novel covid-19 with the assumptions of the economic theory of efficiency by backing up the study arguments on energy consumption. thirdly, we fill the gap of theoretical and operational research by studying the novel covid-19 with co 2 emission and energy consumption. fourth, by this study, we address the special call on 'secure and sustainable energy system' as this historical time is very crucial in developing the new avenues and/or ways forward to secure and stabilize energy system through energy markets-who have imagined a global lockdown and massive energy distress just a few months ago? fifth, we contribute to covid-19, energy regulator (e.g. ogra pakistan) initiatives and energy market stability with the motivation to bring the best findings and policy ways forward to our readers. however, our study contributes to different avenues, most importantly in the covid-19 outbreak and energy consumption, to present a way forward for better planning and administration to meet the energy shortfalls. this article is one of the pioneering studies on the energy economic and environmental impact of the covid-19 pandemic. the rest of the paper is organized as follows: the 'review of literature' section describes the literature review, the 'research method and design' section describes methodology, the 'results and discussion' section describes the results and discussion while the 'conclusion and policy implications' section concludes the study. the pakistani economy is one of the rich oil-producing economies in the world and one of the self-sustainable economies in energy production resources in south asia. ironically, the national revenues, energy market returns, earning capacity, energy market microstructure and energy efficiency are adversely affected due to the covid-19 outbreak (connors 2020) . notably, the pakistani energy sector is broadly susceptible and sensitive to energy crust and turfs, energy preservation and consumption and environmental degradation. due to pandemic persistence, the role of covid-19 outbreak on the energy market and co 2 emission has become an important area of study to study and guide the policymakers to sustain the energy sector at large. before the covid-19 lockdown, the energy consumption patterns of the pakistani economy were much alarming; and therefore, co2 emission and energy consumption have become a puzzle to solve (ataguba 2020) . in contrast, the covid-19 lockdown has proved the significance of less energy consumption due to lower co 2 emission in the local context (wang et al. 2020a) . in the emergence of 2020, the covid-19 outbreak has become a lifetime emergency that affected the energy sector and economies as a whole. in response, national governments and regulatory authorities are combating with covid-19 pandemic resiliently (fornaro and wolf 2020) . in times of highly volatile momentum energy consumption and co 2 emission, the covid-19 pandemic emerged as a big crisis (asbahi et al. 2019) . interestingly, the covid-19 outbreak locked the nations of nations into the self-isolation centres, and by the fact, this reduced co 2 emission at large and co 2 emission and energy consumption in so many countries like china, usa, spain, italy and pakistan. on this momentum, emission trading system (ets) and european union (eu) emission led a new policy framework on energy emission, such as co 2 emission and energy consumption (liu et al. 2020; iqbal et al. 2020b) . while, geographically, such policy frameworks were developed far away from asia, however, these are not considered, studied and implemented in the pakistani energy sector. considering the energy consumption way forward, it has been noticed from previous studies that many of the energy consumption and energy sustainability frameworks have been implemented in the annual year of 2020. conversely, the covid-19 outbreak has postponed the entire activities related to the energy sector (disemadi and shaleh 2020) . likewise, due to covid-19, such policy frameworks are being altered drastically ). thus, new policy frameworks on energy consumption, co 2 emission leading towards energy sustainability (dong et al. 2015; zheng et al. 2019; iqbal et al. 2019c) or energy efficiency are prerequisite in accordance to structurally imposed scenarios persistent in the world with the covid-19 pandemic (colenda et al. 2020) . in short, the energy sector needs adaptive policies that could enhance energy sustainability. a large-scale reduction in travel and transport activities has dampened the oil demand due to the covid-19 outbreak and by the fact (ghg) is also reduced. this is the common proposition that ghg emission is probable to be unmaintainable in the long run. however, a reduction in oil demand has raised an important point of concern that what would be the future of the climate and clean energy development. similarly, green credit assurance and assessment of the income which is produced from energy facilities provided by the supplier to the financial expert related to the environment by use of friendly power (khokhar et al. 2020) . it might endanger green capital and affect the revenues of environmental ventures. here advancement features are also described for the improvement of green money and speculation (ciaschini et al. 2013) . thus, recent research also intends to add two related structures sponsored by a hypothetical method like with green account and speculation which depend on task size. the impact of the pandemic on the energy market is phased into two sections. first is the effect of covid-19 on the energy sector in determining energy consumption pattern from the raw material of production (oil demand, supply and consumption) to end-product (electricity and end mean of fuel used in the travel and transport industry). second, how the energy market will reshape a shift and recover after a pandemic or, in other words, how energy market will revive after a pandemic is the most important question of recent times that need answer (igwe 2020) . endorsing the previous literature, a recent study is extending the theoretical contribution by testing these missing links between the covid-19 outbreak, energy consumption and co 2 emission. moreover, based on published studies, our study enhanced the empirical evidence by considering the recent reality of pandemic. the covid-19 outbreak indicates that carbon dioxide emission will decline during this year and historically a drop-down in co 2 emission was observed in 2009, and the declining percentage ranged from 0.3 to 1.2% approximately (burkle 2020) . thus, the covid-19 outbreak has locked down the entire business of life in so many countries around the globe, and mainly china is affected by this particular virus (chohan 2020) . due to said specific lockdown, megaindustries and small-and medium-sized (sme) businesses are in lockdown that reduced the demand for oil as china is the largest exporter of oil products. by this, oil consumption is reduced, and with this effect, co 2 emission is also reduced. considering the pandemic and opportunity, when industries are in lockdown, this is the high time to shift the industries towards renewable energy with the mission to reduce oil consumption and co 2 emission and to develop clean and green china for upcoming generations. however, there is dire need to redress energy margin and shift on renewable energy. considering the theory of economic efficiency supporting energy consumption in terms of energy efficiency in a recent study, we established various energy efficiency and energy sustainability frameworks into the question particularly energy consumption in the pakistani context due to the covid-19 effect (coccia 2020) . the covid-19 effect on the energy sector is temporal and multifold, such as short-run and long-run effects. in the short run, the pandemic lockdown, often termed as self-isolation, has decreased air pollution and co 2 emission caused by various precautionary measures taken by the airline and transport industries and production schedule shutdowns, while the long-term effect of pandemic lockdown is depending on the structural implementation of such decisions in cited industries on a large scale and will result in energy crisis and/or an economic shock to all population (gilbert et al. 2020; iqbal et al. 2019a) . notably, this situation of pandemic lockdown is and will be a great source of uncertainty and will scale larger implications for the energy sector (das 2020) . this led a probability to face the mighty challenges by the energy sector by deciding to (1) revise the energy sustainability policies concerning covid-19 for the long-lasting sustainability in the energy sector and (2) prioritize the policy framework that may lead to clean and green energy consumption by satisfying the 'clean and green pakistan vision'. however, endorsing the covid-19 outbreak as an opportunity, it is the need of the time to safeguard the local environment and make it carbon emission-free by transiting the energy consumption on modern and innovative tools (department of economic and social affairs 2020). thus, addressing the objective of study for sustainable energy development and environmental protection is important for the pakistani community as the population is increasing in the figure of 212.2 million (source: bauru of statistic (2018), pakistan). extending to it, the effect of the pandemic with carbon emission and energy has become much important as the pandemic effect raised the extent it lowers the carbon emission and energy consumption (wren-lewis 2020; wang et al. 2020b) . from a practical perspective, the recent study would help the policymakers to understand that how they may stimulate the covid-19 impact on energy consumption and carbon emission, which they can facilitate and collaborate to develop a new way forward to remediate the pandemic impact on energy consumption. we found limited literature suggesting pandemic effect, more specifically, covid-19 outbreak on energy consumption and co 2 emission combined, and literature lacks in suggesting the concrete solution to manage the energy consumption shortfall caused by covid-19 outbreak. we discussed the theory of economic efficiency to address and to explain the cause and effect of a recent study framework. the findings of solangi et al. (2020) supported that extended lockdown lowers co 2 emission that causes a reduction in energy consumption. therefore, the extension in lockdown or self-isolation has a direct and adverse effect on energy consumption and co 2 emission. thus, considering the cited arguments, we hypothesized that there is an adverse effect of covd-19 outbreak on co 2 emission and energy consumption (öncü 2020; parth 2020) . in doing a recent inquiry, we used daily data of covid-19 outbreak, co 2 emission and energy consumption, taken from different national and international databases. the covid-19 outbreak is measured by the number of days of lockdown, and the data is acquired from covid. gov.pk and worldometers.info. the data on co 2 emission is from the statistical review of world energy, and the energy consumption data is obtained from the daily summary statistics of economic surveys of pakistan and bauru of statistics (noy et al. 2020) . we collected the data with effect from the first day of pandemic lockdown in pakistan dated 13 march 2020 until 30 april 2020 (around 48 days) ( table 1) . co 2 emission measurement co 2 scaling method is used to measure co 2 emission. arango-miranda et al. (2018) presented a significant and linear relationship between per capita gross domestic product (gdp) and per capita emission of co 2 in developing economies. this relationship remained significant with the condition that the population of the respective country should remain stagnant and less mobile (wang et al. 2016; p. 3) . notably, study authorized this assumption and assumed that study population remained static, under the structurally imposed lockdown of covid-19 pandemic, and during this period, a little physical movement of population is observed. therefore during the covid-19 outbreak, the co 2 emission factors of pakistan showed a decline. in other words, the stationary level of co 2 emission factors designed a decreasing trend in co 2 emission line on a larger extent. considering these assumptions and real conditions of covid-19 outbreak, our study further endorsed the scaling method of in measuring co 2 emission. for this, industrial classification and actual state of oil and gas sector, transport sector, electricity sector, and cement sector of pakistani context were used. hence, co 2 emission is measured using the gdp of industry (gdp) i and carbon emission factors (ef) i , assuming (ef) i will remain stationary. if (ef) i remains the same, the decline in co 2 emission is indicated with δco 2 emission (see eq. 2). using these measures, on the basis of emission features, we parted study sectors into two groups (e.g. transport sector and non-transport sector). measurement the non-transport sector gdp of the country is taken, and for non-transport, traveling distance and decline in transport services is also obtained from different databases (national highway authority database and ministry of statistics database). however, the δco 2 emission of the transport sector is measured by using eq. 3, the emission of transport sector was combined with oil and gas, electricity and cement sectors for empirical analysis co 2 emission in the recent study. the energy consumption is measured by taking the net energy consumption (ec) in all the provinces of pakistan. the estimate of energy consumption is further classified into different proxies, such as energy consumptions (ec) are substituted with electricity consumptions (ec1) and fossil energy consumptions (ec2). according to the pakistan economic survey (2019-2020), the installed electricity generation capacity reached 37,402 mw in 2020. the maximum total demand coming from residential and industrial estates stands at nearly 25,000 mw, whereas the transmission and distribution capacity is stalled at approximately 22,000 mw. moreover, thermal power generation is more than 65% of total electricity consumption in pakistan. however, various secondary energy sources are suggested to adapt as primary energy sources. therefore, total electricity consumption and total fossil energy consumption (ec2) are good proxies suggested to use in measuring total energy consumption. considering the theoretical foundation to infer the estimation, unit root test including llc test presented by levin et al. (2002) , ffp and fadf test presented by choi (2001) and ips test given by pesaran (2007) are used. the adf, pp and ips unit root tests have individual unit root processes. these three unit root tests have the null hypothesis of unit root, where the alternative hypothesis does not contain a unit root. in this research, to explore the long-run and short-run association between estimated variables, we applied the panel ardl method due to the mixed nature of the stationarity of the variables. the panel ardl method has various advantages: traditional methods of cointegration only assess the long-term correlation in the equations, and the panel ardl technique is more compact (pesaran and shin 1998) . according to eq. 1, our studied variables are stationary at i(0), i(1) or the level at first difference (sulaiman and abdul-rahim 2018). our baseline model can be written as the algorithm form of eq. 2 is developed and shown in eq. 3, where, i = 1, …, n as indicator sign, t is time period and ɛ is error term. ec indicates energy consumption and co 2 is co 2 emission. the study also used panel quintile regression (pqr) to infer the robustness of the results (lamarche 2010) . importantly, pqr reduces the probability of outlier's occurrence, when ɛ is not normal. however, pqr is most effective relevant test to infer robustness than the ordinary least square (ols) method. subsequent to study operationalization, pqr is relevant to test the impact of covid-19 outbreak on co 2 emission and energy consumption, where the dynamics of study are more contextual. the empirical findings of growth regression are presented in table 2 . we regress the covid-19 lockdown on national energy consumption and co 2 emission shown in the first column. the resulting output of growth regression indicated that the covid-19 lockdown is adversely affecting co 2 emission and energy consumption. likewise, this effect is significant in both series. the findings of study imply that 1% variation or extension in lockdown leads to − 0.2971 × (0.000)% variation in co 2 emission and − 0.1762 × (0.000)% variation in energy consumption gauged from fixed effect modelling. this point estimation shows the similar variation in co 2 emission as − 0.3796 (0.002) and energy consumption as − 0.1494 (0.000) acquired from 2-stage least square test. we identified a highly dependent island in the occurrence group during the complete sampling tenure, and the direction is generally sharped to the leftward. an upward arrow to the right can observe other coherence which shows the cyclic relationship between covid-19 and oil. the oil price shows a rapid reduction during the covid-19 outbreak (fig. 1) . these results indicate that due to travel constraints and lower predictable production progression in european countries and china, the covid-19 pandemic seems to have had a serious impact on oil price volatility through the demand side. figure 2 shows the world crude oil future. the results show that covid-19 has affected local oil prices that are clarified by imposing travel restrictions. the robustness test estimates the wavelet-based causality in the 6 occurrence groups, explaining that the time-frequency changes the temporal series of the covid-19-oil relationship since 3 months. table 3 shows descriptive statistics. the study used plas method to test the gdp-to-co 2 emission reduction by taking the provincial statistics of pakistani context. the co 2 emission were found to be decreasing in sindh, punjab, baluchistan and khyber pashtun khawah (kpk). the obtained values of gdp are tabulated in table 3 with the significant difference. notably, this difference and decline in co 2 emission is noteworthy. moreover, due to lack of detailed variation rate for plas sector data, during the covid-19 outbreak, the punjab province shown a higher variance (see table 2 ). while sindh scored second position in co 2 emission reduction with 6.5 emissions score, kpk reduced on third position with 3.0 and baluchistan remained in last with a 2.8 score. yasmeen et al. (2019) revealed that oil and gas is the largest sector of pakistani economy contributing to co 2 emission transmission. our study findings are coherent with this narrative, and due to the covid-19 outbreak, a downward structural shift is inferred in this sector. secondly, the transport sector showed a significant decline in co 2 emission. during this period of the covid-19 lockdown, from 13 march 2020 to 30 april 2020, public transport, airways, urban transport, motorways, various production industries, oil and gas consumers were shut down. people were officially and publically notified to stay at home and maintain social distancing and standard procedures to mitigate threat of covid-19 pandemic. all these precautionary measures reduced public gathering, closed business activities, economic activities and movement of public. in result, a massive structural decline is observed in transport and oil and gas sector that supported structural and procedural cleaning of the environment. the findings show that panel unit root outcomes of study constructs were stationary at the l(1). this stationary level suggested applying ardl technique to infer a connection between covid-19 outbreak, energy consumption and co 2 table 3 ). pesaran and shin (1998) introduced ardl approach and is advanced by pesaran et al. (2001) . the ardl technique has several advantages over a cointegration test (johansen and juselius 1990; engle and granger 1987) . first, this approach does not impose the condition that the variables have the same order of integration. however, it takes into account variables that are order 1 or order 0 integrated. next, it is adapted to small samples. in fact, johansen's cointegration method requires a large number of observations for the estimation to be reliable. finally, in the ardl model, the dependent variable is explained by its past and by the past of the other independent variables. table 4 indicates that co 2 emission is negatively affected as − 8.55* by the covid-19 outbreak with the p value as 0.000 (< 0.05). similarly, the total energy consumption (tec) is also negatively significant as − 3.13* with the 0.000 p value as < 0.05; the total electricity consumption (ec1) is negatively affected by the covid-19 outbreaks as − 1.27* with the 0.000 p value as 0.05; and the total fossil fuel consumption (ec2) is also negatively impacted by the structural imposed crises of covid-19 pandemic as − 2.12* (0.000), and the p value of ec2 is also less than 0.05 level of significance. in addition − 0.2105* with (0.000) level of significance is acquired at full level. by this, the hypothesis of study is accepted that the covid-19 outbreak has negatively affected energy consumption and co 2 emission in the context of pakistan. likewise, ardl results show that r 2 of the study model is 0.59. thus, considering the energy consumption and carbon emission, our findings are aligned with lin and raza (2019), revealing the analysis of co 2 emission and energy consumption. one of the potential reasons of the decline in carbon emission during the covid-19 lockdown is the decrease in oil consumption and transportation mobility. energy and carbon intensity are the key antecedents causing reduction in energy consumption and carbon emission. according to official statistics of ogra, an 11% reduction rate in energy consumption is observed during the month of march (2020). and evidently, the pakistani energy sector is more inclined towards thermal energy consumption generated from petroleum products and fuel substitution. secondly, according to historic statistics of energy associations, around 85% of pakistani energy mix is dependent on fuel, and as mentioned earlier, this percentage faced a decline of 11% and redressed a new 74% of new energy mix. therefore, the covid-19 lockdown has resulted in a massive reduction in energy consumption in the study context. interestingly, this adverse effect leading to reduction in carbon emission is an opportunity of modern times to control this emission by maximizing the rapid growth through ideal energy sources. historical studies widely used ordinary least square (ols) technique to gauge robustness in the findings of these investigations, but this technique has some limitations that ols fails to portray a comprehensive look of empirical distributions of dependent variable. in a heterogeneous context like pakistan, the impact of the covid-19 outbreak on energy consumption and co 2 emission are likely to be robust at different quantiles. for this, panel quantile regression (pqr) technique is suggested. this technique allows the coefficients to vary with multiple quantiles and has distinctive advantages of detecting the variation in the impact of covid-19 outbreak on energy consumption and co 2 emission. moreover, the quantile regression approach is also useful for addressing problems that may severely affect the accuracy of estimation, including heteroscedasticity, outliers, and unobserved heterogeneity. therefore, this paper adopts the quantile regression to infer the robustness of the study results more comprehensively. the findings of pqr technique confirmed the results of ardl model and showed robustness, as the impact of covid-19 outbreak on energy consumption and co 2 emission is negatively significant in all the quantiles, where, τ = 10th, τ = 25th, τ = 50th, τ = 75th and τ = 90th at 5% of level of significance (e.g. p value < 0.05) ( table 5 ). in the recent topicality, the role of the covid-19 outbreak is evident and a big challenge for energy sustainability in upcoming time. therefore, a policy plan is much needed to enhance energy sustainability in pakistan and is suggested in the next section of this study. subsequent to the findings of the study, the covid-19 outbreak has several structural influences on the energy market of pakistan and environmental pollution, and importantly, these two aspects need more visionary attention to fix and to gain economic advantage on a national basis. for this, energy consumption indicators, energy efficiency and environmental pollution indicators should be carefully watched and managed. however, we suggest developing and implementing an economic action plan by considering energy consumption indicators and environmental pollution elements to give a boost to national economy of pakistan. incentivizing the energy consumption patterns could also generate a shift in consumption behaviour of the general public and corporate owners. in addition, most of the arrows turn left and left, which means that there is a counter-cyclical effect between covid-19 and the us stock index with covid-19 as the main index (fig. 3) . uncertainty is mainly related to the long-term development of the pakistan economy and how the fed will deal with the significant increase in uncertainty and the bad news of covid-19. this is an adverse effect on the potential output and unemployment rate in the usa, which are completely independent of monetary policy. the coronavirus (covid-19) epidemic spread from wuhan (hubei region to china), where the first case of infection is reported on 31 december 2019. forty-nine days after this, on 21 january, the world health organization (who) released the first corona virus monitoring report. by 2020, more than 100,000 people in more than 100 countries around the world will be affected. although covid-19 does not present similar patterns in terms of mortality severe acute respiratory syndrome (sars) or in terms of global spread in 2002-2003. compared with the 1919 spanish flu pandemic, the new coronavirus is highly contagious and creates a lot of uncertainty in the real economy and financial markets. creating short-term fluctuations in food prices affects aggregate demand and imminent the movement of workers and tourists. in addition, covid-19 creates fear and extra stress. financial markets, where price fluctuations are constantly increasing. hope to be strong. because of declining global demand in the coming period, saudi arabia started an oil price war from 9 march 2020, and flooding the market with oil. in a single day, the price of crude oil falls more than 20% of the shock spreads to falling financial markets in a single day. covid-19 seems to be the main geopolitical shock in the world. in the past few years, energy crises in pakistan are managed by the fossil fuels that raised the co 2 emission at large, and because of the effect of the pandemic, energy association and regulatory authorities of pakistan have given less effort in managing energy sustainability. our study is one of the first studies to gain the attention of regulatory authorities in a local context and to present the a way forward to enhance the energy sustainability by reducing carbon emission and energy consumption. for instance, considering the bright side of covid-19 outbreak the energy consumption can be managed through innovative and advanced tools by replacing the fuelbased energy resources on renewable energy sources and/or green energy sources (gautret et al. 2020) . a significant reduction in carbon emission is one of the hard-core benefits of such renewable or green energy sources. covid-19 outbreak highlighted a structural impact on energy consumption and carbon emission, and this was the motivation of recent research to inspect the role. our findings are consistent with pegels (2010) and gugler et al. (2013) . we found a negatively inverse significant role of covid-19 outbreak on energy consumption and carbon emission. the findings are revealed by the co-efficient alpha of growth regression accepted by the study hypothesis. in short, a significant decline in energy consumption and carbon emission is observed due to pandemic effect. by the fact, the covid-19 outbreak extended the lockdown, and entire world is shifted in self-isolation. this impact lowered the burden of energy consumption; very less vehicles are mobilized around the globe that resulted in a massive decline in energy consumption and carbon emission. on this, it is difficult to persuade each and every stakeholder associated with energy sector, and realistically, this is the internal energy consumption position (kost, 2020). on energy production and consumption, pakistan is mainly depending on traditional sources of energy generation, from which, oil material and fossil fuels are most prominent (van de ven and fouquet 2017; , trotta 2018; iea 2017) . as previous literature suggested, this source of energy will be vanished from the world in upcoming sources (zameer and wang 2018) . thus, it is important to consider and plan about alternative energy generation sources to stabilize energy consumption and reduce environmental pollution (mirza and kanwal 2017) . it is important to consider the covid-19 outbreak as an opportunity to redesign the energy sector of pakistan as the energy demand is declined in most of the commercial sector. by underscoring the findings, we concur the results as model and country specific, and we warrant the caution that the comparability of findings with other context may result in heterogeneity in terms of energy consumption and the covid-19 outbreak. by endorsing the countryspecific findings, our study is providing certain policy measures. practically, responding to the covid-19 outbreak, oil prices and dampened oil demands should be managed especially in the wake of opec price game, and this affected energy consumption. these concerns are driving our research. this study is the first attempt to analyze the relationship between covid-19 outbreak, energy consumption and co 2 caused by lead-lag interaction. here, due to differences in risk conditions, different expectations and different understandings of risks, investors from all over the world may respond differently to investment decisions during the investment period. for example, market traders are aware of the 'bad' news inherent in the world's rising cases of covid-19 infection, deaths, government alienation guidelines and the impact of oil price changes. fear of contagion and lack of vaccine availability worsen the private spending with a combined effect of declining income. service, tourism and entertainment sectors are being affected, which are more particularly associated with public events and catering services. income and job insecurity will be raised because of reduced working hours especially to those who have no access to social safety net. the panic and uncertainty of the pandemic will cause delay in private investment, but the demand of government will go up in order to meet emergency health assistance initiative. despite all the pandemic crisis of covid-19, the negative net demand effect is assumed to be short lived. on the supply side, the manufacturing activity will be halted in most affected regions. reduced production will cause bottleneck in worldwide supply chain. unplanned accumulation of inventory would be depressing down production capacity resulting in sinking gdp. the covid-19 has already exhausted inventory stock by fluctuating the globalized production structure. such production variability will in turn generate extensive factory lockdowns for shortage of intermediary inputs. we contributed in literature by presenting a novel study on the covid-19 effect on carbon emission and energy consumption in modern time when the world is finding the solution for each and every sector and each and every aspect to make it sustainable. our study inferred the adverse effect of the covid-19 outbreak on energy consumption and co 2 emission. we inquired and contributed by presenting the practical solution to stabilize energy consumptions and co 2 emission in pakistan. we highlighted the negligence of energy authorities of pakistan and also contributed by directing the implications to sustain energy demand, energy prices by changing energy consumption and co 2 emission behaviours in time. hence, to the best of our knowledge, this would be the one of the pioneer studies on covid-19 outbreak and energy consumption. the economic and social costs of the covid-19 pandemic are related to society, policy makers, and all financial market participants and individual investors. our findings provide novel and outstanding policy and practical significance. it is becoming more and more obvious as the covid-19 outbreak is causing an interruption to oil demand and energy consumption, while there is an abnormal increase in uncertainty of an economic policy. & policy 1: we suggest to manage the energy consumption more carefully because due to the covid-19 outbreak, the energy sector expects to face few massive shocks like health emergency leading to continuous lockdown, coping with low oil prices simultaneously and a decline in energy revenues due to lower oil revenues. to sustain energy sustainability by managing energy consumption, we suggest energy regulatory authorities to come up with contingent plans that may enhance operational effectiveness during and after covid-19 to reach the threshold level of energy consumption. in due course, when the threshold limit is achieved, then the upcoming energy demands should be replaced by the renewable energy sources. therefore, for the energy sector, we argue that the covid-19 is an opportunity to revive, redevelop and reconfigure energy consumption patterns. & policy 2: during covid-19, we also observed few bitter realities in the energy sector of pakistan backing the study findings. first, poor attention in managing energy demand, oil prices and revenue shortfall has placed a big and clear question mark on the immediate future of energy sector. secondly, less visionary and less proactive leadership in energy regulatory authorities of pakistan is another big challenge to fix. thirdly, none of energy sustainability action plan is given by these regulatory authorities with respect to the covid-19 outbreak. this would not be false to say that such regulatory authorities as sleeping rabbits, and if they have not managed in time, there is a probability of energy chaos to knock at the door steps, just because the energy sector of pakistan is more fragile in comparison with developed countries. & policy 3: we suggest to ogra to develop a system to manage oil demand and oil prices mechanism as per local demographics instead of international spillover effects, to play a visionary and proactive role to enhance the energy sustainability in pakistan, to continuously plan implement and re-plan on energy consumption and carbon emission to achieve the threshold limit, to replace traditional sources by the renewable sources, and to disclose a national action plan for energy sector and then implement this plan phasewise. & policy 4: the government must acknowledge the electrical distribution organizations, such as wapda and paec, to provide all the support services at par so that energy consumption may be actively managed by considering the pre-and post-effect of the covid-19 outbreak. & policy 5: all the household and families should be provided with an energy consumption guide by the provincial and local governments. similarly, standard operating procedures for energy consumption must be given to the business sector. for greater awareness, a campaign on electronic, print and social media should be launched by the government of pakistan with the intent to stabilize energy consumption and co 2 emission on a sustainable basis. we extend to guide that the government of pakistan should publically provide an 'energy consumption and co 2 emission plan'. by this, the national government should sustain energy and the environment in recent time and the potential consequence of such outbreak(s) in future. just because, this is the high time to change the behaviour of energy consumers and co 2 emitters in all over the pakistan. we further suggest to the pakistan bureau of statistics to keep the updated data files on energy consumption and carbon emission during the period of the covid-19 outbreak. this would help a lot to us researchers and will save our time in doing quality research. two of the major limitations in conducting the recent inquiry: one is the lack of literary evidences on covid-19 association with energy consumption and carbon emission, and secondly, scattered form of empirical data in national databases consumed much time to gather the facts and figures. author contributions conceptualization, methodology, writing of the original draft: sajid iqbal; review, supervision: ahmad raza bilal; data curation, visualization: wasim iqbal; visualization, editing: mohammad nurunnabi; writing and software: yazeed alfakhri; writing, visualization and editing: nadeem iqbal. data availability the data that support the findings of this study are openly available on request. competing interests the authors declare that they have no competing interests. ethical approval and consent to participate we declare that we have no human participants, human data or human issues. carbon dioxide emissions, energy consumption and economic growth: a comparative empirical study of selected developed and developing countries novel approach of principal component analysis method to assess the national energy performance via covid-19 pandemic, a war to be won: understanding its economic implications for africa trilemma assessment of energy intensity, 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environ.+res.+public+health&title=international+journal+of+ environmental+research+and+public+health&volume= 17&issue=7&spage=&epage=&aulast=liu&aufirst=wei&auinit= w.&aufull=liu+w.&coden=&isbn=&pages=-&date= 2020&auinit1=w& covid-19 in latin america: political challenges, trials for health systems and economic uncertainty energy consumption, carbon emissions and economic growth in pakistan: dynamic causality analysis the socio-economic implications of the coronavirus pandemic (covid-19): a review measuring the economic risk of covid-19 triggering a global financial crisis: covid-19 as the last straw the economic cost of covid-19: a potential pandemic impact on indian economy renewable energy in south africa: potentials, barriers and options for support a simple panel unit root test in the presence of crosssection dependence an autoregressive distributed-lag modelling approach to cointegration analysis bounds testing approaches to the analysis of level relationships review on natural 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emissions in china publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations consent for publication we do not have any individual person's data in any form. key: cord-308556-xi2un0kc authors: saadat, s.; mansoor, s.; fahim, a. title: covid-19 seidrd modelling for pakistan with implementation of seasonality, healthcare capacity and behavioral risk reduction date: 2020-09-02 journal: nan doi: 10.1101/2020.09.01.20182642 sha: doc_id: 308556 cord_uid: xi2un0kc introduction: december 2019 saw the origins of a new pandemic which would soon spread to the farthest places of the planet. several efforts of modelling of the geo-temporal transmissibility of the virus have been undertaken, but none describes the incorporation of effect of seasonality, contact density, primary care and icu bed capacity and behavioural risk reduction measures such as lockdowns into the simulation modeling for pakistan. we use above variables to create a close to real data curve function for the active cases of covid-19 in pakistan. objective: the objective of this study was to create a new computational epidemiological model for pakistan by implementing symptomatology, healthcare capacity and behavioural risk reduction mathematically to predict of covid-19 case trends and effects of changes in community characteristics and policy measures. methods: we used a modified version of seir model called seidrd (susceptible exposed latent diagnosed as mild or severe recovered deaths). this was developed using vensim ple software version 8.0. this model also incorporated the seasonal and capacity variables for pakistan and was adjusted for behavioural risk reduction measures such as lockdowns. results: the seidrd model was able to closely replicate the active covid-19 cases curve function for pakistan until now. it was able to show that given current trends, though the number of active cases are dropping, if the smart lockdown measures were to end, the cases are expected to show a rise from 28th august 2020 onwards reaching a second peak around 28th september 2020. it was also seen that increasing the icu bed capacity in pakistan from 4000 to 40000 will not make a significant difference in active case number. another simulation for a vaccination schedule of 100000 vaccines per day was created which showed a decrease in covid cases in a slow manner over a period of months rather than days. conclusion: this study attempts to successfully model the active covid-19 cases curve function of pakistan and mathematically models the effect of seasonality, contact density, icu bed availability and lockdown measures. we were able to show the effectiveness of smart lockdowns and were also to predict that in case of no smart lockdowns, pakistan can see a rise in active case number starting from 28th of august 2020. december 2019 saw the origins of a new pandemic which would soon spread to the farthest places of the planet. several efforts of modelling of the geo-temporal transmissibility of the virus have been undertaken, but none describes the incorporation of effect of seasonality, contact density, primary care and icu bed capacity and behavioral risk reduction measures such as lockdowns into the simulation modeling for pakistan. the aim of this study was to create a new computational epidemiological model for pakistan by implementing symptomatology, healthcare capacity and behavioral risk reduction mathematically to predict of covid-19 case trends and effects of changes in community characteristics and policy measures. to achieve this we propose a novel sir-type metapopulation transmission model and a set of analytically derived model parameters. the objective of this study was to create a new computational epidemiological model by implementing symptomatology, healthcare capacity and behavioral risk reduction mathematically to predict of covid-19 case trends and effects of changes in community characteristics and policy measures. real world covid-19 data utilized for this study can be found on the following repository maintained by the center for systems science and engineering (csse) at johns hopkins university and "our world in data" website page "coronavirus pandemic (covid-19)" https://github.com/cssegisanddata/covid-19 https://ourworldindata.org/coronavirus we used a modified seir model with slight modifications in the compartmentalization and parameterization of an existing example (1) . we call this model seidrd for the presence of susceptible, exposed-latent, infectious, detected-symptomatics (mild or severe), recovery and deaths compartments ( table 2) . following is detailed look into these compartments: figure 1 . basic compartmental modeling setup with seidrd compartments arranged as above. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september 2, 2020. . this represents the population set which is susceptible to covid-19. any exposure to presymptomatic infectious (pi), mild symptomatic (ms) or severe symptomatic (ss) populations can lead to a conversion of susceptible persons to an exposed-latent (e) patient with a probability of beta (β) ( table 1 ). the transition equation for this population's conversion into exposed-latent population is given as: ∂s/∂t = (fs.br.rcd).(pi(β) + ms(β)(1−ief) + ss(rβ)(1−ief)) in this equation, fs represents fraction susceptible, br is behavioral risk factor while rcd represents relative contact density ( table 1) . each of these parameters are additional controlling levers which can either increase or decrease the rate of conversion into exposed-latent population. a decrease in fs reflects less susceptibility to infection, low br reflects better hygienic and social isolation behaviour while a low rcd reflects sparse population density when number of susceptibles decreases, thus naturally low contact between the remaining susceptibles as they are far apart. decrease in any or all of these parameters can slow down the rate of conversion into the next compartment. the second part of the equation represents the ability of pi, ms and ss to infect a susceptible person with the probabilities of β, (β)(1−ief) and (rβ)(1−ief) ( table 1) respectively. β reflects the probability of getting infected from a pi population, rβ represents the relative change in probability of getting infected if the infection is coming from a severe case to a susceptible, while (1−ief) is a measure of isolation effectiveness (table 1) . isolation effectiveness (ief) is a measure of effectiveness of isolating total symptomatic patients. it is one if every symptomatic patient is completely isolated and cannot infect any other susceptible person. it does not cover the pi population as they are usually not identified unless symptomatic thus does not have a huge impact. this population represents the patients who have acquired the disease but are neither showing any symptoms nor able to transmit the disease. this population converts into presymptomatic infectious population. the transition equation is given as: here, niϵ represents non-infective-epsilon which represents the probability of transmission from exposed latent to presymptomatic infectious state. these are the patient population who have acquired the disease and are infectious to others but have not developed any symptoms yet. thus, they usually remain under the healthcare radar and are usually the most common source of disease spread. they transition into either mild symptomatic cases of severe symptomatic ones. the transition equations is as follows: here ∂pi(mc_t)/∂t represents the rate of change of pi into mild symptomatic cases while ∂pi(sc_t)/∂t represents the transition into severe symptomatic cases. the probability of conversion from pi into the next compartment is represented by iϵ (infective-epsilon) while out of this converted population, the probability all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september 2, 2020. . of converting into severe symptomatic population is given by ps. the probability of detection / diagnosis is given by pdxm and pdxs for mild and severe cases respectively (table 1) . this compartment represents the patients who have now developed mild symptoms and are most likely to either recover or a minority could still die. being mildly symptomatic, they can also infect the susceptible population with a rate of (β)(1−ief) if isolation effectiveness is not one as described above. the transition equations for this compartment are as follows: here ∂ms(mr)/∂t represents the rate of change of ms cases into recovered population with a total probability of μ x 1-pdm while ∂ms(md)/∂t represents the conversion of ms cases into the cases who die with a total probability of μ x pdm (table 1 ). mu (μ) represents the probability of transitioning from any symptomatic case into any next compartment. this represents the severe cases compartment which are converted from pi compartment. this compartment then transitions into either recovered cases or deaths as given by following equations respectively: here, ∂ss(sr)/∂t represents the rate of conversion of ss population into recovered ones with a probability of (1-pds) while ∂ss(sd)/∂t represents the rate of conversion of ss population into deaths with a probability of pds (table 1). the probability of deaths in severe cases (pds) is in turn calculated as combined mortality rate (cmr) ( table 1 ). this cmr variable is in effect determined by minimal rate of mortality (as in mild cases) plus any additional mortality risk imparted by the lack of hospital capacity. thus, if hospital strain (severe cases / available hospital capacity) is high, there is additional mortality risk imparted and thus the mortality in severe cases will be at-least the same as in treated mortality plus an additional risk. its maximum value can get as high as the untreated mortality (table 1) . this compartment represents all those who have recovered after being mildly or severely symptomatic. this represents total deaths observed as converted from either mild or severely symptomatic compartments. behavioral 60, 162 time in days when first and the first detected cases were found on all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september 2, 2020. . second (smart lockdown) episode of behavioral risk reduction measures are started 26/2/2020 but the disease must have reached pakistan before it. the time to first lockdown was 30 days after the first case was reported. we take the total time (real start time + time from 1st detection) to be 60 days as it produces the most representative curve of active cases. similarly, the second set starts with initiation of smart lockdowns at day 162. note: above we imply that during the lockdown phase, apply the maximum behavioral reduction but apply a negative value of it when lockdown lifts. for the second set of lockdowns (smart lockdowns) we imply a half of its negative value thus second time around, people go to their socialization half as much probably because of learned behaviors. reflects the effect of social smooth3(1-step(behavioral risk all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september 2, 2020. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september 2, 2020. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september 2, 2020. note: time mentioned above in days is based on the simulation time and begins when the simulation starts. change in susceptible population which are transitioning into exposed population over the given time period t exposed-latent (e) e_t -i_t patients exposed to covid-19 but have neither yet developed the symptoms nor can they spread the disease. infecting (i_t) ∂e/∂t = e.niϵ change in exposed populations which are transitioning into the presymptomatic infectious population. after experimenting with the values, we assumed that during lockdown phases, people have a reduction in spread of active cases by a factor of behavioral risk reduction (brr) value but non lockdown periods, people often go back to socialization and spread of disease activity is increased by the brr value. time to react we assume that it takes around 3 days for people to properly respond to any risk reduction measures like lockdowns hospital capacity we assume that beds needed for severe cases equates to itu beds available. everyone who gets infected is removed from the population either through recovery or death. the population is large, fixed in size and it is confined geographically. recovered individuals cannot be reinfected, although the only evidence so far is for rhesus macaques (ota, 2020) and who is still investigating the issue. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september 2, 2020. note: the root mean squared error for above table equals 4157. this is high for the early phase of the disease but relatively small when total cases get to a hundred thousand mark. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september 2, 2020. . https://doi.org/10.1101/2020.09.01.20182642 doi: medrxiv preprint above in table 1 , we present the parameters chosen for the model. these have been derived after literature review and represent either the best estimates mentioned in the literature, or most plausible values by the authors based on the epidemiological knowledge on sars-cov-2 and other viruses. we split the total time between a person gets infected and develops symptoms into non infective latent period (ni) and infective (i) latent periods. we then calculate the parameters niϵ and iϵ, using the estimates of average latency period (lp) (2) and non infective latency period (lpni) (wallinga & teunis, 2004) as given by the formulae in table 1 . we chose to use korean proportion of "severe" to diagnose cases as a base for the probability of developing the severe condition (ps), and we set it to 0.01. among other important parameters were β, rβ and μ which represent the effective contact rate, reduction in contact rate in severe cases and rate of transitioning from symptomatic cases. β can be calculated from previous parameters as: there are widely varying estimates for r0 in literature with values ranging from 1.4 to 6.49 (10) (11) (12) (13) (14) we decided to choose the r0 of 4.4 reflecting a relatively higher rate of spread which is well within the range of 2-5, modelled 223 for sars (3) . we derive μ from a safe quarantine period for diagnosed cases equal to 10 days (15). we assumed 1/μ to last on average for 7 days from symptoms development to recovery. the sum of1/ μ and previously estimated lpi (presymptomatic infectious period) results in 11.5 days which represents the total duration from becoming infectious till recovery after a person acquires the disease. using μ and (1/lpi), we can now calculate β which comes equal to 0.383. we also selected rβ to be 0.5 following the assumption for this parameter used in the 2009 influenza outbreak (16) . this is because patients who have severe disease are mostly admitted, thus isolated and have reduced rates of transmission. the probability of death or mortality rate varies widely from values around 0.01 to 0.1 based on age and other parameters (17) , (18) , (19) . for rate of mortality in mild cases (pdm), we chose a value on the lower spectrum of 0.01, based on the results obtained from early wuhan studies (20) . for severe cases admitted in itus, the mortality rate spectrum ranges from 0.11 to 0.42 depending on the age group with an average of 0.35 (21) . in one study, the mortality rate in icu patients was reported as high as 0.67 (6) . in order to calculate the combined rate of mortality in severe cases (cmr) ( table 1) , we used two types of mortality estimates: 1. untreated mortality rate, which was chosen to be 0.67 being on the higher end of the spectrum, 2. treated mortality rate, which was set at 0.35, assuming it to be on the lower end of the spectrum but still representing an average value. in order to analyse the model for pakistani population we choose the parameters based on the most recent available literature as given in table 1 with references. we choose the total population to be 207,774,520. based on a report from the world bank, the total bed capacity for pakistan was calculated to be 0.6 per thousand (5) . we chose this value to represent the total public health capacity as in the ideal case scenario, all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september 2, 2020. . any symptomatic case will be admitted and isolated for the disease duration. for the purpose of hospital capacity variable, we selected the total number of ventilators (4000) as a surrogate for the total icu beds in pakistan (8) . we use vensim ple software version 8.0 (http://www.vensim.com) for the model development and numerical integration. vensim, the ventana simulation environment, is an integrated framework for conceptualizing, building, simulating, analyzing, optimizing and deploying models of complex dynamic systems (22) for our purpose, we use first order euler integration technique to solve the equations numerically which is built into the software (23). the simulation period was selected to be 12 months. in order to simulate the covid-19 curve of pakistan, some of the assumptions in table 3 were made. we then used the constants and variables as defined in table 1 and 2 to come up with the most similar curve of total symptomatic (reported) cases in pakistan. we divide the derivation into following experimental stages: experiment 1 creates a base model with seasonal variation incorporated and shows the expected curve if none of the lockdown measures or risk reduction methods were implemented. in experiment 2, we implement the first set of lockdown measures and see their effect without the subsequent smart lockdowns. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september 2, 2020. . in the third experiment, we fully implement the smart lock downs as well and observe the similarity between actual case number and our predicted ones. in the fourth experiment, we test two assumptions; 1. what if the smart lockdown measures end? 2. what if some form of smart lockdown measures persist. finally, in the fifth experiment, assuming that covid-19 returns, we observe the effect of varying hospital, public health capacity and possible vaccination and its impact. before reviewing the following experiments, it's important to note that the simulation time starts 36 days before the first 2 cases were officially reported in pakistan (table 4 ), thus any of the day references mentioned below are from the simulation timescale. in this experiment, we run the simple base model consisting of seidrd compartments as explained in the methodology section. this run was under the assumption that none of the lockdown measures have been imposed and the cases are spreading at a natural rate. this model also incorporates the seasonality adjustment ( table 2) . as per this model, the cases start rising around day 70 to 75 simulation time. the cases peak at around day 125 with a maximum of around 200000 cases being reported each day. the numbers then start to decline but very slowly. as this model assumes no behavioral risk reduction measures, this would have been the worse case scenario were it not for the timely lock downs. the second experiment assumes the implementation of the 1st set of lockdown measures. it mimics the timings on which the first lockdown was started around day 60 and stopped after 52 days simulation time. this model represents the scenario when only a single down is put in place only to lift it later as happened in pakistan from march 24 to may 9, 2020 (table 4) . this model mimics the initial rise of cases in pakistan closely peaking at around 100000 cases on day 150 and then plateauing subsequently for some time. this model shows a better case then the base model but it predicts a subsequent rise from day 175 if no further lockdown measures are put in place. figure 6 . shows the experiment 2 curve for total symptomatic cases against the simulation time period. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september 2, 2020. . this model represents the implementation of the second set of lockdown measures also known as the "smart lockdowns". since in our model, we assume the population to exist in a single geographic area homogeneously, the concept of smart lockdowns is implemented as the one before. it is evident that the cases follow a similar curve until day 175 but then after a brief plateau, they start to decrease as happened in pakistan (table 4 ). since this model assumes the second set of lockdown measures to start around day 162 and persist up to 38 days, the cases start to rise again around day 220 after reaching the lowest case report number of 2829 per day. as per this model, if the smart lockdowns are completely lifted, the cases will rise again and eventually reach a maximum of 200000 cases per day around day 250 simulation time ( september 27, 2020). here we also present the other compartmental graphs as below: (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september 2, 2020. . https://doi.org/10.1101/2020.09.01.20182642 doi: medrxiv preprint experiment 4 (sustained smart lockdowns): continuing from above, if the smart lockdown measures are kept in place with maximum effect, the total number of active cases are shown to drop to less than 1 by day 273 (october 20th, 2020). this model assumes that the lockdown measures don't lose their efficacy and are kept in place indefinitely which can be difficult in a real world scenario. any compromise in efficacy of sustained lockdown measures will result in a curve which is intermediate between experiment 3 and 4. figure 10 . shows the experiment 4 curve for total symptomatic cases against the simulation time period. finally, we take the model from experiment 3, assuming that a sustainable option of smart lockdowns is impossible and implement some of the possible solutions into the future. 1. we observe the change in mortality per day by increasing the total number of available itu beds from an available 4000 (table 1) to 40000. as in the graph below, the observed change is not much even though there is a definite decrease in mortality because of better respiratory support. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september 2, 2020. . figure 11 . shows the experiment 5 curve for deaths per day against the simulation time period comparing scenarios with 4000 vs 40000 icu bed availability in pakistan. it shows no significant difference between both scenarios. 2. as part of a second predictive analysis, we increase the number of available public health beds (includes all available hospital beds and social care services). we increase it from an available number of 124700 to 1 million ( table 1) . as shown in the graph below no significant change in total symptomatic cases was observed. figure 12 . shows the experiment 5 curve for total symptomatic cases against the simulation time period comparing scenarios with 124700 vs 1 million public health capacity units / beds availability in pakistan. it shows no difference between both scenarios. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september 2, 2020. . https://doi.org/10.1101/2020.09.01.20182642 doi: medrxiv preprint 3. as part of final analysis, we introduce a vaccination schedule of 100000 vaccines per day starting from day 220 simulation time (when a rise in cases is expected). as shown in the graphs below, there is an evident decline in the number of active cases per day and in deaths per day though the rate of decline is slow. it shows that without any complementary social distancing / behavioral risk reduction measures, mere act of vaccination would take years for the disease to come under control if the vaccination starts after the second peak is achieved. figure 13 . shows the experiment 5 curves for total symptomatic cases and deaths per day against the simulation time period comparing scenarios with none vs 100000 vaccinations per day starting from day 220 simulation time. it shows a visible decline in the incidence of new cases in both curves after the start of vaccination schedule. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september 2, 2020. . our study shows the implementation of the seidrd model for predicting the incidence of active covid-19 cases in pakistan. it tests several experimental scenarios with or without conventional or smart lockdowns, with improvement in bed capacity and with vaccination. it was shown based on the seidrd model that after the end of smart lockdowns in pakistan, the covid-19 active cases in pakistan are expected show a rise at the start of september 2020 and if no risk reduction measures are taken, they are expected to achieve a second peak around 27th september 2020. we also observed that increasing the itu bed capacity to a 10 time current value will not have a significant impact on the number of active cases or mortalities per day. finally, a vaccination schedule of 100000 vaccines per day started after the second peak of covid-19 will cause a drop in active cases and mortality per day but the effect will be observed over a period of few years without any risk reduction measures. based on above findings, we recommend to put in place minimum risk reduction measures (smart lockdowns in high risk areas) at least until the availability of any form of vaccination. from a single host to global spread. the global mobility based modelling of the covid-19 pandemic implies higher infection and lower detection rates than current estimates the incubation period of coronavirus disease 2019 (covid-19) from publicly reported confirmed cases: estimation and application different epidemic curves for severe acute respiratory syndrome reveal similar impacts of control measures covid-19 pandemic in pakistan -wikipedia 000 people) | data characteristics and outcomes of 21 critically ill patients with covid-19 in washington state study in icu finds 30.9% mortality rate from covid-19 -futurity pakistan plans another covid-19 lockdown. will it work? -the diplomat covid-19 pandemic in pakistan -wikipedia who international health regulations emergency committee for the covid-19 outbreak. epidemiol health statement on the second meeting of the international health regulations (2005) emergency committee regarding the outbreak of novel coronavirus (2019-ncov) early in the epidemic: impact of preprints on global discourse about covid-19 transmissibility an updated estimation of the risk of transmission of the novel coronavirus (2019-ncov) viral dynamics in mild and severe cases of covid-19 virological assessment of hospitalized patients with covid-2019 modeling the spatial spread of infectious diseases: the global epidemic and mobility computational model covid-19: death rate is 0.66% and increases with age, study estimates covid-19 death rate by percentage, sex, pre-existing condition | disabled world fact check: cdc estimates covid-19 death rate of 0.26% [internet estimating clinical severity of covid-19 from the transmission dynamics in wuhan, china study in icu finds 30.9% mortality rate from covid-19 -futurity reference manual > the vensim modeling language > integration key: cord-268149-narre5e7 authors: aziz, muhammad abdul; khan, amir hasan; adnan, muhammad; ullah, habib title: traditional uses of medicinal plants used by indigenous communities for veterinary practices at bajaur agency, pakistan date: 2018-01-29 journal: j ethnobiol ethnomed doi: 10.1186/s13002-018-0212-0 sha: doc_id: 268149 cord_uid: narre5e7 background: the pastoral lifestyle of indigenous communities of bajaur agency is bringing them close to natural remedies for treating their domestic animals. several studies have been conducted across the globe describing the importance of traditional knowledge in veterinary care. therefore, this study was planned with the aim to record knowledge on ethnoveterinary practices from the remote areas and share sit with other communities through published literature. methods: data was gathered from community members through semi-structured interviews and analyzed through informant consensus factor (fic) to evaluate the consent of current ethnoveterinary practices among the local people. results: in total, 73 medicinal plants were recorded under the ethnoveterinary practices. most widely used medicinal plants with maximum use reports (urs) were visnaga daucoides gaertn., foeniculum vulgare mill., solanum virginianum l., withania somnifera (l.) dunal, glycyrrhiza glabra l., and curcuma longa l. new medicinal values were found with confidential level of citations for species including heracleum candicans and glycerhiza glabra. family apiaceae was the utmost family with high number (7 species) of medicinal plants. maximum number of medicinal plants (32) was used for gastric problems. high fic was recorded for dermatological (0.97) followed by reproductive (0.93) and gastrointestinal disorders (0.92). the main route of remedies administration was oral. conclusions: current study revealed that the study area has sufficient knowledge on ethnoveterinary medicinal plants. this knowledge is in the custody of nomadic grazers, herders, and aged community members. plants with new medicinal uses need to be validated phytochemically and pharmacologically for the development of new alternative drugs for veterinary purposes. the historical utilization of plants as health remedies both for human and animal is centuries old. it has been recognized that plants have the capacity to combat several types of diseases ethnoveterinary medicines, a term generally used for folk skills, beliefs, knowledge, practices, methods related to animals' health, and cure of various ailments in the rural areas [1] . ethnoveterinary practices have achieved immense significance for the last decade owing to the discovery of some effective ethnoveterinary products [2] . the utilization of traditional remedies poses a cheaper, easier, and sustainable alternative to synthetic drugs and pharmaceuticals [3] . it has been reported that due to lack of proper animal husbandry practices, about 30-35% of the losses occur in the animals' breeding sectors especially in developing countries [4] , where the rural people are heavily dependent on livestock farming for their livelihood activities [5] . the indigenous communities living in rural and mountainous territories of developing world consider livestock a vital source for economy, social security, and food and is thought to be a symbol of prestige for a particular family [6] . livestock being as a subsector contributes around 56% of value addition in the agriculture sector and approximately 11% towards the gross domestic product (gdp). about 30 million people living in the rural areas of the country are involved with the livestock subsector [7] . hence, livestock raring plays a significant role in poverty reduction strategies. according to the report of economic survey of pakistan [8] , the national herd of pakistan includes 53.8 million goats, 29.6 million cattle, 27.3 million buffalos, 26.5 million sheep, and 0.9 million camels. people residing in the remote areas utilize medicinal plants for livestock's health. particularly, the conventional lifestyle of nomadic and pastoralists makes it difficult for them to reach veterinary extension services due to high costs and less availability of allopathic medicines [9] . in south asia, several ethnoveterinary studies have been conducted [10] [11] [12] [13] [14] [15] [16] [17] [18] including pakistan [6, 9, [19] [20] [21] [22] [23] [24] [25] [26] . however, scarce studies on ethnoveterinary medicines have been reported from the federally administrated tribal areas (fata) of the country. the tribal areas mainly comprised of mountainous territories where people use medicinal plants to treat livestock's diseases. traditional ethnoveterinary knowledge is mainly transmitted orally from one generation to another generation in the form of folk remedies, drawing stories, poems, drawing stories, folk myths, songs, and proverbs. this transmission of indigenous knowledge through oral way faces critical threats of extinction. therefore, it is necessary to record, document, and encourage the ethnoveterinary medication and integrate them into the existing animal health care services [5] . bajaur agency is among one of the federally administrated tribal areas (fata) of pakistan having diversity of medicinal plants being used for the livestock's healthcare services. due to remote nature and lack of quality education, the area has been little explored for the scientific documentations of traditional knowledge. there is a dire need to explore the folk knowledge about the utilization of herbal remedies for veterinary practices prior to being extinct. hence, the current study was planned to investigate and document the traditional ethnoveterinary knowledge and practices and release it from the custody of knowledge bearers for sharing it with other communities through publish literature. bajaur (khar: headquarter) is the smallest agency of the fata having a total area of 1290 km 2 . it shares 52 km border with afghanistan, which is of great importance to pakistan and the region. the study area lays at an altitude of 1126 m above the sea level and geographically exists between 34°-30°and 34°-58°latitudes and 71°-11°and 71°-30°longitudes. the agency is surrounded to the west by kunar valley of afghanistan being separated by the rugged hindukush hills and other mountain passes known as nawa pass, ghakhi pass, and letai sar being the notable ones. the agency borders on south with mohmand agency, on east with lower dir district and the panjkora river, and on north with the watershed between bajaur agency and district dir. moreover, the agency is situated at the extreme end of the himalayan range. the areas dominated by agricultural lands are receiving about 800 mm of average rain fall per annum. the two main tribes of bajaur agency known as tarkani and utman khel are mainly populated into seven tehsils including barang, nawagai, khar, mamund, salarzai, utman khel, and chamarkand. by profession, mostly, the people are farmers, teacher, drivers, and doing small scale businesses and jobs inside/outside the country. almost every household has a herd of domestic animals for socioeconomic gains. there are only three degree-level colleges and five higher secondary schools. moreover, there are only two government hospitals in the study area, while most people are deprived of modern health facilities, which justify their reliance on local herbalists (hakims). the study area consists of one veterinary hospital and 20 small dispensaries to treat the domestic cattle. however, the local people still rely on traditional recipes due to larger distances from the aforementioned health centers. the dominant vegetation in the area is comprised of ailanthus altissimo, eucalyptus camaldulensis, ficus carica, melia azedarach, morus indica, morus nigra, olea ferruginea, pinus roxburghii, quercus baloot, and rumex hastatus. in the month of april, respondents were targeted based on their strong reputation in the field of ethnomedicinal knowledge while field survey was conducted from may to august 2016. field visits were carried out prior to medicinal data collection in order to acknowledge the cooperation of the indigenous communities. mr. amir hasan khan, the local occupant of the area, visited different sites with his volunteer team including a taxonomist and a pharmacist. he arranged several meetings with the local representatives known as maliks, to whom objectives of the study were presented. a semistructured questionnaire was developed to gather knowledge on ethnoveterinary plants by following the method adopted by martin [27] . mostly, the folk knowledge was gathered from nomads, farmers, and aged community members. the interviews were conducted at various places and in the local language called "pashto." each informant was acknowledged by presenting the main theme of the study to them in order to gain their consent and trust, which allowed the informants to talk more freely and openly. the recorded information was once again redisplayed to the informants to avoid errors and falsification. data was collected from different sites known as pashat, tali, inayat kali, ghar shamozai, loe sum, barang, mandal, khar, mamund, and salarzai. accordingly, the sites were categorized into foot hill villages and mountainous villages (fig. 1) . a total of 80 key respondents were selected belonging to different age groups, i.e., 68 males and 12 females ( table 1 ). the selection of respondent was based on their high reputation with respect to traditional knowledge on ethnoveterinary plants. continuous relationships were maintained with the indigenous communities throughout the course of survey for the strong validation of traditional knowledge. surveyed ethnoveterinary medicinal plants were collected and identified by taxonomist at the department of botany, shaheed benazir bhuto university sheringal, district dir (upper), khyber pakhtunkhwa, pakistan. species botanical names and their family names were corrected and verified through the website www.kew.org/mpns. after collection, plants were pressed and dried under the shade, were poisoned (1% hgcl 2 solution), and were mounted properly on the herbarium sheets for future reference. each herbarium sheet was labeled with a voucher number and submitted to the aforementioned department [28, 29] . for each of the specie, use reports (urs) (citations) were counted. ur may be defined as the utilization of part of a plant species for a particular disease mentioned by an informant. to determine the informant consensus factor (fic), the reported species were arranged in various groups according to the ailment treated [11] . ten ailment categories were prepared from the data. to calculate the fic, we used the formula, i.e., fic = nur − nt/ nur − 1. here, nur indicates the number of citations in each use category and nt represents the number of species cited. prospects and challenges to traditional ethnoveterinary knowledge indigenous communities play significant role in reporting traditional uses of medicinal flora. indigenous knowledge can be used as a tool to conserve and maintain the green diversity, and could be further utilized for scientific validation [12] . during the 32nd session of united nations educational, scientific and cultural organization (unesco), traditional knowledge on ethnoveterinary medicines was declared an important part of cultural heritage, which is required to be brought under study, sustenance, and protection [30] . indigenous communities at bajaur agency are dependent on livestock for supporting their livelihood. medicinal plants have a pivot role in the treatment of livestock's ailments in the area. usually, this treatment process depends either on the traditional knowledge being orally transmitted to the current generation of local people from their ancestors or through personal experiences. previous scientific literature has focused on the correlation of traditional medical expertise to ethnobotanical knowledge for the treatment of human ailments [31, 32] , although the same plants may be used to treat livestock [33, 34] . in our study, we have observed that the herders, farmers, and older community members are more equipped with traditional knowledge and familiar with veterinary medications, diagnosis process, and treatment. indigenous people of the study area are rich in traditional knowledge on veterinary medicines, which may be due to their close observation on domestic animals being considered as an important part of traditional lifestyle. most commonly, the male community member grazes herds of animal, while females take part in households' management. figures 2 and 3 showed some of the images of the grazed domestic animals, which are treated with medicinal plant in the area. other studies have explained this in a different way that men due to close proximity tend to know more about the animal behavior than women [31] . people of the study area use plants not only for medicinal purposes to treat their domestic animals but also as a fodder. local community also prevents their animals from such nutrition, which is not healthy in certain conditions and seasons. one may consider this prevention to be a part of ethnoveterinary practices. nutrition is playing an important role in ethnoveterinary practices in both prevention and cure of domestic animals [35] . livestock usually ingests some extra and non-important food substances in the green fodder, which could be termed as food medicines or medicinal food [36] . studies have highlighted the importance of "food as medicines" in the context of local traditional knowledge; however, possible health advantages of food in ethnoveterinary methods need further attention [37] . testing the nutritional status of each traditional ethnoveterinary remedy is not necessary; however, it is essential to evaluate the biological efficacy from the phytochemical, pharmacological, toxicological, and clinical perspectives for wider application. a considerable proportion of the documented uses of plant taxa in our study are in accordance with the established pharmacological effects [36] . the prevailing indigenous ethnoveterinary knowledge in the study area is facing certain constrains leading it towards extinction. as an example, the nature of traditional knowledge is making it more difficult to learn and then transfer it in an accurate way. furthermore, practicing traditional therapies are not being respected by the new generation. other challenges include low literacy rate in the study area, no proper documentation of indigenous knowledge, and introduction of modern allopathic medicines, rapid technological advancement, and environmental degradation. similar kinds of threats have also been reported in other communities across the world [38] [39] [40] . informants with little education were found less familiar to the traditional knowledge while people having no formal education were more responsive in this regard. some studies have found that education can be correlated with expertise either positively [41, 42] or negatively [43] , while others found no relationship [44] . moreover, it is also ambiguous to determine the effect of "modernity" on the loss of ethnomedicinal knowledge. modernity has an established association with greater medicinal competence in dominica [45] but appeared unrelated to variation in expertise among tsimane horticulturalists in bolivia [41] . furthermore, it is also unclear whether correlation of expertise exists between ethnomedicinal knowledge and ethnoveterinary approaches; however, livestock keepers hold extensive knowledge related to disease prevention, diagnosis, and both traditional and novel biomedical treatments [26] . in summary, despite maintaining knowledge on ethnoveterinary practices by the locals, the tendency to utilize modern pharmaceuticals is increasing day by day. hence, the conservation of ethnomedicinal knowledge by the local communities is extremely important for the livestock's health in the remote areas. the use of plants for medical purpose to treat a wide array of maladies emanates traces since the recorded history and even before. in our study, 73 plant species belonging to 43 families were documented. table 2 presents details on the documented medicinal plants including their botanical names, vernacular names, family names, specimen numbers, parts used, medicinal uses, and use reports. family apiaceae (7 species) has the high number of individual species used in ethnoveterinary practices followed by fabaceae (5 species). other studies have also reported apiaceae as the dominant plant family being used in traditional medications [37, 46] . the rationale of high use of apiaceae species in the current study, though based on traditional evidence, may be referred to their chemical constituents such as phenolics, poly phenolics, lectins, alkaloids, terpenoids, and essential oils, which carry antimicrobial potential [47] . due to the predominance of sheep, goats, cows, and donkeys in the study area, we have specifically recorded the ethnoveterinary practices used for the treatment of these four types of domestic animals. key informants declared extensive uses of visnaga daucoides gaertn. table 2) . medicinal plants with high urs strengthen the concept that such species are more significant to the local population and useful in sharing the traditional knowledge with one another in the area. in our study, v. daucoides is used to treat diarrhea, abdominal pain, and retained placenta in domestic animals. a whole plant is subjected to powder and is combined with flour and black tea to treat digestive problems especially in cow and buffalo. amaryllidaceae bulb of the herb is crushed and added milk for orally given to animals (6-8 days) for curing digestive complaints. bulb is crushed and mixed with way to administered orally for several days in order to rate of fertility in domestic animals. narcissus tazetta l. "sbbu-59" gul-e-nargas leaves 10 along with gurr and flour, fresh leaves (¼ kg) are boiled and orally given to livestock for the retained placental removal. apiaceae tea is prepared from its fruit (¼ kg), and then, it is combined with flour and given to cattle for 3 days in order to treat gastric problems. cuminum cyminum l. "sbbu-63" half kilogram of fruit is boiled in black tea and orally given for 15-20 days on daily basis for the expulsion of intestinal worms and treated gastric problems. eryngium biehersteinianum (m. bieb.) nevski "sbbu-5" stem and leaves and stem 23 powder of its stem and leaves is orally given for the treatment of liver problems up to the duration of 8-12 days. foeniculum vulgare mill. "sbbu-61" fruit, leaves 47 decoction is made from it fresh leaves and fruit (150-200 g), and t hen, it is combined with gurr, given orally to livestock for appetite and as sedative for the duration of 5 to 6 days. wall. ex dc. "sbbu-17" fresh root of the plant (200 g) is combined with wheat flour and made to paste which is orally given to goat, cow, and sheep as sexual tonic and to enhance the rate of fertility up to 3 days. trachyspermum ammi (l.) sprague "sbbu-60" seeds (¼ kg) of the plant, allium cepa, wheat flour, and foeniculum vulgare are thoroughly mixed. the resultant blend is then orally given (15 days) and is considered as good appetizer. tea is made from its fruit and given orally to sheep, goat, cow, and buffalo while treating diarrhea, abdominal pain, and retained placenta. the remedy is constantly utilized for the duration of 3 days. calotropis procera (aiton) dryand. "sbbu-18" plants' fresh leaves are taken and decoction is made, and after that, the decoction is combined with "ajuga integrifolia" and is used for dermal parasites for 3 to 5 days. nerium oleander l. "sbbu-22" to relieve the external parasite, the decoction of its leaves is used for animal bathing especially goat and cow. the decoction obtained from its bark and is combined with butter which is administered orally to all type of domestic animals to treat skin problems and as blood purifier. cassia fistula l. "sbbu-4" amaltas fruit 13 fruit of the plant is subjected to boiling along with milk and administered orally up to 3 days to all sort of domestic cattle to relieve fever and gastric complexities. glycyrrhiza glabra l. "sbbu-26" khwaga waly roots 33 root (¼ kg) is subjected to paste which is mixed with flour and oil and then is given to goat, sheep, cow, and buffalo to increase milk production and enhance the rate of fertility. the remedy is used for the duration of 5 to 7 days. lotus corniculatus l. "sbbu-72" stem and leaves, 19 stem and leaves are crushed in weight of ¼ kg and orally given to cattle along with bread or dough for 7 to 10 days as sexual tonic and for urinary tract infections (uti). trigonella foenum-graecum l. "sbbu-11" malkhoozi seeds 9 seeds (150 g) are crushed and given in dough to animals (5-6 days) against gastric disorders. decoction is made from the leaves and then gurr is added. this remedy is given orally to cattle for blood purification and as vormifuge. the water is applied topically to treat skin ailments. mentha spicata l "sbbu-58" powder is made and decoction is made and then mixed with gurr and taken by animals to cure digestive problems. ocimum basilicum l. "sbbu-9" kashmaly leaves seed 11 plant leaves and seeds are subjected to decoction and used topically for skin problems. salvia moorcroftiana wall. ex benth. "sbbu-13" kharghwag leaves 9 decoction of its leaves is given orally daily for the treatment of digestive problems. gossypium arboreum l. "sbbu-43" pomba kal 11 about ¼ kg of its powder is mixed with gurr and used for 10 to 12 days. this remedy is administered orally on daily basis as galactagogue. grewia optiva j.r.drumm. ex burret "sbbu-62" whole plant 6 dried plant powder is subjected to oil (250 ml), administered orally and topically twice a day for 5 to 7 days for wound healing process. the usage mode of ethnoveterinary plant species by one ethnic community is different from other communities due to difference in traditional knowledge [10, 15] . previous literature has shown that decoction of the fruit of v. daucoides is used during abdominal pain, which is used to enhance body temperature in the study area [21, 48] . in the same way, the f. vulgare is considered as a strong appetite and sedative. in other cultures across the globe, f. vulgare is used for various livestock problems. for instance, this plant is effective in digestion and diarrhea, when mixed with camellia sinensis, trachyspermum ammi, ghee, and sugar [6, 21] . pneumonia is also being treated by giving its seeds to the animals [24] , while other uses include galactagogue and ruminative [49] . various parts of s. virginianum are taken for the treatment of cough, fever, milk production, and pain. there is scarce literature on the use of s. virginianum as galactagogue, which shows the unique use of this plant species in the study area and familiarity of local population through longtime experiences. published literature has indicated that the plant is also used for wound healing process [20] fever, cough, and intestinal infections [20] . roots and leaves of w. somnifera are given to sheep, cow, and buffalo for milk production and used as antipyretic and sexual tonic. indigenous populations comprising of various cultures residing in lesser himalayas (pakistan) use w. somnifera for bovine mastitis [6] , while in ethiopia, this plant is being used to protect animals from bad evils [50] . the plant has carminative effects and is used to remove the flatulence [25] . additionally, this plant is used as refrigerant and for abdominal pain, digestion, jaundice, skeletonmuscular ailments, and wound healing against sunstroke [26] ; for treating diarrhea [22] ; for trypanosomiasis [9] ; and for anorexia [50] . informant reported g. glabra as galactagogue and enhances the rate of fertility. mussarat et al. [22] reported that this plant is culturally used for the treatment of cough by the indigenous communities residing near the indus river, pakistan. however, from the literature, no conclusive evidence was found on the reported uses of g. glabra in our study. such evidence-based observations could justify the idea of cultural diversity across the regional level in plant remedies. previous studies related to the human's uses of g. glabra have demonstrates its effectiveness in the treatment of sex hormone imbalances and menopausal symptoms in women [51] . in the current investigation, rhizome of c. longa is used as antiparasitic and treating genital infection and problems. in other cultures, across the country, the dried rhizome of c. longa is mixed with eggs and given for mastitis [22] , jaundice, and skeleton muscular ailments [26] . decoction of its leaves is mixed sugar, which is used as wound healing agent [6, 19] . a root of c. longa is used for hoof problems and sore joints [52] . in our study, the mustard oil is mixed with whey and is taken orally to relieve abdominal pain. the cultural ethnoveterinary uses from the lesser himalayas (pakistan) include that the oil extracted from b. rapa seeds is utilized for stomach disorders, eye infection, and skin diseases [6] . furthermore, brassica rapa l. seeds are used for the retention of fetal membrane, while its oil is effective in treating genital prolepses and sores [53] . this plant is also used in placental retention and mastitis and as antiparasitic [19] ; myiasis, mange, and helminthiasis [20] ; and flatulence [49] . all these researchbased findings showed that the same medicinal plants are being used in different parts of the country; however, their uses differ from area to area and from culture to culture [48] . the ethnoveterinary plants use by one ethnic community is almost different from other communities due to several reasons. to make a comprehensive comparative cultural diversity analysis of plant utilization in ethnoveterinary practices, we have selected a study conducted by aziz et al. [48] in the fata region of pakistan. in comparison, we have found that most widely used medicinal plant species in our study are v. daucoides, f. vulgare, s. virginianum, w. somnifera, g. glabra, and c. longa. while according to aziz et al. [48] , the ethnic communities in south waziristan agency are widely utilizing plant species such as b. rapa, punica granatum, capparis decidua, mentha longifolia, withania coagulans, and c. longa, during comparative analysis, it was found that only 15 medicinal plants were commonly used in both regions for ethnoveterinary practices, which include acacia modesta wall, allium cepa l., allium sativum l., b. rapa, calotropis procera (aiton) dryand., cannabis sativa l., chenopodium album l. c. longa, f. vulgare, juglans regia l., nicotiana tabacum l., peganum harmala l., quercus oblongata d. don, trachyspermum ammi (l.) sprague, and v. daucoides. certain variations in the utilization of these plants and their parts were observed in both areas. for instance, the bulb of a. cepa is used as galactagogue by waziristanian communities while in bajaur, it is used to treat digestive problems. a. sativum is utilized for genital prolapsed while the same plant is used as sexual tonic for animals in bajaur agency. the seeds of b. rapa are widely used as appetizer and tonic and for cough, seasonal allergies, stomach disorders, and skin infections in south waziristan agency, while in the other region, it is used only against gastro-intestinal disorders. the indigenous communities at south waziristan agency consider the leaves of c. procera useful in joint pain while on the other side, the residents of bajaur agency used the latex against skin problems. c. album is used for wound healing and flatulence at waziristan while as stomachic at bajaur agency. j. regia is given for the retention of placenta at waziristan while gastric problems in bajaur. p. harmala is extensively used for gastrointestinal problems, as antiparasitic, and for skin diseases by waziristanian communities, while it is used only for the riddance of external parasites in bajaur. the possible reason for low consensus of the two regions in ethnoveterinary medicinal plants may be due to unique vegetation and distinct socio-cultural values. according to a survey, out of 122 plant-derived pure compounds, 80% (94 plant species) were having the same potential as indicated in traditional medications [54] . as an example, galegine is obtained from galega officinalis l. and is used in the production of metformin and other bisguanidine-type anti-diabetic drugs [55] ; khellin, extracted from v. daucoides., led to the development of cromolyn in the form of sodium cromoglycate, which is used as a bronchodilator; and papaverine isolated from papaver somniferum forms the baseline for verapamil, which is generally utilized for hypertension [55] . survey participants did not describe the standardized dosage and recovery time like other previous ethnoveterinary documentations. the main problem highlighted in other studies is the lack of accuracy in such ethnoveterinary practices, which also push the locals towards modern allopathic drugs for livestock health maintenance [20, 56] . the main reason that veterinarian has always complained is the non-standardized dosage in traditional medicines. though this is an accusation, one ethnomedicine does not mean that they lack efficacy but require standardization, which could benefit the traditional system by minimizing risks and toxicities. according to kearns [57] , ethnoveterinary medicines are facing a great intellectual challenge from social theory and postmodernism, and this challenge was focused while detecting variations in animal health practices, beliefs, and experiences of various social groups. generally, it is not possible for all ethnoveterinary practices to be effective and, at the same time, they have certain weakness in terms of their efficacy as compared to modern medications [58] . though it is convincing that most of the traditional veterinary medications have clear and sound health effects, many modern allopathic drugs are based on these medicines [59] . certain plants in our study were used in single form for more than one disease. for example, cedrus deodara (roxb. ex d. don) g. don is used in a condition, in which milk obtained from the cattle gives bad smell, then the oil is given orally to the cattle. it is also used as a cooling agent and in treating digestive problems. in large quantity, the oil have the potential to depress the sexual power of male animals [49] . monteiro et al. [60] also reported similar findings from pakistan and brazil, respectively, where they described multiple uses of a single medicinal plant. utilization of certain plant species for multiple diseases is a widespread practice in ethnoveterinary medications. in contrast, some ethnoveterinary remedies (polyherbal formulations) are being made by combing two or more plants and additives such as whey, ghee, and sugar. this addition is generally followed in remedies to counteract the astringent taste, dilute, and reduce the relative potency of the remedy [61] . in the study area, a total of 32 plants were reported for gastrointestinal problems with maximum use reports of 433 (table 3) , which is regarded as the most common disease category in domestic animals being represented by abdominal pain, diarrhea, and digestive problems. these health issues can be easily detected by the respondents and may explain the fact that why the gastric problem category is high in ours as well as in others studies. different ailments were categorized into 10 groups such as dermatological, gastrointestinal, galactagogue, reproductive, respiratory disorders, tonic, wound healing fever, and miscellaneous. those medical conditions, which were not fully described by the interviewees, were placed into the miscellaneous category. these include eye problems, weakness, and abnormal conditions related to various organ systems of animal bodies. highest fic values were recorded for dermatological problems (0.97) followed by reproductive ailments (0.93) and gastric disorders (0.92) ( table 3) . fic value is an indicator of showing the consent of the local people on a specific plant species and efficacy of a certain taxa [62] . sharma et al. [63] declared that when fic becomes 1, it means that the local population is exchanging their view, ideas, and information about traditional medications, while on the other side, if the fic value is 0, then it is vice versa. fic value in the current study was recorded in between 0.85 and 0.97 for various livestock ailments (table 3 ). these findings indicate the highest consent among the local people on traditional herbal therapies. previous research studies conducted in other areas also agreed to high consent of local people on traditional animal therapies. for instance, the reported fic values for dermatological problems were 0.93, 0.93, and 0.82 [26, 64, 65] ; for reproductive disorders, 1.00 and 0.89 [65, 66] ; for gastric problems, 0.90, 0.70, 0.92, 0.95, and 0.94 [26, [64] [65] [66] ; for galactagogue, 0.83 and 0.50 [6, 65] ; and for wound healing, 0.40 and 0.45 [6, 67] . heinrich et al. [68] has submitted the idea that high fic values can be used as a tool to target the plants for the isolation of biologically active components. in our study, most livestock's ailments were mentioned to be seasonal and epidemic due to change in fodder. furthermore, the concept of hot and cold food is also famous in order to prevent animals from diseases. the local residents change the relative fodder in different seasons in order to minimize the chances of various health problems in cattle. as an example, the seeds of the nigella sativa l. and kernels of q. oblongata are given to the cattle to energize them during the cold season. similarly, the fruits of the streblus asper lour. produce cooling effects and considered to be a better remedy during hot summer season. in the same manner, local communities tend to give the infusion of cannabis sativa l to their livestock in the summer season. quinlan [69] and raziq et al. [9] has also mentioned the concept of hot and cold food in traditional veterinary medications. drugs derived from plants or their extracts have certain therapeutic properties. to replace antibiotics by suitable therapeutic agents, plants can play an important role in combating with bacterial pathogens. there are several essential oils, which can be used as alternate of antibiotics. these oils can be easily isolated, having low toxicity on mammalian cells, and can be easily degraded in soil and water [70] . in this section, we will analyze the pharmacological evidences of the most utilized studied medicinal plant species in order to check their therapeutic efficacy. in f. vulgare, phenols, phenolic glycosides, and volatile aroma compounds such as transanethole, estragole, and fenchone are reportedly the key phytoconstituents and responsible for its antioxidant activity. f. vulgare is pharmacologically validated (in vitro and in vivo) in demonstrating activities such as antibacterial, antifungal, antioxidant, antithrombotic, and hepatoprotective [71] . by investigation, it was found that the leaf extracts of s. virginianum is more active against candida albicans, salmonella typhi, staphylococcus aureus, and nematodes [72, 73] . for various extracts obtained in alcohol and water, it was found that w. somnifera has antibacterial potential, antihypercholesterolemic activities as well as diuretic potential [72, 74] . it has been reported that alcoholic and aqueous extracts of c. longa have shown antibacterial activity [74] while its ethanol, petroleum, water, and chloroform extracts are effective against certain strains of viruses, bacteria, and fungi and also have shown anti-inflammatory effects [75] . researchers have claimed that plant-derived medicines used in traditional systems across the globe can be used as an indicator to consider them more effective than modern drugs [6] . livestock keepers are using several plant-derived remedies for various acute as well as chronic disorders of cattle. plant-derived medicines have been used by physicians for hundreds of years in traditional systems, and most of the world population rely on these products for health care systems [76] . there are several thousand plants across the globe being utilized for various therapeutic purposes both animals and humans [49] . out of these medicinal plants, very low proportion has been investigated and proved scientifically for their indigenous uses [77] . the essential oils in medicinal plants are having strong antimicrobial potential. as an example, essential oils of cinnamon, thyme, and oregano are therapeutically effective [78] . antibiotic resistance is an emerging global concern related to veterinary and human medications [79] . hence, it is necessary to search for new compounds to combat antibiotic resistant bacteria. improper therapeutic utilization of antimicrobial medicines in fishery, poultry, agriculture, and animal farming facilitates the emergence and production of drug resistant strains. additionally, poor prevention and control of unhygienic practices contribute in resistance emergence. the world health organization, food and agriculture organization, and world organization for animal health are stressing to promote best practices to avoid the emergence and spread of antibacterial resistance. continuous attempts are in progress to promote the moderate use of antibiotics in human as well as in animals to tackle the problem of antimicrobial drug resistance [80] . in general, plants should be used as an alternative to synthetic drugs and investigated for their therapeutic efficacy. certain plants in our study including boerhavia erecta l., celtis australis l., chamaecyparis obtusa (siebold & zucc.) endl., eryngium biehersteinianum (m. bieb.), gossypium arboreum l., h. candicans wall. ex dc., narcissus tazetta l., opuntia littoralis (engelm.) cockerell, and s. asper need comprehensive phytochemical, pharmacological, and toxicological investigations. current study, one health concept, and changing environment current study reports that there are several ailments being treated with medicinal plants by the indigenous populations. most prevalent disease categories were dermatological, reproductive, and gastric problems. the dominance of these diseases not only poses threats to the domestic animals but also increases the chances of zoonoses. local population uses various animal products; hence, there are maximum chances of the migration of infectious diseases from these animals to humans. linkage of the ethnoveterinary studies with the researches of other disciplines may form an interdisciplinary approach to combat several types of health issues in both animals and plants. this approach mainly led to the concept of one health, which contributes towards understanding the complexities in health problems of living beings [81] . a recent surge in emerging infectious diseases and their putative associated costs to society have reignited interest in the drive of disease emergence. a number of pathogens have emerged in the last 20 years, including the severe acute respiratory syndrome virus, hendra virus, and nipah virus. however, there is a growing concern about the h 5 n 1 influenza virus, which fuelled much of the recent debate around emerging infectious diseases (eids) [82] . one of the benefits that accrued from the attention on eids has been an increased recognition across a range of disciplines that the health of animals (including humans) and the health of the broader ecosystem are inextricably linked, which certainly given momentum to one health movement. one health is not all about eids, but it also covers important issues of food security and food safety [83] . there is a strong consensus that the climate is changing now and that human activities are the primary cause [84] . however, it is clear that climate change will alter the distribution and incidence of a wide range of diseases either directly or indirectly (e.g., diseases with a development stage outside the host) [85, 86] . the pathways by which climate change can affect host pathogen vector interactions have recently been well described by gallana et al et al. [86] . one health initiative task force (ohitf) [87] defines one health as "the promotion, improvement, and defense for the health and well being of all species by enhancing cooperation and collaboration between physicians, veterinarians, and other scientific health professionals and by promoting strengths in leadership and management to achieve these goals". the one health approach plays a significant role in the prevention and control of zoonoses. approximately 75% of new emerging human infectious diseases are defined as zoonotic [79, 88] . of the 1461 infectious diseases, approximately 60% are caused by multi-host pathogens, characterized by their movement across various species [89] . this gives significant credence to the importance of examining health effects across species, in order to fully understand the public health and economic impact of such diseases and to help implement treatment and preventive programs. the application of one health approach has been recognized as a critical need by international organizations as well as the preferred approach to address global health issues. it is also noted that knowledge in veterinary medicine and animal nutrition and husbandry could provide insights into human nutrition and growth. it is a widespread phenomenon that natural resources including plants are always prone to threats in their natural habitat due to rapid human intervention and destructions of natural resources. the collection process of medicinal plants for ethnic practices and other anthropogenic practices is not only destructing the indigenous flora but also posing a threat to the traditional knowledge. unesco has emphasized on the documentation and preservation of traditional knowledge in south asia generally and pakistan and india particularly. however, efforts are going on but they are not sufficient for the conservation of traditional knowledge persistent since several centuries, which can lead to valuable discoveries in modern healthcare system. the local perception of indigenous communities regarding the threats being faced to the ecological resources especially the medicinal plants was examined in the current study. the lack of awareness has been observed as a major threat to the conservation of plant resources. it was also observed that different factors including time of collection, processing, storage, and herbal preparations are important and necessary steps to be considered for both economic returns and conservation. mainly, the local healers are involved in the collection of medicinal plants. a study in the swat region of pakistan has shown that higher economic outcomes can be obtained from proper harvesting of wild medicinal plants as compared to the standard cash crop [90] . other studies are supporting our results by showing an enormous potential in improving the harvesting, storage, use, preparation, and marketing of the herbal product as a source of income [91] . in the remote areas of the study region, local inhabitants obtained significant economic advantages from forest products. similar advantages have been reported for other mountainous communities in the northern parts of pakistan [26] . there are certain other threats to the medicinal plant resources of the study area, which include deforestation, heavy grazing pressure, uncontrolled collection of fodder, and other non-timber forest products by the local people and traders. several studies have reported a decrease in the number of medicinal plants due to over exploitation and environmental degradation [92, 93] . it is therefore a dire need to manage and design the overall grazing system to encourage the sustainable regeneration and protection of medicinal plants. keeping the observation and findings of the current investigation, proper management steps should be taken with the active participation from the indigenous communities to conserve this precious flora. it is also important to aware the local people about the market value and sustainable harvesting of medicinal plants. rapid modernization and urbanization is not only a threat for plant species' degradation but also a threat for the associated folk knowledge. that is why that the disappearance of folk knowledge has been declared more in danger than the natural resources themselves [94] . therefore, we present a strong recommendation that ethnobotany as a subject should be included into the curriculum to help students in recognizing the endangered and medicinally important species of their respective regions. in addition, incentives may be given to farmers for the cultivation of medicinal plants on marginal lands and home gardens. indigenous communities at bajaur agency are dependent on medicinal plants for ethnoveterinary practices. knowledge about the traditional medicinal system is restricted to the herders, farmers, and elder community members. the younger generation is unaware of this traditional treasure and takes no interest due to modernization. hence, this study is an attempt towards the preservation of traditional ethnoveterinary knowledge from being extinct. there are several medicinal plants, which are being used in traditional herbal system of veterinary disorders. some of the important are v. daucoides, f. vulgare, s. virginianum, w. somnifera, g. glabra, and c. longa. new ethnoveterinary uses used at the study area were found for h. candicans and g. glabra. apiaceae is utmost plant family being in use for various livestock ailments. thorough phytochemical and pharmacological investigations are required by isolating the active compounds and testing the in vitro or in vivo efficacy of the abovementioned plants against the targeted veterinary diseases. furthermore, critical toxicological investigations are also required to ensure the safe and secure use of documented ethnomedicines. in order to share and further maintain this knowledge, it is direly needed to aware the rural population about the significance 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to health, emergence detection, and response medicinal and aromatic plant cultivation in the swat valley, north-western pakistan, for economic development and biodiversity conservation ethnomedicinal survey of important plants practiced by indigenous community at ladha subdivision, south waziristan agency ethnobotanical profile of plants of shawar valley, district swat, pakistan an ethnobotanical study of medicinal plants in high mountainous region of chail valley (district swat-pakistan) conserving indigenous knowledge as the key to the current and future use of traditional vegetables the authors extend their high appreciation and acknowledgment towards the local communities by providing moral support to the authors. this research study did not receive any grant from any organization. data gathered during the course of the study has been included in the article.authors' contributions ahk and hu conducted the field work. maa wrote the draft manuscript. ahk and hu helped in the compilation of data. ma gave technical comments on the draft and indicated the language and grammatical mistakes. maa and ma supervised all the stages. all the authors read and approved the manuscript.ethics approval and consent to participate not applicable the authors declare that they have no competing interests.• we accept pre-submission inquiries • our selector tool helps you to find the most relevant journal submit your next manuscript to biomed central and we will help you at every step: key: cord-017731-xzfo5jjq authors: todd, ewen c. d. title: foodborne disease in the middle east date: 2016-11-25 journal: water, energy & food sustainability in the middle east doi: 10.1007/978-3-319-48920-9_17 sha: doc_id: 17731 cord_uid: xzfo5jjq food safety is a concern worldwide and according to the world health organization, developing countries are probably more at risk of foodborne illness because many of these, including those in the middle east, have limited disease surveillance and prevention and control strategies. specifically, the middle east and north africa (mena) region has the third highest estimated burden of foodborne diseases per population, after the african and south-east asia regions. however, it is difficult to determine what the burden is since little is published in peer-reviewed journals or government reports for public access. this chapter reviews 16 autonomous nations, namely, afghanistan, bahrain, egypt, iran, iraq, israel, palestine, kuwait, lebanon, oman, pakistan, qatar, saudi arabia (ksa), syrian arab republic (syria), united arab emirates (uae) and yemen. countries range in size from bahrain with 1.8 million inhabitants to pakistan with a population of 184 million. agriculture and local food production is much influenced by water availability for irrigation. water shortages are most severe in the gulf countries which rely on aquifers, desalination, and recycled waste water for most of their water supplies. this means that most food is imported which is expensive if not subsidized through petrodollars. this impacts food security which is a particular concern in countries under conflict, particularly, syria, yemen and iraq. gastrointestinal infections are frequent in this region from salmonella typhi and other salmonella spp., shigella spp., campylobacter jejuni and c. coli, rotavirus, hepatitis a virus, parasites, and more rarely from aeromonas, yersinia enterocolitica, brucella spp., and middle east respiratory syndrome coronavirus (mers-cov). reports indicate that children are the most susceptible and that many isolates are multidrug resistant. chemical contamination of water supplies and crops are probably more of a concern than published reports indicate, because of widespread indiscriminate use of fertilizers, antibiotics, and pesticides, coupled with increased industrial pollution affecting the water supplies. like many other parts of the developing world, foodborne disease surveillance is limited and outbreaks are most often reported through the press but with insufficient detail to determine the etiological agents and the factors contributing to the outbreaks, leading to speculation to the cause by those interested or responsible for food prevention and control. however, there are some well investigated outbreaks in the region that have those details, and reveal where the shortcomings of both the establishments and the inspection systems have been. where the causative agents are known, the kinds of pathogens are generally similar to those found in the west, e.g., salmonella, but many outbreaks seem to have short incubation periods that point to a toxin of some kind of chemical or biological origin, but these are almost never identified. because of sectarian warfare, residents and refugees have been given food that has made them sick and solders? have been deliberately poisoned. research has been focused on microbial contamination of locally-sold foodstuffs and manager and employee knowledge of food safety and hygienic conditions in food preparation establishments. an innovative pilot project in qatar is to use seawater and sunlight for raising crops through the sahara forest project. all countries have some kind of food establishment inspection system, but they tend to be punitive if faults are found in management or employees on the premises rather than being used for their education for improving food safety. restaurants may be closed down and owners and employees fined for often unspecified infringements. however, some food control agents are moving towards employee training through seminars and courses before problems occur, which is a good disease prevention strategy. unfortunately, many of the food handlers are from asian countries with languages other than arabic and english, which makes effective food safety communication and training difficult. tourists visiting popular resorts in turkey and egypt have suffered from foodborne illnesses, usually of unknown origin but poor hygienic conditions are blamed with law suits following, and the adverse publicity affects the long-term viability of some of these resorts. food exports, important for local economies, have occasionally been contaminated resulting in recalls and sometimes illnesses and deaths, notably fenugreek seeds from egypt (e. coli o104:h4), pomegranate arils from turkey (hepatitis a virus), and tahini from lebanon (salmonella). overall, in recent decades, the middle east has made strides towards improving food safety for both residents and foreign visitors or ex-pat workers. however, within the countries there are large discrepancies in the extent of effective public health oversight including food safety and food security. currently, almost all of the countries are involved to a greater or lesser extent in the civil wars in syria and yemen, or are affected through political tensions and strife in egypt, iraq, iran, israel, palestine, lebanon and turkey. in addition, the current overproduction of oil on a world-wide scale has led to a rapid decrease in revenues to most gulf states. all this points to a severe setback, and an uncertain foreseeable future for improvements in obtaining both sufficient and safe food for residents in this region. the world health organization (who) eastern mediterranean region, comprising countries in the middle east and north africa (mena), has the third highest estimated burden of foodborne diseases per population, after the african and south-east asia regions. according to the who ( 2015a), more than 100 million people living in this region are estimated to become ill with a foodborne disease every year and 32 million of those affected are children under 5 years. diarrheal diseases caused by e. coli, norovirus, campylobacter and nontyphoidal salmonella account for 70% of the burden of foodborne disease. an estimated 3000 people die each year from unsafe food, caused primarily by diarrheal diseases, typhoid fever, hepatitis a, and brucellosis. both typhoid fever and hepatitis a are contracted from food contaminated by the feces of an infected person and the source of brucellosis is typically unpasteurized milk or cheese from infected goats or sheep. half of the global cases of brucellosis are in people living in this region, with more than 195,000 people infected every year, causing fever, muscle pain or more severe arthritis, chronic fatigue, neurologic symptoms and depression. cholera, which after a short incubation period of 2-5 days causing severe diarrhea and dehydration, is returning to those countries with limited public health infrastructure caused by conflict, such as iraq (agence france-presse 2015). the list of countries covered by this chapter is similar to that of who but leaving out north african countries except egypt (which has territory in eastern asia) and adding turkey which is not always considered in the region because it is not arabic, but has interesting food safety data. therefore, the countries under review are afghanistan, bahrain, egypt, iran, iraq, israel and palestine, kuwait, lebanon, oman, pakistan, qatar, saudi arabia (ksa), syrian arab republic (syria), united arab emirates (uae) and yemen. gulf countries bahrain, kuwait, oman, qatar, ksa and the uae have similar social, political, economic, culture, religion, language and ancestry with several similarities in their food control systems and food safety programs (al-kandari and jukes 2009). a food and agriculture organization (fao) report covering international investments in agriculture in the near east (not identical to the countries chosen for this chapter, but many of the findings apply) states that this region is characterized by a mix of very different countries' resources and incomes (tanyeri-abur and elamin 2011). the wealth in the richer countries of the region is primarily dependent on oil revenues and the past economic growth has been closely linked to the oil market; about 43% of regional gross domestic product (gdp) is concentrated in the high income countries (qatar, kuwait, uae, saudi arabia, and bahrain) which are home to only11.8% of the population in the region, and many of these are expatriates working in these countries. the report indicates that food insecurity varies sharply in the region but overall the percent of the undernourished population does not exceed 57% in most countries of the region, except for sudan, mauritania, djibouti and yemen where the proportion of undernourished exceeds 25%; however, in 2016 these percentages will be totally out of date for countries like syria and iraq and in neighboring countries where refugees have reached because civil war and jihadi terrorist groups have put considerable stress on public health facilities and food availability. the countries in the region however, are largely similar when it comes to the challenges in achieving sustainable agriculture and food security. for most of these countries, the overwhelming concern is to secure adequate and stable supplies of food at the national level, making food security a concern for both rich and poor countries of the region (tanyeri-abur and elamin 2011). the three major problems affecting most of the countries are (i) limited water availability; (ii) population growth; and (iii) heavy dependence on food imports. water scarcity in particular, is the most critical development problem in the region and the single most important factor in limiting agricultural growth, and water availability has been declining steadily since the late 1950s. the region as a whole has 70% less availability of renewable water per person in 2003-2007 than in 1958-1962 . lack of water for irrigating crops but also for potable water supplies affects many of the countries, particularly in the gulf region. it is important to note that the wealthiest countries are also those with the highest water depletion record, namely, the uae and qatar. the unprecedented growth in investment in agriculture is in large part a result of the food crisis of 2007, which brought about a rethinking of agricultural support policies, mostly in countries of the gulf and particularly saudi arabia, which has invested heavily in the last 30 years in large-scale agricultural production using up valuable water resources. saudi arabia announced in january 2008 that it would phase out wheat and agricultural production in the course of the next 8 years. in july 2008, qatar and uae took similar policy decisions (tanyeri-abur and elamin 2011). crops grown in the region may serve as fresh food sources for the population, but much of the food is imported with limited locally processed products, and if the policies of ksa, qatar and uae expand to other countries, more will be imported in the future (tanyeri-abur and elamin 2011). thus, the main foodborne disease issues are with homemade, restaurant and street food, where isolated claims of illness are followed up by inspections and possible punitive action by public health agencies responsible for food safety. those countries that rely on tourism for their main source of gdp have sometimes been damaged by adverse publicity, e.g., egypt, and to a lesser extent, turkey and lebanon. according to the food and agriculture organization, less than 4% of the world agricultural trade is conducted in the region. even though by tradition many of these countries relied on growing their own food, today some of these countries import almost 90% of their food; 2.3% of the food in the world alone was imported to saudi arabia and united arab emirates in 2007, and the food trade balance in food in middle east is negative, estimated at over 50 us $ billion dollars (tajkarimi et al. 2013 ). there are specific restrictions prevalent in the arab-speaking countries related to islam and judaism with the prohibition of eating pork and blood, the drinking of alcohol, and mixing dairy foods and meat under halal and kosher food laws. therefore, parasites related to pigs, e.g., trichinella and taenia spp., are unlikely to be prevalent in these populations. however, there are many muslim and jewish feast occasions with large gatherings such as eid linked to ramadan and particularly the muslim hajj, which put a strain on food preparation, distribution and storage. good health conditions for travelers to saudi arabia for the pilgrimage to mecca (hajj) are critical and any incident that occurs has to be quickly contained to prevent extensive infectious disease outbreaks (memish and al rabeeah 2011) . traditional middle eastern foods are mainly related to legumes, leafy greens, fruit, dairy products and meat on special occasions; details can be found in brittin (2010) . in urban areas today, grocery stores and supermarkets can supply most of the food requirements of a family but imported foods tend to be expensive. also, some fruit and vegetable items are seasonal and are only available once or twice a year such as local plums, almonds and bananas, which tend to be cheaper than imported varieties. quality of raw produce in stores varies but they often have short shelf lives and can spoil quickly because of harvesting ripe products, bruising, and high storage temperatures. traditional rural foods include aromatic stews, stuffed vegetables, wild leaves, pulses and cracked wheat, and occasional goat or lamb meat. a typical middle eastern meal starts with a variety of cold and hot mezze (appetizers), salads and pastries, especially in greece, turkey and lebanon. many contain herbs, cheese, pickles, nuts, seeds, and parsley and lettuce are widely eaten in salads or traditional mezzes. most mezzes are vegetarian and fresh fruits and vegetables are an integral and important part of the cuisine when they are in season. tabbouleh, a salad where parsley is a major ingredient with small pieces of tomato, and some bulgur (ground wheat) in it, is often served in leaves of romaine lettuce or raw cabbage. almost as popular is fattoush, a mixed bowl of lettuce, tomatoes, cucumbers, and fried or toasted pita chips, typically seasoned with a dusting of sumac and pomegranate molasses. since leafy greens do not have a final decontamination step, they are at risk from environmental fecal contamination as reported in lebanon by faour-klingbeil et al. (2016) . hummus, a smooth chickpea paste made with tahini/tehineh, lemon juice or citric acid, garlic and salt, and often served with olive oil, is the most ubiquitous mezze. since tahini and hummus are major exported products from the region, particularly lebanon, they are prone to salmonella contamination, and are sometimes recalled from other countries, which is damaging to the local economies. dairy products are also served regularly at meals and these are locally made or imported. labneh, strained yogurt, very similar to greek yogurts, is widely used as a base for mezze which might have olive oil, pine nuts or za'atar (a mixture of thyme, sumac, and sesame seeds) added. cheeses including the popular haloumi are frequently served in restaurants. shawarma/ shwarma is frozen or refrigerated raw or marinated meat (lamb, beef or chicken) cooked on a vertical rotisserie popular throughout mena countries and now frequently seen in western nations. higher fish consumption tends to be close to where these are locally caught, either sea or river netted. one example from iraq is masquf (split large fish cooked on stakes over a fire, and eaten outdoors by a river, served with slices of tomato and onion and arab bread. crustaceans are less frequently eaten but can be obtained from imports. cosmopolitan foods are widely available in the larger cities, as are multinational fast-food chains. foodborne illnesses have been sporadically reported throughout the region over the past decades and global assessments of the kinds of problems encountered reviewed, e.g., todd (2001) and al-mazrou (2004) and more recently by tajkarimi et al. (2013) . these last authors indicate that reporting foodborne disease is functioning well in jordan, kuwait, oman, saudi arabia and uae, compared to other countries in the region. however, the foodborne outbreak surveillance systems in middle eastern developing countries are still limited with reporting of less than 1% of the actual outbreaks; one reason is that many foodborne illnesses occur in homes and those ill may not visit medical care facilities. in addition, available laboratory analytical support for public health agencies is often minimal or lacking, even though some research institutions may have up-to-date equipment and technical expertize. change is gradually coming and a food and drug authority has been established in both saudi arabia and jordan (al-kandari and jukes 2009). also, new food legislation has been initiated by egypt, lebanon and syria (tajkarimi et al. 2013) , but is currently stalled in last two countries. improvements in inspection service, hand held computers, customized software and improved surveillance systems are some examples of developments in food safety systems in the region. jordan, saudi arabia and bahrain have been developing unified food safety activities from farm to fork (al-kandari and jukes 2009). however, there is a need for substantive food safety education for all foodservice staff. increasing quality and quantity of the food safety training and human resources in governmental agencies in the region will improve the public health infrastructure. for example, the municipality of dubai has established an international annual food safety conference to improve the food safety education system of those in the region, now in its 10th year (2016). the following sections of the chapter focus on five aspects: gastrointestinal infections; foodborne disease outbreaks in specific countries; food safety related research and surveys; issues relating to tourism and exported food; and government oversight of the food industry, with specific examples from countries in the region. gastrointestinal diseases are frequently encountered in the middle east and many etiological agents have been identified where specific studies have been carried out to look for bacterial, viral and parasitic pathogens. the average annual incidence of culture-proven shigellosis in israel was 97/100,000 from 1998 to 2012, but each reported case was considered to represent 25 cases indicating the high burden of the disease in the country (cohen et al. 2014) . orthodox jewish communities, living in highly crowded conditions and with a high number of children aged <5 years were the epicenter of country-wide biennial propagated epidemics of s. sonnei shigellosis. s. flexneri was the leading shigella serogroup in israeli arabs. isolates showed high rates of resistance to ampicillin and trimethoprim/sulfamethoxazole, but very low rates to quinolones and third-generation cephalosporins. there is no indication if foods or water were vehicles of these shigellosis cases. also, in israel a study of pregnancy-related listeriosis cases from 1998 to 2007, identified 166 cases, resulting in a yearly incidence of 5-25 cases per 100,000 births (elinav et al. 2014 ). there were 29 fetal deaths, two neonate deaths and one maternal mortality. the incidence of israeli pregnancy-associated listeriosis has a high yearly variability and is one of the highest worldwide. the geographical distribution varied greatly between years and had a different epidemiological pattern compared with nonpregnancy-related listeriosis. the sources of the infections were not studied but all listeriosis cases have a foodborne link. this has to be further researched as to diet, and the unawareness of the israeli public of the risk for certain food products contributing to the extremely high incidence in israel, in both general and pregnancy-associated listeriosis, as occurs in other countries. a total of 132 stool samples were collected from palestinian patients with acute diarrhea from which 12 (9.1%) yielded enteropathogenic bacteria. salmonella, campylobacter coli/ jejuni, and aeromonas hydrophilia were isolated in equal numbers from samples 3/12 (25% each), shigella boydii 2/12 (16.7%), yersinia enterocolytica 1/12 (8.3%) (abdelateef 2011) . many strains were antibiotic-resistant. children younger than 5 years old were more susceptible to infectious diarrhea; in addition, diarrhea was more frequent in those living in crowded houses, and in houses rearing poultry, including pigeons. salmonella enterica serovar typhi continues to be an important public health problem in kuwait. analysis of the isolates from 163 patients, collected between 1995 and 2003, showed that the majority were from patients from the indian sub-continent, and many strains were drug resistant (dashti et al. 2008) . typhoid fever in kuwait is predominantly associated with those who have traveled from endemic areas to work in kuwait. the circulation of enteric viruses among the population of cairo, egypt, between march 2006 and february 2007 was studied by kamel et al. (2009) . at least one type of virus was detected in 50% of fecal samples, 57.4% of which were positive for rotavirus, 26% for norovirus, 10.4% for adenovirus, and 1.7% for astrovirus. over 10% of infections were mixed infections. among the noroviruses, half belonged to the predominant ggii.4 cluster which were similar to those circulating elsewhere, but there were also new ggii.4 variants that were not associated with any previously known ggii.4 isolate. although norovirus is rarely implicated in foodborne outbreaks compared with the us and other western countries, it is clearly present in egypt. further studies are required to assess the disease burden of enteric viruses in egypt and the impact of atypical strains. the disease burden of hepatitis a and e in egypt is one of the heaviest worldwide, based on serological analysis, with hav infections occurring very early in life, with almost 100% seropositivity after the first years of life (kamel et al. 2011) . to determine the actual contamination levels in the environment, these authors conducted a survey of hav and hepatitis e virus (hev) in sewage in cairo. hav was detected by rt-pcr in 11 of 76 (15%) sewage samples. in addition, all the hav-positive samples were also positive for enteroviruses. that only one stool sample was hev-positive might be explained by the lower level of excretion of the virus in stools, the fragility of the virion in the environment, and technical difficulties in concentrating and amplifying the virus with standard methods. bacterial etiology was found in 15.2% of cases of childhood diarrhea in dhahira, oman, mostly shigella sonnei and to a lesser extent salmonella (patel et al. 2008) . antibiotics were prescribed in 36.2% of cases and the resistance to the common antibiotics tested was low. one reason for the low pathogen isolation rate could be that many cases had viral etiology. rotavirus was detected in stool specimens from 1712 (49%) of 3470 children, who were admitted to 11 regional public hospitals in oman for a median of 3 days with severe diarrhea (al awaidy et al. 2009) . a diverse rotavirus strain pattern in oman was identified with g2 (37%), g1 (38%), and g9 (11%) accounting for most of typeable strains. the authors estimated the burden for the omani government at us$791,817 and us $1.8 million annually to treat rotavirus-associated diarrhea in the outpatient and hospital settings, respectively. they recommended a rotavirus vaccination program that would substantially reduce the burden of severe diarrhea among children in the country. unlike the above countries where the health care system functions for most residents, though not always to western standards, the same cannot be said for pakistan, particularly in rural areas. poor nutrition combined with diarrheal and other foodborne diseases puts the population at risk for serious illness and death, especially among infant and children in pakistan (akhtar 2015) . cholera, campylobacteriosis, e. coli gastroenteritis, salmonellosis, shigellosis, typhoid, and brucellosis have been demonstrated to be the major foodborne illnesses in the country as well as infectious diseases caused by viral and parasitic agents. many fatalities have been associated with food poisoning but the actual agent has rarely been determined. many health experts believe that rapid spread of gastrointestinal diseases cannot be controlled if the public has no awareness of prevention and control measures against cholera and other forms of gastroenteritis, and that in most parts of the country, sewage is continuously contaminating streams, lakes, springs, wells, and other drinking water sources (qasim 2009 ). in may 2011, an epidemic of diarrhea and gastroenteritis occurred in kamalia, toba tek singh, with over 30 children and others being admitted to hospitals which had few medical supplies. apart from lack of potable drinking water, the main reason given for the rise in cases was the heat of summer when there were frequent power cuts so that food "rots" or becomes "stale" (islam 2011) . in remote areas of pakistan, cholera has been responsible for many outbreaks. two examples in july and august of 2013, both in areas of conflict near afghanistan, give an idea of local but severe outbreaks. in one case authorities seemed not to want to be involved and in the other vaccinations are carried out. although water is the primary vehicle of the vibrio cholerae pathogen, it can easily contaminate prepared foods through poor hygienic practices. in july 2013, five deaths from cholera occurred in pashtoon kot area, balochistan region of pakistan (federally administered tribal areas) along the afghan border (staff 2013), some 70 km from quetta, in the absence of any emergency medical aid. the condition of an additional 20 people suffering from the disease was said to be critical. a local tribal elder expressed the fear that outbreak of cholera might cause loss of life at large scale. he complained that the doctor and paramedics deployed at the basic health center in panjpai live in quetta and are rarely seen at the center. officials of the provincial health department appeared to be unaware about the cholera outbreak and loss of lives (or ignored these), as they sent no medical teams to the affected area. in fact, pakistani government rebuffed international media's claims, and did not respond to requests to dispatch healthcare professionals to the balochistan area. it was assumed the outbreak would continue without medical aid. in 2012, cholera outbreaks killed hundreds of people, mostly children, in flood-hit districts of nasirabad, jaffarabad and jhal magsi where waterborne diseases were reported at a large scale because of consumption of contaminated water by local people. in august 2013, two people died and 320 others had fallen ill, following a cholera outbreak in kurram tribal agency near afghanistan (hussain 2013) . dhand and kudiad khel were the worsthit areas but vaccinations were carried out amid tight security, and tribesmen were instructed not to drink water directly from the well and boil it first instead since the wells had been contaminated from the rain water. around 100 people were shifted to parachinar headquarters hospital, while others were discharged after medical aid. sometimes diseases kept at bay by functioning public health systems come back when these break down as is occurring in a few of the countries embroiled in internal strife and outside attacks. for instance, in iraq in october, 2015, >1800 cases and 6 deaths of cholera occurred which started along the euphrates valley in september with the governorates of baghdad and babil, south of the capital, being the worst affected with more than 500 cases each. the epidemic then spread to the northern autonomous kurdish region, which hosts hundreds of thousands of people displaced by conflict from other parts of iraq (agence france-presse 2015). a previous outbreak killed four people in the kurdistan region in 2012. the united nations says the number of people displaced by conflict in iraq since the start of 2014 has topped 3.2 million which would exacerbate the spread of the disease. authorities blamed the cholera outbreak mostly on the poor quality of water caused by the low level of the euphrates. limited vaccination programs are in place in areas of conflict. in october, 2015, two persons arriving in kuwait from iraq tested positive for cholera and both were provided proper treatment and recovered. the ministry of health recognized that further cases could be discovered among people arriving from iraq, but because kuwait has a well-structured health infrastructure with water and sewers grids, and a supply of healthy and safe food, the disease should not spread into the kuwaiti population (anonymous 2015a) . probably there are some cases in yemen and syria, countries also with limited public health infrastructures, but have yet to be identified. in saudi arabia, a country with a well-maintained health system, the main infectious disease concern today are the infections and deaths arising from exposure to the middle east respiratory syndrome corona virus (mers-cov), which has reservoirs in camels and bats (todd and greig 2015) . a potential food source for this virus and other pathogens is from unpasteurized camel milk, as camel farmers drink the milk as well as being exposed through other aspects of camel contact. this brief review indicates that diarrheal diseases, caused by cholera, dysentery, hepatitis a, salmonellosis, shigellosis, typhoid fever, and other enteric diseases through water and food are major contributors to ill health in the region in agreement with the who (2015b) report on global estimates of foodborne diseases. in the region, not very many outbreaks of foodborne disease tend to be investigated, or at least reported publically, and those that are tend to have fatalities or are very large. for instance, in june, 2009, two children and one adult were brought to a hospital in dubai, uae, with suspected food poisoning (vomiting) after they ate take-away food (the father was out of town). although the mother eventually recovered, the two young children (5 and 7 years old) died, one on arrival and the other the next day. the cause was not determined (saberi and scott 2009) . it is not known if the family or restaurant was primarily responsible for the deadly gastrointestinal attack as bacteria can multiply quickly in the hot summer months, and the public had been recently warned to minimize eating out at this time of year, especially at smaller eateries where hygiene levels are often of lower standard. a toxin was likely involved to cause fatalities so rapidly, but it could have been an accidental contamination of the food with a chemical such as a pesticide, as much as it could have been with an enterotoxin produced by staphylococcus aureus or bacillus cereus through careless ambient temperature storage. unfortunately, this was one episode in a string of incidents, most of them with fatalities, in the county. in april, 2007, a 3-year-old died of suspected food poisoning in sharjah, and in august, a 10-year-old girl died of food poisoning in abu dhabi. in march, 2008, six people fell ill after eating buffet food at a restaurant in the large ibn battuta mall, dubai; in november of the same year, 14 employees at a cement factory were hospitalized after consuming what was considered rotten food prepared at the factory kitchen in another emirate, ras al khaimah. in may, 2009, a 4-year-old girl died of suspected food poisoning in sharjah. the indian family of four rushed to the hospital after series of vomiting but were too late to save the girl. dubai has been reporting foodborne outbreaks and cases through its foodborne disease investigation and surveillance system since 2011; in that year there were 1663 cases reported in the first nine months (saseendran 2014) . in 2013, 1123 suspected cases of foodborne illnesses were reported but only 518 cases were confirmed. no deaths were reported since the surveillance system was in place. egypt has had a particular problem with foodborne illnesses in universities and schools, mostly without a confirmed etiology, which seem to be related to poor food quality. food poisoning is not uncommon in egyptian university dormitories, where basic hygiene standards are often not observed, but the following outbreak was one of the largest. on april 2, 2013 hundreds of egyptian students angered by a mass outbreak of food poisoning at a cairo university stormed the offices of the country's top muslim cleric and university president, ahmed el-tayeb, because of the 479 students who were hospitalized after a meal served at the university dormitories in the nasr city district of cairo (associated press 2013). the university is affiliated with al-azhar mosque, the world's foremost seat of sunni muslim learning, and awards degrees in sciences and humanities, as well as in religious studies. in the protest, thousands of al-azhar students blocked roads, broke into el-tayeb's offices by the main campus, and chanted slogans against the university's management. the causative agent was unknown, and only with the incubation period, types of symptoms and their duration would it be possible to consider the potential etiologies of this illness. because of their poor quality, campus meals were not very popular before they were being blamed for the current food poisoning outbreak. although investigators were not able to find a specific cause, the university suspended its food services director and some other staff members. within a few weeks food poisoning affected 161 students on april 29, 2013 at the same university, al-azhar (masriya 2013) . investigations were initiated within the university and by the ministry of health, and apparently "bad tuna" had been served at the campus cafeteria; no further details were given. if tuna was the vehicle of the outbreak, scombroid poisoning was the likely cause of the illnesses. the allergic-like symptoms generally begin 15-60 minutes after ingestion and usually resolve in a few hours. scombroid fish poisoning occurs after fish, most frequently tuna, with high levels of accumulated histamine or other biogenic amines, is eaten. but "bad tuna' could equally be contaminated with bacterial or viral enteric pathogens with a longer incubation period. a month later there was another outbreak. because at least three outbreaks of food poisoning occurred at al-azhar university between april and may 2013 with over 700 cases of food poisoning detected in the university's male dorms, the dorm's director, the university's kitchen manager and eight chefs were sentenced in november, 2013, to 5 years in prison with a financial bail. in a similar situation, egypt's top prosecutor ordered a swift investigation into the 178 cases of food poisoning reported in two primary schools in october, 2014, in suez (masriya 2014 ). an official of the ministry of education indicated that the poisoning was caused by the consumption of milk provided by the schools. the distribution of milk to all schools in the governorate was halted until the milk's validity was ensured. if milk was responsible, the etiological agent could be bacillus cereus enterotoxin if the onset time was short, or less likely an infectious disease pathogen such as salmonella or e. coli o157:h7. on january 1, 2015, 150 female students were diagnosed with food poisoning at al-azhar university in upper egypt's assiut/ asyut governorate, by the banks of the nile, and were briefly hospitalized in an assiut city (anonymous 2015b) . this follows a similar incident which occurred in april 2014 when 29 students, also in the girls' dormitories, contracted food poisoning on the university campus in luxor. this report also flags two major poisoning incidents involving at least 500 students ill consecutively at its campuses in cairo in 2013 (probably the ones already discussed). the reason given for these repeated mass foodborne illnesses among university students is the quality of the food served them. apparently cheap, subsidized food is poorly stored, cooked and distributed to the poorer university students. in most cases the attorney general would open a criminal investigation that would be closed without knowing the microbiological cause of these outbreaks. the promed-mena editor speculated that enterotoxins of staphylococcus aureus were the most probable cause of such communal food poisoning, as a toxic dose of less than 1.0 microgram in contaminated food is sufficient to produce symptoms of staphylococcal intoxication. this toxin level is reached when s. aureus populations exceed 100,000/g, a condition likely to be present in these university kitchens because of intense pressure on them to feed a huge number of students in a short time, taking into consideration that most of these kitchens lack basic hygienic measures with regard to safe food handling. the editor also considered shigella, with its low infective dose (10-200 depending on the species) as another possible agent. however, the incubation period and symptoms of s. aureus intoxication and shigellosis or dysentery are quite different. pakistan is similar to egypt in that much of the country is rural but with very large cities with high populations (total population is 89 million in egypt and 184 million in pakistan, the most populous of all middle eastern countries). in september, 2010, more than 250 of the 1400 flood victims at a relief camp in bengali boys sindhi section school in ibrahim hyderi vomited after eating cooked food and then fell unconscious; 59 of them had to be taken to a nearby hospital (aligi 2010) . a local philanthropist had been providing cooked food to the flood victims but by the time the food arrived at the relief camp, the cooked rice had turned "stale". since the rice did not show any sign of spoilage, it was served to the flood victims. a similar incident had taken place 3 days earlier at another town where more than 80 flood affectees had fallen unconscious after consuming "stale" food and 10 were hospitalized. none was seriously affected. during the investigation, it was noticed that the sanitary situation in and around the relief camps was very poor. even though the reason for the illness was not determined, the police took action against the donor and two caterers. in fact, based on the information of the vehicle and the symptoms, bacillus cereus enterotoxin which is known to be produced in boiled rice, was the most likely agent. in the following two outbreaks yoghurt is blamed for the serious illness and deaths though details of the symptoms are not given. rapid onset of symptoms indicates the presence of a toxin of some kind, although yoghurt is not a food known to be frequently contaminated with pathogens because of its high acidity. either the yoghurt was made under very unhygienic condition with the source of the milk perhaps being spoiled (possibly containing bacillus cereus enterotoxin), or a chemical had been added accidently such as a pesticide, or deliberately and illegally to enhance the flavor. however, it is possible other foods were involved and yoghurt was not the contaminated vehicle. in january 2011, in lahore, a hospital employee died and two other employees became critically ill after eating contaminated yoghurt. the three employees ate rice with yoghurt at a local restaurant (ians 2011) . action was taken against the restaurant owner and manager. no further details are known. in early april, 2014, a rawalpindi family of ten became seriously ill after eating a home-prepared evening meal where yoghurt was suspected to have been the contaminated food, and they were taken to a hospital, where a teenage boy and 7-year-old girl died (asghar 2014) . the surviving family members remained in critical condition for some time but eventually recovered; the cause of the illnesses was not discovered, although it was postulated by a relative who had eaten the yogurt with the meal that it was possibly poisonous or, strangely he thought a lizard might have fallen into it. in february 2012, at least four people died and another seven were hospitalized in a critical state after eating home-cooked biryani (a dish made with spices, rice and meat or vegetables) in a suburb of karachi (mahmood 2012) . the owner of a grocery shop, who provided the ingredients, was arrested, and a sample taken for analysis. it is not known if any toxin was found. a month later in march, in faisalabad, more than 60 children and women were ill after eating contaminated aalo-chanay (potatoes, chick peas, onions, tomatoes and spices) purchased from an unidentified vender (anonymous 2012c) . as soon as the children ate the aalochaney, they felt ill and started vomiting. although they were immediately rushed to a rural health center, one boy died. a medical opinion was given that the eaters suffered from "diarrhea and cholera". however, the onset was too rapid for anything but a toxin of some kind, most likely heat-resistant since the aalo-chanay was cooked. also, in march 2012, as many as 47 student nurses and eight staff nurses were hospitalized with acute food poisoning at a hospital in rawalpindi after eating food at the nursing hostel, but none was critically ill (anonymous 2012d). the nurses residing in the hostel started reporting complaints of vomiting and diarrhea along with high-grade fever at an undisclosed time after a meal. the hospital administration was criticized for failing to provide safe food and drinking water to its employees and demanded immediate inquiry into the case, but none was reported on. the illnesses are consistent with an enteric infection such as salmonella or norovirus. in april 2015, at least 20 constables suffered from diarrhea and were admitted to hospitals when they ate food during the sehat ka insaf program, which is a blanket method of administering the polio vaccine along with eight other vaccines, hygiene kits and vitamin a drops in order to circumvent polio-specific terrorist attacks in pakistan. local administration purchased packed food, including piece of chicken and juices from a local supporter (mayar 2015) . no further details are given but the chicken could have been undercooked or cross-contaminated with enteric pathogens such as salmonella and campylobacter; if the packs had been left at ambient temperatures for some time, these pathogens could have multiplied on the chicken to large numbers. over thirty children in faisalabad were hospitalized over 4 days because of diarrhea and gastroenteritis, three seriously, and other children were expected to be ill. undetermined contaminated food was postulated as the cause, more than usual because of the extreme seasonal heat combined with frequent power outages to allow rapid bacterial growth in contaminated food. the unavailability of clean drinking water was mentioned as a contributing factor to the increasing number of gastrointestinal disease cases. hospital administrators complained that vaccines and medications were required but were not forthcoming from the health department. probably many family meals were contaminated because of the lack of potable water and any unspecified enteric bacterial pathogens present could grow rapidly in the heat. children are more vulnerable than healthy adults to infections which might explain the high proportion of sick children seeking medical help. botulism outbreaks occur periodically in iran. in a study of stool and serum specimens of 115 patients with clinical symptoms of botulism, who were at inpatient and outpatient medical centers in tehran and other areas of iran, between april 1984 to august 1994, specimens of 73 patients showed the toxin and spores of c. botulinum (modarres 1997) . type e was the most common causative agent found in this study, being responsible for 71.2% in all specimens; other etiologic types, in order of frequency were types a (16.4%) and b (12.3%). type e strains are typically associated with fish and freshwater and marine sediments. the results of this study indicate that the cases had consumed salted fish, smoked fish and canned fish, along with cans of green beans and cucumbers. a similar result over a decade later confirms that c. botulinum type e is a major pathogen in iran. in gilan province, of 146 fish samples collected in 2008, 11% of processed fish and 7.5% of non-processed fish contained clostridium botulinum, mainly type e (tavakoli and imani fooladi 2011) . the processing is insufficient to kill the spores or reduce much of toxin produced because the fish tend to be partly cooked with the intestines kept intact. a total of 131 traditional food product samples (57 cheese, 11 kashk [a type of dried yoghurt or thick cream], and 63 salted fish) were examined using a bioassay method for detection of clostridium botulinum toxin (hosseini et al. 2010) . standard monovalent antitoxins were used to determine the toxin types. c. botulinum toxins were detected in 4.6% of examined samples (3.5% of cheese samples and 6.4% of salted fish samples). none was found in kashk samples. c. botulinum types a and e were dominant in cheese and salted fish samples, respectively. consumption of these traditional foods either raw or processed may contribute to foodborne toxicity in iranian populations. in may 2014, a quickthinking mother immediately brought her 7-month old boy to an israeli hospital when she saw he was suffering from vomiting, difficulty in breathing, listlessness, glassy-eyed, apathetic, and an inability to nurse or eat (bender 2014) . a doctor at the hospital diagnosed the child as suffering from infant botulism. he decided to treat the baby with the antitoxin stored in the emergency stocks, even before they got back the lab test results. the hospital like all israeli medical facilities keep ample supplies of biological and chemical warfare antidotes on hand in case of war or terrorist attacks, and staffers are regularly drilled in dealing with the symptoms of various chemical, neural and blister agents. the infant started recovering soon after the administration of the antidote. in the rare disease of infant botulism, spores of clostridium botulinum are ingested and the infant's flora is not mature enough to prevent germination and slow growth of the toxigenic pathogen. it is entirely possible that infant botulism occurs more frequently in the region but is not diagnosed. foodborne disease surveillance depends on an infrastructure of reporting and diagnosis in hospitals, epidemiologists, and food testing laboratories. lebanon is an example of a country where modernization in public health seems to occur at a glacial pace. however, diseases including those of foodborne and waterborne origin, are documented and published. the law of december 31, 1957 regarding communicable diseases in lebanon mandates all physicians, from private or public sectors, in hospitals or ambulatory services, to declare to the epidemiologic surveillance unit of the moph all diseases considered a risk to public health. the data available at the ministry of public health (moph) are compiled from different sources, and the declaration of cases remains irregular and insufficient (moph 2012) . in 2011, foodborne and waterborne diseases were the most frequently reported in lebanon at a rate of 0.4 â�° (total of 1468 cases), with the highest rate in the bekaa (0.7 â�°) and the lowest in the south (0.1 â�°). the most common infection was viral hepatitis a, which represented 30.5% of the total food and waterborne diseases with 448 cases. there were also 362 cases of typhoid (24.7%), 311 cases of food poisoning (unspecified, 21.2%), 186 cases of dysentery (12.7%), 34 cases of brucellosis (9.1%, 15 cases of parasitic worms (1.0%) and 12 cases of hydiatic cyst (0.8%). no cases of cholera and trichinosis were declared. hydiatic cyst (cystic echinococcosisis) caused by echinococcosis (typically e. granulosis) is acquired by contact with animal feces contaminated with tapeworm eggs. sources include contaminated food (meat), water, and animal fur. cysts containing tapeworm larvae may grow in the body for years before symptoms appear. when cysts become large, they may cause nausea, weakness, coughing, and belly or chest pain. occasionally, well-investigated outbreaks are published; the following two examples are from lebanon and neighboring jordan. in may 2004, 32 employees suffered from diarrhea, fever, and abdominal pains 5.5-22.5 h (mean, 10.3 h) after eating chicken noodles au gratin at a catered lunch served at a bank cafeteria (hanna et al. 2009 ). a few cases had systemic infections. salmonella enteritidis (se) was confirmed in stool and blood cultures within 48-72 h after hospital admission of the first cases, and also in leftovers of the suspect food. the same dish had been served at the bank in the past with no apparent health problems. preparation normally started in the evening prior to the day the dish is served. however, in this instance, some of the constituents had been prepared 3 days ahead, because the dish was to be served on a monday, immediately after the week-end closure. no salmonella was found in rectal and nasal mucosal swabs taken from all 18 kitchen workers, or in the tanker water supply (although it had high fecal coliform counts), but se was found in a frozen batch of the same raw chicken breast consignment that had been used for the chicken noodles. the batch of chicken came from a large producer of poultry and eggs in lebanon, who was advised of its potential involvement in a major foodborne outbreak. however, the investigators were refused access to the poultry-producing facility. it is highly likely that contaminated chicken carcasses had been, and would continue to be, shipped to many parts of lebanon. that the same se strain occurred in the patients, the raw chicken, and the leftover food was confirmed through random amplified polymorphic dna polymerase chain reaction (rapd-pcr). it would appear the 3-day delay in the chicken noodle preparation was significant in allowing the salmonella present in the ingredients not only to survive but probably to grow; undercooking, cross-contamination, inadequate storage and reheating all may have played a role in the outbreak, but no more information was available to determine which of these were the key factors in the outbreak. the bank management decided to sue the caterer and because they were aware of apparently inefficient way that public authorities were conducting the procedure, they took the initiative to call upon an independent investigative team to obtain solid evidence to win any court action. the caterers, concerned that they would be the only party blamed for the salmonella outbreak, had succeeded in concealing some raw and cooked items from destruction by the public health authorities, which was their normal practice after a complaint. these items were central to establishing contamination upstream from the caterer's kitchen. no action seems to have been taken against the poultry producer who was the source of the se, a pathogen that is invasive of flocks and difficult to eradicate. the authors complained about the obsolete lebanese laws dating back to the 1930s that still governed what should be done following a report of "food poisoning". public health officers are mandated to stop the spread by destroying allegedly contaminated food items and closing down incriminated facilities. hanna et al. (2009) stated that this kind of action is generally lauded by the public but does not help determine the cause to develop appropriate prevention and control strategies. they also complained that because no investigation is typically done, many non-implicated foods and ingredients are wastefully discarded. the jordanian example is over two decades old, but is worth noting in detail. in september 1989, a 183-case outbreak of salmonellosis occurred in a university hospital in amman after employees, patients and visitors ate in the cafeteria. the incubation period ranged from 16 to 72 h. symptoms included diarrhea (88%), fever (71%), abdominal pain (74%), dehydration (34%), and bloody stool (5%); 84 were hospitalized (khuri-bulos et al. 1994) . cultures of eight food items were negative, but stool culture on 90 of 180 patients and 11 of 61 kitchen employees yielded salmonella enteritidis (se) group d1. a cohort study revealed a foodspecific attack rate of 72% for the steak and potato meal and 18% for the rice and meat meal. stratified analysis of the steak and potato meal revealed that the potatoes were implicated most strongly. cultures were obtained from all kitchen employees, who showed no symptoms of illness, but 11 of 61 grew se group d1. one asymptomatic, culture-positive employee had prepared the mashed potatoes on september 23, 16 h before the first case presented at the hospital emergency with severe gastroenteritis symptoms. all of the food workers had negative stool cultures 3 months earlier. the potatoes were mashed by machine, but peeled after boiling and mixed with milk by hand, using a ladle but no gloves. two different batches, the first of which was served exclusively to hospitalized patients and the second to a few remaining patients and employees, were prepared and served within 30 to 60 minutes of preparation. from the epidemiological data it can be assumed that the infected handler fecally contaminated only the second batch of potatoes, thus sparing most of the highly susceptible inpatients from exposure. furthermore, while potatoes clearly were implicated, individuals who ate steak only had an elevated risk of being attacked. this probably was due to surface contamination of foods being served on the same plate. kitchen employees harboring salmonella were excluded from work until they had three negative stool cultures taken 1 week apart; it took 6 weeks for them to return to work. stool surveillance that was routinely carried out in the hospital was ineffective in detecting infected employees to prevent this outbreak and the investigators recommended that employees adhere to proper hygienic practices including thorough washing of hands, especially when preparing food. today, salmonella is only one of many of the pathogens that can be encountered in foodborne illness. one of the newer pathogens, well established in the west is norovirus (nov), which causes more cases of foodborne disease in the u.s. than any other agent (scallan et al. 2011 ). in may 2009, a significant increase in acute gastroenteritis (age) cases was noted in the american health clinic at incirlik air base (iab) in adana, turkey. this increased rate of age led to discussions with local turkish military public health authorities, which confirmed that the turkish military community and the residents of adana were also experiencing an anecdotal increase in age illnesses (ahmed et al. 2012 ). an epidemiologic investigation was launched to attempt to identify the cause and possible source of this age outbreak at iab from may to june with the peak incidence of cases during the week of may 31-june 6, with a total of 71 patients seeking medical care at the clinic. of the total 187 infected persons, 82 patients completed the case survey, 79% reported diarrhea, 46% reported vomiting, and 29% reported fever. the median number of days between symptom onset and clinic visit was 2 days. during the 7 days prior to symptoms, 73% of respondents reported travelling off base, 56% reported eating off base, and 24% reported using an outdoor pool. this outbreak had a significant negative operational impact, degrading mission readiness with nearly 20% of the american population in a 1-month period affected. initiation of a clinic case-based investigation yielded 37 stool specimens in which nov was detected in 43%, with 81% of the positive nov specimens identified without a copathogen. dna sequencing data demonstrated that several relatively rare genotypes of nov contributed to this outbreak; four different genotypes were isolated from 16 positive specimens. two of the nov strains were previously reported in iraq and only from deployed troops, while the other two genotypes were reported in south africa and in the us. in turkey, little systematic data on circulating nov genotypes exist. however, giib/gii.4 strains have been frequently identified in turkish children with gastroenteritis; strains belonging to this genotype have been found in europe and mainly in children. previous reports from british troops deployed to iraq indicated that two nov strains isolated were responsible for cases of gastroenteritis there. similar mixed nov outbreaks have been previously observed and are often attributed to systematic failure of cooking/cleaning/drinking water supplies (ahmed et al. 2012) . one limitation of this investigation was that the survey was not used to capture data from a control group, those without recent age, preventing carrying out a risk factor analysis. another limitation was the lack of environmental samples that could be tested for nov in order to track the source of outbreak. from anecdotal information, it is likely many in the local population and the turkish military base were ill, but a formal outbreak investigation in the turkish population was never performed. from the multiple genetic types involved, one specific contaminated food or water source seems unlikely. the largest turkish nov outbreak was in keã§iborlu province of isparta county between april 5 and 17, 2010, with 1428 patients seeking medical help from the healthcare centers, after suffering from nausea, vomiting and abdominal pain (more frequent than diarrhea) (sâ�¬ ozen et al. 2014) . because of underreporting, the number of affected people was estimated to be higher. municipal water was the suspected source but no samples tested positive. as a cautionary note, the authors suggest that nov may not be the only causative agent of gastroenteritis outbreaks, especially from an undetermined fecal source, and bacterial, viral and parasitic agents should be examined together with the nov. in saudi arabia, a national policy for reporting, notifying, and recording incidents of bacterial food poisoning was established in 1984 (al-joudy et al. 2010). since then salmonella food poisoning outbreaks have been reported from different regions of ksa, exhibiting seasonal and regional variations, with chicken, meat, and rice being commonly incriminated food items, and frequently reported in the saudi epidemiological bulletin. al-mazrou (2004) reviewed the history of foodborne outbreaks in ksa and saw an increase over the last few decades, especially those caused by salmonella, with the main food vehicles being chicken, meat and eggs, and s. enteritidis being the most frequent salmonella serovar responsible. according to promed editorials, restaurants and communal feasts and institutional feeding (such as in school cafeterias, hospitals, nursing homes, prisons, etc.) where large quantities of food are prepared several hours before serving are the most common settings in which foodborne illness incidents occur (http://www.promedmail.org). for instance, in 2005, a hospital in the jizan region received 19 suspected food poisoning cases that were ill after taking meals from a restaurant, including a woman who suffered from severe diarrhea, abdominal pain, vomiting and dizziness (fagbo 2005) . the restaurant was closed down and three of its workers were detained pending the results of laboratory tests. the report of an investigative committee could not find a specific cause, but noted that the restaurant had earlier been responsible for some hygienic violations. in 2015, 80 cases suspected of foodborne illness after eating a meal at a restaurant were admitted to various hospitals in the najran region (alhayat 2015) . most of the cases were not seriously ill. no report was given on the samples that were taken from the suspected restaurant, which was closed temporarily. there is an interesting observation related to variant creutzfeldt-jakob disease (vcjd); four cases have occurred in the us since the disease was first diagnosed in the united kingdom in 1996 linked to consumption of cow meat suffering from bovine spongiform encephalopathy (bse); two of these were associated with the united kingdom (where bse was first reported), but one came from saudi arabia and the most recent case in 2014 had extensive travel to the middle east and europe (cdc 2014) . this may indicate some source of vcjd in the middle east including saudi arabia. one of the big concerns for ksa is the annual hajj with millions of muslims from around the world converging on mecca, in saudi arabia, each year. no other mass gathering can compare with the hajj, either in scale or in regularity, and various communicable disease outbreaks of various infectious diseases have been reported repeatedly, during and following the hajj (memish 2010) . in 2006, an outbreak during the hajj occurred where all the cases came from one tent occupied by 50 soldiers located in a government camp in mina, makkah province, near mecca (al-joudi 2007). the camp was served by a catering company that prepared and distributed three meals daily (breakfast, lunch, and dinner). a case was defined as any individual who developed diarrhea with or without abdominal pain after eating at the camp in mina in january, 2006. of the soldiers who were interviewed, 16 (39%) had developed gastroenteritis, most commonly manifested by diarrhea (100%), and abdominal pains (87.5%). the mean incubation period was 12.6 ae 4.9 h and the epidemic curve suggested a common point source outbreak. out of three served meals, lunch with a rice dish was found to have a statistically significant association with illness. unfortunately, no food remnants were found for sampling, and the results of stool cultures of all diarrhea patients, and rectal swabs from all food handlers were inconclusive. temperature abuse was cited as a contributory factor in this outbreak. based on the incubation period and symptomatology, bacillus cereus would be the most likely etiological agent. another example of a foodborne illnesses associated with the hajj occurred in 2011 when 81 bangladeshi pilgrims were taken to hospitals in madina (medina) after eating a meal prepared by an unlicensed caterer (promed-mena 2011). they suffered from abdominal pains associated with diarrhea and vomiting. the pilgrims were all treated and discharged, except for one who remained hospitalized. samples of the food they had eaten were sent for analysis but the results are not known. considering the mass of people converging on this small part of the middle east, it is surprising there are not more foodborne disease outbreaks. this may mean excellent food control by the authorities or some illnesses are simply not recognized and reported. at least 750 bahrainis suffered from food poisoning after eating catered sandwiches served during a wedding celebration, the biggest mass poisoning outbreak in the country's history (promed-mena 2002) . the wedding took place in the safala village, near the eastern island of sitra. all eventually recovered after treatment but one man who had sickle cell disease, died. teams were formed to investigate the outbreak, and blood specimens from all workers at the bakery who prepared the egg, cheese, and mayonnaise sandwiches along with leftover sandwiches and their ingredients on the caterer's premises were sent for bacteriological analysis. the bakery which supplied the sandwiches was closed by the public health directorate at the ministry pending the investigation's results. unfortunately, no final report was released to the public. the promed editor considered the etiological agent could be salmonella or staphylococcus aureus enterotoxin, depending on the length of the unstated incubation period. the region experiences some unusual type of illnesses relating to on-going hostilities. for instance, the united nations has been sending aid to reach besieged towns in syria, close to the lebanese border, but in october, 2015, it sent hundreds of boxes of "moldy" high-energy biscuits past their 'sell-by' date in september (320 of the 650 boxes transported) to zabadani and madaya, apparently causing food poisoning (afanasieva et al. 2015; muhkalalati and kieke 2015) . officials stated these could be the only cause of an outbreak of food poisoning among almost 200 residents who came to makeshift hospitals, mainly children who had vomiting, diarrhea and abdominal swelling almost immediately after eating the biscuits. the biscuits were described as "moldy and rotten and had been poorly stored". apparently, when the last aid order that was sent was filled, there was a shortage of food. the red crescent, who was filling the order, took some of the expired goods to complete it. however, these biscuits had only just expired and normally would not have posed any health risks to those eating them. nevertheless, the words poorly stored suggest that moisture may have encouraged microbial growth (visible mold more likely than bacteria because fungi can grow aerobically in the presence of the presumably elevated sugar content in the high energy biscuits). also, contributing to the symptoms, the residents of zabadani and madaya had been blockaded for 120 consecutive days, and their immune systems were extremely weak. refugees are also at risk of gastrointestinal diseases from contaminated water or food. up to two million syrian migrants fleeing syria due to the civil war were living in turkey, and supplying them with safe and secure food supplies is a challenge for any host country. one incident, no doubt, one among many indicates the risk of contaminated food. in april, 2015, five security forces were injured after syrian migrants in a tent city in turkey's southeastern province of mardin reportedly attacked guards over allegedly being poisoned from the lunch at the camp (anadolu agency 2015). some 17 syrian migrants were detained after the incident; 66 syrian migrants out of the 5230 currently residing in the temporary sheltering center in mardin's derik district applied to the center's hospital with symptoms of food poisoning, dizziness, and vomiting. after treatment they were discharged, none of them in a critical condition. although an investigation was conducted and samples from the lunch sent to the lab for analysis, no further information was available on the outbreak. promed speculated that if the lunch food was the vehicle, it would be a short incubation illness likely caused by staphylococcus aureus, bacillus cereus, clostridium perfringens, or possibly a non-biological toxin. these illnesses may cause vomiting, diarrhea, or both, and are usually short in duration (less than 24 h), and are not associated with prominent fever. in iraq, no recent foodborne disease outbreaks have been published, but no doubt many have occurred in the last decades with so much public health infrastructure dismantled. only the most newsworthy of outbreaks are being covered by the press today. iraq and other middle eastern countries are in sectarian turmoil and on two occasions islamic state (isis/is/isil) fighters (jihadis) were likely poisoned by cooks who infiltrated their camps. in november, 2014, a group of defected syrian soldiers (free syrian army men) who posed as cooks reportedly poisoned isis militants after they ate a contaminated lunch at the fath el-sahel camp, where 1200 of them were based (gee 2014 ). apparently about a dozen of the jihadis were killed and 15 taken to nearby field hospitals. the 'cooks' immediately fled, along with their families, with the help of fellow revolutionaries. seven months later, in july 2015, 45 jihadis died after ingesting an iftar meal eaten by 145 isis militants (akbar 2015; variyar 2015) . it remains unclear whether the jihadis, who were breaking their ramadan fast in mosul, iraq, died of accidental food poisoning or intentional poisoning, but it is likely a repeat attack of the earlier incident described above. the nature of the poison or details of the illnesses in either episode are not known. however, in both episodes, onset and severity of the attack were rapid, probably caused by a relatively tasteless chemical in lethal doses added to one or more foods. targeting the military by any means including poisoning food has always been a strategy of opposing forces. in february 2012, a deliberate attack was foiled when afghan border police detected a significant amount of bleach in fruit and coffee stored at their main border checkpoint between afghanistan and pakistan, a likely attempt to poison the afghan security forces (tucker 2012) . the police decided that although none of this food had been consumed, the level of contamination was high enough to cause serious injury, and it must have been done intentionally. there had been previous incidents of intentional food poisoning aimed at afghanistan's civil defense forces, including an episode in kabul in 2011 when several people were sickened. in 2012, in southern helmand province militants killed four afghan policemen and two civilians inside a police checkpoint by poisoning their yoghurt coordinated with an attack (anonymous 2012a). there had been several recent poisoning incidents involving members of the afghan national police, as part of attempts by the taliban to infiltrate the security forces; three police officers were reported missing, along with their weapons and a police vehicle, following that attack in helmand province. taliban militants had first poisoned the police officers' yoghurt before launching a full scale attack on the checkpoint. similar tactics had been used by insurgents in helmand before. the same thing happened again in january 2016 when a rogue policeman collaborating with insurgents in southern province of uruzgan shot dead 10 colleagues after first poisoning their food, but no further details are given (reuters 2016 ). turkey does have food laws that are supposed to limit food contamination and resultant foodborne illnesses. the 2000 turkish food code stipulates that all turkish food businesses have to provide food hygiene training commensurate with the work activities of their staff. to see what progress had been made in this area baå� et al. (2006) evaluated knowledge, attitudes, and practices concerning food safety issues among food handlers in ankara, conducting face to face interviews and administrating questionnaires. the majority of the 764 food handlers who responded (47.8%) had not taken a basic food safety training (and probably most of non-respondents had not either). the mean food safety knowledge score was 43.4 ae 16.3 of 100 possible points. the self-reported hygienic practices showed that only 9.6% of those who were involved in touching or distributing unwrapped foods always used protective gloves during their working activity. of those food handlers who used gloves, only 8.1% and 3.8% always washed their hands before putting them on and after removing them, respectively. in addition, there was a difference handlers' scores depending on where they worked. scores were higher for food handlers in catering establishments (50.4 ae 9.4), school food services (52.5 ae 9.2) and hospital food services (50.9 ae 9.2) than restaurants (47.3 ae 8.6), hotels (47.4 ae 8.3), takeaways (44.1 ae 2.5) and kebab houses (37.9 ae 6.7). these scores may also be biased upwards since they were self-reported and not observed practices. the study demonstrated that food handlers in turkish food businesses often have lack of knowledge regarding the basic food hygiene, e.g., critical temperatures of hot or cold ready-to-eat foods, acceptable refrigerator temperature ranges, and cross-contamination. those who were trained scored better, and the authors stated there was an immediate need for education and increasing awareness among food handlers regarding safe food handling practices. in istanbul from 2005/2006, thermophilic campylobacter was isolated from 11.1%, 21.6%, and 50.4% of beef, mutton, and chicken samples tested, respectively (bostan et al. 2009 ). there was no significant seasonal variation in the prevalence of the pathogen. c. jejuni was the species most commonly isolated from chicken meat, while c. coli was the most common in beef (63.3%) and mutton (63.9%) carcasses. campylobacter isolates were most often resistant to tetracycline (69.1%), followed by trimethoprim-sulfamethoxazole (64.2%), nalidixic acid (58.1%), erythromycin (56.9%), enrofloxacin (48.8%), ciprofloxacin (42.7%), chloramphenicol (36.2%), and gentamicin (26.0%). the results of this study suggest that a high proportion of meat samples, particularly chicken carcasses, are contaminated by campylobacters, most of which are antimicrobial-resistant strains. in yemen, the prevalence of salmonella in food was determined in sana'a city from april 2009 to april 2010 by ahmed (2013) . of the 362 different food samples collected from local markets, salmonella spp. were isolated from 26 (7.2%). the highest prevalences were in red meat (14.7%), chicken (12.1%), eggs (11.8%), cooked foods (9.5%), raw milk and milk products (5%), juices (4.8%), vegetables (4.4%), sandwiches (3%), and pastries (2.6%). serogroups identified were b, c1, c2-c3, d1, e1, and e4, and some foods contained more than one isolate with different serogroups, especially red meat. because handlers in foodservice facilities play a major role in transmission of foodborne diseases (greig et al. 2007) , studies have been carried out to demonstrate their knowledge of practices related to food safety. in jordan, osaili et al. (2013) measured food safety knowledge of food handlers working in fast food restaurants in the cities of amman and irbid. a total of 1084 food handlers in 297 fast food restaurants participated in this question survey study. the overall knowledge of food handlers on food safety concepts was considered to be fair (69.4%). the food safety aspect with the highest percentage of correct answers was "knowledge of symptoms of foodborne illnesses" (81.7%) and "personal hygiene" (79.9%), while the lowest percentage of correct answers was for "safe storage, thawing, cooking and reheating of the foods" (52.4%), critical practices to prevent the survival and growth of pathogens. the mean knowledge score of "personal hygiene" reported in the study was much higher than 51.5% and 31.8% reported by martins et al. (2012) and baå� et al. (2006) , for the food handlers in portugal and turkey, respectively. also, only 31.9% of respondents considered the duration of hand washing to be !20 s. when they were asked how they check that the poultry is sufficiently cooked, only 31% knew "when the meat has the correct thermometer reading", although 85% of the respondents had thermometers in their restaurants. about 25% of them answered that poultry is cooked "when it has been cooked for the stated time" (24%) and "when it looks cooked" (27%). about 50% of them would store leftovers on the steam table (40%) and in the refrigerator (53%) while about 27% of the correspondents would store leftovers at room temperature in kitchen or in the oven. a low percentage of the respondents (20%) reheated leftovers to the appropriate temperature (73 c). about 40% and 20% of the respondents had heard about salmonella and hepatitis a virus, respectively, but 10% of the respondents knew about listeria monocytogenes, staphylococcus aureus, bacillus cereus, escherichia coli o157:h7, clostridium perfringens, campylobacter jejuni, or shigella. food workers who had enrolled in a food safety training course had significantly higher total food safety knowledge score than those who did not take any training. there was no association between the experience or any other characteristic of food workers and total food safety knowledge score. this study suggests adopting proper food safety education training courses to food handlers, periodic evaluation of food handlers' knowledge and food safety training course materials. also, the authors considered that better pay for food handlers would improve the food safety status in foodservice institutions. similar concerns over practices that could lead to food contamination and foodborne illnesses were demonstrated in lebanon. a survey was conducted in beirut to evaluate the knowledge, attitudes and practices related to food safety issues of food handlers (n â¼ 80) in foodservice establishments (n â¼ 50), and to assess the influence of management type on enactment of safe practices on food premises (faour-klingbeil et al. 2015) . the data suggest that while respondents do have some knowledge of food safety aspects, substantial gaps in their knowledge and self-reported practices associated with critical temperature of foods and cross contamination remain, therefore posing health risks to consumer health. food handlers in corporate managed food outlets showed a significantly higher awareness on food safety practices. it is concluded that the management type is an integral element of the theory of planned behavior that influence food handlers' practices and substantiate the need for more research work on safe food handling in the context of food safety culture framework in food businesses. as in many other mena countries, there is a critical need for food safety education interventions and technical guidance fostered by synergistic participation of the private and public sector to support food handlers in smes (small and medium sized enterprises). parasites are not often looked for in middle eastern countries but they are frequent, and one of the ones of most concern for pregnant women is toxoplasma gondii which is transmitted through undercooked meat and cat feces. since stray cats are common in some localities, of 240 fecal samples of stray cats examined in kuwait, 22 (9.2%) were found to be infected with oocysts of coccidian protozoa (abdou et al. 2013) . toxoplasma gondii was found in 2.1%, and cats <6 months old had higher infection rate with oocyst of enteric protozoa than older cats. a serosurvey of the 240 stray cats revealed that 19.6% were positive to t. gondii igg. toxoplasma sero-positivity was observed in a higher number of adult cats compared to younger ones suggesting that with age the risk of exposure to t. gondii increases. thus, pregnant women handling cats and particularly kittens or cleaning out sand boxes have a chance of infecting their fetuses and eating raw meat. in pakistan, enteric pathogens are present not only in water but also foods contaminated from the environment or through human actions. mishandling of foods allows these pathogens to contaminate and multiply in them. for example, street-vended fruit salads, locally called fruit chats, offered for sale at high ambient temperatures without coverings, and khoya and burfi, two indigenous sweet dairy products, and locally produced ice cream are often heavily contaminated with enterobacter, e. coli, klebsiella, salmonella and s. aureus (akhtar 2015) . these contamination scenarios have led to outbreaks with cases severe enough to be hospitalized. bus and train stations where pulses (edible seeds of various crops as peas, beans, or lentils), ground meat dishes, and chickpeas are sold to passengers, and are also heavily contaminated with bacteria including clostridium perfringens. sweet dishes and home-prepared foods in small communities are commonly contaminated with s. aureus, c. perfringens, and bacillus cereus leading to rapid intoxications. one study confirmed campylobacters to be present in 48% of 1636 tested samples of milk and meats and 40.9% of vegetables in three major cities of pakistan (akhtar 2015) . a wide array of vegetables is routinely consumed in this country and serve as a rich source of vitamins, minerals, bioactive compounds, and fiber but these can be sources of enteric infections if they are consumed contaminated. shigella spp. has been shown to develop resistance and is generally thought to be a major cause of foodborne illnesses, especially among the poor where health care facilities are minimal; shigellosis is associated with poor sanitary conditions and unsafe water for drinking and preparing foods. possible etiologies can be postulated in the following outbreaks. unfortunately, it is not only pathogens that give rise to food-associated disease. soomro et al. (2008) highlighted the indiscreet use of pesticides in agriculture and its impact on environmental pollution. despite the increased production cost associated with extensive use of pesticides, their use is common in developing countries. numerous studies have demonstrated substantial levels of pesticide residues in various foodstuffs in pakistan, and the groundwater has been observed to be considerably polluted in many parts of punjab and sindh provinces of pakistan (akhtar 2015) . commonly used open rural wells in the punjab were polluted with six pesticides: bifenthrin, î»-cyhalothrin, carbofuran, endosulfan, methyl parathion, and monocrotophos. in the hyderabad region 61% of the tested samples of eight vegetables (cauliflower, green chili, eggplant, tomato, peas, bitter gourd, spinach, and apple gourd) were found to be contaminated with pesticide residues exceeding maximum recommended limits (mrls) (tariq et al. 2003; anwar et al. 2011) . heavy metals such as cadmium (cd), copper (cu), lead (pb), and zinc (zn) arising from increased industrialization can contaminate agricultural soils and these can be found in fruits (including widely-consumed mangoes), fruit juices, vegetables directly from soil uptake or from the processing and packaging (akhtar 2015) . for instance, spinach, coriander, and peppermint, grown in sindh province contained 0.90-1.20 mg/kg of arsenic resulting in a total ingestion of arsenic 9.7-12.2 î¼g/kg body weight/day in diet (arain et al. 2009; khan et al. 2010) . aluminum concentration in branded and nonbranded biscuit samples from hyderabad were found to range 7.4-84.3 and 34.5-70.2 mg/kg, respectively (jalbani et al. 2007) . similarly, javed et al. (2009) detected higher concentrations of cd, cr, ni, and pb residues (mg/l) in bovine and goat milk. pakistani foods are more prone to aflatoxin contamination because of the warm and humid climate, and the situation is exacerbated by malpractices during handling and storage of edible commodities (mobeen et al. 2011) . samples of broken rice, wheat, maize, barley, and sorghum ranged 15-45% with the highest aflatoxin concentration (15.5 î¼g/kg), in wheat samples (akhtar 2015) . chilies are widely eaten and exported, but aflatoxin levels can be eightfold higher than the eu permissible limits to pose a potential health risk to pakistani consumers; concentrations can be reduced by more appropriate care and handling of the chilies at pre-and postharvest stages. nuts and dried fruits in pakistan are cultivated and processed in the northern areas and have been shown to have aflatoxin levels above the eu limit of 4 î¼g/kg in up to 70% of samples (ahmad et al. 1989; luttfullah and hussain 2011) . aflatoxin m1 in milk and milk products requires regular monitoring in pakistan since 3% of the total tested samples of milk were found to exceed the us tolerance limit of 0.5 î¼g/l (hussain and anwar 2008; hussain et al. 2010) , and buffalo milk had higher levels of aflatoxin compared with cow's milk. intentional deception of consumers by blending low cost and inferior quality ingredients to make more profit of food intended for sale is prevalent in pakistan, where families are exposed toxic dyes, sawdust, soapstone, and harmful chemicals in beverages, oil or ghee, bakery products, spices, tea, sweets, bottled water, and especially milk and milk products where more than 50% of samples tested have had adulterants added (akhtar 2015) . one of the more innovative research projects to provide more home-grown food is in qatar. the sahara forest pilot (sfp) pilot study demonstrated that there are significant comparative advantages using saltwater for the integration of food production, revegetation and renewable processes: (1) seawater cooling system for greenhouses supports production of high-quality vegetables throughout the qatari summer, and reduces freshwater usage to less than half that of comparable greenhouses in the region; (2) solar and desalination technologies were successfully integrated as designed into the sfp system, such as the greenhouse and evaporative hedges providing wet-cooling efficiencies without cooling towers; (3) the external evaporative hedges provide cooling of up to 10 c for agricultural crops and desert revegetation with vegetable and grain crops growing outdoors throughout the year; (4) commercially interesting algae showed good tolerance to heat and high evaporation rates in the leftover salty water (miss22 2013; clery 2013). the concentrated solar power plant uses mirrors in the shape of a parabolic trough to heat a fluid flowing through a pipe at its focus. the heated fluid then boils water, and the steam drives a turbine to generate power. hence, the plant has electricity to run its control systems and pumps, and can use any excess to desalinate water for irrigating the plants. in summary, sfp allows food production in all 12 months of the year (3 crops) with half the fresh water usage than in comparable greenhouses. on the basis of the pilot success, sfp is now engaged in studies aimed at building a 20-hectare test facility near aqaba in jordan, large enough from the 1-hectare operation in qatar to demonstrate a commercial enterprise. tourism is popular in several middle eastern countries, particularly beach and coastal resorts in egypt and turkey. tourism has been the major economy in egypt for many years but can be threatened not only by civil unrest and terrorism but also by foodborne illness (costa 2008 ). tourists might not stop coming to egypt due to a few reports of diarrhea; however, widespread reporting of severe cases, and lawsuits, will make tour operators much more selective, and bring pressure on the egyptian hospitality industry to improve its hygienic standards. the greater challenge is for egypt to ensure that it has the capacity to sustain a safe food supply for its own people. in doing so, it provides safe food for those who want to explore its rich history and seaside resort areas. multiple reports of illness have been reported from nile river cruises and a resort town on the coast. from september to november, 2008, 34 cases of hepatitis a imported from egypt were reported to the german public health authorities (bernard and frank 2009) . investigations pointed to a continuing common source of infection, most likely linked to nile river cruises. in addition, eight cases from france had been travelling on a nile cruise and one on a red sea diving safari (couturier et al. 2009 ). one specific cruise ship was mentioned by six of ten belgian cases (robesyn et al. 2009 ). those who took a nile cruise had typically done this in combination with a hotel stay. at least three different ships and three different hotel accommodations were mentioned in the travel histories of the french cases. the patients affected had not been vaccinated, which emphasized the need for more effective travel advice before trips to hepatitis a endemic countries (sane et al. 2015) . possible sources of infection might have been contaminated food obtained from a common food catering company consumed onboard, contaminated tap water supplies for the ships' bunkers, or a common exposure on shore (e.g., a restaurant where tourist groups from various ships were taken during day trips). as all of these ships continuously traveled up and down a short stretch of the river (aswan to luxor and back) with standard mustsee stops along the way, the cases possibly shared an exposure on land. both the long incubation period of hepatitis a (15-50 days) and long delays in collecting information on the individual cases precluded any rapid intervention on location. no specific food source was identified but it could have been juices as recognized in an earlier major outbreak. in 2004, tourists returning from egypt included 351 hepatitis a case-patients from 9 european countries who were infected with a single hav strain (genotype 1b) (frank et al. 2007 ). the case-control study identified orange juice most likely contaminated during the manufacturing process, e.g., by an infected worker with inadequate hand hygiene or by contact of fruit or machinery with sewage-contaminated water. citrus fruit and citrus juices have occasionally been implicated as vehicles of hav and salmonella infections, with contamination typically occurring during production, or preparation just before consumption. as hav is resistant to acid, it likely can survive for prolonged periods in orange juice. it is also possible that leafy greens could contribute to foodborne illness in egypt. an international study of contamination of 562 leafy green lettuce and spinach samples taken between 2011 and 2013 from 23 open-field farms in belgium, brazil, egypt, norway, and spain showed that the egyptian samples were the most contaminated at 55.6% (liu et al. 2016) . these authors claimed that temperature had a stronger influence than did management practices on e. coli presence and concentration. region was a variable that masked many management variables, including rainwater, surface water, manure, inorganic fertilizer, and spray irrigation. temperature, irrigation water type, fertilizer type, and irrigation method should be systematically considered in future studies of fresh produce safety. also in the spring of 2008, a young couple was ill with vomiting and abdominal cramps after their first meal at a sharm el sheikh 4-star hotel in the egyptian coastal resort area, and they remained there in their bedrooms for the rest of their week (this is staffordshire 2008). both continued to have ongoing issues 6 months later, with one of them suffering from reactive arthritis. other guests also complained about diarrhea. they stated that the food was disgusting; the meat was undercooked, the buffet was left out for long periods of time, with new food being piled on top of the old food, and there were flies landing on food items. in august 2014, a family stayed at a resort hotel, also in sharm el sheikh, and all suffered severe symptoms including diarrhea, stomach cramps, and vomiting. they were put into the hotel clinic given antibiotics and intravenous drips but had not completely recovered after they returned home (galley 2014) . at the time other guests were also ill. they noticed that the food including chicken and beef, appeared to be undercooked a couple of times, and that one of the chefs touched raw meat and then touched cooked meat without changing gloves. the booking company confirmed that "a very small number" of guests staying at the resort in 2014 reported that they had been unwell, "with symptoms similar to a virus". the company said that guests were offered the appropriate support and advice by their overseas holiday advisors. it claimed that all of its hotels were subject to stringent monitoring and audits and this hotel achieved an extremely high score in its audit carried out in the summer of 2014. however, high audit scores do not necessarily correlate with day-to-day safe hygienic practices (powell et al. 2013) . the popular beach resort of sarigerme, turkey, on the aegean sea also has had a reputation for gastroenteritis, with repeat problems of foodborne illness with british tourists on vacations organized by tour companies, although the actual hotels were different. in 2009, an outbreak of gastric illness at this resort led to â£1.7 m paid out in compensation, with 595 people suffering from infections including salmonella, cryptosporidium, campylobacter and e. coli (hutchison 2015) . in september, 2012, hundreds of british holidaymakers suffered from salmonellosis after returning from a hotel complex in sarigerme (disley 2012) . final figures may have been close to 1000, and several were hospitalized. in october 2014, the swannell family had booked a week's stay at the first choice holiday village resort in sarigerme, when mark swannell, 46, fell seriously ill a few days into the break with diarrhea, abdominal pain, nausea and lethargy (hutchison 2015) . he said that some of the food he was served at the hotel had been undercooked, with some chicken bloody in the middle, food was not served at the correct temperature, food was left uncovered for prolonged periods of time, and the same food had been served more than once. the family stated that cutlery, crockery and table linen used in the restaurant was not up to standard, and they saw cats in the public areas of the hotel and in the restaurant. legal action was taken. in addition to ill tourists in middle eastern countries, contaminated exported food can affect those abroad, as illustrated in the following u.s. outbreak. from march to august 2013, of 165 patients identified with hepatitis a in ten states, 69 (42%) were admitted to hospital, two developed fulminant hepatitis, and one needed a liver transplant, but none died (collier et al. 2014) . almost all cases reported consuming pomegranate arils (seeds) from one retail chain. hepatitis a virus genotype ib, uncommon in the americas, was recovered from specimens from 117 people with hepatitis a virus illness. pomegranate frozen arils imported from turkey were identified as the vehicle early in the investigation by combining epidemiology, genetic analysis of patient samples, and product tracing. the product was then removed from store shelves, the public warned not to eat the seeds, recalls took place, and post-exposure prophylaxis with both hepatitis a virus vaccine and immunoglobulin was provided. this investigation showed that modern public health actions can help rapidly detect and control hepatitis a virus illness caused by imported food. egyptian trade has also been adversely affected by exports. in 2013, there were three outbreaks of hepatitis a sickening 400 persons in 16 -european countries. in the first report in april, 106 persons in four scandinavian countries were infected with hepatitis a (andrews 2014) . epidemiological investigations traced those cases to frozen strawberries grown in egypt and morocco, though no strawberries were found to be positive for hav. the second outbreak in april was larger in extent with 107 ill in 14 countries, all having recently visited egypt, and the outbreak strain of the virus had the same subgenotype as the first outbreak associated with strawberries. an epidemiological investigation into the second outbreak suggested the likely source was strawberries or another fruit distributed to hotels in egypt. the third outbreak was reported in germany in may, after nine germans were infected with hepatitis a after traveling to italy. this third outbreak infected about 200 italian residents, as well as nine germans, one dutch traveler and five polish travelers; 21 irish residents with no travel history to italy were infected by the same strain of the virus. separate investigations in italy and ireland both implicated imported frozen mixed berries as the source, with most of those berries coming from eastern europe. it is not known if these berries came from other regions, such as egypt, or were local to eastern europe. contributing factors to the larger number ill was lack of vaccination. because hav infections were declining in europe over the last few decades, fewer people had developed antibodies to repel the virus. couple that with the fact that hepatitis a was not on the vaccination schedule for citizens of many of the countries affected, and the result was a highly susceptible population. also, most of the european travelers to egypt were not advised to get hepatitis a vaccinations when staying in all-inclusive resorts, which were attracting an increasing number of europeans traveling to egypt. further, the investigators believe contamination of the berries occurred early in the food production chain. investigators suspect that irrigation water contaminated with sewage water likely contaminated the strawberries in the two outbreaks connected to egypt. but the contamination might have also been caused by infected workers in the field or the processing facility, or by contaminated water sprayed on the berries sometime before distribution. the outbreaks indicate that fresh and frozen berries are efficient vehicles of hav infection, as previously demonstrated in the us and elsewhere (palumbo et al. 2013) . european authorities agreed that "the 2013 experience demonstrated the absolute necessity for extensive collaboration between countries and between the public health and food sectors to identify as quickly as possible the vehicle of infection and, ideally, to control the outbreak in a timely fashion." a more serious outbreak damaged egypt's food export trade. in july 2011, the european union (eu) banned the import of certain egyptian seeds and beans till at least october following an official report that a single batch of egyptian fenugreek seeds probably caused two european outbreaks of e. coli infections responsible for 4211 ill persons and at least 50 deaths. a task force of health officials set up by the european food safety authority (efsa) reported that one lot of fenugreek seeds imported from egypt was the most likely common link between the two outbreaks in northern germany and in bordeaux, france (anderson 2011) . both were traced back a year and a half to a shipment of 33,000 pounds (15,000 kg) of fenugreek seeds, that was loaded onto a ship at the egyptian port of damietta on november 24, 2009. on the ship's arrival at antwerp, belgium, the seeds were barged to rotterdam to clear customs. the sealed container was trucked into germany to an unidentified importer, who resold most of the lot. an unidentified german company then resold about 150 pounds of the seeds to the german sprouter, which is believed to be the source of the sprouts that caused the extensive german outbreak. the german importer also sold about 800 pounds of sprout seed to the english company thompson & morgan, which repackaged the seeds into 1.75-ounce (50 grams) packages. those packages were shipped to a french distributor, who resold the seeds to about 200 garden centers around france. investigators believe that one of those packets was the source of the second european outbreak with 16 cases in the bordeaux area. because the seeds were likely contaminated with e. coli o104:h4 at some point before leaving the importer, and more contaminated seeds could be in circulation, it was deemed appropriate to consider all lots of fenugreek from the egyptian exporter as suspect. soil contact or animal or human fecal contamination of the seeds likely occurred during their production or distribution in egypt. even a negative laboratory test of those seeds could not be interpreted as proof that a batch was not contaminated. trace-forward findings indicate the german importer sold seeds from the suspected lot to 70 companies, and the shelf life of the seed can be up to 5 years. by mid-october, 2011, the european commission (ec) lifted import restrictions on fresh and chilled podded peas and green beans and other fresh produce from egypt, but the ban on egyptian seeds and sprouts, scheduled to expire on october 31, was to be extended until the end of march, 2012, following an "unsatisfactory audit" of seed producers in egypt (news desk 2011). the extended ban involved arugula sprouts, leguminous vegetable sprouts (fresh or chilled), soy bean sprouts, dried (shelled) leguminous vegetables, fenugreek seeds, soy beans and mustard seeds. the ec audit showed that measures taken by the egyptian authorities to address shortcomings in the production of seeds that may be sprouted for human consumption were not sufficient "to tackle the identified risks." those shortcomings were not seen in the growing and processing sites for fresh peas and beans, and therefore those vegetables were no longer considered a food safety risk. there is no need for actual illnesses to occur to affect trade. recalls, seizures, and bans can be employed by importing countries if standards are not met, and force exporting countries like egypt to take action. for instance, in 1999 the ec suspended the import of peanuts from egypt due to the presence of aflatoxin in concentrations in excess of maximum levels specified in eu regulations (technical cooperation department 2003) . egypt is a major peanut exporting country and the european markets then accounted for 68% of its peanut exports. this decision was repealed on 1 december 1999 and was replaced by another decision, which imposed a requirement for certification to accompany every consignment and required systematic analysis of consignments and documentation by the importing member state. under this system only 18 egyptian exporters were allowed to ship to the eu. in august 2003, the 1999 decision was replaced by another decision that required the competent authorities in eu member states to undertake random sampling and analysis of 20% only of peanut consignments from egypt for aflatoxin b1 and total aflatoxins. this improvement came as a result of the efforts that the egyptian government put in complying with the requirements of the eu. to this end, the egyptian ministries of agriculture and land reclamation (malr) and ministry of foreign trade (moft) issued ministerial decree no. 2/2000, which covered all stages of production, processing, sampling and exporting of peanuts. the main provisions of the decree were: exported peanuts must be produced, inspected and prepared according to set scientific procedures; and exporters who violate the rules would be suspended for 1 year; the decree also established the legal limit for aflatoxin in peanuts in both the domestic and eu export markets. in the egyptian domestic market, the legal limit was 5 mg/kg aflatoxin b1 and 10 mg/kg total aflatoxin content. for the eu market, the legal limits were 2 mg/kg aflatoxin b1 and 4 mg/kg total aflatoxin content. in addition, the decree specified the sampling procedures that must be followed for export certification. in september of 2001 the food and veterinary office sent a mission to egypt to assess egypt's compliance with its certification system requirements. a number of recommendations on steps egypt should take to improve the control system of foodstuffs intended for export to the eu were made. in response, the egyptian authorities declared that they were taking actions to address the mission's recommendation. but to achieve that there was a need to coordinate among a number of egyptian agencies involved in the production and export of peanuts and aflatoxin control: malr, the central administration for plant quarantine (capq), the agricultural research center (arc), the ministry of foreign trade (moft), and the customs service. also a laboratory capable of testing for mycotoxins was necessary. alongside this; egypt had technical assistance from international organizations in order to build human and physical capacities necessary for achieving compliance. the action by the eu forces egypt to improve the safety of its peanut production which would be beneficial both to europeans and to all who eat products made from egyptian peanuts, including the domestic consumers. lebanon used to be a tourist haven but is less today because of a seemingly dysfunctional government following a civil war. the country produces food for both the domestic and overseas markets. unfortunately, some exported food has caused illnesses and recalls. twenty-three cases of salmonella bovismorbificans in eight states and in the district of columbia (washington, d. c.) from august to november, were linked epidemiologically to hummus eaten at three mediterranean-style restaurants in the d. c. area, all owned by the same individual (goetz 2012) . although samples collected from all ingredients used to make the hummus tested negative for any salmonella, the hummus was recalled and the outbreak ceased. during its investigation of the restaurants, the d.c. department of health discovered multiple food safety violations at the establishments, including inadequate food temperature control, insufficient hand washing, and the presence of pests and insects, which had to be corrected. it is not clear if any abusive temperature conditions could have allowed growth of the salmonella in the hummus. the public was not notified because by the time the hummus had been withdrawn from the market, there were no further cases. however, the contaminated ingredient in the hummus was not discovered until may, 2012, when a traceback by the u.s. food and drug administration (fda) revealed that the tahini used to make the hummus in one of the restaurants had recently been associated with recalls in canada for contamination with s. cubana (september 2011) and s. senftenberg (february 2012). all tahini linked to these outbreaks had been imported from the same company in lebanon. the fda then mandated that all tahini products coming from this lebanese company be tested for salmonella before entering the u.s. and has recommended that u.s. and canadian officials partner to inspect the tahini manufacturing plant. this was the first time s. bovismorbificans had been implicated in a tahini outbreak in the u.s. as a result of this outbreak, the author stated it is important for public health officials and consumers to be informed that products made with imported sesame paste have been shown to be associated with salmonella outbreaks and that they should be considered as possible sources for foodborne illness in the future. in fact, contaminated sesame seed paste was in the news a few days before a cdc report on the outbreak was made public, after a supply of contaminated tahini was stolen from a california importer's warehouse, where it was being stored because a sample had tested positive for salmonella. the tahini, which had also been imported from lebanon but from a different manufacturer, was awaiting destruction, and the fda warned the public that the stolen, potentially contaminated tahini may be on the market. lebanese tahini has been implicated in several outbreaks in the past and subject to recalls (harris et al. 2015) . government oversight of the food industry is variable across the region with many regulations stemming back to colonial days, but modernization changes are gradually being considered or implemented. unfortunately, where some middle eastern countries are slowly moving forward to improve food safety, others are slipping back in their oversight because of conflict and lower public health priorities. there are relatively few large food processing operations except those managed by multinational companies, and most of the government oversight is on smes particularly small foodservice outlets. the states in the gulf cooperation council (gcc), each have an aggressive food safety policy but do not always follow identical approaches, some of which are well-established and some of which are innovative. the ksa has had a food inspection system in place for many years with reports of outbreaks published regularly, though no doubt it could be improved with more cooperation between the ministry of health, the municipalities and the saudi food and drug authority (sfda). the sfda was established under the council of ministers resolution no (1) dated january 1, 2003, as an independent body that directly reports to the prime minister (el sheikha 2015). the sfda is responsible to regulate, oversee, and control food, drug, medical devices, as well as set mandatory standard specifications thereof, whether they are imported or locally manufactured. the control and/or testing activities can be conducted at the sfda or any other agency's laboratories. moreover, the sfda is in charge of consumers' awareness on all matters related to food, drug and medical devices and associated other products and supplies. the sfda has to negotiate with the moh their mutual responsibilities following specific foodborne disease instances or consumer complaints. bahrain claims to have one of the more advanced food control systems in the region. in july 2008, as ambient temperatures heated up, the ministry of heath urged people to make sure the food they consume is properly stored during the summer months to avoid microbial growth and risk of food poisoning, e.g., keeping meat and fish at 4 c and to cook food thoroughly (haider 2008) . the ministry was aware that both visitors and locals want to eat safe food, especially as bahrain is moving towards more tourism with people are eating out more often. the ministry ordered shops to provide appropriate storage facilities, e.g., coolers and refrigerators, for food as part of its efforts to protect the public's health. inspectors were checking food stalls, ice-cream parlors and vegetable shops to ensure that customers were not being sold contaminated or rotten products. the ministry claimed to thoroughly investigate any complaints it receives, and to facilitate this a new hotline number was launched by the ministry for general public to report food contamination complaints against supermarkets, restaurants, coffee shops and hotels. specific advice for consumers included: being careful when buying salads; fruits and vegetables should be washed thoroughly before they are consumed; and dairy products such as milk, cheese and eggs, should always be refrigerated, since microorganisms grow faster in these products. the ministry claimed that bahrain has one of the best food control methods and food safety records in the region, and could even act in the future as a consultant in this field for other countries, including other gcc states. by 2015, government oversight had stepped up. in april, the ministry of health warned people against buying food advertised on social media or sold on the street by unlicensed retailers in bahrain, either made in people's homes or by street hawkers (anonymous 2015c) . the ministry stated that control of these home operations is difficult if someone suffers from food poisoning since inspectors are not allowed to go into homes. many homes sell food without a license and some would-be entrepreneurs even have barns where they slaughter livestock and market the meat illegally. there were 54,968 inspection visits conducted in 2014 by 25 inspectors from the food safety and licenses group, which closed 41 of around 7000 registered outlets. inspections cover imported food from ports right up to where it reaches restaurants and food outlets; 71,886 visits revealed around 883,584 tonnes of imported food were permitted for consumption, but 1873 tonnes were considered as non-consumable (rejected), during the same period. one of the more recent important programs is the smart inspection project launched in april 2012. inspectors, many with masters and phd degrees, visit restaurants and coffee shops to take food samples, as well as explain to staff how to store food and ensure its safety (anonymous 2015c) . it includes awarding food outlets that achieve a 100% food safety standard a blue sticker, while those meeting 80% of standards get a green sticker. outlets that fail to achieve basic standards are warned with a red sticker. the total number of outlets assessed between august 2013 and february 2015 was 241; 17 were presented with blue stickers, 174 with green stickers and 50 with red stickers. this project features daily inspections and is focused on small food outlets, some of which have caused food poisoning in the past. inspection visits depend on the hygiene of each outlet and the complaints received about them; some require two or more visits annually. high-level restaurants already have certified inspectors for evaluation and most of them require only one visit per year. the ministry's ultimate goal through this project is to decrease cases of foodborne disease, particularly important as bahrain is increasing its tourism efforts and, thus, ensuring food safety is essential. to support the ministry's initiatives, live demonstrations on food safety practices were promoted in kitchens in hypermarkets. however, if red sticker facilities fail to take advantage of educational material, they may be punished for neglecting food safety standards and guidelines though public prosecution. in a bid to improve standards of hygiene in restaurants, qatar's supreme council of health (sch) increased the number of spot checks on food outlets and has launched a hotline for residents to report food poisoning (walker 2014 ). the council is responsible for monitoring food establishments and implementing qatar's food laws along with the ministry of municipality and urban planning (mmup/baladiya). the sch embarked on an intensive inspection campaign, collecting food samples from all restaurants and food outlets in the country including suppliers. the inspection teams, which include specialized doctors from the sch's communicable diseases department and the environmental health inspection department, also medically check workers responsible for preparing food to ensure they are not carrying infections. those found to be handling food in an unhygienic way would be immediately dismissed. following a hotline complaint call, a report is filed, a team from the sch visits the affected people, then inspects the related food outlet and collects samples for laboratory examination. the latest crackdown was in response to the illness of a family of four which suffered food poisoning after eating chicken, rice and salad at a popular turkish restaurant which was closed down because a medical report prepared by the sch's environmental health section confirmed that the outlet served contaminated food and violated health regulations. tests conducted in the central food laboratory at sch found three types of bacteria causing diseases in food served by the restaurant. medical tests on the victims also showed that they were infected by the same bacteria, as well as one of the restaurant workers. another popular turkish restaurant was closed for 2 months after it was found that several customers were treated in the hospital for food poisoning symptoms including intense nausea, vomiting and diarrhea. as part of the sch's new campaign, experts would undertake community awareness drives, and organize seminars and training sessions about food contamination to improve understanding among owners and workers in food establishments. other closures occurred because of serving food with moldy ingredients, rotten vegetables in the kitchen, insects in pasta, and generally violating the provisions of the food law. the mmup increased the number of spot-checks and naming and shaming erring establishments on its website in arabic. the 2014 amendments to the food law gave greater powers to authorities to fine and close down venues that break the law including temporarily closing down establishments if it has violated food safety and hygiene regulations, and also has the power to recommend severe penalties. a follow up to one of these closed doha turkish restaurants was after a trial when five staff were each been handed fines, jail sentences and deportation orders after they were found guilty of causing food poisoning to approximately 20 customers ill with vomiting, nausea and diarrhea (santacruz 2015) . the restaurant was accused of serving spoiled and unsafe food on october, 2014. an affected pregnant woman gave birth to her baby 2 months prematurely. the manager of the restaurant was fined approximately $2500 and sentenced to spend 3 months in jail while three other staff members were each fined approximately $2000 and sentenced to 1 month in jail. during an inspection it was found that another staff member did not hold the necessary health certificate and was subsequently fined approximately $1800 and also sentenced to 1 month in jail. as well as the staff members being sentenced to jail and fined, the court of environmental misdemeanours also found that the restaurant itself was guilty of causing the food poisoning outbreak, and issued the restaurant with approximately $8100 in fines and ordered it closed for a further 3 months. in other parts of the world these penalties would seem unduly harsh, as it would be difficult for this restaurant ever to recover financially. coupled with education, there has been recent enforcement blitzes on food establishments such as hotels, restaurants and bakeries by oman municipalities, and a leading bakery in muscat was closed down because of rats in the premises in late december, 2015 (staff 2015 . this led food safety experts and the public to call for stricter rules and heftier fines to be imposed after surprise checks conducted by the muscat municipality, especially when it was disclosed that nearly half the restaurants in the bausher area were not following food safety standards. surprise inspections by the muscat municipality at 125 restaurants in bausher found that around 53 restaurants did not meet food safety standards and were violating rules formulated by the municipality. also, in the same time frame, ibri municipality officials were forced to shut down 42 commercial shops and they destroyed more than 3000 km of outdated food in 2015. according to the municipality's officials, 698 health violation letters were issued throughout the year, as well as 541 warnings were issued to different institutions operating in the wilayat of ibri. there are no easily-accessible reports on government oversight in pakistan and inspection actions are more likely to be released to the public through the press. in 2015, the islamabad capital territory (ict), administration conducted a drive against adulterated food items with unannounced inspections of food outlets in different markets and imposed fines amounting to rs110,000 (about us$1000) on owners for unhygienic conditions at their premises including restaurants, cafes, bakers, candy (sweet) stores, and a hotel was sealed (app 2015) . cleanliness conditions at the outlets' kitchens were found unsatisfactory and unhygienic while workers had not been vaccinated against viral diseases. some business owners were also paying less to their workers in contravention of the minimum wages act. business owners were directed to improve cleanliness conditions and ensure food safety standards failing which strict action would be taken against them. a cattle market was also ordered to "beef up" its security. punjab, pakistan's most populous province, has a population that is more than double that of california, and lahore, the provincial capital, has a vast array of food outlets. from the available press reports, the punjab food authority (pfa) has a mixed record of oversight of food operations. a pfa team visited the polo ground restaurant at the race ground park and found expired food, blocked sinks and unhygienic conditions in the kitchen and food storage area in contrast to the claimed high quality standards by the management of the supposedly high-class restaurant (raza 2015) . the team faced resistance from the management but it managed to enter the kitchen for inspection. pfa officials said the kitchen condition was similar to that of an ordinary road-side eatery, dispelling general perception that restaurants serving the elite follow higher standards of hygiene and food safety. however, the pfa in lahore had received a complaint that an assistant food safety officer had received rs50,000 (about us$475) bribe from the restaurant owner so he could keep his restaurant open (anonymous 2015d) . another restaurant on peco road sealed by the pfa for poor hygiene and unsanitary conditions of its workers in the second week of march, was opened for business the very next day. typically, according to the pfa's standard operating procedure (sop), a restaurant sealed for the first time may resume business after a week. at the end of the week, the proprietor has to submit an affidavit assuring the authority that all problems pointed out by the food safety officer had been taken care of prior to reopening it for business. the pfa director general (dg) had constituted a three-member committee to probe the complaint of bribery but it was later shelved. similar situations occurred when restaurants that had reopened before the stipulated period for closure had expired. in the first week of 2015, a restaurant was fined rs25,000 (about us$240) for unhygienic conditions and lack of soaps in the workers' washrooms, instead of following the pfa sops of sealing the premises. the sops regarding duration of closure and required permission from the pfa dg were stated to be flouted openly. however, a pfa spokesperson denied any wrongdoing, and the sop was being observed to the letter. she said a written permission from the dg used to be mandatory in order to de-seal restaurants, but now an operations deputy director can also issue permission for it. she also stated that the restaurant on peco road had not reopened on orders of the pfa; its owner had de-sealed it illegally. these reports indicate that there may be some illegal activities including bribery by inspectors but miscommunication on how much leeway inspection staff have on prevention and control practices may be more of the issue. in mid-2015 ayesha mumtaz became the new operations director of the pfa, tasked with ensuring food in punjab is unadulterated and safe (reeves 2015) . her self-declared war on unhygienic food generated so much publicity in the last 6 months that she became a household name in pakistan. mumtaz says many food producers know nothing about hygiene but are willing to learn. there's also a hardened mafia who are only interested in profit, she says. everyone in the street seems to know about mumtaz. storekeepers begin shooing away customers, hauling down the shutters, and heading into the shadows in the hope that mumtaz's scrutinizing eye will not fall on them. these traders would sooner lose business than risk a visit from a woman whose campaign to clean up the kitchens and food factories of pakistan has made her a national celebrity. she declared that the pfa cannot allow them to get away with their "perverse" activities and to "play havoc" with the lives of the people. consumers are unaware that the cakes and sweets that they buy over the counter are produced amid unhygienic conditions. she has found spoons encrusted with filth, fly-blown cans of gooey liquid lying around haphazardly, dirty containers, grimy rags and rusty tin cans, moldy scraps of cake, all involved in making cakes and sweets to be sold to the public. civil servants in pakistan are often accused of being lazy and corrupt. mumtaz is being feted as a rare example of a government official who actually champions the public's rights. she and her inspectors have so far raided more than 13,000 businesses, and pakistanis seem to approve. her fans call mumtaz the fearless one. hundreds of thousands have clicked like on the pfa's facebook page in appreciation of her work. there was a very famous hotel in the heart of lahore that she inspected and found the chiller where they keep all the foods together (vegetables with chicken, meat), but also a big rat; this became big news for the public. however, there are complaints that she does her raids with police and cameras to be broadcast nationally even before the owners are convicted, according to the lahore restaurant association. in 2011, the abu dhabi food control authority (adfca) planned to check all food handlers by 2012. the authority's emirate food safety training (efst) program, started in 2008, provides basic training in food hygiene and safety to those who work in food outlets (olarte 2011) . according to the adfca, small catering businesses in most countries have the lowest standards of food safety, and most workers in abu dhabi's 2500 small restaurants are illiterate and do not speak fluent arabic or english, making it a challenge for them to understand and follow safety guidelines and regulations; 69% of managers and 73% food handlers in the capital speak south asian languages such as urdu, hindi and malayalam (pennington 2014) . the training is now offered in four languages -english, arabic, urdu and malayalam -which the majority of food service personnel speak, and covers basic food hygiene issues including staff hygiene, food temperature, cross-contamination, cleaning and sterilization. to help them understand and follow food-safety rules, the adfca is using photographs to teach employees how to handle food safely according to international standards. the scheme is an extension of a pilot involving 600 small restaurants carried out in 2012-2014. as part of the efforts to ensure retention of their learning, the adfca conducted spot checks at 94 food outlets in marina and khalidiya malls, and gave guidance and advice to staff for those with violations, rather than just penalizing them, the normal practice in most middle eastern countries. the field operations manager at the adfca noted that the differing cultures, education and languages are the barriers that sometimes hinder food handlers from carrying out what they are trained to do. he recommends that supervisors should quiz them on hygienic and safety issues so that they know how to properly prepare and serve food. those who have learning difficulty or are illiterate are given assistance through illustrations, in order to make it through the lessons and pass the examination. one of the critical elements of food safety that the adfca has to monitor and ensure, is that food handlers are aware of cold ready-to-eat food being kept at 4 c, while hot food should be kept and served very hot > 60 c. the adfca categorizes the food premises and carries out inspections based on their risk factors -high, medium and low. restaurants and hypermarkets belong to the high-risk group; warehouses to the medium risk; while groceries, honey shops and vegetable and fruit outlets are considered low risk. recently, the establishment of the egyptian food safety authority was initiated by the minister of trade and industry, with the support of the ministry of health and the ministry of agriculture. it would be responsible for food safety and consumer protection through the provision of sound data and guidance to deal with processed or genetically modified food in accordance with food safety standards (anonymous 2012b) . the strategic plan for the new draft law includes a revision of all egyptian laws and legislation that deal with food safety since 1893, including around 2446 other legislations. the authority would need to apply food safety standards on imported food the same way it does for locally produced foodstuffs. adopting the draft law would in effect cancel all existing laws and create one food safety law for the country. the food safety authority plans to monitor the foods consumed by egyptians of different age groups as a basis for where to put resources. another issue to be faced is that studies in egypt based on us statistics have revealed that the cost of food spoilage costs the country 144 million egyptian pounds annually. the chamber of food industries indicated that a unified body for food safety to apply international quality specifications and unite regulators was lacking. this reduced the competitiveness of local products, especially since most foreign countries do not recognize egyptian regulations. it was hoped that investors in food industries would bring in new investments to the sector in the upcoming period if a food safety authority were to be established, as per a ministerial decision issued in 2011. the food safety authority has received several approvals from governments that ruled during the 4-year period following the revolution, but apparently nothing has been yet finalized until recently (mefreh and saeed 2015) . in a similar way to egypt, the lebanese government has been debating a new law on food safety for many years but unlike egypt, it has yet to make much progress. lack of agreement at the parliamentary level has resulted in different ministries (health, agriculture, industry, environment, tourism) taking action as they see fit. the latest was in november 2014, when the minister of health conducted an extensive campaign of inspections in lebanese establishments and naming of facilities that did not meet the ministry's expectations (naylor 2014) . the minister personally revealed that numerous supermarkets, bakeries, butchers and restaurants had been violating food safety and sanitation standards. they shut down slaughterhouses, restaurants, supermarkets and other retailers selling contaminated food. for instance, changes needed to be made for the slaughterhouse to conform to health standards; the report said livestock must be hanged during slaughter and not laid on the ground and that the abattoir should also be equipped with refrigerators and storage units for separate types of meat and their cuts. however, discord among ministries is apparent with the tourism minister trying play down the publicity of the health minister's food safety blitzes by saying "we are in favor of full transparency, but we feel like we were 'deceived' because the food safety situation in lebanon is good and better than other countries. we apologize to tourists, but more importantly, any of the ministry of health staff is ready to apologize to the lebanese citizens for the public sector's failures throughout the years?" (yaliban 2014) . foodborne disease surveillance is limited in lebanon and cannot be used to indicate the actual level of foodborne illnesses in the country. lebanese food exports are also being required to conform to international standards. tahini made from sesame seed paste is a major food export to the west, but recalls of tahini manufactured in lebanon because of salmonella contamination are more frequent than they should be; one recent example was a health hazard alert for certain clic, al nakhil and al koura brand tahina products that may have contained salmonella, recall/advisory dated august 16, 2013 posted from canadian food inspection agency [also see tahini/hummus linked illnesses under foodborne disease in specific countries]. under the new us food and drug administration food safety modernization act, foreign companies importing foods to the us must demonstrate that they have the operational plans and facilities sufficient to produce safe food before they can ship any product to the us (fda 2015), which is causing some concern among lebanese tahini manufacturers and government agencies. thus, although there is knowledge about foodborne disease and other food safety issues within government, industry and academia, the political inertia means that many foodborne illnesses will continue to occur but not be properly reported or know what factors were present to cause the outbreaks. industry currently is taking the lead; apart from companies promoting food safety like boecker and gwr food safety, mena food safety associates (mefosa) (http://www.mefosa.com/), based in beirut, assists mena companies hone their competitive edge by establishing and verifying procedures and practices that ensure quality, wholesome and safe products through consulting, auditing and training services in haccp, gmps, and hygienic practices. however, lebanon's lack of a coordinated system of government oversight of the food industry pales into insignificance compared to that in syria. prior to the war, syria's healthcare system had hospital and doctor levels equivalent to other middle-income countries such as brazil, turkey and china, with life expectancy of 76 years, and most of the disease burden being similar to that in the west with non-communicable diseases, but four years of violence have changed all of that. child vaccination levels dropped from 90% pre-conflict to 50% in march 2014 (templeton 2015) . as a result, outbreaks of diseases that had long been under control have spread across the land and into neighboring countries: hepatitis, measles, leishmaniasis, multi-drug-resistant tuberculosis, typhoid and even polio, which had not been seen in the middle east for 20 years. life expectancy has dropped by two decades. medical personnel are clearly targeted because they are seen as potential enemies helping the opposite side. the majority of syria's doctors have been killed or fled the country (>700 medical workers have been killed since 2011). the situation has been called the worst humanitarian catastrophe this century, and the worst concerted attack on healthcare in living memory. at least 300,000 syrians have been killed and more than 11 million others have been forced from their homes since the conflict began on march 15, 2011, with over four million people in areas that are hard to reach for humanitarian aid, and 4ã�5 million have fled mostly to neighboring turkey, lebanon, jordan, and northern iraq, while others have sought safety in europe, provoking a political crisis in the 28-member bloc (devi 2016) . another middle eastern country under stress but with less publicity is yemen. currently there is little government oversight into food as there is little to be had. the situation in yemen is characterized by large-scale displacement, civil conflict, food insecurity, high food prices, endemic poverty, diminishing resources, and movement of refugees and migrants (wfp 2016). the un world food programme (wfp) has been in yemen since 1967. in 2014, wfp conducted a comprehensive food security survey which found that 41% of the people (10.6 million) were food insecure, of which some five million were severely food insecure, meaning they were unable to buy or produce the food they need to survive. the organization's protracted relief and recovery operation (prro), aims to reach six million people between mid-2014 and mid-2016 with 366,734 metric tons of food and us$74.5 million in cash and vouchers at an overall cost of us$491 million. if the conflict continues, this goal is unlikely to be met in time since both the airport and shipping port are areas being fought over. the wfp has been attempting to bring in relief supplies but cannot do so under fire, which means that only small amounts are occasionally delivered to the country (mukhashaf and miles 2015) . one example of this occurred in aden on july 20, 2015 when a ship docked after waiting a month to unload enough u.n. food aid to feed 180,000 people for a month. previous repeated attempts to send ships to aden were been blocked due to severe fighting in the port area. the prro is aligning wfp's activities with moves to increase the government's capacity to respond to the crisis and will promote recovery and resilience to enable food insecure households and communities to better withstand and recover from the effects of conflict and shocks. there are many similarities as well as substantial differences in the descriptions of issues concerning food safety and foodborne disease of each country in the region. gastrointestinal diseases are frequent throughout the middle east with some countries identifying their etiologies, such as egypt, kuwait, israel, pakistan, turkey, yemen. these include bacteria and parasites, e.g., salmonella, shigella, campylobacter, enterotoxigenic e. coli (etec), giardia, entamoeba, and occasionally enteric viruses such as hav and norovirus. however, none of the countries has a well-functioning foodborne disease surveillance system, but a few report on a regular basis like ksa, and starting recently, lebanon with pulsenet. mostly it seems that only large outbreaks or ones with fatalities that are reported on, and mainly through the press. these outbreaks are often related to point sources which are in most cases communal foods prepared for a large number of individuals as in feasts, student hostels, schools, campuses, or military camps. however, the actual etiological agents and the factors contributing to outbreaks are only rarely determined. one example is a very large outbreak in bahrain in 2002 with at least 750 people suffering from foodborne illness after eating contaminated egg-andmayonnaise sandwiches served at a wedding party, but the etiology was not determined, even though clinical specimens and food samples were analyzed, at least in a publically-released report (promed-mena 2002) . based on the type of preparation including the length of time taken for preparation of the implicated food and the time from consumption to the appearance of symptoms of foodborne illness, the types of symptoms, and what has already occurred historically in foodborne disease outbreaks, possible agents can be surmised, such as bacillus cereus and staphylococcal enterotoxins, and salmonella, shigella, or norovirus infections, but promed is continually asking for more information once an outbreak is announced, and hardly ever receiving it (promed-mena 2014). all this indicates that even if clinical specimens or food samples are taken and analyzed, laboratories are only rarely able to determine an etiologic agent, or at least report on their results. most agents described with the little information available seem similar in all the mena countries and to those encountered in the west. however, a few pathogens are more likely to be restricted to a few nations, such polio in pakistan, cholera in iraq, mers-cov in ksa, and botulism in egypt and iran where river fish are often eaten (one case of infant botulism was diagnosed in israel but it is a rare disease anywhere); the first two are more likely transmitted though water or poor hygienic conditions, the third by camels, and only botulism exclusively through food. brucellosis is widespread in the middle east but only a few country studies indicate its link to meat or dairy products. much of the middle east is in the throes of conflict which results in unique situations in specific countries to exacerbate foodborne disease or food poisonings; these include relief agencies supplying "stale" food to those trapped and starving by the syrian civil war, almost lack of food at all in yemen, deliberate poisonings of enemies in afghanistan, syria and iraq, accidental pesticide poisonings in iran, preventing unsafe food being sold to those on the hajj in ksa, improperly prepared catered food for foreign troops in bases in afghanistan, iraq, kuwait, ksa, and turkey. countries where tourism is a major source of income can be adversely affected by bad publicity over complaints over food served in resorts, such as in egypt and turkey. also, gulf countries tend to employ workers from india and other surrounding territories, and these are typically housed in camps or separate communities from citizens and visitors, and are transported to work sites and back; conditions are not always conducive to safe food, and outbreaks are occasionally reported either from their work sites or their overnight residences where meals are prepared or catered. most food to many of these countries is imported, especially those with limited agricultural land and adequate water supplies; fruits and fresh vegetables, tend to be grown in rural or peri-urban settings for local consumption and these can be contaminated at source through polluted river or well water, such as in the bekaa valley of lebanon and mountain communities in pakistan, and the nile, tigris and euphrates fluvial plains. on one occasion, iranian watermelons were recalled and future sales banned in ksa, qatar, and uae because they were suspected of being poisoned or were injected with pesticides (nobody claimed to be ill after eating the melons), because holes were found in a few of them. however, the rationale of iranian farmers deliberately losing money seems to counter this argument, and it is more likely a sectarian economic barrier (abdullah 2015) . in fact, with the temporary ban the price of watermelons went up in the countries that had banned them. random tests carried out on the fruit confirmed they were free from any chemical substances, insecticides or other pollutants. the holes were most likely caused by emerging insect pupae. countries outside the gulf region reported no problems with the imported iranian melons. where some processed foods are exported, there is a risk of the importing countries recalling these if they cause foodborne illnesses or contaminants are found in them. this has happened in egypt with hepatitis a virus in strawberries and e. coli o104:h4 in fenugreek seeds causing serious illnesses in europe and restricting further trade for an extended period. the same issue affected turkish pomegranate arils and lebanese tahini (made from imported ground sesame seeds), both containing salmonella, exported to the us. large to medium operations for broiler chickens and egg layers in ksa, kuwait, lebanon and other countries try and meet national standards or international guidelines for salmonella but are not always achieved, resulting in recalls and fines. governments are also aware of increasing concern over campylobacter in chickens, as widely-eaten poultry is a major source of this pathogen, but campylobacteriosis is not often cited as causing foodborne disease. raw milk (cow, sheep and camel) and raw milk cheese are still widely consumed in the middle east at the local level, though not usually obtained through supermarkets, and the risk of infections is high, as it is in other parts of the world, but with the added concern of brucella spp. and mers cov (the latter in the gulf countries where camels are bred and milked), both serious pathogens. yoghurt, surprisingly since it is acidic and is a source of gut beneficial lactobacilli, apparently was the foodborne vehicle to cause illnesses and deaths in afghanistan, israel, and pakistan. no agent was found in any of the samples. in the afghani example, the yoghurt was claimed to be deliberately poisoned; in the israeli one, it was apparently "stale" given to palestinian prisoners; there were two episodes in pakistan, one was from a home-prepared meal and the other from a restaurant which served rice and yoghurt. for prevention and controls strategies, most countries seem to rely on local authorities (municipalities) to do inspection of food facilities, more typically restaurants than processing plants as there are far more of them. illegal sales for unapproved products by local entrepreneurs are sometimes an issue, e.g., homeslaughtered meat in bahrain, and palestinians shipping food to israel. these illegal operations probably occur more often in porous borders within the region, and are only recognized when authorities decide to become vigilant in this area. some countries have conducted research and surveys much more than others based on the publication record, e.g., egypt, israel, palestine, ksa, turkey, and to a lesser extent, iran, lebanon, pakistan, uae, and yemen, but some research may occur without formal publication in recognized journals, making it difficult to have a true picture of how food safety problems are recognized and controlled. a few surveys have shown that home makers and food employees have limited knowledge of food safety, as in other regions. thus, some agencies or industry associations, sometimes in collaboration with outside organizations like fao or who, have attempted to train food employees in basic haccp principles, including best hand hygiene practices, and speakers give the latest food safety issues at the annual dubai international food safety conference, now in its 10th year. a few governments have established food safety agencies that have broad powers to inspect and control without overlapping responsibilities; these include jordan and ksa with food and drug administrations, uae with abu dhabi and dubai food control authorities, oman with its national food quality and safety centre, and pakistan with a punjab food authority. egypt and lebanon are initiating food safety authorities. israel, palestine and jordan have a cross-border agreement to collaborate on food safety issues. typical of many food control agencies in developing countries, periodic campaigns are launched to "crack down" on foodservice operations and sometimes processing plants. these are usually stimulated by complaints of the public, or the need for the responsible ministry to be seen doing something to justify its existence in compliance with regulations (if they exist). this has occurred recently in lebanon, qatar and pakistan. one issue is that poorly constructed or out-of-date regulations may be interpreted in different ways by the owners and the agencies (kullab 2014) . if a violation is found, the facility may be fined and/or temporarily closed down until it has satisfied the inspectors at the next visit. in one extreme instance in qatar, the owners and employees, were fined, imprisoned and deported. unfortunately, although the names of those at fault are often publicized by the media, their specific violations and how they relate to the regulations are not usually documented or at least publically released. another issue is that whether illnesses are suspected or not following a complaint, inspectors often insist that all food be discarded as soon as a sufficient violation, which may be unrelated to the complaint, has been determined; this prevents any samples being taken for outbreak investigations (hanna et al. 2009 ), as well as using the outbreak for a teaching tool for the owner and other similar operations. in conclusion, some progress has been made in the surveillance of foodborne disease in the middle east, but the disease's health and economic burden is barely being considered in many countries for future decision-making policies, an issue that is being tackled at the global level (who 2015b). food control agencies seem to be trying to stop apparent abuses but have limited resources to do much more. this region, in particular, is severely strained because of sectarian distrust, on-going civil wars, and terrorist attacks, with refugees from iraq seeking shelter toward europe but stalled in turkey and lebanon for long periods of time. the crisis in syria is considered the greatest humanitarian disaster of the twenty first century, or even since world war ii, and it looks like the on-going fighting including outside armed forces will make food insecurity in the affected countries even worse in the foreseeable future. less public attention has been directed to yemen where food insecurity is a major concern. this coupled with gulf countries losing their wealth over low oil prices and a resultant stagnant global economy means a focus on food safety will likely become lower in priority for many of these countries. since secure food has to be safe, as illustrated by "stale" food being issued to besieged syrian residents and prisoners, it is important that relief agencies and countries themselves be aware of the risk of foodborne diseases associated with immunocompromised persons, particularly children. however, even in countries where the food supply is acceptable, inadequate hygienic practices put the local and tourist population at risk of illness and exported foods jeopardize industry profits and a poor reputation for future trade. as demonstrated by ksa, jordan and uae, single agencies or multiple agencies with clear-cut roles responsible for food safety, should be pursued by governments in consultation with industry and academia. duplication creates ambiguities for enforcement and education strategies as well as being unnecessarily costly. water supplies are also critical and some governments are weaning away farmers from depleted groundwater aquifers, and making irrigation more efficient where there are sustainable supplies. water for irrigation and processing has to be both free of pathogens and unacceptable levels of chemicals, and effectively treated waste water can substitute for groundwater. the sahara forest project in qatar is one example of a very dry country using seawater resources effectively; an even larger project is being considered from the 1-hectare in qatar to a 20-hectare test facility in jordan (clery 2013) . all these issues are being compounded by climate change and expected higher temperatures in already arid lands, which will make the region all the more dependent on more expensive imported foods. gulf counties have enough petro-dollars to afford 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