The media reports suggest that many patients in the big cities of Pakistan with typical symptoms of Covid-19 infection do not seek health care, fearing they might be stigmatized or they do not have the means to go to a health care facility or are afraid that they might get sub-standard treatment. Anecdotal reports in the media showed how patients were roaming around in government ambulances to find any hospital while gasping for air. It has also been reported that no uniform policy for triaging, treating and quarantining patients with Covid-19 has been implemented throughout the country. A general sense of depression, lack of control and fear has been reported prevailing in Pakistan due to Covid-19 infection.
It is extremely important that algorithms be created in Pakistan while taking into account the current knowledge and data reported from other countries that have been learning daily from this pandemic, while also considering the prevailing social and economic situation in Pakistan. It is even more important that any clinical pathways created are diligently put into practice in Pakistan as well. Pakistan is a densely populated country with 60% literacy rates and an acute spike of cases in a short period of time can lead to a shortage of hospital beds, laboratory facilities, oxygen cylinders and trained health care providers, overwhelming an already strained health care system. Finally, it is of utmost importance that the public is well informed about the current scientific knowledge available regarding Covid-19 virus, so that it becomes a willing collaborator in implementing government policies to help reduce the burden of the pandemic in Pakistan.
What are the typical symptoms of Covid-19?
In the order of frequency up to 99%, 82%, 70%, 84%, 40% and 35 % patients infected with Covid-19 complain of fever, cough, fatigue, lack of appetite, shortness of breath and muscle ache respectively. In up to 60% patients, loss of smell and taste before the onset of shortness of breath has been reported. Nausea, vomiting, diarrhoea and sore throat are non-specific symptoms. These symptoms can occur independently or in combination among persons exposed to Covid-19 patients.
Sneezing, feeling of irritation in the throat with saliva and a need to clear the throat are common symptoms of allergy and should not be confused with Covid-19 infection. In Pakistan, other febrile illnesses like typhoid, dengue fever and malaria have other specific symptoms and should be considered among patients presenting with fever. A combination of Covid-19 and other prevalent diseases can occur and it is important to test for Covid-19 when dual infection is suspected on a case-by case-basis. Covid-19 syndrome has a median 5-day incubation period and those exposed to the virus can manifest their symptoms between 2-14 days. Those who are in the pre-incubation period and have not yet suffered from any symptoms are at the highest risk of passing the infection to others. Clinically, Covid-19 has a longer incubation period compared to seasonal flu which has a median incubation period of one-day. An incubation period of five days among Covid-19 patients allows a longer period of time for this infection to be transmitted to other unsuspecting individuals.
How does one get infected with Covid-19?
The virus can enter a susceptible person via mouth, nose and eyes. Typically the highest chance of spreading infection is in situations of overcrowding, where many people breathe together for an extended period of time. It has been reported that being in less than 6-feet proximity of Covid-19 infected individual for more than 6 minutes is sufficient for the virus to be transmitted to a susceptible individual. Covid-19 is primarily spread when respiratory droplets from an infected patient reach a susceptible person, who is in close proximity of an infected person who coughs, sneezes or talks loudly with an un-infected person. These large viral droplets allow the virus to find its way into other uninfected persons and is termed person-to-person transmission.
It has also been reported that the Covid-19 virus can live suspended in the air for a few hours after a person infected has aerosolized the virus in the surrounding. In other words, even if an individual is not in close proximity to a person, there is a chance that the environment left behind by a Covid-19 patient, may remain contaminated for a certain period of time and increases risk of transmission. This latter mode of aerosolized transmission however, has been reported to be much less efficient. The virus can also be transmitted by coming in contact with surfaces contaminated with the virus like door knobs, light switches, table tops etc. when they are touched and then a person touches nose or eyes, emphasizing the need for frequent hand washing to avoid this mechanism of transmission. Moreover, it is important to clean the surfaces at home and work with readily available bleach, which effectively kills Covid-19 virus.
Finally, it has been reported that participating in activities like congregating in churches or mosques, or crowding in bazaars and shopping malls can create a perfect storm where both droplet and aerosolized mechanisms might operate together to transmit the viral infection. Outdoor activities in fresh air are much less likely to transmit infection, although the two most important preventing measures including physical distancing and hand washing should be diligently practiced.
How can I avoid getting infected with Covid-19?
One cannot emphasise about practicing two simple preventive measures- social distancing and frequent hand washing- which can significantly reduce the risk of contracting Covid-19. Those who can work from home should stay home; those who can’t should go to work, but ensure that they remain at six-feet distance from co-workers and avoid congregation at lunch or involve in long conversation in company of their colleagues. Keep washing your hands frequently and wipe down the table tops and counters with an anti-septic wipe. You can go out to exercise as long as you are keeping yourself at safe distance from others. In fact, daily brisk walk for a duration of 30-minute will improve your immunity and increase your chances of defeating Covid-19. It is impossible to keep away from household members and the best one can do is to reduce any chances of bringing Covid-19 home. Make sure, family members who are above 60-years old or suffering from obesity or diabetes or hypertension or cancer to remain at home, as such individuals are at risk of getting severe illness with Covid-19. It is also impossible to be safe at mosques where worshippers pray, shoulder-to-shoulder and exit and enter together in groups from the mosque so it is recommended to pray at home.
Should I wear a mask to protect myself from Covid-19?
As scientists we can only advise people when we have concrete scientific evidence at hand. Regarding masks, first we need to understand what kind of masks are we discussing: cloth masks, surgical masks or respirator masks/N-95 masks.
Cloth masks and surgical masks that cover the nose and mouth might reduce virus droplet transmission by no more than 40%. Moreover, we should never have the false sense of security that having a mask on means that now we have no risk of acquiring infection and do not have to practice social distancing-this is a very dangerous assumption. Moreover, public has been witnessed as wearing these masks partially, which is another risky behavior and will provide no protection from Covid-19. Masks must be worn properly; however, social distancing needs to be simultaneously practiced. It is unclear that how much protection surgical or face masks will provide in places where social distancing cannot be practiced.
N-95 masks are appropriately fitted masks with filter on and do provide more than 90% protection from virus transmission. However, these masks are supposed to be worn by individuals infected with Covid-19 when physical distancing is not possible and by health care providers who find themselves in high risk situations in the hospital. N-95 masks cannot be worn for long period of time as they are tightly fitted to the face making it uncomfortable to wear.
What do I do if I feel I have Covid-19?
Don’t panic! More than 80% of patients with symptoms have mild self-limited disease, which gets better within two weeks. Even majority of the rest of the 20%, with more serious infection, improve and do not even need hospitalization. By rough estimates less than 10% of those who are symptomatic with Covid-19 infection require hospitalization and in Pakistan less than 2% of all patients with symptoms have been reported to die.
If you have the typical symptoms of Covid-19, or have come in contact with someone you know has symptoms of Covid-19, stay home and confine yourself in a room with limited contact with household members, keeping a 6-feet distance. You should particularly stay away from elderly family members. Drink plenty of water and keep yourself busy at home with whatever makes you happy such as reading a book or going on the internet or talking to friends on the telephone.
You can approach telehealth consultants who could guide you through your illness. You do not need to be tested either, particularly considering that limited tests are available and even if Covid-19 virus PCR test is negative you may still have a 40% chance of having the infection. Nonetheless, if you have alarm symptoms like difficulty breathing or chest pain or your lips start turning blue, you need to go a health care facility as soon as possible, where you must be tested for Covid-19, appropriately triaged to an area of hospital where you are kept in isolation room with appropriate ventilation. If you are home recovering from Covid-19, do not self-prescribe any antibiotics or medicines that are touted as panacea for Covid-19 on the media. Almost all cases of mild infection with Covid-19 will get better with simple measures like taking paracetamol, up to 2 tablets 4 times daily as needed for pain and fever, besides rest and drinking plenty of fluids.
What kind of tests are available to diagnose Covid-19 infection?
The viral particles can be directly detected in the throat or nose of a patient infected with Covid-19 using a PCR test, where very small quantities of the virus can be multiplied to the level of detectability in the laboratory. Unfortunately, such tests are not very sensitive for the detection of the virus and many patients may test negative when they are actually infected. If you have the typical symptoms of Covid-19, and your PCR test is negative, you might still have the virus and you should remain isolated from other susceptible individuals. As an example, recently, many Pakistani cricketers without any symptoms of Covid-19 tested positive with PCR test. In fact, cricketer Mohammad Hafeez who had no symptoms tested positive for Covid-19 and the very next day tested negative for it. Thus it is important to get information from a qualified health provider before subjecting yourself to testing.
Another type of test called antibody test has also become available. Such tests have no utility in diagnosing active infection, as antibodies develop 2-4 weeks after you are cured of Covid-19. Many patients with Covid-19 remain without symptoms; however, they can develop antibodies to the virus. It remains unclear if having antibodies means that you are already immune to the virus, particularly because antibody tests can be false positives, particularly at this time of the pandemic when less than 10% of population in Pakistan might have been exposed to Covid-19. The importance and utility of antibody tests will become clear in the coming few months. Overall, it appears that if a person becomes symptomatic with Covid-19 and tests positive for antibodies, they may not get infected with Covid-19 for several months and may not transmit infection to others for some period of time; however, as jury is still out about the role of antibodies in Covid-19 control, it is prudent to keep practicing physical distancing and hand washing even if one is tested positive for Covid-19 antibodies.
A chest X-ray is an important tool to diagnose Covid-19. A patient who has typical symptoms of infection, however, tests negative for Covid-19 and other prevalent diseases in Pakistan, but has typical feature of lung involvement on chest X-ray should be considered to have Covid-19 infection.
When can I go back to work after I have Covid-19 infection?
If you had symptoms of Covid-19, you should wait for 10 days after symptoms began, plus at least 3 days without symptoms (without fever and respiratory symptoms) before going back to your life routine. You do not need to be tested negative with the PCR test before you can return to your employment or mingle with your household members. World Health Organization (WHO) changed their criteria that required two negative PCRs before returning to work, after scientific evidence showed that some patients infected with Covid-19 can remain PCR positive, although they have no symptoms. This is another important pitfall of the Covid-19 testing and must be recognized by citizens.
What kind of hospital should I go to if I become seriously ill with Covid-19?
There are good hospitals and excellent doctors in Pakistan. However, keep yourself abreast of latest knowledge about Covid-19, so you can ensure that you have been treated by competent medical personnel. It is your right to ask questions about the plan of care for your health and medical providers should give appropriate and scientific answers to your questions.
When will Covid-19 pandemic end?
This pandemic will not end until 60-70% people are exposed to Covid-19 creating the so-called herd immunity. By rough estimates, no more than 10% population of Pakistan has been exposed to this virus thus far and it can take another year or longer for the virus to continue to burn, either slowly or quickly, through the Pakistani population. Many drug companies are on their toes to create an effective and safe vaccine that will give some protection from this virus for an uncertain period of time before herd immunity is achieved, but many scientists believe that such a possibility is slim because making a vaccine and then delivering it to the public can potentially take many years.
It is essential that the government provides the public with new emerging scientific facts on a regular basis. Not only information should be given, but the source of information and how certain conclusion has been drawn about a recommendation should be shared with the public. Government, media and other public figures should let the public know honestly if they do not have enough knowledge about a certain aspect of Covid-19, as public will appreciate such candid statements. We all need to learn to live with this virus and a complete lockdown of the country for an unlimited period of time is impossible. With proper knowledge, appropriate guidelines and public-government partnership, it is likely that Pakistani nation can go through this pandemic with as little pain and suffering as possible.