essay corona pandemic in pakistan

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

Loading metrics

Open Access

Peer-reviewed

Research Article

COVID-19 in Pakistan: A national analysis of five pandemic waves

Roles Conceptualization, Formal analysis, Investigation, Methodology, Software, Validation, Writing – original draft

Affiliation Research and Development Solutions, Islamabad, Pakistan

Roles Conceptualization, Data curation, Formal analysis, Methodology, Software, Validation, Writing – original draft

Roles Conceptualization, Data curation, Investigation, Methodology, Validation, Writing – original draft

Roles Conceptualization, Data curation, Supervision, Validation, Visualization, Writing – review & editing

Affiliations Ministry of National Health Services, Regulation and Coordination, Islamabad, Pakistan, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan

Roles Conceptualization, Investigation, Project administration, Supervision, Validation, Writing – review & editing

Affiliation Akhter Hameed Khan Foundation, Islamabad, Pakistan

Roles Conceptualization, Funding acquisition, Investigation, Project administration, Supervision, Validation, Writing – review & editing

* E-mail: [email protected]

Affiliations Research and Development Solutions, Islamabad, Pakistan, Ministry of National Health Services, Regulation and Coordination, Islamabad, Pakistan

• Taimoor Ahmad, 
• Mujahid Abdullah, 
• Abdul Mueed, 
• Faisal Sultan, 
• Ayesha Khan, 
• Adnan Ahmad Khan

• Published: December 29, 2023
• https://doi.org/10.1371/journal.pone.0281326
• Peer Review
• Reader Comments

The COVID-19 pandemic showed distinct waves where cases ebbed and flowed. While each country had slight, nuanced differences, lessons from each wave with country-specific details provides important lessons for prevention, understanding medical outcomes and the role of vaccines. This paper compares key characteristics from the five different COVID-19 waves in Pakistan.

Data was sourced from daily national situation reports (Sitreps) prepared by the National Emergency Operations Centre (NEOC) in Islamabad. We use specific criteria to define COVID-19 waves. The start of each COVID-19 wave is marked by the day of the lowest number of daily cases preceding a sustained increase, while the end is the day with the lowest number of cases following a 7-days decline, which should be lower than the 7 days following it. Key variables such as COVID-19 tests, cases, and deaths with their rates of change to the peak and then to the trough are used to draw descriptive comparisons. Additionally, a linear regression model estimates daily new COVID-19 deaths in Pakistan.

Pakistan saw five distinct waves, each of which displayed the typical topology of a complete infectious disease epidemic. The time from wave-start to peak became progressively shorter, and from wave-peak to trough, progressively longer. Each wave appears to also be getting shorter, except for wave 4, which lasted longer than wave 3. A one percent increase in vaccinations decreased deaths by 0.38% (95% CI: -0.67, -0.08) in wave 5 and the association is statistically significant.

Each wave displayed distinct characteristics that must be interpreted in the context of the level of response and the variant driving the epidemic. Key indicators suggest that COVID-19 preventive measures kept pace with the disease. Waves 1 and 2 were mainly about prevention and learning how to clinically manage patients. Vaccination started late during wave 3 and its impact on hospitalizations and deaths became visible in wave 5. The impact of highly virulent strains Alpha/B.1.1.7 and Delta/B.1.617.2 variants during wave 3 and milder but more infectious Omicron/B.1.1.529 during wave 5 are apparent.

Citation: Ahmad T, Abdullah M, Mueed A, Sultan F, Khan A, Khan AA (2023) COVID-19 in Pakistan: A national analysis of five pandemic waves. PLoS ONE 18(12): e0281326. https://doi.org/10.1371/journal.pone.0281326

Editor: Huzaifa Ahmad Cheema, King Edward Medical University, PAKISTAN

Received: January 20, 2023; Accepted: December 12, 2023; Published: December 29, 2023

Copyright: © 2023 Ahmad et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data was provided to the Akhter Hameed Khan Foundation (AHK-F) team for this study as part of its work with Pakistan’s Federal Ministry of National Health Services, Regulations & Coordination (MoNHSR&C) and the National Command & Operation Centre (NCOC) in Islamabad, which are leading Pakistan’s response to the COVID-19 pandemic. The AHK-F team has provided analytical support to the above entities, and such created knowledge that has directly informed pandemic policy-making in Pakistan. COVID-19 data is compiled and shared in daily National Situation Reports, or Sitreps, by the National Emergency Operation Centre (NEOC). Each day’s Sitrep is compiled as a PDF file. The data used for this study was manually compiled from these PDF files and then used in STATA. The parentage of this data is with the NCOC and the MoNHSR&C. The AHK-F team received this data with the express understanding that it would be kept confidential. However, the data can be obtained independently from the NEOC, through a data request procedure, which is subject to approval from the MoNHSR&C. The data request itself is to be addressed to: Dr. Shahzad Baig, National Coordinator, National Emergency & Operation Center, D Block, EPI Building, Chak Shahzad, Park Road, Islamabad. Email: [email protected] Phone: +92-51-8730879. The data on Oxford Health and Containment Index is taken from and publicly available at the following GitHub repository: https://github.com/OxCGRT/covid-policy-tracker/tree/master/data .

Funding: This work was supported, in whole or in part, by the Bill & Melinda Gates Foundation [grant number: INV-025171]. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

In Pakistan, the first case of COVID-19, a novel and little-understood disease, was detected on February 26, 2020. Being a developing country with limited resources, crumbling health infrastructure and low health expenditure [ 1 ], Pakistan has no past experience with pandemics and a high burden of communicable diseases [ 2 ]. As of February 23, 2022, the country had fully vaccinated 43% of its total population [ 3 ] and the Omicron variant of COVID-19 was the dominant strain [ 4 ]. These factors make Pakistan a high-risk country, with a large pool of infection-susceptible people.

The emergence of COVID-19 has arguably been the biggest social and economic disruption in Pakistan in recent history. The pandemic has largely manifested itself in five distinct waves each of which have a rise, plateau, and trough in cases, followed by a period of dormancy, after which the incidence of COVID-19 infections begins to rise again. Thus, each individual wave follows a four-stage pattern followed by endemicity that has been seen for many infectious disease epidemics [ 5 ]. Beyond anecdotal observation, there is evidence that this is happening with COVID-19 as well [ 6 ]. What sets COVID-19 apart is that after completion of an individual wave, a new one would come along shortly, rather than taking much long, for example, annual recurrences for influenza. This pattern has been seen across the globe [ 7 – 11 ] with the timing of COVID-19 waves in different countries broadly coinciding [ 6 ].

In this context, current literature on COVID-19 largely focuses on high-income countries during the initial waves [ 7 , 12 , 13 ], or aggregated at regional levels [ 8 , 14 ]. Given the different capacities of countries to manage the pandemic [ 15 ], there is a need to explore the characteristics of the subsequent pandemic waves in a developing country context, preferably with granularity of a country-level analysis.

This paper aims to offer a comprehensive understanding of the impact of COVID-19 in Pakistan. To achieve this, we examine the five waves of the pandemic in Pakistan, analyzing various key aspects and critical statistics. These include the total number of COVID-19 tests conducted, confirmed cases, hospitalizations, COVID-19-related deaths, and the progress of vaccinations during each wave. Additionally, we employ statistical modeling to identify the significant factors contributing to COVID-19-related deaths. Our goal is to fill the existing gap in the literature by providing valuable insights specific to a developing country like Pakistan, where limited evidence currently exists.

Criteria for COVID-19 waves

We begin by retrospectively defining various time periods between 2020 and 2022 as distinct waves, based on existing literature [ 16 ]. There are a total of 628 observations (daily set of indicators) across these five waves. Based on our criteria, the starting point of each COVID-19 wave is defined as the day with the lowest number of daily new COVID-19 cases preceding a consistent rise in these cases, before the peak of the respective COVID-19 waves. The end of each wave is defined as the day with lowest number of daily new COVID-19 cases following a 7-day decline; this number also needed to be lower than the cases on any of the 7 days that followed it ( Table 2 ).

Data and variables

In order to estimate the pattern for COVID-19 throughout the five waves in Pakistan, we use time series data of various daily indicators from April 3, 2020 to February 23, 2022, which are categorized into the following broad themes:

• i) Wave timespan
• ii) COVID-19 tests
• iii) COVID-19 cases
• iv) Test-to-case ratio
• v) COVID-19 positivity
• vi) Hospitalization and treatment
• vii) COVID-19 deaths
• viii) COVID-19 vaccination
• ix) Policy environment

Several variables in the list above were transformed into ratios for the purpose of describing all five COVID-19 waves in Pakistan ( S1 Table ).

The data for all but two of the above themes, COVID-19 vaccination and policy environment, is compiled from daily national situation reports (Sitreps). These Sitreps are prepared by the National Emergency Operations Centre (NEOC) in Islamabad, Pakistan. Data in these Sitreps have served as the basis for all major COVID-19 policy decisions in Pakistan.

The data for COVID-19 vaccination is sourced directly from the National Command & Operation Centre (NCOC), Islamabad, Pakistan, which is the government forum that brings together the ministries of Health and Planning along with the military to determine pandemic policy and to coordinate the response. Data for the policy environment is taken from a publicly available dataset from the University of Oxford’s Blavatnik School of Governance [ 17 ]. This dataset is compiled by using qualitative information about the non-pharmaceutical interventions (NPIs) in a country and quantifying them into an index called Oxford Containment and Health Index for COVID-19. A detailed methodology of the index calculation can be found in a working paper by the Blavatnik school [ 18 ].

Model specification

Apart from presenting statistics on daily indicators for every wave, we estimate the predictors of daily new deaths due to COVID-19. For our model of daily new COVID-19 deaths, we use a linear ordinary least square (OLS) regression. The data as well as the model is divided into five distinct periods, representing the five waves of COVID-19 in Pakistan, as of February 2022. The manuscript comprises statistical analysis and inferences for each of the five waves separately.

Our independent variables measured at daily intervals are:

• i) Log of daily new COVID-19 cases with 21-day delay ( LnX1 t+21 );
• ii) Log of daily new COVID-19 tests with 28-day delay ( LnX2 t+28 );
• iii) The Oxford containment and health index for COVID-19 with 14-day delay ( X3 t+14 );
• iv) Time variable capturing the time trend ( X4 t );
• v) The number of people on ventilators as a proportion of the total admitted ( X5 t );
• vi) The number of people on oxygen as a portion of the total admitted ( X6 t );
• vii) Log of second doses of COVID-19 vaccines administered with 14-day delay ( LnX7 t+14 )

Daily new COVID-19 cases are regressed with a 21-day lag, since among those who die from COVID-19 infection, death occurs between a median of 14 days [ 19 ] and 25 days (average of three weeks) after presenting symptoms [ 20 , 21 ]. This is pertinent in the case of Pakistan, as most of the COVID-19 testing in the country has been symptomatic, i.e., done when someone develops symptoms of COVID-19 and hence either voluntarily gets tested or is prescribed by a medical professional to do so.

Given the delay for daily new cases, daily new COVID-19 tests are regressed with a delay of 28 days. This delay allows for the time it takes for someone to test positive for COVID-19 and for their symptoms to worsen (for example, by escalating to hospitalization, which takes nearly a week [ 22 ] before resulting in death). For vaccination, a 14-day lag is taken, as immunity from vaccines is generally understood to develop two weeks or longer after receiving a shot [ 23 – 25 ].

The Oxford Containment and Health Index is calculated out of 100 where 100 means strict restrictions and 0 means no restrictions imposed on the general population. This variable is regressed with a 14-day lag, as we assume that any new government restrictions will take approximately that long to have any effect. Additionally, the time variable is meant to capture any unmeasured or seasonal effects on COVID-19 deaths in Pakistan, such as an overall rate of increase or decrease of daily deaths in each wave. We assume the error term is not correlated with any of the independent variables.

Newey-West standard errors are used to account for autocorrelation and potential heteroskedasticity in the error terms. Statistical tests are performed to ensure that the required assumptions for the regression model are met: for heteroskedasticity, the Breusch-Pagan test is applied, whereas for serial correlation, the Durbin-Watson test is used. Variance inflation factor (VIF) is calculated for multicollinearity. The presence of unit roots is tested using augmented Dicky-Fuller tests for each independent variable in our regression model. All the variables are found to be stationary, fulfilling an important pre-requisite for our analysis ( Table 1 ). The statistical analysis is carried out using STATA 17 software.

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0281326.t001

Summary statistics

Pakistan experienced five distinct waves from 3 rd April 2020 till 23 rd February 2022 ( Fig 1 ). Wave 1 lasted the longest (150 days), while the wave 5 was the shortest (83 days). Wave 4 was remarkable for its relatively rapid upslope and a long tail, while wave 5 showed a reverse pattern. The duration of each wave of COVID-19 in Pakistan was shorter than the preceding one apart from wave 4. After wave 1, each wave took less time to reach its peak and took longer to reach its trough, apart from wave 5.

https://doi.org/10.1371/journal.pone.0281326.g001

The capacity to conduct tests expanded over time from an average of 17,142 tests daily during wave 1 to 49,650 during wave 5. The increase in the daily tests peaked during wave 4. The highest average daily number of cases (3147) were observed during wave 3. The rate of increase of COVID-19 cases was the highest during wave 4, but the rate of decline in cases after the peak of a wave was the fastest during wave 5. Test-to-case ratio kept increasing from 15 during wave 1 to 57 during the wave 5. While total positivity varied across waves, the rate in daily change of positivity remained relatively unchanged apart from waves 2 and 3, where it was lower as compared to other waves ( Table 2 ).

https://doi.org/10.1371/journal.pone.0281326.t002

Hospitalizations were the highest for waves 1 and 3 and the lowest for wave 5, whereas duration of hospitalization fell linearly from an initial 13 days during wave 2 to 5 days during wave 5. Hospitalizations became more specific over time in that, nearly two thirds of admitted patients during wave 1 were stable, compared to 9% during wave 5. The average stable-admitted ratio decreased continuously from wave 1 to wave 4 but increased slightly in wave 5. The rate at which people recovered from COVID-19 and/or were discharged from hospital was the fastest in wave 4 but the slowest in wave 2.

The average oxygen beds-admitted ratio continuously increased in each wave, reaching its maximum value in wave 4. During wave 1, 27% of all admissions required oxygen and 7% needed a ventilator, compared to 81% and 10% respectively during wave 5. The average oxygen bed utilization followed a declining trend except for wave 3 (24%) and was the lowest in wave 5 (7%). The trend of average ventilators utilization ratio showed that all available ventilators were not fully utilized in any of the five waves. The highest ventilators utilization was in wave 3 (20%) and the lowest in wave 5 (5%). These two ratios suggest that most critical patients were put on oxygen for recovery and a small proportion of these people were transferred to ventilators.

Deaths from COVID-19 were the highest during wave 3 at 9,423, which also saw the highest daily number of deaths (78.5) and the highest rate of increase in daily deaths. Average daily deaths to hospitalization rate peaked during wave 2, while deaths to ventilator use was the highest during wave 1. Average deaths to case ratio was the highest for wave 3 but was in the 2.2–2.8% range, except for wave 5 when it was 1.1%.

Pakistan’s vaccination drive started towards the end of wave 2, but full vaccination (i.e., people receiving both their doses) did not happen until the beginning of wave 3. Consequently, total and daily new second dose of vaccine administered was highest in wave 5. Government restrictions, measured by the Oxford Containment and Health Index, appeared to be comparable in each wave.

OLS regression results

The linear OLS regression results for daily new COVID-19 deaths indicate that daily new COVID-19 cases were a statistically significant determinant for daily new deaths in all five waves at 95% CI; a one-percentage increase in COVID-19 cases caused a 0.46–0.69% increase in deaths across the five waves ( Table 3 ).

https://doi.org/10.1371/journal.pone.0281326.t003

The daily new COVID-19 tests and Oxford containment and health index, which records the presence of government NPIs and restrictions, were both found to be statistically significant determinants of COVID-19 deaths in wave 1. Increasing daily new tests by 1% reduced daily deaths by 0.65% (95% CI: 0.26, 1.04). An increase in Oxford Containment and Health Index by 1 point resulted in 0.03% reduction in daily new deaths (95% CI: -0.05, -0.005).

The time trend variable was statistically significant in waves 1, 3 and 4. The coefficients indicate that, on average, daily COVID-19 deaths decreased at a rate of 0.04% per day (95% CI: -0.04, -0.03) during wave 1. However, daily new deaths reduced at a rate of 0.01% per day during wave 3 (95% CI: -0.02, 0.002) and wave 4 (95% CI: -0.01, 0.00).

The ventilator-admitted ratio was statistically significant in waves 1, 4 and 5. The coefficient was negative throughout these three waves and significant at 95% CI. The coefficients indicates that if ratio of patients on ventilator out of the admitted increased then daily new deaths would decrease by 14–17%.

Oxygen-admitted ratio was only significant in waves 1 and 2 at 95% CI, where the coefficient was positive, implying that an increase in the ratio of oxygenated patients out of the total admitted increased was associated with an increase in daily new deaths due to COVID-19 by approximately 4%.

Lastly, the number of fully vaccinated people is statistically significant in each of the last three waves. During wave 3, COVID-19 deaths increased by 0.07% (95% CI: 0.006,0.14) as percentage of fully vaccinated people increased by one percent. This rate increased to 0.10% (95% CI: 0.006,0.14) during wave 4. However, during wave 5, daily new deaths due to COVID-19 decreased by 0.38% (95% CI: -0.67, -0.08) as fully vaccinated people increased.

Pakistan experienced 5 distinct waves from 3 rd April 2020 to 23 rd February 2022. Our analysis reflects both the evolution of Pakistan’s response, as well as the differential impact of different variants of the virus shaped the contours and features of each wave. Pakistan experienced its initial wave earlier than other South Asian countries including India, Bangladesh, Sri Lanka and Nepal, while peaks for the subsequent waves coincided with those in other countries [ 26 ].

The upslope, as seen by the rate of change for testing and cases, was always steeper than during the downward slope of a wave. This pattern follows what is known about infectious epidemics in that cases rise quickly, plateau and then fall, slowly to an endemic state where a low ebb of infections persists in the community indefinitely [ 5 ]. In fact, each wave behaved as a typical epidemic caused by a distinct variant of the virus. Wave 1 was dominated by B.1 variant, wave 2 by B.1.36 variant, the wave 3 by Alpha/B1.1.7 and Delta/B.1.617.2 variants, wave 4 had majority cases of the Delta/B.1.617.2 variant [ 27 – 29 ] while wave 5 was driven by Omicron/BA.5.2.1.7 [ 4 ].

A key challenge faced by Pakistan at the beginning of the pandemic was that there was little prior experience with any pandemic outbreak of such level. Although disease surveillance systems exist, they had not been scaled to manage case surveillance, hospital admissions, daily deaths, and eventually large-scale adult vaccination and event tracking. Pakistan has a federal system of governance where provinces provide health services while the federal ministry provides guidance and coordination. In addition, considerable curative care is in the private sector. To address the potential difficulties in mounting a unified national response to the disease in the face of this diversity, a National Action Plan for COVID-19 was formulated in March 2020 that placed the responsibility for the national response in a National Coordination Committee (NCC) that was headed by the Prime Minister and attended by all federal ministers. The NCC set national policy which was implemented by the National Command and Operation Centre (NCOC) that was co-headed by the military and civilian leadership [ 30 ]. The NCOC coordinated the management of the extensive lockdowns, other key NPIs such as school closures, limited opening hours for essential businesses (examples of which included grocery stores and pharmacies), closure of borders, cancellation of public events and social gatherings [ 31 , 32 ]. This was supported based on an elaborate data gathering and analysis system that guided daily decisions.

Wave 1 continued the longest and intervals became shorter between each successive wave. Each wave showed unique features, that were determined by the particular variant that drove that wave, along with the larger context that included the type of the variant driving the wave, the extent and type of preventive interventions and eventually the availability of the vaccine.

Pakistan’s response to COVID-19 evolved over time. For example, wave 1 had the highest positivity rates and the longest duration, in part due to low initial rates of testing, including very little contact tracing in the early days [ 33 ]. As testing increased and mobility restrictions tightened, duration of waves 2 and 3 became shorter. However, by the end of wave 2, intervention fatigue had set in. Implementation was laxer, and these factors contributed to more cases and deaths of any wave during wave 3. Indeed, the Oxford Containment and Health Index was significant only during wave 1 in terms of preventing deaths.

In addition to preventive measures, the higher daily COVID-19 cases in waves 3, 4, and 5 may be attributed to highly transmissible Alpha [ 34 , 35 ], Delta [ 36 , 37 ] and Omicron [ 38 ] variants, and to easing of severe restrictions such as lockdowns and school closures [ 39 ]. It is also possible that many cases were missed during wave 1 due to limited testing. However, the stability of daily testing in waves 3 to 5 suggests a stable equilibrium between the testing system and how cases were being incident–the system was capturing most of the cases from previously recognized populations and locations. It is likely that undiagnosed cases and deaths were few, since as part of the national surveillance, teams kept abreast of burials in large and midsized towns and also periodically canvased opinion of general practitioners about upsurges in respiratory illnesses. On average, Pakistan had fewer cases per million population than neighboring countries of India, Bangladesh, and Iran, as well as several of the developed countries [ 26 ].

As with prevention, clinical management of cases evolved over time. Initially most cases were hospitalized as seen by the high case to hospitalization ratio–only 27% of admissions required oxygen 7% required ventilators during wave 1. In fact, there was a correlation between deaths and oxygenation (which was mostly at hospitals) during waves 1 and 2, a pattern that was seen globally. However, with each succeeding wave, use of oxygen increased while ventilators fluctuated within a narrow range, as was also seen in India [ 40 , 41 ]. Thus, even as COVID-19 hospitalizations peaked during wave 3, hospitalization to case ratio increased, and average duration of hospitalization and the use of hospitals for simple oxygenation fell, suggesting hospitals, ICU and ventilators, were increasingly reserved only for the sickest [ 42 ]. Deaths correlated best with a 21-day delay model rather than a 28-day one, suggesting that most deaths happened early after infection. Higher hospitalizations during wave 3 may also have been attributed to the Alpha followed by Delta variants [ 43 – 45 ]. By contrast, lower hospitalizations, length of stay, and mortality during wave 5 may be attributed to the Omicron variant that was seen worldwide [ 46 , 47 ], and specifically in South Africa [ 48 ] and Brazil [ 49 ] during the Omicron waves. Vaccination started earlier on in wave 3 and more than half of the eligible population was fully vaccinated by wave 5 [ 3 ] and may have contributed to lower hospitalizations in wave 5. Unlike COVID-19 induced major challenges to the healthcare capacity in various countries [ 50 , 51 ], Pakistan was able to build healthcare resources capacity to keep pace with the pandemic. Ventilator and oxygen utilization never exceeded 20% and 24% respectively in wave 3.

Vaccination drive started in Pakistan by the end of February 2021. Despite a slow start, vaccination picked up pace from 26,356 daily vaccinations in wave 3 to 308,129 in wave 4 as it was rolled-out to younger population and vaccine supply increased in the country. Average daily deaths did not reduce significantly due to vaccinations during waves 3 and 4 [ 52 , 53 ], but showed marked reduction in hospitalizations and deaths towards the end of wave 4 and during the entire wave 5 [ 54 ].

From our regression model, we found that daily new COVID-19 cases were statistically significant determinants of daily new deaths due to COVID-19. The association was also observed from the wave 3 as both cumulative cases and deaths were the highest, including the average daily deaths which were considerably higher than any other wave, as seen in other countries [ 55 ]. Secondly, daily new deaths due to COVID-19 increased with patients on oxygenated beds while decreased with patients on ventilators in the initial waves, potentially due to high patients load in hospitals, critical patients were put on oxygen rather than ventilator. Wave 5 experienced the smallest number of daily COVID-19 deaths possibly because it was dominated by the Omicron variant [ 56 ].

Limitations

There are several limitations associated with the data used in this paper. While the official data used for the analysis are disaggregated by sub-national level, demographic disaggregation, such as age or gender, are not available. This limits the analysis in terms of the implication of gender and age on COVID-19 deaths. The national data is compiled by aggregating the numbers for each subnational unit in Pakistan. However, such an analysis would be too extensive to depict and therefore our analysis does not account for subnational differences. It is possible that distinctive cultures, behaviors, and differences in the stringency in enforcement of interventions vary between regions and may in theory, influence the number of COVID-19 cases and deaths.

Similarly, data for hospitalizations is also unaccompanied by any information on comorbidities, as this information was not available beyond treating hospitals, losing a level of richness of analysis that includes such comorbidities. Also, data for daily new hospital admissions started becoming available towards the very end of wave 1. Consequently, the average length of hospital stay could not be calculated for this wave.

The official vaccination data available to us at the time of this analysis is not desegregated by the different types of available vaccines, for example Sinopharm, CanSino, Sputnik V and others. Differential impact of each vaccine on COVID-19 deaths in Pakistan would be informative. All the above limitations notwithstanding, we are confident that this study provides crucial insights into the prevailing trends of COVID-19 in Pakistan in manner that is constructive.

We describe how COVID-19 waves differed in terms of cases, hospitalizations, and deaths in Pakistan, and analyze potential reasons for these differences. Pakistan experienced its initial COVID-19 wave earlier than other South Asian countries, with wave 1 lasting the longest. As testing increased and restrictions were enforced, subsequent waves became shorter, but wave 3 stood out due to lax implementation, resulting in the highest number of cases and deaths. The higher daily cases in waves 3, 4, and 5 were also attributed to the highly infectious Delta and Omicron variants. Wave 3 recorded the most COVID-19 deaths, with 9,423 fatalities, the highest daily death rate, and the steepest increase in daily deaths. Lastly, vaccination began in wave 2, with full vaccination achieved in wave 3, and the highest second-dose vaccinations occurred in wave 5.

At the pandemic’s onset, Pakistan’s lack of prior experience was a challenge. However, a National Action Plan for COVID-19 was established in March 2020. COVID-19 management in Pakistan kept pace with the spread of the disease during five distinct waves and successfully implemented the COVID-19 vaccination drive nationwide. The experiences and limitations offer valuable insights for future pandemic management for a developing country like Pakistan.

Supporting information

S1 table. calculated ratio variables and their descriptions..

https://doi.org/10.1371/journal.pone.0281326.s001

• 1. Noreen N, Dil S, Ullah S, Niazi K, Naveed I, Khan NU, et al. Coronavirus disease (COVID-19) Pandemic and Pakistan; Limitations and Gaps. Global Biosecurity. 2020;1. https://jglobalbiosecurity.com/articles/63/galley/170/download/ .
• View Article
• PubMed/NCBI
• Google Scholar
• 3. NCOC. Vaccine Statistics. 2022 [cited 23 Feb 2022] p. NCOC Official Website. https://covid.gov.pk/vaccine-details .
• 4. Badar N, Ikram A, Salman M, Umair M, Rehman Z, Ahad A, et al. Genomic characterization of SARS-CoV-2 from Islamabad, Pakistan by Rapid Nanopore sequencing.
• 17. OxCGRT. OxCGRT COVID Policy Tracker Data. 2021. https://github.com/OxCGRT/covid-policy-tracker/tree/master/data/timeseries .
• 18. Hale T, Anania J, Angrist N, Boby T, Cameron-Blake E, Folco M Di, et al. Variation in government responses to COVID-19, Version 12.0. BSG Working Paper Series. 2021.
• 26. Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, et al. Coronavirus Pandemic (COVID-19). In: OurWorldInData.org [Internet]. 2020. https://ourworldindata.org/coronavirus .
• 30. National Institute of Health Pakistan. National Action Plan for Corona virus disease (COVID-19) Pakistan. 2020.
• 31. Gul A. Pakistan Seals Borders, Shuts Schools, Bans Public Events Over Coronavirus. Voanews.com. 13 Mar 2020: COVID-19 Pandemic.
• 38. Tian D, Sun Y, Xu H, Ye Q. The emergence and epidemic characteristics of the highly mutated SARS-CoV-2 Omicron variant. 2022.
• 39. Provinces announce easing lockdown even as Pakistan witnesses record rise in coronavirus cases. In: DAWN [Internet]. 2020 [cited 1 Aug 2022]. https://www.dawn.com/news/1555575 .

• Get Involved

COVID-19 pandemic

Covid-19 pandemic response.

Humanity needs leadership and solidarity to defeat the coronavirus

The coronavirus COVID-19 pandemic is the defining global health crisis of our time and the greatest challenge we have faced since World War Two. Since its emergence in Asia late last year, the virus has spread to  every continent  except Antarctica. Cases are rising daily in Africa the Americas, and Europe.

Countries are racing to slow the spread of the disease by testing and treating patients, carrying out contact tracing, limiting travel, quarantining citizens, and cancelling large gatherings such as sporting events, concerts, and schools.

The pandemic is moving like a wave—one that may yet crash on those least able to cope.

But COVID-19 is much more than a health crisis. By stressing every one of the countries it touches, it has the potential to create devastating social, economic and political crises that will leave deep scars.

We are in uncharted territory. Many of our communities are unrecognizable from even a week ago. Dozens of the world’s greatest cities are deserted as people stay indoors, either by choice or by government order. Across the world, shops, theatres, restaurants and bars are closing.

Every day, people are losing jobs and income, with no way of knowing when normality will return. Small island nations, heavily dependent on tourism, have empty hotels and deserted beaches. The International Labour Organization estimates that 25 million jobs could be lost.

UNDP response

Every country needs to act immediately to prepare, respond, and recover. The UN system will support countries through each stage, with a focus on the most vulnerable.

Drawing on our experience with other outbreaks such as Ebola, HIV, SARS, TB and malaria, as well as our long history of working with the private and public sector , UNDP will help countries to urgently and effectively respond to COVID-19 as part of its mission to eradicate poverty, reduce inequalities and build resilience to crises and shocks.

“We are already hard at work, together with our UN family and other partners, on three immediate priorities : supporting the health response including the procurement and supply of essential health products, under WHO’s leadership, strengthening crisis management and response, and addressing critical social and economic impacts.” UNDP Administrator, Achim Steiner

Responding with people at the centre

Pakistan has witnessed a massive increase in its confirmed cases from the initial two confirmed on 26th February 2020. As a country whose economy is highly reliant on manufacturing and service industries, shutdown measures and disruptions in supply chains will negatively impact on the economy and society, particularly the poor. 

As in other countries, the pandemic is likely to stress the capacity of the public health system and result in loss of human lives.  Severe repercussions on livelihoods, especially of the most vulnerable, dependent on government support, are expected.  The shutdown measures have already impacted small businesses, small and medium enterprises and daily wagers associated with various sectors of the economy. Considering that the informal sector in the country accounts for a major share of the national economy[1] and employs 27.3 million individuals, an increase in un(der)employment and poverty coupled with implications on food production and overall food security are anticipated.

The Government of Pakistan is concerned with the social and economic implications of COVID-19 and has established, with the help of UNDP, a COVID-19 Secretariat in the Planning Commission to prepare a coordinated economic and social response and design evidence-informed interventions. The Secretariat is required to ensure adequate coordination between Federal and Provincial Governments, with UN and Development Partners.  

In this regard, the federal government as well as provincial government of Khyber Pakhtunkhwa have requested UNDP’s support on a range of areas including coordination, strategic communications, crisis management, business continuity and digital solutions to manage government response to the pandemic. Assistance with procurement of medical supplies and equipment is also being discussed.

Against this background, UNDP is currently in the following activities in response to COVID-19 in Pakistan.  (This page will be updated regularly.)

Supporting the Federal Government in coordination and strategic communications:

• Supporting the Planning Commission in establishing a Secretariat for coordinating socio-economic impact of COVID-19;
• Supporting the Federal Government and Khyber Pakhtunkhwa Government with Strategic Communications and Awareness;
• Supporting Economic Affairs Division to design ODA coordination system (aid effectiveness).

Supporting Ministry of Health and Khyber Pakhtunkhwa Government in health system response:

• Capacity support in crisis management and provision of digital solutions to enable business continuity;
• Supporting Khyber Pakhtunkhwa Government to enhance supply chain management (including procurement of health supplies and equipment).

Coordination of UN socio-economic impact needs assessment to identify mitigation responses:

• Impact assessment on the most vulnerable, policy recommendations & proposed programme interventions, to feed into the national action plan for COVID-19.

[1] The figure ranges from 18.2% to 71% based on different analysis 

While we do this, we must also consider ways to prevent a similar pandemic recurring. In the longer term, UNDP will look at ways to help countries to better prevent and manage such crises and ensure that the world makes full use of what we will learn from this one.

A global response now is an investment in our future.

• How We Work
• CrisisWatch
• Upcoming Events
• Event Recordings
• Afrique 360
• Hold Your Fire
• Ripple Effect
• War & Peace
• Photography
• For Journalists
• Download PDF
• Early Missteps
• Pandemic Policy in Pakistan’s Fractured Polity
• Mixed Messaging and the Power of the Pulpit
• The Economy, Health Policy and Social Support
• Health Systems in a Pandemic

Pakistan’s COVID-19 Crisis

A federal government misstep – lifting a lockdown too soon – has placed Pakistan among the twelve countries hardest hit by coronavirus. Nor has the economy recovered as intended. Authorities should let provinces make more health decisions and focus on helping citizens in need.

• "> Download PDF

What’s new?  Hoping to mitigate COVID-19’s economic toll, Imran Khan’s Pakistan Tehreek-e-Insaf government lifted a countrywide lockdown in May, leading to a spike in cases. August could see another surge since the public, misled by the clergy and mixed messaging from the government itself, may disregard precautions during religious festivities and ceremonies.

Why does it matter?  Climbing infection rates could overwhelm ill-equipped health systems and hinder economic recovery. If citizens are denied health care or adequate aid as the economy contracts, public anger is likely to mount, potentially threatening social order. Militants could take advantage, as they have in the past.

What should be done?  The federal government should guide provinces on pandemic policy and help reinforce their health systems but also permit them to devise their own local strategies guided by medical experts. It should work with the parliamentary opposition on its response, particularly on providing a safety net to vulnerable parts of society.

I. Overview

On 9 May, the Pakistan Tehreek-e-Insaf government almost completely lifted a nationwide lockdown it had imposed in late March to counter COVID-19. Pakistan subsequently saw a surge in cases, placing it among the top twelve pandemic-affected countries worldwide. The government justifies the easing of nationwide restrictions on economic grounds; indeed, the lockdown’s toll on the most vulnerable, workers and the poor has been brutal. Yet signs of economic recovery since it was lifted are few, while the virus threatens to overwhelm ill-equipped and under-funded health systems. Rising anger and alienation among citizens could threaten social order, potentially giving militants an opening to gain support. The federal government should revise its approach. It should seek consensus with political rivals on its coronavirus strategy, pay greater heed to public health experts, if feasible step up aid to families unable to get by and give the provinces more leeway to lead local efforts to deal with the public health crisis.

The government’s mixed messaging and misinformation from some religious leaders mean that many Pakistanis disregard public health advice. Prime Minister Imran Khan’s initial downplaying of the pandemic’s health risks led to widespread public disregard for social distancing procedures. The removal of restrictions on communal prayers in mosques also increased the risks of new virus clusters. Many clerics advocate religious practices that undercut physical distancing and other preventive measures; they tell worshippers that piety alone, and not health practices, will determine their fate. The federal government’s easing of lockdown measures, despite warnings by the political opposition and medical professionals that transmissions would surge, and the further lifting of the lockdown, on 9 May, encouraged public complacency. Though the government now urges people to respect social distancing rules, these calls are largely ignored. Many believe that the pandemic is over.

The federal government’s adoption of what it calls a “smart lockdowns” strategy may not be enough. The strategy entails removing restrictions in specific areas within cities or regions where the authorities assess that case rates are relatively low and imposing them where they are high. But poor data and low testing rates have hampered efforts to “track, trace and quarantine”, which involve identifying and isolating virus carriers and their contacts and placing hot-spots under quarantine, and are essential to curbing the virus. With COVID-19 spreading in densely populated cities such as Karachi, Lahore and Peshawar, limited closures are unlikely to prevent contagion. While city hospitals are better prepared to deal with the pandemic than some weeks ago, they could again be overwhelmed should cases surge in August, particularly if citizens ignore precautions during Eidul Azha celebrations and the month of Muharram, when large mourning processions are held. The virus has also spread to rural regions, where the health infrastructure is even weaker.

The federal government’s centralised decision-making has often made things worse. It has refused to share authority, even though the constitution grants the provinces responsibility for the health sector. Islamabad’s pandemic policies, devised by the top political and military leadership, have prevailed over provincial preferences, with court rulings strengthening centralised control. The Pakistan Peoples Party’s government in Sindh, the sole opposition-led province, has promoted rigorous restrictions, for instance, but has been unable to implement them in the face of Islamabad’s resistance. The federal government has also been reluctant to work with parliament or main opposition parties to forge a united response. The acrimony is rooted in contested mid-2018 elections, though the opposition has repeatedly offered to assist the government in containing the pandemic.

The public health crisis and economic downturn could be devastating, particularly if people feel it is mismanaged. Anger at the government and social tensions will mount if citizens sense that the government is not adequately looking after their health and wellbeing. In the past, militant groups have exploited such opportunities to gain local support.

While COVID-19 leaves Pakistan’s government few good options, some steps could minimise harm to lives and livelihoods. The prime minister’s fears about the toll of lockdowns are well justified. Yet the economy is unlikely to start moving unless the authorities can keep the virus at bay. Adapting the smart lockdown strategy might avoid the pain of a prolonged lockdown while still saving lives. This could mean allowing provinces, if medical experts so advise, to lock down entire cities and urban districts for short periods, instead of limiting them to partial closures. More broadly, the government should guide the country’s response but give provinces leeway to devise policies tailored to local needs. Bolstering the provinces’ health capacity – particularly testing – should remain a top priority. Emergency assistance to families that fall under the poverty line and unemployed workers remains critical. Prime Minister Imran Khan’s – and the country’s – interests would also be best served by working with the opposition to forge consensus on managing the consequences of an unprecedented and potentially destabilising health crisis.

II. Responding to the Pandemic

A. early missteps.

As happened in many other countries, early missteps overshadowed the Pakistan Tehreek-e-Insaf government’s response. In February, the government refused to repatriate hundreds of Pakistani students in Wuhan, China, fearing they would spread the virus. In itself, the decision appears to have been sensible, though perhaps the government could have brought them home but quarantined them. Yet despite its caution with citizens in Wuhan, it failed to properly screen inbound travellers, many of whom carried the virus. [fn] International flights continued to operate until 21 March. Hide Footnote  The first confirmed COVID-19 case in Pakistan was that of a Karachi student returning from pilgrimage in Iran on 26 February. Shia pilgrims coming home from Iran, at the time the region’s worst-hit country, formed the first major cluster of imported infections. The government quarantined hundreds of pilgrims in overcrowded, unhygienic conditions near the Iranian border but then allowed them to leave for their home provinces without adequate testing or isolation, spreading the virus throughout the country. [fn] Between 28 February and 15 April, 7,000 pilgrims returned from Iran, 6,800 through the Taftan border crossing, where many were initially quarantined. “7,000 pilgrims have returned from Iran since February: FO”, Dawn, 19 April 2020. Hide Footnote

The first major cluster of locally transmitted infections occurred when the ruling party’s Punjab government delayed a decision to cancel the Sunni proselytising group Tableeghi Jamaat’s major annual congregation ( ijtema ), due to take place for five days from 11 March. The organisers ultimately cancelled the ijtema , but only on 12 March, by which time an estimated 100,000 believers, including around 3,000 foreigners, had already set up camp together in close quarters. Had the Punjab government given “clear instructions”, a Tableeghi Jamaat follower said, “the event would not have happened”. [fn] The Punjab police put numbers at 70,000 to 80,000. Other estimates were as high as 250,000. Asif Chaudhry, “Tableeghi Jamaat in hot water in Pakistan too for Covid-19 spread”, Dawn , 8 April 2020. Hide Footnote  After its cancellation, most participants left, but a few hundred stayed on at the organisation’s Raiwind headquarters. They, too, were allowed to leave for their home provinces without being tested or isolated; Tableeghi Jamaat members also went on preaching missions throughout the country. Large clusters of virus transmission in at least two provinces, Punjab and Sindh, have been traced to Tableeghi Jamaat members who had participated in the Raiwind ijtema . [fn] “Limiting the spread,” Dawn, 2 April 2020; “27 per cent of Pakistan’s Covid-19 cases linked to Raiwind Ijtema : report”, The Express Tribune , 23 April 2020. Hide Footnote

B. Pandemic Policy in Pakistan’s Fractured Polity

The Pakistan Tehreek-e-Insaf government was slow to respond as the pandemic spread. The first cabinet meeting devoted to the subject was held on 13 March, weeks after the confirmed case in Karachi. [fn] “Pakistan closes western borders, bans public gatherings as coronavirus cases rise to 28”, Dawn , 13 March 2020. Hide Footnote  The federal government’s approach was then shaped by an adversarial relationship with the opposition and an overreliance on the military’s support.

At a time when political consensus was most needed in forging a national response to the pandemic, the federal government’s relationship with the two largest opposition parties, Nawaz Sharif’s Pakistan Muslim League and Bilawal Bhutto Zardari’s Pakistan Peoples Party, was strained. The antagonism had its roots in the contested July 2018 elections. Both main opposition parties attributed Imran Khan’s victory to manipulation. After forming a government with a razor-thin majority, and entering into coalitions with smaller parties, Imran Khan’s survival tactics have been twofold: to consolidate ties with the country’s powerful military, and to weaken opposition parties by targeting their top leaders, including by charging and imprisoning them on corruption allegations.

By mid-March, as cases of local transmission began to mount, particularly in large, densely populated cities such as Karachi, Lahore and Peshawar, both opposition parties offered to cooperate to counter the pandemic. The federal government, however, chose to sideline parliament, where the opposition had a strong presence. [fn] Because of the political discord, a special pandemic-related parliamentary committee has been dysfunctional since it was set up on 26 March. Composed of both the federal parliament’s houses, with ruling and opposition party representatives, it was meant to review, monitor and oversee issues related to COVID-19 and its impact on the economy. Hide Footnote  Tensions over the direction of pandemic policy also increased between the centre and Sindh (of which Karachi is the capital), the sole opposition-led province.

On 23 March, Sindh’s Pakistan Peoples Party government was the first to impose a province-wide lockdown. Warning of the health dangers, the provincial government urged the centre to devise a national strategy, including through robust shutdown measures. Addressing the nation on 23 March, Prime Minister Khan, who himself holds the federal health portfolio, initially ruled out a countrywide closure, saying it would adversely affect the poor and working class. [fn] “PM rules out lockdown, disapproves of panic buying”, Dawn , 23 March 2020. Hide Footnote  Calling for national consensus and coordinated efforts before the health crisis turned into “a catastrophe”, Pakistan Peoples Party leader Bhutto Zardari responded, “If we are a poor country, we need to lock down more quickly”. [fn] “If we really care about the poor”, he said, “we need to move faster because the poor are more threatened”. “Bilawal wonders at PM decision of not ordering countrywide lockdown”, Dawn, 23 March 2020. Hide Footnote  The military weighed in, supporting a lockdown and deploying troops countrywide to assist civilian administrations in enforcing it. Hours after the prime minister’s address, the federal government reversed course, agreeing to impose a nationwide shutdown, which it subsequently extended until 31 May.

The initial responses of Pakistan’s four provincial governments varied. Sindh was quick in imposing stringent restrictions on non-essential businesses and public movement. Though hindered by limited resources, it also began to aggressively test people and isolate positive cases. [fn] Editorial, “Sindh leads the way”, Dawn , 28 March 2020; Talat Masood, “Leadership is facing its real test”, The Express Tribune , 2 April 2020. Hide Footnote  The three ruling party-controlled provinces, Balochistan, Khyber Pakhtunkhwa and Punjab, also imposed lockdowns. Yet, apparently guided by the prime minister’s aversion to these measures, they opted for looser restrictions, particularly in Punjab, which soon allowed several types of businesses to reopen.

Tense relations between the government and its rivals also hindered coordination between the capital and opposition-held Sindh and among provinces themselves. The Sindh government held the federal leadership responsible for hampering its response. It argues that Islamabad’s support was insufficient, whether in assisting provincial safety protection schemes or providing pandemic-related medical equipment, which, according to the Sindh government, was available but not equitably distributed. [fn] Amir Wasim, “Barbs fly in NA over fight against Covid-19”, Dawn , 12 May 2020; “PPP calls federal govt “incompetent’, blames it for virus spread”, The News , 2 May 2020. Hide Footnote  Inter-provincial coordination was also poor, echoing friction between Khan and his opponents. [fn] Maleeha Lodhi, “Fault lines in focus”, Dawn, 11 May 2020. Dr Lodhi was Pakistan’s permanent representative to the UN (February 2015-October 2019), and twice appointed Pakistan’s ambassador to the U.S. See also “Sindh’s Murtaza Wahab says federal govt ‘didn’t take lead’ over coronavirus pandemic”, The News, 29 March 2020; “Sindh refutes centre’s claim of providing medical equipment”, Dawn , 17 May 2020. Hide Footnote  The three ruling party-held provinces seemingly took their lead from Islamabad’s aversion to working with Sindh. [fn] Fizza Batool, “Pakistan’s Covid-19 political divide”, South Asian Voices , 12 May 2020. Hide Footnote

Much decision-making related to the pandemic has taken place in the federal capital. The main bodies responsible, set up in mid-March, reflect the government and military leadership’s preference for a centralised approach. On 13 March, the National Security Committee, the apex civil-military body, set up a National Coordination Committee for COVID-19, chaired by the prime minister and including Army Chief Qamar Javed Bajwa, the four provincial chief ministers and senior military officers. The National Command and Operation Centre, which sends the committee recommendations on pandemic policy, is headed by the federal minister for planning and development and includes relevant federal and provincial ministers and also several senior military officers.

The stated objective of setting up these two bodies was to bring the federal and provincial governments and military leadership together. [fn] The National Coordination Committee includes the director general of Inter-Services Intelligence directorate, the military’s premier intelligence agency, and the director general of military operations. The command and cooperation centre, according to a military spokesperson, was formed “to collect, analyse and collate information received from the provinces and forward recommendations” to the coordination committee so that it could “make timely decisions”. “Can’t afford ‘indefinite’ lockdown: DG ISPR”, The Express Tribune , 4 April 2020; “Corona has economic, psycho-social impacts: General Qamar Javed Bajwa”, The News , 23 April 2020. See also Zeeshan Ahmed, “A look inside Pakistan’s Covid-19 response”, The Express Tribune, 2 May 2020. Hide Footnote  In principle, responsibility for the health sector lies with the provinces, not the capital. [fn] The 2010 constitutional amendment, which restored federal parliamentary democracy after a decade of military rule, gives provinces this mandate. Hide Footnote  In practice, however, the top political and military leadership in the centre controls pandemic policy, often overriding provincial concerns, not just in opposition-led Sindh but also in the three ruling party-led federal units.

On 14 April, Prime Minister Khan extended the nationwide lockdown until 30 April but also relaxed restrictions. Several non-essential industries, including construction, reopened. Khan said there was “98 per cent consensus among all provinces and the centre on the reopening of some sectors”. [fn] “PM Imran Khan extends lockdown for two weeks”, The Express Tribune, 14 April 2020. Hide Footnote  Yet the Sindh government, disagreeing, opted to retain stricter measures for another two weeks. While acknowledging that it was constitutionally empowered to so, the federal minister in charge of pandemic response warned the provincial government against resisting Islamabad’s directives. [fn] “PM extends lockdown for two weeks”, The Express Tribune , 15 April 2020; “Centre assails Sindh govt over ‘stricter’ lockdown”, Dawn , 16 April 2020. Hide Footnote  Judicial intervention then strengthened the centre’s control over pandemic policy. In a suo moto (on its own volition) hearing on the virus crisis in mid-April, the Supreme Court chief justice called for a uniform policy, warning Sindh not to close businesses and services that generate revenue for the federation. The Sindh government then gave in to the centre’s wishes. [fn] “Sindh can’t close entities paying taxes to centre: SC”, The Express Tribune , 4 May 2020. Hide Footnote

C. Mixed Messaging and the Power of the Pulpit

The mid-April decision to ease the lockdown and the federal government’s mixed messaging about the pandemic left the public confused about its gravity. Early in the crisis, in a televised address on 17 March, Prime Minister Khan had downplayed health risks. “There is no reason to worry”, he said, since 90 per cent of the infected would have mild flu-type symptoms and 97 per cent would recover fully. [fn] “PM Imran tells nation to prepare for a coronavirus epidemic, rules out lockdown”, Dawn, 17 March 2020. See also Khurram Hussain, “Addressing the confusion”, Dawn , 2 April 2020. Hide Footnote  A mid-April decision to reopen mosques for communal prayers further muddled the state’s message.

When the nationwide lockdown was first imposed, provincial governments barred mosques from holding communal prayers. Mosques remained open but only five mosque administrators could participate in prayers. The police were tasked with enforcing the restrictions, which were largely respected in major cities. When clerics violated the curbs in Karachi, for example, police temporarily detained most offenders; charges were lodged against others for inciting violence against police officers. [fn] “Prayer leader, six others sent to jail on judicial remand in Sindh”, The Express Tribune , 5 April 2020. Hide Footnote  As a result, most mosques in Sindh’s cities complied with the health restrictions. [fn] “Has the federal govt erred by not closing mosques in Ramadan?”, Pakistan Today , 30 April 2020. Hide Footnote

In contrast, Islamabad’s police registered cases but made no arrests when Lal (Red) mosque’s hardline clerics openly violated restrictions. Clerical leader Abdul Aziz released footage of large congregations attending Friday prayers. [fn] Kalbe Ali, “More than 50 clerics warn govt not to further restrictions on prayer congregations”, Dawn , 14 April 2020. Hide Footnote  When the police tried to barricade the mosque’s entrance, female madrasa students blocked the road. [fn] In early June, the federal government reportedly reached agreement with Abdul Aziz, mediated by the leader of a banned sectarian group; the police were to remove blockades in return for Aziz’s commitment to vacate the mosque. “Capital administration, former Lal Masjid cleric reach agreement”, Dawn , 3 June 2020. Hide Footnote  The Khan government might have hesitated in taking action against the Lal Masjid clerics, fearing a repeat of the bloody July 2007 standoff, when a military operation against heavily armed jihadists in the mosque left 100 militants and eleven soldiers dead. [fn] For details of the Lal Masjid operation, see Crisis Group Asia Report N°164, Pakistan: The Militant Jihadi Challenge , 11 March 2009. Hide Footnote  Yet in refraining from taking action, it risked creating a major virus cluster in both the federal capital and its twin city, Rawalpindi.

On 18 April, without consulting provincial governments, President Arif Alvi agreed with major religious leaders to reopen mosques nationwide for communal, including taraweeh (special Ramadan), prayers – but under conditions. [fn] Several senior clerics had warned the federal government against retaining restrictions on mosques. “More than 50 clerics warn govt not to further restrictions on prayer congregations”, Dawn , 14 April 2020. Hide Footnote  The agreement specified safety and health precautions, including social distancing, and tasked mosque administrations with enforcing them. To violate the measures, the president said, “would be like a sin because all ulema and mashaikh (religious scholars and spiritual leaders) have agreed” to them. [fn] “PTI govt, Ulema agree on SOPs for Ramazan amid coronavirus outbreak”, The Express Tribune , 19 April 2020. Hide Footnote  Justifying the decision, Prime Minister Khan said he was heeding popular demand. “Pakistan is an independent nation”, he said. “Ramadan is a month of worship, and people want to go to mosques”. His government “could not forcibly tell them not to do so”. [fn] “‘We are an independent nation’: PM Khan responds to questions over keeping mosques open”, Dawn , 21 April 2020. On 21 April, prominent doctors called on the government and religious leaders to reconsider their agreement, warning that removing curbs on communal prayers would create viral clusters and “unwanted loss of lives”. “Failure to close mosques, control virus in Pakistan may be bad for entire Muslim ummah: doctors”, The News , 21 April 2020. Hide Footnote

Yet many clerics have flouted the agreement’s terms. During Ramadan, when mosque attendance is at its highest, clerics made little effort to enforce the protocols. [fn] A survey of mosques in Punjab and the federal capital during Ramadan found that 85 per cent had violated health and safety protocols. Kamila Hayat, “Duel till death”, The News , 30 April 2020; “Violations of SOPs for mosques aggravates virus situation in KP”, Dawn , 6 May 2020. Hide Footnote  Thousands prayed in packed mosques, ignoring health measures and creating new hot-spots of viral infection. [fn] “Violations of SOPs for mosques aggravates situation in KP”, Dawn, 6 May 2020. Hide Footnote  Many clerics appear to have told worshippers to demonstrate piety by praying shoulder to shoulder, warning that the pandemic is a punishment for erring Muslims’ sins, arguing that the faithful are immune and that life and death are in God’s hands alone. [fn] In an Al Jazeera interview, Lal Masjid cleric Aziz said, “In our [religious leaders’] opinion, this is a punishment from God, and is coming because we have filled the world with sins”. Another religious leader said, “there is no coronavirus. This is just a movement to try and target religion and mosques”. Yet another insisted that the only way to get rid of the virus would be to seek forgiveness from God through prayers in mosques. “Pakistanis gather for Friday prayers defying coronavirus advisory”, Al Jazeera, 17 April 2020; “Mosques remain closed amid strict lockdown”, The Express Tribune , 4 April 2020; “‘God is with us’: Many Muslims flout the coronavirus ban in mosques”, Reuters, 13 April 2020; Kalbe Ali, “More than 50 clerics warn govt not to further restrictions on prayer congregations”, Dawn , 14 April 2020. Hide Footnote  As a result, many who regularly attend mosques either believe they will not contract the virus or that prayer will protect them. [fn] A mid-April survey found that 82 per cent believed that ablution for prayers would prevent infection and 87 per cent that communal prayers could not cause contagion. “Survey shows whopping majority thinks inhaling steam, ablution wards off COVID-19”, The News , 12 April 2020. Hide Footnote  Many also chose not to get tested or treated due to religious and social stigma attached to the disease. [fn] Crisis Group telephone interviews, health professionals, Karachi, Islamabad, May 2020. Hide Footnote

III. The Economy, Health Policy and Social Support

On 9 May, after extending relatively weak pandemic-related restrictions for two weeks, the federal government ended the lockdown. Prime Minister Khan insisted that the decision was taken with the provinces’ consensus, but Sindh’s chief minister said Islamabad imposed its will. [fn] “Sindh CM didn’t announce lifting lockdown from Monday, Bilawal”, The Express Tribune , 9 May 2020; Syed Irfan Raza, “Record Covid-19 cases reported in single day”, Dawn , 9 May 2020. Hide Footnote  The Punjab and Balochistan governments, held by the ruling party, also warned against lifting restrictions. [fn] Raza, “Record Covid-19 cases reported in single day”; “Relaxed curbs will mean 1.1.m cases by July”, The Express Tribune , 9 May 2020. Hide Footnote  The judiciary again weighed in. On 19 May, during the coronavirus suo moto case hearings, the Supreme Court noted that provinces were constitutionally bound to follow Islamabad’s directives. [fn] In a June interview, Sindh’s spokesperson noted, “the court said provinces have to follow the lead and advice of the centre. We never stood a chance [after that]”. Dawn TV, 10 June 2020; “Provinces are bound to follow Centre’s directives: SC”, The Express Tribune , 19 May 2020. Hide Footnote

Though the federal government said it would lift the lockdown in phases, by mid-June the country was almost fully open for business. Schools remained closed but all markets and shopping centres were operating and restrictions on most non-essential businesses had been removed. Borders with Iran and Afghanistan were reopened, domestic and international flights resumed, and several train services started up again, as did local public transport. Punjab reopened shrines that traditionally attract large numbers.

Prime Minister Khan’s justifications for lifting the lockdown were twofold: the burden on the poor and working class, and the adverse impact on the national economy. Announcing the National Coordination Committee’s decision to cancel the closures on 7 May, he said, “We are doing it because people are facing extreme difficulties. Small business owners, daily wage earners and labourers are suffering. We fear that small and medium-sized industries might vanish completely if we don’t lift the lockdown”. [fn] “Govt to end lockdown from 9th in phases”, The Express Tribune, 8 May 2020. Hide Footnote  A week earlier, preparing the ground for the announcement, the federal minister heading the National Command and Operation Centre said the government’s revenues would otherwise fall by 30-35 per cent. [fn] “Lockdown to be further eased, says PM Khan”, Dawn, 1 May 2020. Hide Footnote

The pandemic has seriously compounded Pakistan’s already grave economic challenges. Pakistan’s economy was in dire straits even before COVID-19. Since the Khan government assumed office, large-scale manufacturing has declined, exports have fallen, the budget deficit has widened and unemployment has increased. [fn] Sharoo Malik, “Taking stock: The PTI government’s economic performance in its first year”, South Asian Voices, 8 September 2019; “Pakistan premier’s first year: economic hit and miss”, Dawn, 19 August 2020; Hina Ayra, “Pakistan’s economic options during the coronavirus crisis”, The Express Tribune , 3 April 2020. See also editorial, “GDP growth”, The News , 18 May 2020. Hide Footnote  A former finance minister and financial expert had estimated economic growth in the Khan’s government’s first year at 1.9 per cent, the lowest in a decade. [fn] “Hafiz Pasha says GDP growth is 1.9 per cent”, The News , 8 February 2020. Dr Hafiz Pasha, the former finance minister, is now chair of the Panel of Economists, an independent body advising the government. Hide Footnote  Now, exports to traditional markets – Europe, the U.S., China and the Middle East – are fast declining. [fn] Syed Haris Ahmed, “With lockdowns everywhere, export is a difficult job”, The Express Tribune, 6 April 2020; “Pakistan’s deficit and poverty rate to soar due to coronavirus, govt estimates”, Reuters, 14 May 2020. Hide Footnote  Remittances, a vital source of foreign exchange, are likely to shrink as thousands of workers in the Gulf come home. The government estimates that the gross domestic product will contract by 0.38 per cent for the fiscal year 2019-2020. The World Bank has forecast even sharper drops of 2.6 per cent for 2019-2020 and 0.2 per cent for 2020-2021. [fn] The economy has contracted for the first time since 1951-1952. Pakistan Economic Survey 2019-20 ; “Global Economic Prospects ”, The World Bank, June 2020. Hide Footnote

If the government’s goal in lifting the lockdown was to get the economy moving, little suggests that is happening, even as numbers of new cases mount. Indeed, it has become ever clearer that economic growth depends on curbing the virus. On 22 April, days after the lockdown was first eased, the World Health Organisation’s director general had warned, “Without effective interventions [in Pakistan], there could be an estimated 200K+ cases by mid-July. The impact on the economy could be devastating, doubling the number of people living in poverty”. [fn] “WHO, PMA advise for total lockdown”, The News, 24 April 2020. Hide Footnote  Four months on, signs of economic recovery are still few.

The federal government has provided emergency assistance to families in need, including food subsidies and support, but for many this aid is barely enough. The Ehsaas emergency cash program (the renamed Benazir Income Support Program) provides financial assistance to an estimated twelve million families that fall under the poverty line. [fn] Set up in mid-2008, the federally funded Benazir Income Support Program, the country’s largest social safety net, provides cash assistance exclusively through women to economically vulnerable families. Hide Footnote  Islamabad began the scheme on 9 April and extended it the following month to provide a similar amount to four million unemployed workers. [fn] “PM launches cash disbursal program for workers today”, Dawn , 18 May 2020. Hide Footnote  Yet the lump sum cash transfer of approximately $75 to cover four months of expenses hardly covers food costs.

Such support could well be critical for months. According to Prime Minister Khan, the cash disbursement program can only be a temporary solution, which is why the lockdown was lifted. “There’s no way the government can give out handouts to feed people for that long”. [fn] “Millions would have starved if lockdown wasn’t lifted: PM Khan”, Dawn TV, 21 May 2020. Hide Footnote  Yet with the pandemic continuing to hinder any economic recovery, the need for state assistance appears likely to increase further. A prominent public health expert and demographer noted: “There is no choice but to provide the essentials like food, water and health care for the poorest 20 per cent of the population for the next few months. ... [t]he counterfactual is skyrocketing poverty, malnutrition and deaths of key household members that will be difficult to repair financially and emotionally”. [fn] Zeba Sattar, “Lives not worth saving”, Dawn , 13 June 2020. As Pakistan country director of the Population Council, Dr Sattar evaluates health delivery services. According to the World Food Program , 39.6 per cent of the population faces food insecurity, and Pakistan has the second highest rate of malnutrition in South Asia. Hide Footnote

At the same time, the government’s financial resources are strained, though foreign aid should help. Donors have earmarked additional assistance to help Pakistan cope with the pandemic’s economic impact, including through social protection programs for families in need. The government looks set to receive billions of dollars in pandemic-related aid. [fn] The government will likely receive $1.5 to $2 billion in temporary debt relief from G20 member counties; the International Monetary Fund allocated $1.4 billion through its Rapid Financing Instrument, to mitigate the economic impact of the pandemic; the World Bank restored Pakistan’s budgetary support and granted a $500 million loan for pandemic-related health care and social safety nets; the Asian Development Bank approved a $500 million loan for the government’s health and economic response, including social protection for the poor. Bilateral donors, such as Germany, have also extended assistance, with Berlin providing 0.5 million euros to help Pakistan overcome the pandemic’s socio-economic impact at the local level. “Germany backs Pakistan’s efforts to mitigate socio-economic impact of Covid-19”, Dawn, 27 July 2020; “Pakistan to receive $500m loan from ADB to help fight coronavirus, ‘protect poor’”, The News, 10 June 2020; “WB okays $500m loan to help government fight Covid-19”, Dawn , 23 May 2020; “Pakistan wins $1.4b IMF emergency loan”, The Express Tribune , 17 April 2020; Arsalaan Asif Soomro, “Can Pakistan’s economy endure the ramifications of COVID-19?”, The Express Tribune, 15 April 2020. Hide Footnote

The dire economic situation risks playing into militants’ hands, particularly if social support measures fall short. As unemployment rises further and more citizens fall under the poverty line, such groups could exploit the ensuing social discord. If the state fails to deliver, they could have new opportunities to win recruits by tapping economic desperation and social grievances or extending assistance through existing or renamed charities, as they have in the past. [fn] Militant groups have in the past enhanced their local appeal by providing food and other assistance through their charity wings, including after the 2005 earthquake in Pakistan and Pakistan-administered Kashmir. See Crisis Group Asia Briefing N°46, Pakistan: Political Impact of the Earthquake , 15 March 2006. Hide Footnote

IV. Health Systems in a Pandemic

Pakistan’s under-funded health care system is ill equipped to deal with an unprecedented public health emergency. [fn] There are around six hospital beds, 9.8 doctors and five nurses per 100,000 population in Pakistan. Health expenditure is among the lowest in the world, estimated by the World Health Organisation at 2.9 per cent of GDP. “Time to step up”, The News , 23 March 2020. Hide Footnote  Medical professionals have repeatedly called for a stringent nationwide lockdown until transmission rates decline. But the government, concerned about the economic costs, rejects their advice. In some cases, ruling-party leaders have even dismissed concerns as partisan. When positive COVID-19 cases increased by 40 per cent nationwide soon after the lockdown was eased in mid-April, Karachi-based health experts and doctors called for stricter restrictions, warning that major hospitals in the city were overstretched. [fn] “Covid-19 cases up by 40% in five days, doctors”, The Express Tribune , 23 April 2020; “WHO, PMA advise for total lockdown”, op. cit. Hide Footnote  A ruling-party leader accused them of criticising the federal government on behalf of the Pakistan Peoples Party opposition. [fn] “Gill accuses Sindh govt of politicising corona situation thru doctors”, The News , 24 April 2020. Shahbaz Gill has since, in mid-May, been appointed the prime minister’s special assistant on political communication. Also Iftikhar A. Khan, “PPP asks centre to stop playing ‘pandemic politics’”, Dawn , 25 April 2020. Hide Footnote  Professional bodies of doctors countrywide have issued similar calls for a nationwide closure to contain the disease’s spread both before 9 May and afterward. [fn] “Doctors demand strict lockdown, urge religious scholars to review decision to open mosques”, Dawn , 22 April 2020; Amer Malik, “Health care in a fix”, The News, 31 May 2020. Hide Footnote

While the decision on when to lift the lockdown would always involve difficult trade-offs, the government appears to have moved too early. Retaining a nationwide lockdown indefinitely would not have been feasible for economic reasons and due to public fatigue. As Prime Minister Khan says, the lockdown took a heavy toll on impoverished Pakistanis, who survive at subsistence level and need handouts if they cannot leave their homes to work. A protracted nationwide lockdown would have risked fuelling public anger as much as the health emergency. Yet reopening the economy and the country as early as was done, without adequate testing, tracing, isolating and treating the infected, led to a sharp spike in cases. By 9 May, when the lockdown was lifted, the total number of cases was around 29,000 and the death toll was 637. About six weeks later, the total number of cases were more than 175,000; the death toll stood at over 3,000. [fn] “Sindh reports highest single day increase nationwide; nationwide tally soars to 28,818”, The Express Tribune , 9 May 2020; “Pakistan crosses 3,000 deaths due to COVID-19”, Newsweek Pakistan, 18 June 2020; “Pakistan reports 4,471 cases of Covid-19 in a day”, The Nation , 22 June 2020. Hide Footnote

In early June, the World Health Organisation’s Pakistan country head recommended imposing targeted and intermittent two-week-on, two-week-off lockdowns. His letter to the Punjab health minister noted that the country met none of the prerequisites for fully lifting restrictions, including containing disease transmission, detecting, testing, isolating and treating all cases, minimising hot-spots and ensuring preventive measures in workplaces and other public spaces. [fn] “WHO recommends ‘intermittent, targeted’ lockdowns in Pakistan”, The Express Tribune, 9 June 2020. Hide Footnote  Health experts were quick to support his recommendation. But the prime minister’s health adviser said the WHO had assessed Pakistan’s situation through a “health lens” and that the government has “to make tough policy choices to strike a balance between lives and livelihoods”. [fn] “WHO says Pakistan meets no pre-requisite for easing restrictions, recommends ‘intermittent lockdown’”, Dawn, 9 June 2020; “Corona killing four an hour in Pakistan”, The News, 11 June 2020. Hide Footnote

Instead, the federal government has opted for what it calls “smart lockdowns”, a policy it adopted when easing pandemic-related restrictions in mid-April. Its limited lockdowns differ from those recommended by the WHO in that they apply only to specific localities within cities or rural districts where positive cases are high. The government eased or removed them altogether in low-risk areas. [fn] Inter-Services Intelligence, the military’s main intelligence arm, has been tasked with tracing infected persons and their contacts through geo-fencing and phone monitoring systems that it uses for counter-terrorism purposes. Ramsha Jahangir, “Over 5,000 people at risk of contracting Covid-19 identified by track system”, Dawn , 2 May 2020. Hide Footnote  In mid-June, provincial governments imposed two-week lockdowns in areas of cities such as Karachi, Lahore and Peshawar. [fn] On 15 June, the National Command and Operation Centre identified virus clusters in twenty cities across the country. According to a press release from his office, Prime Minister Khan had directed the provincial governments to impose smart lockdowns “in sensitive areas keeping in view ground realities to maintain a balance between economic activities and preventive measures”. Syed Irfan Raza, “PM satisfied with virus testing kits, PPE availability”, Dawn, 16 June 2020. Hide Footnote  The government argues that such limited lockdowns can contain virus spread without economic hardship.

By 2 August, Pakistan had around 280,200 registered cases and close to 6,000 deaths, ranking thirteenth among COVID-19 affected countries globally (in terms of total cases). [fn] See Pakistan’s official COVID-19 website or the Worldometers website for numbers. The death toll is likely under-counted since many families, fearing the religious and social stigma of the disease, do not report infections or seek treatment. The Khyber Pakhtunkhwa government, for instance, is investigating declining mortality figures, to check if patients are dying unrecorded at home. “Govt probing causes of decline in Covid-19 deaths”, Dawn , 23 July 2020. Hide Footnote  According to official statistics, the daily number of confirmed cases has declined considerably since mid-July. The government attributes the reduction to its smart lockdowns. [fn] The prime minister’s health adviser said the government had managed to contain the pandemic through the smart lockdown strategy. “Pakistan’s preparation and response to the coronavirus outbreak has been one of the best in the world”. “Over 204,000 recover from disease as curve flattens”, The Express Tribune , 20 July 2020. Hide Footnote  Yet reduced testing may also partly explain it: official data shows daily nationwide testing rates dropping from on average around 28,500 in June to fewer than 22,00o in July. [fn] In June, the WHO had recommended that Pakistan increased daily testing capacity to 50,000. Daily test numbers, however, fell from the end of June. By 2 August, according to the Worldometers website, Pakistan had conducted 2,010,170 tests for around 220 million citizens: 9,086 per one million population. See also “Pakistan: Situation Report (as of 10 June 2020)”, UN Office for the Coordination of Humanitarian Affairs. Hide Footnote

The smart lockdown’s “track, trace and quarantine” strategy, which involves tracing and isolating virus carriers and their contacts and placing viral hot-spots under quarantine, is hampered by poor data and low testing rates. [fn] Crisis Group interviews, doctors, Karachi, July 2020. Hide Footnote  In June, the minister overseeing the pandemic response had said that authorities would increase daily testing capacity to 100,000 by July. [fn] “Just in a month: Pakistan faced 242pc surge in deaths”, The News , 15 June 2020. Hide Footnote  According to the National Command Operation Centre, testing capacity had increased to over 70,000 by early July. [fn] Calling for increased testing, a doctors’ forum said that the government’s figures of confirmed cases are “not representative of the actual ground situation”, “Doctors’ forum stresses need to enhance Covid-19 testing in Pakistan”, Dawn , 12 July 2020; “Covid-19: Data shows Pakistan utilising only a third of its testing capacity”, The News , 8 July 2020. Hide Footnote  Yet less than one third of that capacity is now being used. [fn] Observers offer various reasons for the decline in testing: international travellers are no longer tested on arrival; groups that were previously targeted, such as Tableeghi Jamaat, journalists and government officials, are no longer tested systematically; tests’ costs mean they are used only for patients with serious symptoms; and, with numbers declining, fewer tests are necessary. Hide Footnote  With the virus appearing in many localities in densely populated cities, limited lockdowns of a few blocks of a city or a part of a rural district appear unlikely to contain it. A Pakistani expert on viral diseases said, “Incomplete lockdowns mean the virus has a chance of finding new hosts”. [fn] Tufail Ahmed, “Containing pandemic: Don’t bother with partial lockdowns, says expert”, The Express Tribune , 16 June 2020. Hide Footnote

The forthcoming religious holidays threaten another uptick. The lifting of nationwide restrictions during Ramadan in June and for Eidul Fitr contributed to the first surge of infections as massive crowds shopped in markets and large congregations prayed in mosques. The government and doctors fear the virus could once again peak should the public disregard safety measures in August during Eidul Azha festivities and in Muharram, when large mourning processions are held. [fn] Prime Minister Khan said, “if we are careless on Eidul Azha, the virus could spread again and there could be a fresh spike of infections”. “PM warns of virus spike of SOPs violated on Eid”, Dawn , 10 July 2020. Hide Footnote  Spiralling numbers of cases could once again overwhelm hospitals and clinics. With case numbers increasing substantially in smaller cities and rural regions, their weaker health facilities could soon be overrun.

V. Conclusion

Chairing a meeting of the National Coordination Council on 1 June, Prime Minister Khan said, “a lockdown isn’t a solution or treatment. … Nothing can be done about it. The virus will spread, and our death toll will also rise” until a vaccine is found. He added, “If we have to live successfully with the virus, it is the responsibility of the people. If they take precautionary measures, we can tackle the virus and live with it”. [fn] Khan also decided to further ease the few remaining restrictions, including on domestic tourism. “Pakistan to ease lockdown, open more businesses amid surging COVID-19 infections”, The News , 1 June 2020; “PM Khan bats for unlocking economy, eases coronavirus lockdown”, The Express Tribune , 2 June 2020. Hide Footnote  Placing the onus of preventing contagion on citizens also appears at the heart of a new strategy, “Living with the Pandemic”, discussed by the Command and Operation Centre a day earlier. [fn] “88 deaths, 3,039 new cases in a single day: Provinces differ over smart lockdown”, The News , 1 June 2020; “NCOC mulls over ‘living with the pandemic strategy’ to cope with coronavirus”, The News, 30 May 2020. Hide Footnote

Mixed and confused signalling by Prime Minister Khan and his top advisers early in the crisis mean that people often now ignore their calls to observe social distancing and other health guidelines. Many still believe that the pandemic has ended, and largely brush off calls for responsible public behaviour. Public health specialists also warn that “leaving people to determine the rules of restoring normality could prove fatal if growth in cases and deaths continues at average rates or may even increase further”. [fn] “Easing Lockdown in Pakistan: Inevitable but Potentially Catastrophic”, Institute of Public Health, Jinnah Sindh Medical University, May 2020. Hide Footnote

A rethink is urgently needed. Federal policy should be based on the best available medical advice, even while factoring in social and economic costs. The government should continue to guide the provinces on pandemic policy, including by helping them shore up health facilities and making preventive measures, such as enforcing the use of face masks outdoors. Yet Islamabad should also allow provincial authorities to devise tailored strategies, guided by medical experts, as they confront new challenges. Not only is health a provincial responsibility, but provincial leaders are better placed to adapt to local needs. Both federal and provincial authorities should also prioritise funding for the health sector.

Islamabad could consider revising its smart lockdown strategy. If deemed necessary, and based on medical advice, provinces should be allowed to shut down entire cities and rural districts with high infection rates for limited periods to interrupt virus transmission. In areas where the virus transmission rate is lower, they should enhance testing, contact tracing and treating the infected. Lockdowns along these lines should be better able to contain virus spread without too onerous a burden on the economy.

Efforts to build the capacity of health care facilities to prevent a repeat of the crisis in June, when cases surged, should continue. In June, intensive care units and beds in major cities like Karachi, Lahore and Peshawar reached or neared capacity. [fn] By early June, critical care wards for COVID-19 patients in some of Karachi’s major government and private hospitals were full to capacity. Hospitals in Lahore were also under strain. Crisis Group telephone interviews, doctors, nurses, Karachi, Lahore, June 2020. Hide Footnote  The provinces have since bolstered health facilities for COVID-related cases, including with federal assistance. [fn] “NDMA reaches target of 2,000 oxygenated beds in hospitals across Pakistan”, The Express Tribune , 22 July; “Sindh has 253 million beds for Covid-19 patients”, The Express Tribune, 14 July 2020. Hide Footnote  Pressures on hospitals have also eased since patients with moderate symptoms are now isolated at home. Yet another sharp surge of infections could once again overwhelm that capacity.

Lastly, instead of bypassing parliament, the federal government should work with the opposition. The parliament should play a more active role, particularly with regard to fiscal and other assistance for the most vulnerable sections of the population. The federal government’s continued targeting of top opposition leaders, including through the National Accountability Bureau, is particularly unhelpful. The Khan government itself would benefit from mending fences with its rivals. The military leadership might be an equal, if not dominant, partner in the pandemic response. Yet citizens will hold the elected leadership accountable if the pandemic response falters. Sharing responsibility with opposition leaders for what are difficult and contentious decisions would not only benefit Pakistan’s body politic but also make sense for the premier himself. The alternative is that COVID-19 leaves a weakened federal government even more reliant on the military to retain power.

Karachi/Islamabad/Brussels, 7 August 2020

Related Tags

More for you, raising the stakes in jammu and kashmir, pakistan: challenges of a weak democracy, subscribe to crisis group’s email updates.

Receive the best source of conflict analysis right in your inbox.

This site uses cookies. By continuing to browse the site you are agreeing to our use of cookies. Review our privacy policy for more details.

United States Institute of Peace

Home ▶ Events

Pakistan’s Coronavirus Crisis: Impact and Solutions

Date:  Thursday, April 23, 2020  /   Time:  9:30am - 10:30am 

Center: Asia Center

In addition to the severe human cost, the COVID-19 crisis has forced Pakistan’s already suffering economy to a grinding halt. Social distancing policies, necessary to stop the spread of the virus, have sent the global economy reeling, paralyzed the informal economy, and left Pakistan’s most vulnerable without income and sustenance. Meanwhile, despite a $7.5 billion relief package, both central and provincial governments have struggled to respond as the number of confirmed cases continues to rise daily. As the situation stands, much more will be needed for Pakistan to effectively address the crisis.

Continue the conversation on Twitter with #COVIDPakistan .

On April 23, USIP hosted a virtual expert panel to discuss the economic, political, and governance impacts of the COVID-19 crisis in Pakistan as well as potential long-term solutions.

Cyril Almeida Visiting Senior Expert, U.S. Institute of Peace

Khurram Husain Business Editor, Dawn Newspaper

Elizabeth Threlkeld Deputy Director, South Asia, Stimson Center

Uzair Younus Nonresident Fellow, Atlantic Council

Tamanna Salikuddin , moderator Director, South Asia, U.S. Institute of Peace

Related Publications

Toward a Durable India-Pakistan Peace: A Roadmap through Trade

Thursday, June 27, 2024

By: Sanjay Kathuria

Despite a three-year long cease-fire along their contested border, trade and civil society engagement between India and Pakistan has dwindled, exacerbating the fragility of their relationship. With recently re-elected governments now in place in both countries, there is a window of opportunity to rekindle trade to bolster their fragile peace, support economic stability in Pakistan, create large markets and high-quality jobs on both sides, and open doors for diplomatic engagement that could eventually lead to progress on more contentious issues.

Type: Analysis

How Have India’s Neighbors Reacted to Its Election?

Tuesday, June 25, 2024

By: Humayun Kabir;   Geoffrey Macdonald, Ph.D. ;   Nilanthi Samaranayake ;   Asfandyar Mir, Ph.D.

Narendra Modi was sworn in on June 9 for his third consecutive term as India’s prime minister. Public polls had predicted a sweeping majority for Modi, so it came as some surprise that his Bharatiya Janata Party (BJP) lost ground with voters and had to rely on coalition partners to form a ruling government. Although India’s elections were fought mainly on domestic policy issues, there were important exceptions and Modi’s electoral setback could have implications for India’s regional and global policies.

Global Elections & Conflict ;  Global Policy

What Does Further Expansion Mean for the Shanghai Cooperation Organization?

Thursday, May 30, 2024

By: Bates Gill;   Carla Freeman, Ph.D.

Last week, foreign ministers from member-states of the Shanghai Cooperation Organization (SCO) gathered in Astana, Kazakhstan. The nine-member SCO — made up of China, India, Russia, Pakistan, Iran, Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan — represents one of the largest regional organizations in the world. And with the SCO’s annual heads-of-state summit slated for early July, the ministers’ meeting offers an important glimpse into the group’s priorities going forward. USIP’s Bates Gill and Carla Freeman examine how regional security made its way to the top of the agenda, China’s evolving role in Central Asia and why SCO expansion has led to frustrations among member states.

Type: Question and Answer

Global Policy

Asfandyar Mir on Balancing Counterterrorism and Strategic Competition

Tuesday, May 21, 2024

By: Asfandyar Mir, Ph.D.

As terror threats emanating from Afghanistan and Pakistan rise, many may see counterterrorism as a distraction from other U.S. priorities, such as competition with China and Russia. But investment in counterterrorism can work “preventively, to shield the strategic competition agenda,” says USIP’s Asfandyar Mir.

Type: Podcast

• - Google Chrome

Intended for healthcare professionals

• My email alerts
• BMA member login
• Username * Password * Forgot your log in details? Need to activate BMA Member Log In Log in via OpenAthens Log in via your institution

Search form

• Advanced search
• Search responses
• Search blogs
• News & Views
• Covid-19: Is a second...

Second wave of Covid-19 in Pakistan; are more episodes down the road?

Rapid response to:

Covid-19: Is a second wave hitting Europe?

Read our latest coverage of the coronavirus outbreak.

• Related content
• Article metrics
• Rapid responses

Rapid Response:

Dear Editor,

With the unavailability of a specific antiviral or a vaccine, non-pharmaceutical interventions could be the benchmark in curbing SARS-CoV-2 spread and non-compliance to the latter is the obvious cause of a second wave of Covid-19 in Europe [1] and in Pakistan. The government announced a second spell of Covid-19 in Pakistan on October 28, 2020, when a daily increase in cases reached 750 compared to 400 to 500 a few weeks ago. Sudden increase in active cases from 6,000 to 11,000 and hospital admissions with critical cases of 93 on ventilators were recorded across the country [2]. The data released by the National Command and Operation Centre (NCOC) indicate that the current percent positivity rate is closed to 3 compared to the previous figure of less than 2 and the average number of deaths is exceeding 11 per day.

The government is censuring the public for the rise and worsening situation of the pandemic in Pakistan by not observing standard operating procedures (SOPs)--apparently to mask its failure in not taking appropriate steps and decisions which led to the current situation. After the first case of Covid-19 in the last week of February, the infection spread at an alarming speed, albeit the authorities did not address the issue as it should have been done. A meeting of the National Security Committee on March 13 was called on to look into the developing situation after it was declared a pandemic by the World Health Organization. Lockdown like measures were announced later in March but were symbolic as mainly restricted to some major cities, lasted for a period of less than 2 months and were lifted (May 08, 2020) when the damage was the highest for a single day [3].

After the regular activities for a couple of weeks, the ‘smart lockdown’ concept was introduced and hailed by the authorities [4] as an effective tool to curb the virus. In a meeting of the National Coordination Committee (NCC) on August 7, it was announced that COVID-19 pandemic had been controlled due to effective strategy and the country was declared open for routine [5]. The tally went on to 295, 236 mark through September and a new version of the smart lockdown, the 'mini smart lockdown’, was pronounced in some parts of the country [6]. Lack of a stringent policy and lockdown gamble paved the way for SARS-CoV-2 spread through social, political, religious and regular business activities, transport and tourism. Schools, colleges and universities were re-opened for regular activities across the country.

Ultimately, a second wave of the pandemic erupted, according to the authorities. The ground was all set for such a situation in Pakistan [7, 8] but the scary part is that circulation of the SARS-CoV-2 will not stop here and it is highly probable that Covid-19 can become a source of persistent infection if the lesson is not learnt. The first wave claimed 6795 lives, infected 332,186, left behind 632 on ventilators [9] and suffered millions and now we have to watch the second episode, just started in the country.

References 1. Looi MK. Covid-19: Is a second wave hitting Europe? BMJ 2020;371:m4113. doi:10.1136/bmj.m4113 pmid: 33115704 2. Junaidi I. Second Covid wave under way in Pakistan. Dawn. 28 October 2020. https://www.dawn.com/news/1587316 . 3. Abrar M. Pakistan eases lockdown as Covid-19 kills 46 in single-day spike. Pakistan Today. 08 May 2020. https://www.pakistantoday.com.pk/2020/05/07/govt-announces-to-exit-lockd... 4. Pakistan among pioneers of 'smart lockdown' approach, says PM Imran. Dawn. 06 June 2020. https://www.dawn.com/news/1561766 5. COVID lockdown over: Pakistan to open from Monday. The News. 07 August 2020. https://www.thenews.com.pk/print/696942-covid-lockdown-over-pakistan-to-... 6. Sindh govt imposes mini smart lockdown in Karachi as COVID-19 cases spike. The News. 30 September 2020. https://www.thenews.com.pk/latest/722513-sindh-govt-imposes-mini-smart-l... 7. Ali A, Zhongren M, Baloch Z. Covid-19 in Pakistan and potential repercussions for the world: is the infection on the verge of endemicity? BMJ 2020;369:m1909. doi:10.1136/bmj.m1909 pmid: 32409494 8. Ali A, Ma Z, Bai J. Aftermath of torrential rains and covid-19 in Pakistan. BMJ 2020;370:m3776. doi: 10.1136/bmj.m3776 pmid: 32994213 9. Government of Pakistan. Pakistan statistics. http://covid.gov.pk/

Email: [email protected]

Competing interests: No competing interests

• Fact sheets
• Facts in pictures
• Publications
• Questions and answers
• Tools and toolkits
• Endometriosis
• Excessive heat
• Mental disorders
• Polycystic ovary syndrome
• All countries
• Eastern Mediterranean
• South-East Asia
• Western Pacific
• Data by country
• Country presence 
• Country strengthening 
• Country cooperation strategies 
• News releases
• Feature stories
• Press conferences
• Commentaries
• Photo library
• Afghanistan
• Cholera 
• Coronavirus disease (COVID-19)
• Greater Horn of Africa
• Israel and occupied Palestinian territory
• Disease Outbreak News
• Situation reports
• Weekly Epidemiological Record
• Surveillance
• Health emergency appeal
• International Health Regulations
• Independent Oversight and Advisory Committee
• Classifications
• Data collections
• Global Health Estimates
• Mortality Database
• Sustainable Development Goals
• Health Inequality Monitor
• Global Progress
• World Health Statistics
• Partnerships
• Committees and advisory groups
• Collaborating centres
• Technical teams
• Organizational structure
• Initiatives
• General Programme of Work
• WHO Academy
• Investment in WHO
• WHO Foundation
• External audit
• Financial statements
• Internal audit and investigations 
• Programme Budget
• Results reports
• Governing bodies
• World Health Assembly
• Executive Board
• Member States Portal
• Feature stories /

COVID-19 in Pakistan: WHO fighting tirelessly against the odds

So far Pakistan has fared well in its fight against COVID-19. In a country with over 212 million inhabitants, to date roughly 303 000 cases have been recorded and the curve of new infections has flattened since its peak in May and June.

For a developing country facing other crises, this has been a welcome relief.

At the heart of the country’s battle has been Dr Palitha Mahipala, WHO Representative and Head of Mission, originally from Sri Lanka and based in Islamabad, who has been working around the clock seven days a week since the beginning of the pandemic.

“WHO focuses on different aspects of the COVID-19 response in each country. But in Pakistan, the Organization has been involved on every level and has had a significant impact”, says Dr Mahipala.

WHO had been working on many fronts in Pakistan during the pandemic even before the country recorded any cases.

Policy engagement and expert support

Dr Mahipala acknowledges that he wouldn’t be able to lead WHO’s crucial work without the support of Pakistan’s Ministry of Health, with whom he meets “every day or every other day”.

Working with the Government on high level advocacy and policy dialogue is the first level of WHO’s multi-faceted approach to fight COVID-19 in Pakistan.

“What are the measures the government is taking? What is the highest level of commitment we can have?” These are some of the questions that drive the doctor’s work in the policy area.

Technical assistance is another area of WHO’s work plan.

“From early January, the moment WHO headquarters sent us the technical guidance, I was working the same day with the Minister of Health on our response strategy. At that time, we didn’t have a single case. We didn’t have testing capacity. The first thing we did was to draw up a national action plan according to the pillars identified by WHO,” says Dr Mahipala.

On 23 April 2020, Pakistan launched its Strategic Preparedness and Response Plan , prepared by WHO, as a global online event and platform where it was able to raise US $595 million from donors around the world. The plan and the funds got Pakistan off to a strong start in its fight to stop the spread of COVID-19.

Strengthening points of entry and testing

When Pakistan didn’t have any cases of the new coronavirus, and neighbouring countries such as Iran were recording high numbers, controlling points of entry was crucial. WHO played a strong role in trying to slow the arrival the disease.

In mid-January, WHO and the Ministry of Health began screening potential cases and distributing information pamphlets about the risk of the disease to arriving passengers at Islamabad airport. To protect airport staff, WHO provided training and distributed personal protective equipment (PPE). After working on securing Islamabad airport, Dr Mahipala and WHO teams assessed and strengthened other airports as well as isolation and quarantine centres with the Ministry of Health. 

When asked about Pakistan’s biggest gaps, Dr Mahipala says that in the beginning of the crisis Pakistan could only test about 200 people per day. But WHO quickly helped the country ramp up its testing capacity.

“Within six to eight weeks we were up to 30 000 tests per day. We expanded that further and now we can do more than 50 000 tests per day,” he says.

Once again WHO was involved in all the areas of strengthening Pakistan’s testing capacity. WHO obtained tests, supported the hiring and training of staff to carry out testing, and assessed labs all over the country. The Organization has also been providing staff with PPE, transporting test samples and adding PCR machines to the country’s testing system.

Protecting frontline health workers

WHO has been committed to protecting frontline health workers throughout the crisis and Pakistan is no exception, although sadly there have been casualties.

At the time of speaking, Dr Mahipala says that he knows of more than 6 000 doctors, nurses and paramedics who have been infected as well as some deaths.

To support those who also work to protect the rest of the country population, WHO and the Ministry of Health created the WECARE program, which so far has trained 100 000 health care workers on safety practices. In addition to training, the program supplies PPE and motivational support through videos, TV and radio programs.

Acknowledging the crucial role of health workers, Dr Mahipala says: “We need to recognize them as frontline heroes looking after patients and putting their lives at risk.”

Another stream of WHO’s work in Pakistan is research and development, which has involved undertaking large scale studies of COVID-19 cases by staff in Pakistan and supported by WHO colleagues in Geneva. “That will add knowledge not only to Pakistan but also globally,” the doctor points out.

Success factors

The groundwork WHO and Pakistan have laid on combatting other diseases has been a decisive factor in limiting the severity of the COVID-19 outbreak so far.

From the beginning of the crisis, polio staff carried out surveillance and provided training to frontline health workers. “The polio infrastructure we have and related campaigns were fully utilized for COVID-19,” says Dr Mahipala.

WHO Director-General Dr Tedros  Adhanom Ghebreyesus had previously commended how the country capitalized on its previous work on polio: "Pakistan deployed the infrastructure built up over many years for polio to combat COVID-19. Community health workers who have been trained to go door-to-door vaccinating children have been utilized for surveillance, contact tracing and care."

This success has also helped WHO in Pakistan raise further funds.

With cases at a low level, another problem is arising—complacency among the population in cooperating with public protective measures.

In the current phase of the outbreak, Dr Mahipala and his colleagues are focusing more on communications as a key  aspect of the response.

“We really built on communications channels we set up for polio. Radio penetration is high and so is social media, which we were already using for polio.”

Mobile phone communications has also been key. “Here even people who have barely anything have a mobile phone, or more than one,” he explains.

WHO has also worked with religious groups and scholars to get their messages out in Pakistan.

Despite relative success in the fifth most populous country in the world, COVID-19 has been a formidable challenge.

Dr Mahipala realizes how fortunate Pakistan has been so far and recognizes the dedication of the people who have helped tackle COVID-19.

“There are people who are totally steadfast devoted, who haven’t been home since January.”

But the work goes on, he says.

“We change our strategy as the pandemic evolves. We change our plans as cases rise and fall.”

Read more about WHO’s work in Pakistan

Show your support and donate today

Pakistan: Coronavirus Pandemic Country Profile

Research and data: Edouard Mathieu, Hannah Ritchie, Lucas Rodés-Guirao, Cameron Appel, Daniel Gavrilov, Charlie Giattino, Joe Hasell, Bobbie Macdonald, Saloni Dattani, Diana Beltekian, Esteban Ortiz-Ospina, and Max Roser

• Coronavirus
• Data explorer
• Hospitalizations

Vaccinations

• Mortality risk
• Excess mortality
• Policy responses

Build on top of our work freely

• All our code is open-source
• All our research and visualizations are free for everyone to use for all purposes

Select countries to show in all charts

Confirmed cases.

• What is the daily number of confirmed cases?
• Daily confirmed cases: how do they compare to other countries?
• What is the cumulative number of confirmed cases?
• Cumulative confirmed cases: how do they compare to other countries?
• Biweekly cases : where are confirmed cases increasing or falling?
• Global cases in comparison: how are cases changing across the world?

Pakistan: What is the daily number of confirmed cases?

Related charts:.

Which world regions have the most daily confirmed cases?

This chart shows the number of confirmed COVID-19 cases per day . This is shown as the seven-day rolling average.

What is important to note about these case figures?

• The reported case figures on a given date do not necessarily show the number of new cases on that day – this is due to delays in reporting.
• The number of confirmed cases is lower than the true number of infections – this is due to limited testing. In a separate post we discuss how models of COVID-19 help us estimate the true number of infections .

→ We provide more detail on these points in our page on Cases of COVID-19 .

Five quick reminders on how to interact with this chart

• By clicking on Edit countries and regions you can show and compare the data for any country in the world you are interested in.
• If you click on the title of the chart, the chart will open in a new tab. You can then copy-paste the URL and share it.
• You can switch the chart to a logarithmic axis by clicking on ‘LOG’.
• If you move both ends of the time-slider to a single point you will see a bar chart for that point in time.
• Map view: switch to a global map of confirmed cases using the ‘MAP’ tab at the bottom of the chart.

Pakistan: Daily confirmed cases: how do they compare to other countries?

Differences in the population size between different countries are often large. To compare countries, it is insightful to look at the number of confirmed cases per million people – this is what the chart shows.

Keep in mind that in countries that do very little testing the actual number of cases can be much higher than the number of confirmed cases shown here.

Three tips on how to interact with this map

• By clicking on any country on the map you see the change over time in this country.
• By moving the time slider (below the map) you can see how the global situation has changed over time.
• You can focus on a particular world region using the dropdown menu to the top-right of the map.

Pakistan: What is the cumulative number of confirmed cases?

Which world regions have the most cumulative confirmed cases?

How do the number of tests compare to the number of confirmed COVID-19 cases?

The previous charts looked at the number of confirmed cases per day – this chart shows the cumulative number of confirmed cases since the beginning of the COVID-19 pandemic.

In all our charts you can download the data

We want everyone to build on top of our work and therefore we always make all our data available for download. Click on the ‘Download’-tab at the bottom of the chart to download the shown data for all countries in a .csv file.

Pakistan: Cumulative confirmed cases: how do they compare to other countries?

This chart shows the cumulative number of confirmed cases per million people.

Pakistan: Biweekly cases : where are confirmed cases increasing or falling?

Why is it useful to look at biweekly changes in confirmed cases.

For all global data sources on the pandemic, daily data does not necessarily refer to the number of new confirmed cases on that day – but to the cases  reported  on that day.

Since reporting can vary significantly from day to day – irrespectively of any actual variation of cases – it is helpful to look at a longer time span that is less affected by the daily variation in reporting. This provides a clearer picture of where the pandemic is accelerating, staying the same, or reducing.

The first map here provides figures on the number of confirmed cases in the last two weeks. To enable comparisons across countries it is expressed per million people of the population.

And the second map shows the percentage change (growth rate) over this period: blue are all those countries in which the case count in the last two weeks was lower than in the two weeks before. In red countries the case count has increased.

What is the weekly number of confirmed cases?

What is the weekly change (growth rate) in confirmed cases?

Pakistan: Global cases in comparison: how are cases changing across the world?

In our page on COVID-19 cases , we provide charts and maps on how the number and change in cases compare across the world.

Confirmed deaths

• What is the daily number of confirmed deaths?
• Daily confirmed deaths: how do they compare to other countries?
• What is the cumulative number of confirmed deaths?
• Cumulative confirmed deaths: how do they compare to other countries?
• Biweekly deaths : where are confirmed deaths increasing or falling?
• Global deaths in comparison: how are deaths changing across the world?

Pakistan: What is the daily number of confirmed deaths?

Which world regions have the most daily confirmed deaths?

This chart shows t he number of confirmed COVID-19 deaths per day .

Three points on confirmed death figures to keep in mind

All three points are true for all currently available international data sources on COVID-19 deaths:

• The actual death toll from COVID-19 is likely to be higher than the number of confirmed deaths – this is due to limited testing and challenges in the attribution of the cause of death. The difference between confirmed deaths and actual deaths varies by country.
• How COVID-19 deaths are determined and recorded may differ between countries.
• The death figures on a given date do not necessarily show the number of new deaths on that day, but the deaths  reported  on that day. Since reporting can vary significantly from day to day – irrespectively of any actual variation of deaths – it is helpful to view the seven-day rolling average of the daily figures as we do in the chart here.

→ We provide more detail on these three points in our page on Deaths from COVID-19 .

Pakistan: Daily confirmed deaths: how do they compare to other countries?

This chart shows the daily confirmed deaths per million people of a country’s population.

Why adjust for the size of the population?

Differences in the population size between countries are often large, and the COVID-19 death count in more populous countries tends to be higher . Because of this it can be insightful to know how the number of confirmed deaths in a country compares to the number of people who live there, especially when comparing across countries.

For instance, if 1,000 people died in Iceland, out of a population of about 340,000, that would have a far bigger impact than the same number dying in the United States, with its population of 331 million. 1 This difference in impact is clear when comparing deaths per million people of each country’s population – in this example it would be roughly 3 deaths/million people in the US compared to a staggering 2,941 deaths/million people in Iceland.

Pakistan: What is the cumulative number of confirmed deaths?

Which world regions have the most cumulative confirmed deaths?

The previous charts looked at the number of confirmed deaths per day – this chart shows the cumulative number of confirmed deaths since the beginning of the COVID-19 pandemic.

Pakistan: Cumulative confirmed deaths: how do they compare to other countries?

This chart shows the cumulative number of confirmed deaths per million people.

Pakistan: Biweekly deaths : where are confirmed deaths increasing or falling?

Why is it useful to look at biweekly changes in deaths.

For all global data sources on the pandemic, daily data does not necessarily refer to deaths on that day – but to the deaths  reported  on that day.

Since reporting can vary significantly from day to day – irrespectively of any actual variation of deaths – it is helpful to look at a longer time span that is less affected by the daily variation in reporting. This provides a clearer picture of where the pandemic is accelerating, staying the same, or reducing.

The first map here provides figures on the number of confirmed deaths in the last two weeks. To enable comparisons across countries it is expressed per million people of the population.

And the second map shows the percentage change (growth rate) over this period: blue are all those countries in which the death count in the last two weeks was lower than in the two weeks before. In red countries the death count has increased.

What is the weekly number of confirmed deaths?

What is the weekly change (growth rate) in confirmed deaths?

Pakistan: Global deaths in comparison: how are deaths changing across the world?

In our page on COVID-19 deaths , we provide charts and maps on how the number and change in deaths compare across the world.

• How many COVID-19 vaccine doses are administered daily ?
• How many COVID-19 vaccine doses have been administered in total ?
• What share of the population has received  at least one dose  of the COVID-19 vaccine?
• What share of the population has  completed the initial vaccination protocol ?
• Global vaccinations in comparison: which countries are vaccinating most rapidly?

Pakistan: How many COVID-19 vaccine doses are administered daily ?

How many vaccine doses are administered each day (not population adjusted)?

This chart shows the daily number of COVID-19 vaccine doses administered per 100 people in a given population . This is shown as the rolling seven-day average. Note that this is counted as a single dose, and may not equal the total number of people vaccinated, depending on the specific dose regime (e.g., people receive multiple doses).

Pakistan: How many COVID-19 vaccine doses have been administered in total ?

How many vaccine doses have been administered in total (not population adjusted)?

This chart shows the total number of COVID-19 vaccine doses administered per 100 people within a given population. Note that this is counted as a single dose, and may not equal the total number of people vaccinated, depending on the specific dose regime as several available COVID vaccines require multiple doses.

Pakistan: What share of the population has received  at least one dose  of the COVID-19 vaccine?

How many people have received at least one vaccine dose?

This chart shows the share of the total population that has received at least one dose of the COVID-19 vaccine. This may not equal the share with a complete initial protocol if the vaccine requires two doses. If a person receives the first dose of a 2-dose vaccine, this metric goes up by 1. If they receive the second dose, the metric stays the same.

Pakistan: What share of the population has  completed the initial vaccination protocol ?

How many people have completed the initial vaccination protocol?

The following chart shows the share of the total population that has completed the initial vaccination protocol. If a person receives the first dose of a 2-dose vaccine, this metric stays the same. If they receive the second dose, the metric goes up by 1.

This data is only available for countries which report the breakdown of doses administered by first and second doses.

Pakistan: Global vaccinations in comparison: which countries are vaccinating most rapidly?

In our page on COVID-19 vaccinations, we provide maps and charts on how the number of people vaccinated compares across the world.

Testing for COVID-19

• The positive rate
• The scale of testing compared to the scale of the outbreak
• How many tests are performed each day ?
• Global testing in comparison: how is testing changing across the world?

Pakistan: The positive rate

Here we show the share of reported tests returning a positive result – known as the positive rate.

The positive rate can be a good metric for how adequately countries are testing because it can indicate the level of testing relative to the size of the outbreak. To be able to properly monitor and control the spread of the virus, countries with more widespread outbreaks need to do more testing.

It can also be helpful to think of the positive rate the other way around:

How many tests have countries done for each confirmed case in total across the outbreak?

Pakistan: The scale of testing compared to the scale of the outbreak

How do daily tests and daily new confirmed cases compare when not adjusted for population ?

This scatter chart provides another way of seeing the extent of testing relative to the scale of the outbreak in different countries.

The chart shows the daily number of tests (vertical axis) against the daily number of new confirmed cases (horizontal axis), both per million people.

Pakistan: How many tests are performed each day ?

This chart shows the number of  daily  tests per thousand people. Because the number of tests is often volatile from day to day, we show the figures as a seven-day rolling average.

What is counted as a test?

The number of tests does not refer to the same thing in each country – one difference is that some countries report the number of people tested, while others report the number of tests (which can be higher if the same person is tested more than once). And other countries report their testing data in a way that leaves it unclear what the test count refers to exactly.

We indicate the differences in the chart and explain them in detail in our accompanying  source descriptions .

Pakistan: Global testing in comparison: how is testing changing across the world?

In our page on COVID-19 testing , we provide charts and maps on how the number and change in tests compare across the world.

Case fatality rate

• What does the data on deaths and cases tell us about the mortality risk of COVID-19?
• The case fatality rate
• Learn in more detail about the mortality risk of COVID-19

Pakistan: What does the data on deaths and cases tell us about the mortality risk of COVID-19?

To understand the risks and respond appropriately we would also want to know the mortality risk of COVID-19 – the likelihood that someone who is infected with the disease will die from it.

We look into this question in more detail on our page about the mortality risk of COVID-19 , where we explain that this requires us to know – or estimate – the number of total cases and the final number of deaths for a given infected population.

Because these are not known , we discuss what the current data on confirmed deaths and cases can and can not tell us about the risk of death. This chart shows both those metrics.

Pakistan: The case fatality rate

Related chart:.

How do the cumulative number of confirmed deaths and cases compare?

The case fatality rate is simply the ratio of the two metrics shown in the chart above.

The case fatality rate is the number of confirmed deaths divided by the number of confirmed cases.

This chart here plots the CFR calculated in just that way. 

During an outbreak – and especially when the total number of cases is not known – one has to be very careful in interpreting the CFR . We wrote a  detailed explainer  on what can and can not be said based on current CFR figures.

Pakistan: Learn in more detail about the mortality risk of COVID-19

Learn what we know about the mortality risk of COVID-19 and explore the data used to calculate it.

Government Responses

• Government Stringency Index

To understand how governments have responded to the pandemic, we rely on data from the Oxford Coronavirus Government Response Tracker  (OxCGRT), which is published and managed by researchers at the Blavatnik School of Government at the University of Oxford.

This tracker collects publicly available information on 17 indicators of government responses, spanning containment and closure policies (such as school closures and restrictions in movement); economic policies; and health system policies (such as testing regimes).

How have countries responded to the pandemic?

Travel bans, stay-at-home restrictions, school closures – how have countries responded to the pandemic? Explore the data on all policy measures.

Pakistan: Government Stringency Index

The chart here shows how governmental response has changed over time. It shows the Government Stringency Index – a composite measure of the strictness of policy responses.

The index on any given day is calculated as the mean score of nine policy measures, each taking a value between 0 and 100. See the authors’  full description  of how this index is calculated.

A higher score indicates a stricter government response (i.e. 100 = strictest response).

The OxCGRT project calculates this index using nine specific measures, including:

• school and workplace closures;
• restrictions on public gatherings;
• transport restrictions;
• and stay-at-home requirements.

You can see all of these separately on our page on policy responses . There you can also compare these responses in countries across the world.

Our World in Data is free and accessible for everyone.

Help us do this work by making a donation.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Asian Bioeth Rev
• v.12(4); 2020 Dec

COVID-19 and its Challenges for the Healthcare System in Pakistan

Atiqa khalid.

1 Sahiwal Medical College (affiliated with the University of Health Sciences, Lahore), Sahiwal, Pakistan

2 Allama Iqbal Open University, Islamabad, Pakistan

This article aims to highlight the healthcare issues raised by COVID-19 in Pakistan’s scenario. Initially, Pakistan lacked “standard operating procedures,” and the government had to ship testing kits from China and Japan. Moreover, due to violations of the lockdown and standard operating procedures (SOPs), the rapidly increasing number of cases created a burden on the healthcare system. More and more, this pandemic and its impact have grown. As vaccine development has not been successful yet, “herd immunity” can only be achieved if about three quarters of the population contract the virus—requiring immunocompromised citizens to be sacrificed for the sake of the country. Moreover, Pakistan has limited testing capacity, so most COVID-19 tests are missing their mark even as the virus spreads. The current scenario is also raising several concerns about the capacity of the government to tackle the prevailing healthcare crisis. In this regard, healthcare professionals suggest that the government must act responsibly to ensure better security provided to healthcare professionals. Identifying suspected cases, introducing personal protective equipment, and taking administrative measures to ensure that better security is provided to healthcare professionals are the needs of the hour to improve outcomes of COVID-19 patients. Testing, tracking, and lockdowns must be focused on areas where clusters are detected. The healthcare professionals must be given utmost protection before this pandemic could wreak havoc in terms of fatalities. Investing in the chronically underfunded healthcare system is needed, so that Pakistan can build capacity to fight the pandemic.

Introduction

The new strain of the coronavirus, which is causing the current pandemic, is called COVID-19. The Chinese authorities distinguished this strain of the virus on 7 January 2020 (World Health Organization 2020a ). It started to spread globally from country to country (World Health Organization 2020b ) and the cases were expanding day by day (Prompetchara et al. 2020 ). As of June 2020, there are no successful vaccines (Ahmed et al. 2020 ; Prompetchara et al. 2020 ) and no drug treatment is specifically recommended (Sanders et al. 2020 ). However, convalescent plasma transfusion can be a potential treatment, but it is in experimental stages (Chen et al. 2020 ).

Preventive measures are highly effective to prevent its rapid spread but for these to be helpful, influential policies must be taken for appropriate health education of people. This pandemic has severely affected some countries and their healthcare systems have reached the point of exhaustion. Amid the chaos and the rising human toll, healthcare services are undergoing decentralization and fragmentation in many severely affected countries (Boccia et al. 2020 ). Vulnerable communities are disproportionately impacted in this catastrophic situation. This pandemic is relentless. In a crisis-stricken world gripped by challenges, it has exposed the vulnerabilities of the global capitalist system, driven by the delayed response (Yang and Wang 2020 ). An avalanche of cases has overburdened healthcare structures in developed countries. In developing nations with long neglected and underfunded public health sectors, the pandemic is leading to mayhem (Gates 2020 ). Experts fear if its spread is not curtailed by taking bold steps and consistent management choices, it may result in unprecedented human catastrophe (Prompetchara et al. 2020 ). The 2019–2020 COVID-19 pandemic began to spread across Pakistan in February 2020. This paper provides an account of the governmental and institutional response to COVID-19 in Pakistan. It explains some of the severe economic and social constraints that have hindered an effective response, and it critically analyzes the policy of pursuing herd immunity. The paper ends with some key take-home messages about lessons to be learned from Pakistan’s experience.

COVID-19 in Pakistan

The current COVID-19 pandemic has cut a swath around the globe due to decentralization and fragmentation of healthcare services in many severely affected countries (Armocida et al. 2020 ). The COVID-19 outbreak has affected the whole world. However, the situation is comparatively worse in the countries having weak healthcare strategies and system. This has become an intense catastrophe due to a brisk increase in the pandemic outbreak from region to region (Lai et al. 2020 ). The Chief of the World Health Organization, Tedros Adhanom Ghebreyesus, urged countries to invest in getting their healthcare system rather than to scramble for solutions when the next pandemic arrives as it is stated “we cannot continue to rush to fund panic but let preparedness go by the wayside. The world spends $7.5 trillion annually on health” (World Health Organization 2020a ). Especially in Pakistan, this pandemic has been a rude wake-up call regarding our weak health infrastructure as it comes under unbearable strain during this period (Spinelli and Pellino 2020 ). Thus, the 2019–2020 COVID-19 pandemic was affirmed to reach Pakistan in February 2020, with over 255,769 cases and 5386 deaths, as of 15 July 2020 (World Health Organization 2020b ).

Lack of Medical Facilities

As a middle-income country, with a weak healthcare infrastructure and a population of around 197 million (Hayat et al. 2020 ), Pakistan is vulnerable to COVID-19 (Raza et al. 2020 ). The Federal Minister of Health reported the first two confirmed cases of COVID-19 on 26 February 2020 in Karachi and Islamabad (Ali et al. 2020 ). Within 12 days, the number of cases reached 20 with 5 cases in Gilgit-Baltistan, 14 cases in Sindh, and 1 in Baluchistan. Bordered with the epicenter of the pandemic, China and Iran, its geographical location required highly influential policies and strategies to counteract against the situation (Saqlain et al. 2020 ). According to the World Health Organization ( 2020c ), countries should take all the preventive measures to limit the virus transmission by continuous surveillance, quarantine, awareness campaigns, and early detection. Besides, counteracting against other healthcare challenges is a major concern today (United Nations 2020 ). On the contrary, during the first few days, Pakistan lacked medical facilities and suspected samples were sent to China (Khanain 2020 ). Moreover, only a few specific quarantine centers were present with limited diagnostics and treatment facilities (92 News 2020 ) until the government received primers, testing kits, and equipment from other countries. As of 27 June 2020, many testing centers were available in Pakistan (Khanain 2020 ). The World Health Organization also established test centers for COVID-19 in seven hospitals countrywide (Saqlain et al. 2020 ). Initially, only a few quarantine centers were present in Pakistan. However, over time, more were established with foreign assistance. Still, centers ran out of rooms. Moreover, before the pandemic, sufficient facemasks were available to fulfill the needs of the general public, but with increased infection rate and exporting them, they became scarce and costly. Many drugs and equipment needed during the time of pandemic ran short in the pharmacies and stockiest started their business. But the Government of Pakistan took actions and the situation is now under control (Daily Times 2020a , b ). Similarly, Karachi, Lahore, and southern Sindh provinces, which make up more than 70,000 of the country’s 98,000 cases, have just 14,000 beds including both private and state-run hospitals. Dozens of patients were contacting hospitals’ administrations but due to lack of medical facilities, hospitals are unable to provide enough medical assistance (Latif 2020a ). Quarantine centers were established in Baluchistan but they lacked standard care and screening process (Khan 2020a ).

As the cases of COVID-19 grew in Pakistan, hospitals groaned under the weight of patients. Government policies have failed due to the indifferent attitude of the public. The advice of public health officials was disregarded (Kermani 2020 ) and the government eased lockdown (Hashim 2020b ). A bitter harvest was reaped from this decision. Caregivers were stressed, laboratory facilities were strained, and emergency rooms overflowed with infected patients. Likewise, the workforce dwindled, ICUs ran short of space, and the cost of care has increased (Hashim 2020a ).

Even basic medical equipment was dysfunctional and there was lack of doctors and paramedical staff. No specialized training was provided to health professionals regarding the pandemic (Jaffery 2020 ). Expensive medical equipment remained nonfunctional for years. Elite class got a preferential treatment leaving poverty-stricken people behind (Hadid and Sattar 2020 ). Even maintenance and repair of healthcare facilities was also ignored. Moreover, it was not unusual to witness scenes of general public smashing hospital equipment. Grief of death of their loved ones turned into pandemonium as it was solely “mistake of doctors.” Angry families were beating doctors and ransacking hospitals as healthcare professionals turn away COVID-19 patients—saying their facilities were already in short supply (Kermani 2020 ). COVID-19 cases spike can quickly overwhelm Pakistan’s healthcare system. As it seems this pandemic was here to stay. The state had a shortage of medical equipment and personnel and obsolete infrastructure (Afzal 2020 ).

Preliminary researches suggest that plasma of recovered patients contain antibodies that can be helpful for infected patients (Duan et al. 2020 ) but COVID-19 pandemic had sadly brought out the worst in the people of Pakistan. Instead of donating plasma as a noble gesture to help those suffering from this potentially fatal disease, recovered patients were making it their business. Convalescent plasma transfusion was not cure but a line of therapy and still in experimental stages. It should only be employed in controlled settings. Under no circumstances, should public be experimenting it without doctors’ approval (Epstein and Burnouf 2020 ). Similarly, different drugs including dexamethasone were no more available in pharmacies as they were declared helpful for COVID-19 patients (Qureshi 2020 ). Therefore, much more efforts are needed to cope with the situation. Experts fear if its spread is not curtailed by taking bold steps and consistent management choices, it may result in unprecedented human catastrophe (Yi et al. 2020 ).

Violation of Standard Operating Procedures

Policies, designs, strategies, and actions to cope with infectious diseases change over time. For this purpose, standard operating procedures (SOPs) play a vital role to hinder the virus transmissions as an outbreak generally creates major challenges for the healthcare systems (Singh 2019 ). Besides the local healthcare system, sometimes the public also has to follow the designated SOPs to counteract against the outbreak (World Health Organization Regional Office Africa 2014 ). For instance, during the H1N1 outbreak in the USA, the government introduced SOPs to overcome the crisis condition. Those SOPs contained guidelines for healthcare providers, introduction of the new medical teams, and also certain precautionary measures for the public. As a result, the government effectively controlled the outbreak (Adini et al. 2010 ).

The spread of infection in Pakistan was lower than feared even though we have righted some wrongs and wronged some rights by not completely implementing as well as following the SOP’s (Primary, and Secondary Health Care Department, Government of Punjab 2020 ). As unfortunately, the public in Pakistan appeared to have thrown caution to the wind, seeming to be in no mood to comply with SOPs as if it was somehow immune to the virus. They blatantly flouted government orders, underplayed the threat, and took it casually (Noreen et al. 2020 ). “They dithered, wavered and waffled. After doing this, they Flip Flopped then hemmed and hawed” wasting precious time instead of taking bold steps. After a brief hiatus, unmasked and unloved people violating lockdown seem everywhere who have recklessly abandoned all to fate and chance (Adams 2020 ).

Even as deaths due to this pandemic spiral, life is normalized everywhere. Due to this dangerous and cavalier attitude, a rapid jump in cases was recorded after relaxation in lockdown with total cases crossing 255,769 as of 15 July 2020. The initial public response to COVID-19 was casual and indifferent. Myths largely circulated, reinforcing an explicit violation of lockdown (ur-Rehman et al. 2020 ). Conservative individuals perceived this outbreak as a conspiracy to prevent their religious practices (Khattak 2020 ). Despite the threat, the mass events of prayers continued and public activates largely facilitated the virus transmission (ur-Rehman et al. 2020 ). Individual indices also came into consideration; for instance, people traveling from Spain escaped from screening both after positive test results, which further transmitted the virus to his community and family (Chaudhry 2020 ). Likewise, some patients also broke their quarantine camp in Sakkhar , infected several other people (ARY News 2020 ). Thus, this noncooperative behavior further fueled the virus transmission across the country (Javed et al. 2020 ).

Pakistan’s Current Scenario

The current healthcare scenario (Chart ​ (Chart1) 1 ) is unsatisfactory as Pakistan is a highly populated country, requiring a high level of sustained medical facilities. As compared to developed countries, i.e., the UK, China, and the USA, Pakistan is financially unstable and preventive measures concerning the outbreak were not followed completely (Waris et al. 2020 ). The current scenario of disease transmission in Pakistan is of greater concern. Moreover, developing countries were comparatively more vulnerable to the healthcare crisis, and Pakistan was unable to overcome this briskly growing pandemic (Nafees and Khan 2020 ). As of 15 July 2020, the total 255,769 of the cases reported with 5386 deaths (Government of Pakistan 2020a ). The current surge of the spread of this pandemic in Pakistan was due to the relaxation of lockdown (Adams 2020 ).

COVID-19 cases in Pakistan (Government of Pakistan 2020a )

A number of cases were also rising due to inadequate testing facilities and fear of people to disclose the fact that they have contracted the infection. Pakistan is ill-prepared to encounter a crisis that can arrive in merely weeks (Javed et al. 2020 ).

Furthermore, China flattened the curve, giving a breather to the over-stressed health system. Curve refers to the number of people affected in a particular interval of time. The steeper the curve, the quicker a country’s healthcare system will be overwhelmed, reaching its peak in a shorter duration of time. China showed systematic, comprehensive, and coordinated response through rapid self-correction and building a score of temporary hospitals and imposing countrywide lockdown. These measures lead to fruition (Liu et al. 2020 ). A more detailed record of confirmed cases as of 15 July 2020 is given in Table ​ Table1 1 .

Detailed record of confirmed cases as of 15 July 2020 (Government of Pakistan 2020a )

The “series” of events leading to the current crisis in Pakistan: February 2020 —first case of COVID-19 in Pakistan; March 2020 —the government took action, lockdown implemented; April 2020 —relaxation in lockdown in religious places as the government caved to demands of Muslim scholars; May 2020 —further loosening of lockdown in markets and malls imposed (during the second week of May); June 2020 —lockdown reemployed. Source: Government of Pakistan ( 2020a )

Besides, lifting lockdown for the last 3 weeks of May added 20,000 more confirmed cases as the daily aggregate of positive results escalated, on average, from 11.5 to 15.4% in the subsequent duration (Greenfield and Farooq 2020 ). To learn lessons through this pandemic and willing to take action (Boccia et al. 2020 ), many more efforts are needed instead of showing a muddled approach (Yang and Wang 2020 ). In this regard, the Government of Pakistan is rigorously making new policies and strategies, including awareness campaigns, quarantine facilities, testing services, and lockdown to overcome the outbreak (Waris et al. 2020 ). Along with the government, valiant doctors and overburdened medical staff in Pakistan are on the front line and are essential to the battle being fought against this pandemic trying to take the wild virus by the horns (Shanafelt et al. 2020 ). They are under tremendous stress putting themselves and their family members especially immunocompromised citizens at greater risk. By continuing to attend to patients, many healthcare professionals have contracted the infection (Greenberg et al. 2020 ). They are in constant danger as they do not have adequate personal protective equipment (PPE) and many have lost their lives (Latif 2020b ).

RT-PCR done through nasopharyngeal swabs, though not a perfect test, remains the only dependable investigation as of June 2020 (Chan et al. 2020 ). A positive test clearly shows that a person is infected but the negative test may be false negative due to different reasons. The percentage ratio of people who have been tested positive among the entire population of those who have been tested is very low (Government of Pakistan 2020a ). If people refuse to get themselves tested, the chances of community transmission will increase—because the spread of the virus to elderly, vulnerable, and immunocompromised individuals will go undetected. Therefore, it is extremely important that authorities communicate how crucial testing is and show how citizens can responsibly play their part in curbing transmission by reporting themselves if they experience COVID-19 symptoms. Such fear and reluctance will only add to the spread of the virus. The test, trace, and isolate (TTI) strategy is recommended by the World Health Organization. In Pakistan, testing capacity was half of what recommended by the World Health Organization (Hashim 2020b ). However, according to Pakistan’s policies, symptomatic passengers were tested and quarantined until the availability of test results. Provinces test and track the negative cases that were sent to home. Positive cases were handled as per health protocol. Positive cases belonging to other provinces were quarantined for a 14-day period by the province of arrival and could not be allowed to travel before completion of a prescribed period (Government of Pakistan 2020b ).

Herd Immunity

Many government officials suggested “herd immunity” as a compelling solution to the problem. However, its implementation will be a gamble as the World Health Organization has warned developing countries regarding the potential threat (Greenfield and Farooq 2020 ; Husain 2020 ). As per noted by Fine et al. ( 2011 ), there are certain legal and ethical challenges concerning herd immunity implementation because authorities are required to pressurize, force, or entice individuals to be immunized through herd immunity. Also, immunization can have other side effects that further challenge this idea (Isaacs et al. 2009 ).

The first indication of herd immunity in Pakistan came from Dr. Zafar Mirza who gave remarks after relaxation of lockdown, “For the future of Pakistan regarding this pandemic, it will be better if COVID-19 spreads at a certain rate in Pakistan so that people become immune to it” (Dawn 2020 ). However, if three quarters of the population contract the virus, results would be catastrophic as it can come up with a very high cost (Anderson et al. 2020 ). Still, the Government of Pakistan is indecisive about the implementation of herd immunity as the disease has killed more than 430,000 people worldwide and the COVID-19 vaccination is years away (Siddique 2020 ). Allowing the virus to spread among the general public is unacceptable and inhumane as it will require vulnerable community members, immunocompromised citizens, and elderly to be sacrificed to achieve this strategy (Khan 2020b ).

Thus, with each passage of time, the pandemic is amplifying its presence and magnifying its impact on our lives (World Health Organization 2020a ) as the number of infections and deaths in Pakistan has risen nearly 500% (Gul 2020 ). Providing PPE and resources to healthcare staff in the best possible way helps them fight this pandemic (Kiani and Malik 2020 ). As COVID-19 is a global healthcare concern that greatly halted the normal life, coping with this phenomenon demands quick and effective decision-making ability. The best approach will be introducing new policies and making influential strategies to bring changes on the grass-root level (Kiani and Malik 2020 ). Therefore, this pandemic should be accompanied by the realization that health should be treated not as a privilege, but as a right (UN News 2019 ).

In a developing country like Pakistan, disease outbreaks greatly challenge the healthcare system. Lack of basic health facilities, insufficient health policies, weak governance, and an indifferent attitude of the public towards general protective measures further worsen the scenario (Jaffery 2020 ).

The crucial lesson to learn from struggles is that our dilapidated and shabby healthcare system is a finite source. Epidemiology and microbiology lack the exactness of physics. Hence, our experts can provide only guesstimates and advice on management choices. Although Pakistan has limited sources, it can make better use of them. It needs to show a disciplined, clear, tangible, swift, comprehensive, rational, and collective response. This can be achieved by testing a significant proportion of individuals and then isolating those cases after positive test results of COVID-19, introducing PPE, building healthcare capacity, and taking administrative measures to ensure better security is provided to healthcare professionals. Also, to provide resources to healthcare staff in the best possible way helps them fight this pandemic. Fixing primary and secondary healthcare systems is also needed, as they will take the pressure off the tertiary healthcare systems. If major issues in the management system are fixed, a profound impact can be created (Mukhtar 2020 ).

All provincial authorities and government officials must ensure better security provided to healthcare professionals, spreading awareness campaigns and addressing the fear of citizens.

• Hospital staff must be given utmost protection at all cost before this pandemic could wreak havoc in the healthcare system in terms of infections and fatalities.
• Government must act responsibly educating the public and ensuring the fact that its message must lay out the fact that there is no guarantee that Pakistan’s numbers will remain lower than in the West.
• After positive test results of COVID-19, quarantine and social distancing must be aggressively implemented.
• The ramshackle public health sector must get the funding and the priority it deserves.
• Testing, tracking, and lockdown must be focused on areas where clusters have already been detected so infection transmission rate must be locally contained. Meticulously, locate all who might have encountered the virus

Take-Home Message

By keeping the current pandemic under consideration, some basic guidelines can help to mitigate the potential impacts of this pandemic. According to the World Health Organization ( 2020c ), sustaining essential practices by following the recommendations can create an impact. Therefore, these guidelines may include the following:

• Local governments should implement health and social measures to halt the virus transmission by ensuring equal engagement from all members of society. In this regard, the World Health Organization ( 2020c ) suggests media-based campaigns to spread awareness among the public.
• Evidence showed that COVID-19 can exist in humid places and low temperature for at least 9 days on the surface of shared rooms and areas, i.e., bathrooms, smoking areas, offices, and changing rooms. Using adequate sanitary measures can help to disinfect these areas by using hydrogen peroxide (0.5%), ethanol (61–71%), or hydrogen hypochlorite (0.1–0.5%). Therefore, disinfecting and extra cleaning can greatly help to hinder the virus transmission (Cirrincione et al. 2020 ).
• In order to address the specific challenges being faced by Pakistan in responding to the COVID-19 pandemic, we suggest that the following recommendations—permitted from official bodies and existing literature—are a defensible and ethical start for the country to get on track in clamping down on this virus. The government should establish a psychological hotline to provide psychological assistance to active doctors and other medical staff. Moreover, the hospitals’ staff should be adequately provided PPE to save them from the infection (Beijing Center for Disease Prevention and Control 2020 ).
• Healthcare professionals should be given sufficient training to choose suitable protective equipment as during the current pandemic. They may have a variety of options, but they can find it difficult to choose the appropriate ones (Balachandar et al. 2020 ).
• The healthcare professionals should be provided with the basic equipment including N95 and surgical masks, face sheets, and spaces to later dispose of this equipment as (Public Health Ontario 2020 ) this equipment cannot be reused and if not properly discarded can become a source of virus transmission.
• Proper collection, transfer, and elimination of waste material is an important concern. Especially, menstrual hygiene material and tissues used for coughing and sneezing should be properly managed. Likewise, the local government should rethink about sanitation system, as public lanterns can also become a potential source of virus transmission. Moreover, human feces can be one of the most common sources of microbial pathogen transmission. In this regard, only a well-managed sanitation system would limit transmission of virus especially in developing countries where the governments have to remake its waste management plan (UNICEF 2020 ).
• The risk of infection much relies upon the distance to an infected person and the type of facemask worn. From policy debates and research evidence, minimum 1-m physical distancing is highly recommended as a basic protective measure (Chu et al. 2020 ). Due to this reason, keeping an appropriate distance and wearing facemask in public settings, outside of home, are highly recommended measures to prevent the rapid spread of COVID-19 (Centers for Disease Control and Prevention 2020 ).

Limitations and Recommendations

This study is based on COVID-19 situational reports, lacking any methodological analysis, which limits its scope. Moreover, due to a limited number of relevant studies in Pakistan, the data is mostly taken from websites of local and national newspapers, which further narrows down its scope. However, the researchers made every possible effort to bring clarity in the topic and recommend studies on theoretical and methodological grounds to highlight the healthcare challenges raised by COVID-19 in Pakistan.

Author Contributions

AK conceived the paper and constructed a first draft. SA elaborated arguments and contributed to subsequent drafts of the paper. All authors revised the document for critical intellectual input, and all authors approved the final version.

Compliance with Ethical Standards

Informed consent was received from all the sources whose data and figures are used.

The authors declare that they have no competing interests.

This study was approved by Sahiwal Medical College Ethical Review Committee and Government of Pakistan.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

• 92 News. 2020. Coronavirus quarantine center with 300 beds established in Islamabad. 92 News HD Plus , 3 March 2020. https://92newshd.tv/coronavirus-quarantine-center-with-300-beds-established-in-islamabad/#.XtOYajllDIV .
• Adams, Brad. 2020. Pakistan reopens malls claiming no Covid-19 crisis: response to pandemic is endangering people’s health. Human Rights Watch , 19 May 2020. https://www.hrw.org/news/2020/05/19/pakistan-reopens-malls-claiming-no-covid-19-crisis .
• Adini B, Goldberg A, Laor D, Cohen R, Bar-Dayan Y. Do standard operating procedures for pandemic influenza impact on emergency preparedness? Prehospital and Disaster Medicine. 2010; 25 (S1):S25–S25. doi: 10.1017/s1049023x00022329. [ CrossRef ] [ Google Scholar ]
• Afzal, Madiha. 2020. With a mix of pandemic denialism and exceptionalism, Pakistan makes a cynical bet on the coronavirus. Brookings , 5 June 2020. https://www.brookings.edu/blog/order-from-chaos/2020/06/05/with-a-mix-of-pandemic-denialism-and-exceptionalism-pakistan-makes-a-cynical-bet-on-the-coronavirus/ .
• Ahmed SF, Quadeer AA, McKay MR. Preliminary identification of potential vaccine targets for the COVID-19 coronavirus (SARS-CoV-2) based on SARS-CoV immunological studies. Viruses. 2020; 12 (3):254. doi: 10.3390/v12030254. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ali, Imtiaz, Syed Ali Shah, and Naveed Siddiqui. 2020. Pakistan confirms first two cases of coronavirus, govt says ‘no need to panic’. Dawn , 27 February 2020. https://www.dawn.com/news/1536792 .
• Anderson RM, Heesterbeek H, Klinkenberg D, Déirdre Hollingsworth T. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet. 2020; 395 (10228):931–934. doi: 10.1016/S0140-6736(20)30567-5. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Armocida, Benedetta, Beatrice Formenti, Silvia Ussai, Francesca Palestra, and Eduardo Missoni. 2020. The Italian health system and the COVID-19 challenge. Lancet Public Health 5 (5): e253. 10.1016/s2468-2667(20)30074-8. [ PMC free article ] [ PubMed ]
• ARY News. 2020. Coronavirus patients, suspects break out of Sukkur quarantine facility. ARY News , 12 March 2020. https://arynews.tv/en/sukkur-quarantine-facility-coronavirus-suspects/ .
• Balachandar V, Mahalaxmi I, Kaavya J, Vivekanandhan G, Ajithkumar S, Arul N, Singaravelu G, Senthil Kumar N, Mohana Devi S. COVID-19: emerging protective measures. European Review for Medical and Pharmacological Sciences. 2020; 24 (6):3422–3425. doi: 10.26355/eurrev_202003_20713. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Beijing Center for Disease Prevention and Control. 2020. Prevention and control measures of COVID-19 in Beijing, China.
• Boccia S, Ricciardi W, Ioannidis JPA. What other countries can learn from Italy during the COVID-19 pandemic. JAMA. 2020; 180 (7):927–928. doi: 10.1001/jamainternmed.2020.1447. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Centers for Disease Control and Prevention. 2020. COVID-19: considerations for wearing cloth face coverings. CDC , 28 June 2020. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html .
• Chan, Jasper Fuk-Woo, Shuofeng Yuan, Kin-Hang Kok, Kelvin Kai-Wang To, Hin Chu, Jin Yang, Fanfan Xing, Jieling Liu, Cyril Chik-Yan Yip, Rosana Wing-Shan Poon, Hoi-Wah Tsoi, Simon Kam-Fai Lo, Kwok-Hung Chan, Vincent Kwok-Man Poon, Wan-Mui Chan, Jonathan Daniel Ip, Jian-Piao Cai, Vincent Chi-Chung Cheng, Honglin Chen, Christopher Kim-Ming Hui, Kwok-Yung Yuen. 2020. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. The Lancet 395 (10223): 514–523. 10.1016/S0140-6736(20)30154-9 [ PMC free article ] [ PubMed ]
• Chaudhry, Asif. 2020. Single Covid-19 patient infects 27 others in Gujrat. Dawn , 29 March 2020. https://www.dawn.com/news/1544552 .
• Chen L, Xiong J, Bao L, Shi Y. Convalescent plasma as a potential therapy for COVID-19. Lancet Infectious Diseases. 2020; 20 (4):398–400. doi: 10.1016/S1473-3099(20)30141-9. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Chu DK, Akl EA, Duda S, Solo K, Yaacoub S, Schünemann HJ, Chu DK, et al. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet. 2020; 395 :1973–1987. doi: 10.1016/s0140-6736(20)31142-9. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cirrincione L, Plescia F, Ledda C, Rapisarda V, Martorana D, Moldovan RE, Theodoridou K, Cannizzaro E. COVID-19 pandemic: prevention and protection measures to be adopted at the workplace. Sustainability. 2020; 12 (9):3603. doi: 10.3390/SU12093603. [ CrossRef ] [ Google Scholar ]
• Daily Times. 2020a. Total chaos—hospitals in Pak lack facilities to treat corona patients. Daily Times , 27 February 2020. https://dailytimes.com.pk/566099/total-chaos-hospitals-in-pak-lack-facilities-to-treat-corona-patients/ .
• Daily Times. 2020b. Govt warns stern actions against traders who raise face mask price: Nausheen Hamid. Daily Times , 1 March 2020. https://dailytimes.com.pk/567976/govt-warns-stern-actions-against-traders-who-raise-face-mask-price-nausheen-hamid/ .
• Dawn. 2020. Herd immunity? Dawn , 10 May 2020. https://www.dawn.com/news/1555939 .
• Duan K, Liu B, Li C, Zhang H, Yu T, Jieming Q, Zhou M, et al. Effectiveness of convalescent plasma therapy in severe COVID-19 patients. Proceedings of the National Academy of Sciences of the United States of America. 2020; 117 (17):9490–9496. doi: 10.1073/pnas.2004168117. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Epstein, Jay, and Thierry Burnouf. 2020. Points to consider in the preparation and transfusion of COVID-19 convalescent plasma. Vox Sanguinis , published online 22 April 2020. 10.1111/vox.12939. [ PMC free article ] [ PubMed ]
• Fine P, Eames K, Heymann DL. ‘Herd immunity’: a rough guide. Clinical Infectious Diseases. 2011; 52 (7):911–916. doi: 10.1093/cid/cir007. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gates B. Responding to Covid-19—a once-in-a-century pandemic? New England Journal of Medicine. 2020; 382 :1677–1679. doi: 10.1056/NEJMp2003762. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Government of Pakistan. 2020a. Current policies. COVID-19 health advisory platform by the Ministry of National Health Services Regulations and Coordination. Accessed 12 July 2020. http://covid.gov.pk/stats/pakistan .
• Government of Pakistan. 2020b. Pakistan cases details. COVID-19 health advisory platform by the Ministry of National Health Services Regulations and Coordination. Accessed 12 July 2020. http://covid.gov.pk/intl_travellers/current_policies .
• Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during Covid-19 pandemic. BMJ. 2020; 368 :m1211. doi: 10.1136/bmj.m1211. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Greenfield, Charlotte and Umar Farooq. 2020. After Pakistan’s lockdown gamble, COVID-19 cases surge. Reuters , 5 June 2020. https://www.reuters.com/article/us-health-coronavirus-pakistan-lockdown/after-pakistans-lockdown-gamble-covid-19-cases-surge-idUSKBN23C0NW .
• Gul, Ayazgul. 2020. COVID-19 infections rise nearly 500% in Pakistan. Voice of America , 3 June 2020. https://www.voanews.com/covid-19-pandemic/covid-19-infections-rise-nearly-500-pakistan .
• Hadid, Diaa, and Abdul Sattar. 2020. Pandemic panic in Pakistan: ‘people are just literally fighting for beds’. National Public Radio , 19 June 2020. https://www.npr.org/sections/goatsandsoda/2020/06/19/878896370/pandemic-panic-in-pakistan-people-are-just-literally-fighting-for-beds .
• Hashim, Asad. 2020a. Pakistan hospitals struggle as coronavirus cases explode. Al Jazeera , 12 June 2020. https://www.aljazeera.com/indepth/features/pakistan-hospitals-struggle-coronavirus-cases-explode-200612084123797.html .
• Hashim, Asad. 2020b. WHO says Pakistan should reimpose lockdown to curb coronavirus. Al Jazeera , 10 June 2020. https://www.aljazeera.com/news/2020/06/pakistan-reimpose-lockdown-curb-coronavirus-200610093521629.html .
• Hayat K, Rosenthal M, Xu S, Arshed M, Li P, Zhai P, Desalegn GK, Yu F. View of Pakistani residents toward coronavirus disease (COVID-19) during a rapid outbreak: a rapid online survey. International Journal of Environmental Research and Public Health. 2020; 17 (10):1–10. doi: 10.3390/ijerph17103347. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Husain, Fahd. 2020. Is Pakistan considering herd immunity? Dawn , 15 May 2020. https://www.dawn.com/news/1556710 .
• Isaacs D, Kilham H, Leask J, Tobin B. Ethical issues in immunisation. Vaccine. 2009; 27 (5):615–618. doi: 10.1016/j.vaccine.2008.11.002. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jaffery, Rabiya. 2020. Pakistan struggles to fight COVID-19. The Diplomat , 15 April 2020. https://thediplomat.com/2020/04/pakistan-struggles-to-fight-covid-19/ .
• Javed B, Sarwer A, Soto EB, Mashwani Z-u-R. Is Pakistan’s response to coronavirus (SARS-CoV-2) adequate to prevent an outbreak? Frontiers in Medicine. 2020; 7 :7–10. doi: 10.3389/fmed.2020.00158. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kermani, Secunder. 2020. Coronavirus: rumours, fear and rising Covid deaths in Pakistan. BBC News , 2020. https://www.bbc.com/news/world-asia-52925286 .
• Khan, Asim. 2020a. Coronavirus quarantine centre at Pak-Iran border runs out of space. SAMAA , 5 March 2020. https://www.samaa.tv/news/pakistan/2020/03/coronavirus-quarantine-centre-at-pak-iran-border-runs-out-of-space/ .
• Khan, Mishal Samar. 2020b. Questions about Pakistan’s Covid-19 control strategy. The News , 21 June 2020. https://www.thenews.com.pk/tns/detail/674891-questions-about-pakistans-covid-19 .
• Khanain, Wajiha. 2020. Pakistan now equipped to test for novel coronavirus, says PM’s aide. Dawn , 12 February 2020. https://www.dawn.com/news/1532077 .
• Daud Khattak. 2020. Pakistan’s confused COVID-19 response. The Diplomat , 9 June 2020. https://thediplomat.com/2020/06/pakistans-confused-covid-19-response/ .
• Kiani, Shafaq and Javed Malik. 2020. How local government can strengthen Pakistan’s fight against Covid-19: Democracy Reporting International. Democracy Reporting International , 16 April 2020. https://democracy-reporting.org/dri_publications/how-local-government-can-strengthen-pakistans-fight-against-covid-19/ .
• Lai CC, Wang CY, Wang YH, Hsueh SC, Ko WC, Hsueh PR. Global epidemiology of coronavirus disease 2019 (COVID-19): disease incidence, daily cumulative index, mortality, and their association with country healthcare resources and economic status. International Journal of Antimicrobial Agents. 2020; 55 (4):105946. doi: 10.1016/j.ijantimicag.2020.105946. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Latif, Aamir. 2020a. Pakistan: lifting virus lockdown may lead to ‘herd immunity.’ Anadolu Agency , 14 May 2020. https://www.aa.com.tr/en/asia-pacific/pakistan-lifting-virus-lockdown-may-lead-to-herd-immunity/1840326 .
• Latif, Aamir. 2020b. Pakistan reports death of 3rd doctor from coronavirus. Anadolu Agency , 6 April 2020. https://www.aa.com.tr/en/asia-pacific/pakistan-reports-death-of-3rd-doctor-from-coronavirus/1794673 .
• Liu W, Yue XG, Tchounwou PB. Response to the Covid-19 epidemic: the Chinese experience and implications for other countries. International Journal of Environmental Research and Public Health. 2020; 17 (7):1–6. doi: 10.3390/IJERPH17072304. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mukhtar, Sonia. 2020. Pakistanis' mental health during the COVID-19. Asian Journal of Psychiatry , published online 23 April 2020. 10.1016/j.ajp.2020.102127. [ PMC free article ] [ PubMed ]
• Nafees M, Khan F. Pakistan’s response to COVID-19 pandemic and efficacy of quarantine and partial lockdown: a review. Electronic Journal of General Medicine. 2020; 17 (6):em240. doi: 10.29333/ejgm/7951. [ CrossRef ] [ Google Scholar ]
• Noreen, Nadia, Saima Dil, Saeed Ullah Khan Niazi, Irum Naveed, Naveed Ullah Khan, Farida Khudaid Khan, Shehla Tabbasum, and Deepak Kumar. 2020. COVID-19 pandemic & Pakistan; limitations and gaps. Global Biosecurity 1 (4). 10.31646/gbio.63.
• Primary & Secondary Health Care Department, Government of Punjab. 2020. COVID-19 notification/SOPS & guidelines. https://pshealth.punjab.gov.pk/Home/Covid19SopsGuidelines .
• Prompetchara E, Ketloy C, Palaga T. Immune responses in COVID-19 and potential vaccines: lessons learned from SARS and MERS epidemic. Asian Pacific Journal of Allergy and Immunology. 2020; 38 (1):1–9. doi: 10.12932/AP-200220-0772. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Public Health Ontario. 2020. IPAC recommendations for use of personal protective equipment for care of individuals with suspect or confirmed COVID-19 . Toronto, ON: Queens’s Printer for Ontario. Accessed 12 July 2020. https://www.publichealthontario.ca/-/media/documents/ncov/updated-ipac-measures-covid-19.pdf?la=en .
• Qureshi, Zubair. 2020. COVID-19: ‘breakthrough’ drug dexamethasone running short in Pakistan markets. Gulf News , 19 June 2020. https://gulfnews.com/world/asia/pakistan/covid-19-breakthrough-drug-dexamethasone-running-short-in-pakistan-markets-1.72136756 .
• Raza, Sohail, Muhammad Asif Rasheed, and Muhammad Khalid Rashid. 2020. Transmission potential and severity of COVID-19 in Pakistan. Preprints 2020040004. 10.20944/preprints202004.0004.v1.
• Sanders JM, Monogue ML, Jodlowski TZ, Cutrell JB. Pharmacologic treatments for coronavirus disease 2019 (COVID-19): a review. JAMA. 2020; 323 (18):1824–1836. doi: 10.1001/jama.2020.6019. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Saqlain M, Munir MM, Ahmed A, Tahir AH, Kamran S. Is Pakistan prepared to tackle the coronavirus epidemic? Drugs and Therapy Perspectives. 2020; 36 (5):213–214. doi: 10.1007/s40267-020-00721-1. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA. 2020; 323 (21):2133–2134. doi: 10.1001/jama.2020.5893. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Siddique, Abubakar. 2020. By inaction, Pakistan looks to be choosing herd immunity as coronavirus response. Gandhara , 15 June 2020. https://gandhara.rferl.org/a/by-inaction-pakistan-looks-to-be-choosing-herd-immunity-as-coronavirus-response/30672411.html .
• Singh, Madhav Madhusudan. 2019. What are the SOPs (standard operating procedures) and its benefits? Research Foundation of Hospital and Healthcare Administration. Accessed 13 July 2020. https://www.researchgate.net/publication/337074540 .
• Spinelli A, Pellino G. COVID-19 pandemic: perspectives on an unfolding crisis. British Journal of Surgery. 2020; 107 (7):785–787. doi: 10.1002/bjs.11627. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• UN News. 2019. ‘Health is a right, not a privilege’ says WHO chief on World Health Day. UN News , 7 April 2019. https://news.un.org/en/story/2019/04/1036221 .
• UNICEF. 2020. COVID-19 emergency preparedness and response WASH and infection prevention and control measures in schools. UNICEF , 25 March 2020. Accessed 13 July 2020. https://www.unicef.org/documents/wash-and-infection-prevention-and-control-measures-schools .
• United Nations. 2020. United Nations guidance note on addressing and countering COVID-19 related hate speech. United Nations Office on Genocide Prevention and the Responsibility to Protect , 11 May 2020. https://www.un.org/en/genocideprevention/publications-and-resources.shtml
• ur-Rehman, Zia, Maria Abi-Habib, and Ihsanullah Tipu Mehsud. 2020. ‘God will protect us’: coronavirus spreads through an already struggling Pakistan. New York Times , 26 March 2020. https://www.nytimes.com/2020/03/26/world/asia/pakistan-coronavirus-tablighi-jamaat.html .
• Waris A, Atta UK, Ali M, Asmat A, Baset A. COVID-19 outbreak: current scenario of Pakistan. New Microbes and New Infections. 2020; 35 :100681. doi: 10.1016/j.nmni.2020.100681. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• World Health Organization. 2020a. Coronavirus (COVID-19) events as they happen. Accessed 13 July 2020. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen .
• World Health Organization. 2020b. WHO coronavirus disease (COVID-19) dashboard. Accessed 13 July 2020. https://covid19.who.int/ .
• World Health Organization . 2019 novel coronavirus (2019-nCoV): strategic preparedness and response plan. 3 February 2020. Geneva: World Health Organization; 2020. [ Google Scholar ]
• World Health Organization Regional Office Africa. 2014. Standard operating procedures for coordinating public health event preparedness and response in the WHO African region . Brazzaville: World Health Organization Regional Office Africa. Accessed 13 July 2020. http://www.who.int/hac/techguidance/tools/standard_operating_procedures_african_region_en_2014.pdf .
• Yang P, Wang X. COVID-19: a new challenge for human beings. Cellular and molecular immunology. 2020; 17 (5):555–557. doi: 10.1038/s41423-020-0407-x. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Yi, Ye, Philip N.P. Lagniton, Sen Ye, Enqin Li, and Ren-He Xu. 2020. COVID-19: what has been learned and to be learned about the novel coronavirus disease. International Journal of Biological Sciences 16 (10): 1753–1766. 10.7150/ijbs.45134. [ PMC free article ] [ PubMed ]

The mpox strain spreading now is different from the one in 2022: Here's what to know

The World Health Organization’s decision to declare mpox a global public health emergency for the second time in two years may seem like déjà vu — but there are key differences between the strain that’s causing international concern now and the one that spread in 2022.

Mpox, formerly known as monkeypox, is a viral infection characterized by painful lesions. It’s spread by direct contact with an infected person, animal or contaminated items like clothing or bedding.

The virus is classified into two distinct groups: clade I and clade II. 

Clade II was responsible for the 2022 outbreak, which has led to around 100,000 cases worldwide . 

But now, a version of clade I has spread internationally. The outbreak started in January 2023 in the Democratic Republic of Congo, and has since reached 12 other countries in the region.

On Thursday, Sweden confirmed the first known infection of clade I outside Africa , though Swedish health officials said the person was infected while spending time in Africa. Health authorities in Pakistan also confirmed a case of mpox on Friday but have not identified the strain yet. 

Clade I is more transmissible than clade II and capable of being more severe, so infectious disease experts are concerned about further international spread.

“We should have learned a lesson from 2022 that an infection anywhere is potentially an infection everywhere,” said Anne Rimoin, an epidemiology professor at the University of California, Los Angeles Fielding School of Public Health.

How does this version of mpox spread?

Mpox has historically spread in a few ways. The first is through close, personal contact with an infected person, such as skin-to-skin contact with rashes or with saliva or mucus. The second is via contact with contaminated materials. And the third is contact with infected animals: hunting, trapping or cooking them, touching sick rodents or getting bitten or scratched. 

In 2022, the version of clade II that spread globally, dubbed clade IIb, was passed primarily through sexual contact, particularly among men who have sex with men.

In the Democratic Republic of Congo recently, clade Ib has also been spreading through sexual contact among female sex workers and men who have sex with men. Research that hasn’t yet been published or peer reviewed linked an outbreak in an eastern mining town in Congo to professional sex work in bars.

But that’s not the only way the virus is being transmitted. Dr. Stuart Isaacs, an associate professor of medicine at the University of Pennsylvania, said much of the spread of clade I could be due to exposure to animals and transmission within households, but limited surveillance in the regions where the virus is make it difficult to know for sure. 

Isaacs said there’s early evidence that clade Ib has certain “properties that are allowing it to spread more readily person to person.”

How severe are the recent cases?

In the past, outbreaks of clade I have been deadlier than clade 2, killing up to 10% of people who got sick . But more recent outbreaks have had lower death rates. Out of an estimated 22,000 cases in this outbreak in Congo , more than 1,200 people have died — which puts the fatality rate at just above 5%. 

By comparison, clade II outbreaks in Africa have generally had a mortality rate of around 1%, and just 0.2% of cases linked to the 2022 global outbreak were fatal.

Rimoin said the disease’s severity “can have less to do with the actual clade and more to do with route of transmission, the immune system of the individual, the source of the infection.” 

The threat in the U.S. could be milder than in Africa, according to Marc Siegel, an associate professor of medicine at the George Washington School of Medicine and Health Sciences.

“The underlying health conditions of the population in the DRC are probably contributing to the current case fatality rate,” he said, using the acronym for the Democratic Republic of Congo. “With less malnutrition and better access to health care resources, I would imagine that the case fatality rate will not be as high as we’re seeing in the DRC.”

Vaccines for mpox are also widely available in the U.S., following a major rollout effort in 2022. Two doses of the mpox vaccine or a previous clade II infection should protect against severe illness from clade I, the Department of Health and Human Service said Wednesday.

Do mpox symptoms differ between the clades?

Symptoms of the two mpox clades can be difficult to distinguish from each other.

The illness generally starts with a rash that progresses to small bumps on the skin, followed by blisters that fill with whitish fluid — a hallmark of the disease — and eventually scab over. People may also experience a fever, headache, muscle aches, back pain, low energy and swollen lymph nodes.

These symptoms often disappear on their own within a few weeks. But in severe cases, people may develop larger, more widespread lesions, secondary bacterial infections, pneumonia, heart inflammation or swelling of the brain. Immunocompromised people may develop atypical symptoms and have a greater risk of hospitalization and death. 

Historically, mpox lesions have tended to appear on the face, chest, palms of the hands and the soles of the feet. But during the 2022 outbreak, people frequently developed lesions around the genital and anal region or inside the mouth and throat, presumably because of how the virus was spreading at the time . The lesions were also fewer in number and less pronounced overall.

Some cases of this nature have also been detected in the current outbreak in Congo. 

“There is talk that there are more people that have lesions around the genitals this time around than previous clade I outbreaks,” said Amira Albert Roess, a professor of global health and epidemiology at George Mason University. “It’s going to take us some time to really understand what may be going on here.”

Aria Bendix is the breaking health reporter for NBC News Digital.