Exploring the reasons for defaulting from childhood immunization: a qualitative study in Pakistan.

BACKGROUND: Childhood vaccination is widely recognized as the most effective means to prevent various diseases. However, a considerable amount of children still miss out on their vaccination schedules. Therefore, this study explores the reasons for defaulting from the expanded program on immunization in district Swat, Pakistan. METHODS: A qualitative phenomenological approach was used. Data collection took place from March to September 2022. Thirty-six in-depth interviews were conducted with participants who had defaulter children. The collected qualitative data were analysed thematically to identify key patterns and themes related to the reasons for defaulting from childhood vaccination schedules. RESULTS: Six themes emerged, i.e., illness of the defaulter child at the scheduled time, perceived side effects of the vaccination, factors related to caregivers, myths and misconceptions, vaccinators attitudes and crowed vaccination centres, as well as poor immunization service arrangements. Four subthemes arose related to caregivers, such as lack of clear understanding about completion of vaccination, least priority for child's vaccination, cultural restriction on mothers, and the loss of vaccination card. CONCLUSION: According to the study's findings, caregivers have their own perceptions regarding the non-completion of their children's vaccination schedule. The childhood immunization defaulting arises from various factors including child illness, Adverse Events Following Immunization (AEFIs) concerns, misconceptions, improper injection techniques, and negative vaccinator attitudes. The vaccination completion rate may be increased if the concerns of the caregivers are appropriately addressed.

Oral health behind the bars: oral health seeking behavior among jail prisoners at central jail of Peshawar, Pakistan: a cross-sectional study.

BACKGROUND: The oral health care-seeking behavior among prison inmates is an overlooked area, often leading to deteriorating general health due to the prisoners' limited awareness of oral hygiene practices. It is crucial to address this issue and understand the factors associated with oral healthcare-seeking behavior in prisons. OBJECTIVE: To assess the oral healthcare-seeking behavior of prison inmates at Central Prisoner Jail, Peshawar Pakistan and to look the factors associated with their dental care utilization. MATERIAL AND METHODS: This cross-sectional study was conducted at Central Prisoner Jail, Peshawar Khyber Pakhtunkhwa, Pakistan from November 2021 to April 2022. A consecutive sampling technique was used to collect data from both convicted and under-trial prisoners by using a pre-tested WHO Basic Oral Health Survey 2013 tool. Our outcome variable was "Visit to a dentist in the last 12 months (Never/Once or more than one visit). Chi-square test was used to determine univariate association with other explanatory variables while multivariable logistic regression was performed to adjust for potential confounders. RESULT: A total of 225 participants were recruited to the study with a mean (SD) age of 32.9(11.4). More than two-thirds of 200(88.9%) of the participants were males. One-third of the sample never visited the dentist75(33.3). Participants who completed college/university education and never visited the dentist in the last 12 months constituted a smaller proportion (17.6%) compared to those who visited the dentist once or more than once n = 28(82.4%, p-value = 0.003). Individuals who were using toothbrushes were most frequently visiting the dentist n = 130(72.6%=p value = 0.001) as compared to never visitors. Multivariate logistic regression analysis revealed that Participants who experienced teeth pain or discomfort had 0.42 times lower odds of visiting the dentist compared to those who did not experience any pain or discomfort [AOR 0.42 (95% CI 0.17-0.80), p = 0.04]. Similarly, Participants who do not use any denture have 4.06 times higher odds[AOR 4.06(95% CI 1.76-9.36), p = 0.001] of visiting the dentist compared to those who use a denture. CONCLUSION: Our result demonstrates that those prisoners who were experiencing tooth pain or discomfort and not using dentures were the strong predictors with lower dental visit frequency to seek oral health care.

Healthcare workers safety in the COVID-19 era: the impact of pre-pandemic personal protective equipment (PPE) training in Pakistan.

BACKGROUND: The COVID-19 pandemic has revealed vulnerabilities in healthcare systems worldwide, emphasizing the importance of healthcare worker safety through adequate utilization of personal protective equipment (PPE). This study aims to assess the impact of pre-pandemic PPE training on the practices and other associated factors among frontline healthcare workers during the COVID-19 pandemic in Pakistan and provide insights into the implications of such training programs for future initiatives. METHODS: A cross-sectional study from May 9th to June 5th, 2020 was conducted among the frontline healthcare workers against COVID-19 in Pakistan, utilizing an online structured questionnaire shared via WhatsApp and Facebook by using purposive sampling. Statistical analyses, including chi-square tests for proportion and logistic regression for the association while multi-logistic regression for potential confounders, were performed using SPSS version 22. RESULTS: A total of 453 healthcare staff participated, with 68.9% (n = 312) reporting no prior PPE training and 31.1% (n = 141) having received training. Significant associations were found between prior training and healthcare group distribution (p = 0.006), with doctors exhibiting the highest proportion of training 82 (37.61%), followed by nurses 50 (27.32%) and paramedics 9 (17.31%). Those who didn't receive any prior training in PPEs showed a higher perceived professional risk of 216 (69.23%) compared to those who received prior PPE training 96 (30.77%, p-value 0.005). Similarly, a higher frequency 137 (63.72%) of Perceived Personal risk was observed in those who didn't receive training, labeled as "high risk" compared to those who were trained 78 (36.28%, P value 0.02). Multi-logistic regression analysis identified paramedics as 0.26 times less likely to have received prior PPE training (Adjusted OR 0.26, 95% CI 0.10-0.65, p = 0.01) compared to medical doctors. Healthcare workers in tertiary care hospitals were 0.46 times less likely to undergo PPE training (Adjusted OR 0.46, 95% CI 0.25-0.87,p = 0.01) compared to those working at COVID-19 facilities/hospitals/quarantine centers. Likewise, individuals who doffed disposable gowns [Adjusted OR 3.86, (95% CI, 1.23-12.08, p = 0.02] were 3.86 times more interested in getting prior training in PPE compared to those who don't have skills to wear them. CONCLUSION: Our findings highlight that healthcare levels, type of healthcare, and doffing skills are important predictors of whether healthcare workers have taken prior training in PPE. These findings imply developing effective training programs for healthcare workers to ensure safety while providing care during pandemics like COVID-19.

Novel mutations in genes of the IL-12/IFN-γ axis cause susceptibility to tuberculosis.

BACKGROUND: The IL-12/23/ISG15-IFN-γ pathway is the main immunological pathway for controlling intra-macrophagic microorganisms such as Mycobacteria, Salmonella, and Leishmania spp. Consequently, upon mutations in genes of the IL-12/23/ISG15-IFN-γ pathway cause increased susceptibility to intra-macrophagic pathogens, particularly to Mycobacteria. Therefore, the purpose of this study was to characterize the mutations in genes of the IL-12/23/ISG15-IFN-γ pathway in severe tuberculosis (TB) patients. METHODS: Clinically suspected TB was initially confirmed in four patients (P) (P1, P2, P3, and P4) using the GeneXpert MTB/RIF and culturing techniques. The patients' Peripheral blood mononuclear cells (PBMCs) were then subjected to ELISA to measure Interleukin 12 (IL-12) and interferon gamma (IFN-γ). Flow cytometry was used to detect the surface expressions of IFN-γR1 and IFN-γR2 as well as IL-12Rß1and IL-12Rß2 on monocytes and T lymphocytes, respectively.The phosphorylation of signal transducer and activator of transcription 1(STAT1) on monocytes and STAT4 on T lymphocytes were also detected by flow cytometry. Sanger sequencing was used to identify mutations in the IL-12Rß1, STAT1, NEMO, and CYBB genes. RESULTS: P1's PBMCs exhibited reduced IFN-γ production, while P2's and P3's PBMCs exhibited impaired IL-12 induction. Low IL-12Rß1 surface expression and reduced STAT4 phosphorylation were demonstrated by P1's T lymphocytes, while impaired STAT1 phosphorylation was detected in P2's monocytes. The impaired IκB-α degradation and abolished H2O2 production in monocytes and neutrophils of P3 and P4 were observed, respectively. Sanger sequencing revealed novel nonsense homozygous mutation: c.191 G>A/p.W64 * in exon 3 of the IL-12Rß1 gene in P1, novel missense homozygous mutation: c.107 A>T/p.Q36L in exon 3 of the STAT1 gene in P2, missense hemizygous mutation:: c.950 A>C/p.Q317P in exon 8 of the NEMO gene in P3, and nonsense hemizygous mutation: c.868 C>T/p.R290X in exon 8 of CYBB gene in P4. CONCLUSION: Our findings broaden the clinical and genetic spectra associated with IL-12/23/ISG15-IFN-γ axis anomalies. Additionally, our data suggest that TB patients in Pakistan should be investigated for potential genetic defects due to high prevalence of parental consanguinity and increased incidence of TB in the country.

Association and comparison of periodontal and oral hygiene status with serum HbA1c levels: a cross-sectional study.

BACKGROUND: Diabetes Mellitus and periodontitis are chronic diseases with known reciprocal association. Studies have shown that uncontrolled diabetes increases the risk of development and progression of periodontal disease. This study aimed to explore the association and severity of periodontal clinical parameters and oral hygiene with HbA1c levels in non-diabetics and T2DM patients. MATERIALS AND METHODS: In this cross-sectional study, the periodontal status of 144 participants, categorized into non-diabetics, controlled T2DM, and uncontrolled T2DM and were assessed via the Community Periodontal Index (CPI), Loss of Attachment Index (LOA index), and the number of missing teeth, while oral hygiene was measured by utilizing the Oral Hygiene Index Simplified (OHI-S). SPSS was used for data analysis. Chi-square test was used to find out the association of different independent variables with HbA1c groups, while ANOVA and post-hoc tests were run for inter-group and intra-group comparison respectively. RESULTS: Out of 144 participants, the missing dentition was prevalent in uncontrolled T2DM with mean 2.64 ± 1.97 (95% CI 2.07-3.21; p = 0.01) followed by controlled T2DM 1.70 ± 1.79 (95% CI 1.18-2.23; p = 0.01) and non-diabetics 1.35 ± 1.63 (95% CI 0.88-1.82; p = 0.01) respectively. Furthermore, non-diabetics had a higher proportion of CPI score 0 (Healthy) [30 (20.8%); p = 0.001] as compared to uncontrolled T2DM [6 (4.2%); p = 0.001], while CPI score 3 was more prevalent in uncontrolled T2DM in comparison to non-diabetics. Loss of attachment (codes-2,3 and 4) was also frequently observed in uncontrolled T2DM compared to non-diabetics (p = 0.001). Similarly, based on Oral Hygiene Index- Simplified (OHI-S), the result showed that poor oral hygiene was most commonly observed in uncontrolled T2DM 29 (20.1%) followed by controlled T2DM patients 22 (15.3%) and non-diabetic [14 (9.7%); p = 0.03]. CONCLUSION: This study showed that periodontal status and oral hygiene status were deteriorated in uncontrolled T2DM patients compared to non-diabetic participants and controlled T2DM.

Patient Satisfaction and Utilization of Ambulance Services in Prehospital Services at a Tertiary Care Hospital: A Cross-Sectional Study in Peshawar, Khyber Pakhtunkhwa, Pakistan.

OBJECTIVE: Patients reporting to emergency departments frequently use different ambulance services; therefore, the measurement of patient satisfaction is relevant to encouraging those services to meet patient expectations. The aim of this study was to determine the patients' satisfaction and utilization of different ambulance services at a tertiary health care hospital in Peshawar relating to prehospital services. METHODS: This cross-sectional study was conducted at Lady Reading Hospital, Peshawar, Khyber Pakhtunkhwa, Pakistan, from July 2019 to January 2020 using a consecutive sampling technique with a total sample size of 378. The patients reporting to the emergency department using any ambulance service were included in this study. Different types of ambulance services were used as an outcome variable. Proportions were compared for the categoric variables using the chi-square test, whereas the 1-way analysis of variance test was used to determine the mean response time and age. Results were considered significant at a P value ≤ .050. All analyses were completed using SPSS version 20 (IBM Corp, Armonk, NY). RESULTS: Of the total 378 study participants, approximately 166 (43.9%) used Rescue 1122 services, 99 (26.2%) used private ambulance services, and 44 (11.6%) used public ambulance services. Road traffic accidents were the most common complaint by 98 (25.9%, P < .003) participants. The mean response time for Rescue 1122 was 13.2 ± 18 minutes followed by the Chippa Foundation (private) at 17.8 ± 20 minutes (P < .005). Males (n = 254) were the predominant users of all services. Participants from the urban region (n = 112) used Rescue 1122, whereas the public ambulance service was used only by 31 patients (P < .005). Among all the ambulance services, 19 (61.3%) participants were not satisfied with the Chippa service regarding vehicle cleanliness, whereas participants were highly satisfied with Rescue 1122. CONCLUSION: Overall, the patients were more satisfied with the services provided by the Rescue 1122 ambulances compared with all other ambulance services.

Analysis of associated risk factors among recurrent cutaneous leishmaniasis patients: A cross-sectional study in Khyber Pakhtunkhwa, Pakistan.

BACKGROUND: Leishmaniasis is the second and fourth highest cause of mortality and morbidity respectively among all tropical diseases. Recurrence in the onset of leishmaniasis is a major problem that needs to be addressed to reduce the case fatality rate and ensure timely clinical intervention. Here we are investigating the association of risk factors with recurrent cutaneous leishmaniasis to address this issue. MATERIAL AND METHODS: Patients received by Nasser Ullah Khan Babar Hospital in Peshawar, Pakistan from March 2019 to July 2020 were enrolled in this study. Those patients who developed symptoms after completion of treatment were included in Group-A while those who had atypical scars like leishmaniasis but were negative for cutaneous leishmaniasis were included in the comparison group tagged as Group B. All those individuals who had completed six weeks of treatment for CL but had normal complete blood counts (CBC) were included to avoid other underlying immunological pathologies, while we excluded those participants who had co-morbidities like diabetes, liver disease, cardiac disease, and pregnant and lactating women through their history Association was tested between Group-A and Group-B with other explanatory variables through chi-square test. The regression model was proposed to determine the predictors. RESULT: A total of 48 participants of both sexes were included in the study with a mean age of 32.2 ± 15.10. The data suggest that females are overrepresented among the patients with recurrent leishmaniasis [21(53.8 %,); p = 0.07]. Compared to patients; healthy participants had a higher proportion of adults (19-59 years) versus adolescents (13-18 years) [26(66.7 %) vs 07(17.9), p = 0.004]. Multivariate logistic regression analysis shows that females are 2.1 times more prone to infections among cases as compared to healthy individuals [unadjusted OR 2.20, 95 % confidence interval (CI) 1.5-10.6, p = 0.02; adjusted OR 2.1, 95 % CI 1.50-10.69, p = 0.02]. We propose that patients receiving intradermal were less likely to be infected as compared to those receiving intralesional injections [unadjusted OR 0.07.0, 95 % confidence interval (CI) 1.18-3.37, p = 0.03; adjusted OR 0.06, 95 % CI 1.18-3.38, p = 0.03]. CONCLUSION: Old age (adults) and sex (females) were the strongest predictors to be associated with recurrent leishmaniasis. Similarly, the choice of intradermal as compared to intralesional injection and the prolonged treatment duration were strongly associated with greater chances of recurrence.

Diabetic ketoacidosis amongst patients with COVID-19: A retrospective chart review of 220 patients in Pakistan.

OBJECTIVES: To determine the frequency of diabetes mellitus and diabetic ketoacidosis and associated factors in COVID-19-positive patients. BACKGROUND: High mortality amongst SARS-Cov2 patients may be attributed to diabetes and diabetic ketoacidosis. METHODS: A total of 220 COVID-19 positive patients, hospitalized in North West General Hospital & Research Center, Peshawar, KP, Pakistan, from April to September 2020, were analysed using STATA 14. Patients with positive PCR were labelled as COVID-19 positive and were included in the study. Patients with a clinical picture of COVID-19 and negative PCR were excluded from the study. Those having ketonemia >0.6 and random blood glucose level >250mg/dl, while HCO3 (bicarbonate) ≤18, were labelled as diabetic ketoacidosis. The statistical significance level was set at p < .05. RESULTS: A total of 220 COVID-19 patients were admitted; 166 (75.4%) were male and 54 (24.5%) were female. The mean age in years of the patients was 55.95 (SD13.9). About 57.7% of patients had diabetes mellitus, and 15 (6.8%) patients developed diabetic ketoacidosis. Amongst those with DKA, 5 patients died during hospital admission. The use of steroids was significantly higher (p < .001) in the DKA group compared with non-DKA patients. Hypertension (103,46.8%) and fever (170,77.3%) were the most reported comorbidity and symptom respectively. CONCLUSION: The proportion of diabetes mellitus is high in patients with COVID-19. Diabetic ketoacidosis is a frequent complication in this group associated with in-hospital mortality. Steroid administration for COVID-19 should be balanced with strict glycemic control to prevent diabetic ketoacidosis and increase hospital survival.

A pilot trauma registry in Peshawar, Pakistan - A roadmap to decreasing the burden of injury - Quality improvement study.

BACKGROUND/LOCAL PROBLEM: In Pakistan, trauma is a significant public health issue accounting for the second leading cause of disability and fifth for healthy years of life lost. Well-developed trauma systems, utilizing trauma registries, have been proven to decrease morbidity and mortality from injuries, and helped to reduce the number of injured patients. In Pakistan, most data on injury are acquired through methods that are retrospective, incomplete, and open to recall bias. To that end, a trauma registry was piloted at the Lady Reading Hospital (LRH) in Peshawar, Pakistan to elucidate the importance of trauma registries in designing healthcare targeted quality improvement initiatives. INTERVENTION: Upon receiving ethics approval, a twenty-five-point registry was piloted at the Lady Reading Hospital. METHODS: The pilot implementation was carried out from May 9th to May 13th, 2018. RESULTS: A total of 267 patients were included in the pilot registry. Motor vehicle collisions were the most prevalent cause of injury (46%). The other causes of injury included falls (24%), blunt assaults (9%), stabs/cuts (8%), gunshots (6%), crush injuries (3%), burns (2%), and blasts/landmines (2%). Most patients were treated in the trauma bay and required no further acute intervention (51%). CONCLUSION: This 5-day pilot trauma registry was the first of its kind in Peshawar, Pakistan, and despite its short course, an immense amount of data was garnered on the epidemiology of injury in the region. Significantly, the data collected can already be used to develop evidence-based changes, which will effectively minimize the impact of trauma.

Perceptions of COVID-19-related Risks and Deaths Among Health Care Professionals During COVID-19 Pandemic in Pakistan: A Cross-sectional Study.

COVID-19 is an established challenge to the health care professionals (HCPs) having physical, emotional, and psychological repercussions. We determine the perceptions of Pakistani HCPs regarding the risks and deaths related to COVID-19. A cross-sectional study was conducted among HCPs throughout Pakistan from 16th February 2021 to 6th March 2021 by disseminating an online Google questionnaire via all possible social media platforms including WhatsApp, Facebook, Twitter, and emails. Out of total of 462 HCPs, 33.55% tested COVID-19 positive and 49.43% had received their first dose of COVID-19 vaccine. The proportion of HCPs worried about contracting COVID-19 was 46.97%. A total of 69.48% mentioned that doctors are at a higher risk of dying from COVID-19 infection compared to the general population. In a dichotomous analysis done for risk perception, 72.06% of doctors reported a high-risk perception of contracting COVID-19 in hospital settings. The main reasons identified to be associated with higher mortality amongst the HCPs, specifically doctors, included comorbidities (47.26%), working in high-risk wards (24.02%) and lack of adequate personal protective equipment (PPE) (28.72%). Using univariate and multivariate regression the HCPs tested positive rated two-fold high risk while performing professional duty during COVID-19 pandemic [unadjusted odds ratio (OR) (95% confidence interval (CI)): 2.23 (1.24-4.02), P = .007; adjusted OR (95% CI) 2.27 (1.22-4.19), P = .009]. In conclusion, Pakistani HCPs have significant COVID-19-related concerns and anxieties. The doctors perceived to be at a higher risk of dying with COVID-19, due to a variety of personal and professional reasons.

Novel IL-12Rß1 deficiency-mediates recurrent cutaneous leishmaniasis.

BACKGROUND: The IL-12/IFN-γ axis plays a vital role in the control of intramacrophagic pathogens including Leishmania infections. OBJECTIVE: The aim of this study was to investigate genetic defects in the IL-12/IFN-γ axis in cutaneous leishmaniasis patients, using immunological and genetic evaluation. METHODS: Enzyme-linked immunosorbent assay was used to quantify IFN-γ , while flow cytometry was performed to analyze surface IL-12Rß1/IL-12Rß2 expression and phosphorylation of signal transducers as well as the activator of transcription 4 (pSTAT4). Sequencing was carried out for genetic analysis. RESULTS: The peripheral blood mononuclear cells from the two patients (P1 and P2) demonstrated impaired production of IFN-γ. Furthermore, abolishment of the surface expression of Il-12Rß1 was observed in lymphocytes, with consequent impairment of STAT4 phosphorylation in the lymphocytes of P1 and P2. IL-12Rß1 deficiency was identified, which was caused by a novel homozygous missense mutation (c.485>T/p.P162L) and a novel homozygous nonsense mutation (c.805G>T/P.E269*) in the IL-12Rß2 gene of P1 and P2, respectively. In silico analyses predicted these novel mutations as being pathogenic, causing truncated proteins, with consequent inactivation. CONCLUSION: Our data have expanded the phenotype and mutation spectra associated with IL-12Rß1 deficiency, and suggest that patients with CL should be screened for mutations in genes of the IL-12/IFN-γ axis.

Prevalence of Parental refusal rate and its associated factors in routine immunization by using WHO Vaccine Hesitancy tool: A Cross sectional study at district Bannu, KP, Pakistan.

OBJECTIVE: To determine the vaccination refusal rate, associated factors and perceptions of parents who refused routine immunization for their children using the World Health Organization (WHO) SAGE Working Group on Vaccine Hesitancy Survey Tool. MATERIALS AND METHODS: A cross-sectional survey was conducted using multi-stage cluster sampling in Bannu District, Khyber Pakhtunkhwa Province, Pakistan from March 2019 to July 2019. A WHO validated questionaire was used. The outcome variable was parental refusal of routine immunization of their children. Logistic regression was performed for associations, and multi-regression was applied to identify any confounders. RESULTS: Of 610 parents, 170 (27.9%) refused vaccination of their children. Of these, the majority of mothers had no education [n = 145 (85.3%); p = 0.03], and mothers were less likely to own a mobile phone than fathers [24 (14.1%) vs 152 (89.4%); p ≤ 0.001]. The vaccination refusal rate was higher in parents with food security [n = 88 (51.8%)] compared with parents with minimal food insecurity [n = 62 (36.5%)] and high food insecurity [20 (11.8%); p ≤ 0.05)]. On multi-variate logistic regression, fathers who were employed [adjusted odds ratio (OR) 0.59, 95% confidence interval (CI) 0.37-0.94; p = 0.02] and had a high level of education (adjusted OR 0.21, 95% CI 0.08-0.50; p ≤ 0.001) were less likely to refuse vaccination of their children. Parents with high food insecurity were more likely to refuse vaccination of their children (adjusted OR 2.2, 95% CI 1.0-0.50; p = 0.04) compared with parents with minimal food insecurity (adjusted OR 1.6, 95% CI 1.0-2.5; p = 0.02). CONCLUSION: The vaccination refusal rate was very high among parents, and this was associated with inability to read or write, no education, owning a mobile phone, unemployment and food security.

Access and Use Experience of Personal Protective Equipment Among Frontline Healthcare Workers in Pakistan During the COVID-19 Emergency: A Cross-Sectional Study.

Healthcare workers are at the highest risk of contracting novel coronavirus disease 2019 (COVID-19) and, therefore, require constant protection. This study assesses access to personal protective equipment (PPE), availability of adequate information about PPE use, self-reported ability to correctly wear and remove (donning and doffing) PPE, and risk perceptions associated with COVID-19 among frontline healthcare workers in Pakistan. Using a structured and validated questionnaire, an online survey was conducted from May 9 to June 5, 2020. Responses were received from 453 healthcare workers. Of these, 218 (48.12%) were doctors, 183 (40.40%) were nurses, and 52 (11.48%) were paramedical staff. Only 129 (28.48%) healthcare workers reported having adequate access to PPE at all times, whereas 156 (34.44%) never had access to PPE and 168 (37.09%) had access to PPE occasionally. Lack of access to PPE led the majority (71.74%) of healthcare workers to use coping strategies such as reuse of N95 and surgical masks. A total of 312 (68.87%) respondents believed that the risk of contracting COVID-19 in the work environment was high and the majority (62.69%) adopted precautionary measures at home to keep their families safe. A significantly high (n = 233, 51.43%, P = .03) number of respondents reported self-medicating. Of all the respondents, only 136 (30.02%) were tested for COVID-19 at least once, of which 32 (23.53%) ever tested positive. These findings suggest that healthcare workers in Pakistan had limited access to PPE. Adequate provision and training is vital to protect the healthcare workforce during the COVID-19 pandemic.