Indirect effects of COVID-19 pandemic on reproductive, maternal, newborn and child health services in Pakistan

Background: COVID-19 is having many impacts on health, economy and social life; some due to the indirect effects of closure of health facilities to curb the spread. Closures were implemented in Pakistan from March 2020, affecting provision of reproductive, maternal, newborn and child health (RMNCH) services. Aim: To appraise the effects of containment and lockdown policies on RMNCH service utilization in order to develop an early response to avoid the catastrophic impact of COVID-19 on RMNCH in Pakistan. Methods: Routine monitoring data were analysed for indicators utilization of RMNCH care. The analysis was based on Period 1 (January–May 2020, first wave of COVID-19); Period 2 (June–September 2020, declining number of cases of COVID-19); and Period 3 (October–December 2020, second wave of COVID-19). We also compared data from May and December 2020 with corresponding months in 2019, to ascertain whether changes were due to COVID-19. Results: Reduced utilization was noted for all RMNCH indicators during Periods 1 and 3. There was a greater decline in service utilization during the first wave, and the highest reduction (~82%) was among children aged < 5 years, who were treated for pneumonia. The number of caesarean sections dropped by 57%, followed by institutional deliveries and first postnatal visit (37% each). Service utilization increased from June to September, but the second wave of COVID-19 led to another decrease. Conclusion: To reinstate routine services, priority actions and key areas include continued provision of family planning services along with uninterrupted immunization campaigns and routine maternal and child services.

Protecting health care workers from COVID-19: implementing a training programme on personal protective equipment in Pakistan

Background: Pakistan’s Ministry of National Health Services, Regulations and Coordination, with support from the World Health Organization, developed and implemented the “We Care” programme to protect frontline health care workers engaged in the coronavirus disease 2019 (COVID-19) response. Aims: This paper reports on the training part of the programme, which aimed to train 100 000 frontline health care workers on the proper use of personal protective equipment (PPE) and on the lessons learnt from implementation of the training. Methods: A team of experts developed the curriculum and its accompanying material. Initial training was given to deans of all participating institutions and to master trainers from each university. Staff of all public and private hospitals enrolled in the training and other frontline health care workers were invited to register individually. Four types of educational material were produced and used: a guidance booklet, a training video, a set of PowerPoint presentations to explain the PPE and their use, and a poster. Results: A total of 2000 training sessions were conducted across the country from May to December 2020 and 100 000 frontline health care workers were trained on the use of PPE. Of those trained, 25% were doctors, 35% were nurses and paramedics, and 40% were allied health staff, with an almost equal gender distribution. Conclusions: With limited resources and over a short period, the We Care programme trained a large number of frontline health care workers, which enhanced their safety and reduced the irrational use of PPE.

Balancing science and public policy in Pakistan’s COVID-19 response

Background: Coronavirus disease 2019 (COVID-19) has affected the world in an unprecedented manner and South Asian countries were among the first to experience imported cases. Pakistan’s response to COVID-19 has been under scrutiny for its granularity, reach and impact. Aims: to evaluate objectively the chronology and depth of the response to COVID-19 in Pakistan. Methods: We evaluated available national and subnational epidemiological and burden information on COVID-19 cases and deaths in Pakistan, including projection models available to the Government at an early stage of the pandemic. Results: Pakistan, with a population of 215 million and considerable geographic diversity, experienced case introduction from pilgrims returning from the Islamic Republic of Iran, followed by widespread community transmission. The National Command and Operations Centre, established through civilian and military partnership, was critical in fast tracking logistics, information gathering, real-time reporting and smart lockdowns, coupled with a massive cash support programme targeting the poorest sections of society. Cases peaked in June 2020 but the health system was able to cope with the excess workload. Since then, although testing rates remain low (> 300 000 cases confirmed to date), case fatality rates have stabilized, and with 6300 deaths, Pakistan seems to have flattened the COVID-19 curve. Conclusion: Despite notable successes in controlling the pandemic, several weaknesses remain and there are risks of rebound as the economy and educational systems reopen. There is continued need for strong technical and programmatic oversight, linked to civic society engagement and working with religious scholars to ensure nonpharmacological intervention compliance.

Elucidation of larvicidal potential of metallic and environment friendly food-grade nanostructures against Aedes albopictus.

To combat health challenges associated with mosquito-borne diseases, the larvicidal activity of metallic nanoparticles, food-grade polymeric nano-capsules and insecticides was investigated against larvae of Aedes albopictus as an effective alternate control approach. The Ae. albopictus was identified using sequencing and phylogenetic analyses of COXI, CYTB and ITS2 genes. The characterization of synthesized nanostructures was performed through Zetasizer, UV-VIS spectroscopy, atomic force microscopy, scanning electron microscopy and energy dispersive X-ray spectroscopy. The mosquito larvae were exposed to varying concentration of nanostructures and insecticides, and their percentage mortality was evaluated at different time intervals of 24 h and 48 h exposure. The highest efficacy was observed in zinc oxide nanoparticles (ZnO-NPs) and polymeric nanocapsules FG-Cur E-III (LC50 = 0.24 mg/L, LC90 = 0.6 mg/L) and (LC50 = 3.8 mg/L, LC90 = 9.33 mg/L), respectively, after 24 h; while (LC50 = 0.18 mg/L, LC90 = 0.43 mg/L) and (LC50 = 1.95 mg/L, LC90 = 6.46 mg/L), respectively, after 48 h against fourth instar larvae of Ae. albopictus. Ag, CuO, NiTiO3 and CoTiO3 nanoparticles evaluated in this study also showed promising larvicidal activity. Although ZnO-NPs proved to be effective larvicides, their possible toxicity (producing ROS species) can limit their use. The curcumin nanostructures (FG-Cur E-III) stabilized by food-grade materials are thought to exert their larvicidal activity by binding to sterol carrier protein-2, and depriving the larvae from the essential dietary cholesterol, and bears effective larvicidal potential as safe alternative for chemical larvicides, due to their environment friendly, food-grade and easy biodegradability.

Health system barriers to access and use of magnesium sulfate for women with severe pre-eclampsia and eclampsia in Pakistan: evidence for policy and practice.

Severe pre-eclampsia and eclampsia are rare but serious complications of pregnancy that threaten the lives of mothers during childbirth. Evidence supports the use of magnesium sulfate (MgSO4) as the first line treatment option for severe pre-eclampsia and eclampsia. Eclampsia is the third major cause of maternal mortality in Pakistan. As in many other Low- and Middle-Income Countries (LMIC), it is suspected that MgSO4 is critically under-utilized in the country. There is however a lack of information on context-specific health system barriers that prevent optimal use of this life-saving medicine in Pakistan. Combining quantitative and qualitative methods, namely policy document review, key informant interviews, focus group discussions and direct observation at health facility, we explored context-specific health system barriers and enablers that affect access and use of MgSO4 for severe pre-eclampsia and eclampsia in Pakistan. Our study finds that while international recommendations on MgSO4 have been adequately translated in national policies in Pakistan, the gap remains in implementation of national policies into practice. Barriers to access to and effective use of MgSO4 occur at health facility level where the medicine was not available and health staff was reluctant to use it. Low price of the medicine and the small market related to its narrow indications acted as disincentives for effective marketing. Results of our survey were further discussed in a multi-stakeholder round-table meeting and an action plan for increasing access to this life-saving medicine was identified.