COVID-19 and alarming dengue co-epidemics in the dilapidated healthcare system in Pakistan: Where to focus!

Dear Editor,

Coronavirus disease (COVID-19) is caused by the severe acute respiratory syndrome coronavirus (SARS-CoV-2). The WHO classified it a worldwide pandemic. COVID-19, a new virus, has been identified in 221 developing and developed nations. , Globally, there are 239,973,250 confirmed COVID-19 cases, 4890,002 deaths, and 217,312,219 recovered cases. In Pakistan, the overall number of confirmed cases has reached 1,261,685, with 28,201 fatalities.

Dengue outbreaks have occurred frequently in Pakistan during the previous three decades, perpetuating dengue endemicity. The current COVID-19 pandemic coincides with an outbreak of dengue fever, a viral infection caused by Aedes albopictus and Aedes aegypti mosquito vectors that pose a substantial threat to human health. As a result of the COVID-19 pandemic, dengue-endemic countries in Latin America and Southeast Asia have a heightened risk of infection overlap. Each year, more than a hundred countries face a pandemic burden of 50 million dengue cases. Dengue fever was verified in 132,977 cases and 588 deaths in Pakistan over the previous decade, according to the Ministry of National Health Services. In Pakistan, confirmed dengue pandemic cases were 52,485 in 2019, including 91 deaths and 4024 in 2020. During the COVID-19 pandemic of 2021, just 2875 cases were reported until September, with 678 occurring in Lahore, the capital of Punjab Province. During the rainy season, dengue disease is growing rapidly in Lahore. The number of actual dengue cases may be higher than reported in the literature, as many of the patients were asymptomatic. Dengue infection and COVID-19 are co-related by laboratory features and clinical demonstration, which can lead to misdiagnosis. Patients co-infected with dengue and COVID-19 show initial symptoms like rash, high fever, and headache, while as diseases progress, the symptoms can be distinguished separately. There is an increase in dengue cases in Pakistan because COVID-19 hype has diverted focus and led to a lack of supervision. Dengue cases normally start to appear post monsoon season and are highest in September and October in Pakistan. Since last year dengue cases have been occurring along with COVID cases, and even co-infection can be seen in certain patients like other dengue-endemic countries, for example, South East Asia, Brazil, Thailand, India, France, and Malaysia.

The co-infection of COVID-19 and dengue cases reported in Singapore had similar symptoms of headache and high fever. In Pakistan, cases of co-infection have been reported, and a study showed that patients suffering from dengue and COVID-19 have more mortality rate than patients who only have COVID-19. Similarly, COVID-19 mono-infected patients have different biochemical and hematological parameters than those who are co-infected. For example, co-infected patients suffered from severe thrombocytopenia while mono-infected patients did not. There was also an increase in creatine phosphokinase, urea, prothrombin time, creatinine, alanine aminotransferase, and bilirubin concentrations in co-infected patients.

Since 2010, Pakistan has been witnessing a dengue fever outbreak, which has resulted in 16 580 confirmed cases and 257 fatalities in Lahore, and almost 5000 cases and 60 deaths in the rest of the nation. Khyber Pakhtunkhwa, Punjab, and Sindh are the three provinces affected by the disease. Dengue fever is native to Balochistan's coastal regions but has historically been more prevalent in Khyber Pakhtunkhwa Province. Pakistani authorities recorded 3442 dengue fever cases in 2017, almost 3200 in 2018, about 24,547 in 2019, and 3442 in 2020. In the first half of the year, more than 820 reported cases have been reported, with 687 of those occurring in Lahore. In 2019, more than 8670 instances with a total of over 50,000 were recorded in Punjab. During the research period (2006–2017), 2011 was Pakistan's most destructive year. In a single year, Lahore had almost 17,000 confirmed cases and 290 fatalities. Between 1995 and 2019, over 147 200 dengue illness cases and over 800 fatalities. As of September 30, 2021, the total number of confirmed dengue cases in Lahore has reached 1180. On November 6, 2019, the country's dengue outbreak hit a new record, with over 44,000 individuals afflicted and 66 deaths. In 2011, 27,000 individuals were infected, yet the illness claimed nearly six times as many lives as in 2019, when 370 people died. According to the Ministry of National Health Services, Regulations, and Coordination, the number of dengue cases increased about 15-fold from 3204 cases in 2018 to 47,120 cases in 2019, although the true figure is expected to be considerably higher. Similarly, 416 confirmed dengue cases had been reported considerably earlier in 2020, during the post-monsoon months. , There is a likelihood of an increase in dengue cases due to the COVID-19 lockdown; people remain at home to avoid contracting the fatal virus, and dengue vector mosquitos are bred in the clean waters of home gardens. Even if they get fever due to dengue, many are afraid to contact a physician for fear of contracting COVID-19. In a study by Siddique A. at Islamabad's Holy Family Hospital, 20 patients admitted to the intensive care unit with severe respiratory disorders were sent to the virology department for real-time reverse transcription-polymerase chain reaction (RT-PCR) diagnosis. All twenty patients tested positive for COVID-19, and five were co-infected with dengue and COVID-19. Fever was seen in 100% of co-infected individuals and in 80% of mono-infected patients. Both groups had low lymphocyte, neutrophil, platelet, and white blood cell counts and concentrations. Mono-infected patients survived, while 60% of co-infected individuals did not, indicating a greater death risk in co-infected patients. A developing countries like Pakistan having deteriorated health system two pandemics co-existing is a great threat, especially dengue infection that emerges and re-emerges every few years. Healthcare authorities should take the necessary measures against the spread of epidemics like COVID-19 and dengue and spread awareness about their co-existence in one patient to restrain the exposure and transmission ways.

Declaration of Competing Interest

The authors declare that, they have no conflict of interests.