Evolution of COVID-19 infection in Punjab; trends during five waves of infection in the province of Punjab – BMC … – BMC Infectious Diseases

The work presented in this manuscript provides trends in infection in the 5th wave, which was predominantly by the Omicron variant. The wave was associated with increased transmission rates. The Ct data indicated that younger individuals, irrespective of gender, had lower Ct values, indicative of higher viral burden which is likely to be associated with severe infections. Additionally, the disease severity was derived from total no. of cases tested, tested positive and negative. The compasrison of all waves showed that 5th wave has highest cases that were tested positive which is indirectly related to the transmission and incident rate.

A significant difference was observed in positivity rates and transmission dynamics of infection over the five waves. Our findings are in line with the global ternd which showed that different variants have a distinct global spatiotemporal pattern, explaning the occurrence of the five waves in the pandemic. Moreover,different variants demonstrated a distint pattern of transmission, in that Omicron variant indicated better transmissibility in comparison to all previous variants, underscoring the importance of monitoring of any new variants to prevent further transmission [15, 16].

In this study, among the 525,376 confirmed cases, there were 439 reported deaths, including 126 critical cases and 6,507 recoveries. The fatality rate was 1.8%, while the recovery rate was 27%. The incidence of community transmission was reported to be as high as 91% [17]. The elevated rates of prevalence and fatalities in Punjab may be associated with asymptomatic transmission and with the initial untraceable spread of the virus across various districts. The phenomenon was observed globally, where overall asymptomatic transmission accounted for an overall 20% of infection. Epidemiological estimates and mathematical modles demonstrated a 15% transmission in family clusters and 20.5% transmission among adults in general from asymptomatic contact [18]. Further contributing to the infection rate was the rate of mobility. Lahore remains the largest municipal locality in Punjab, followed by Faisalabad, Sialkot and Sargodha. The city is also equipped with state-of-the-art diagnostic facilities. Therefore, a significant number of patients were brought into Lahore from the periphery, thus adding to the number of positive cases.

Increasing age increases the likelihood of hospitalization and death. High-quality evidence shows an age-related risk increase of 5.7% for in-hospital mortality, 7.4% for case mortality and 3.4% for hospitalization [19]. No discernible elevated risk was associated with age for admission to the intensive care unit or intubation. Additionally, a specific age group was not associated with disease severity and mortality [20].

It has been reported that males were at a higher risk of infection, hospitalization, disease severity, and mortality [21]. Several hypotheses, including the possibility of androgen-driven pathogenesis, the potential effect of estrogen in females, testosterone deficiency leading to an inflammatory response, and the notion of an inborn error in cytokine immunity, have been proposed to explain this difference between the two genders [22]. However, additional research is needed to explore these possibilities. The cause is likely multifactorial, with these different hypotheses potentially sharing some common features [23]. Males and people 70 years of age have been reported to be more susceptible to infection and severe disease [24]. Adolescents are believed to share a comparable susceptibility to infection with adults, while children exhibit a lower susceptibility. Nevertheless, the data for this study presents conflicting findings, and a more comprehensive understanding of the relationship between age and vulnerability to infection requires additional research [25, 26]. However, children are not at a higher risk for developing severe disease [27]. Compared to wild-type viruses, variants have the potential to spread more efficiently and quickly among young children, although there has been a reduction in hospitalization rates [28, 29].

Global COVID-19 data analysis indicates a higher incidence of COVID-19 infection in men than as compared to women [30]. Additionally, a compromised immune system significantly heightens the susceptibility to COVID-19, particularly among the elderly, increasing the likelihood of hospitalization due to virus-related complications. Nevertheless, several studies conducted in Pakistan have presented a paradoxical trend, where the highest number of COVID-19 cases are found in the age groups of 2029 years and 3039 years, while the elderly, who are generally more susceptible due to weakened immunity and health issues, have lower infection rates [7, 17, 31]. This apparent discrepancy can be better understood by examining Pakistan's social and demographic structure. According to data from the United Nations, only 4% of Pakistan's population is above 65 years old, with an average population of 22 years. This contrasts sharply with countries heavily impacted by the virus, where older and less healthy individuals are more likely to experience severe consequences due to their weakened immune systems [32].

The epidemiology and trends in spread of infection in Pakistani community can be further explained by the fact that during COVID-19 pandemic, Pakistan, like many other countries, implemented various public health measures. Partial and full lockdowns were imposed in various regions to limit mobility and reduce the spread of the virus. Social distancing measures were put in place together with international and domestic travel restrictions. s. Wearing masks in public places and on public transport was encouraged and, in some cases, made mandatory. In the 2nd wave, in addition to previous restrictions, the government and health authorities launched public awareness campaigns to promote wearing masks, hand hygiene, and social distancing. Increased testing and contact tracing efforts were undertaken to identify and isolate cases promptly. Vaccination efforts began in early 2021 during the 3rd wave, initially targeting healthcare workers and elderly populations. In the 4th wave, concerns about the Delta variant led to increased monitoring of international travellers. Efforts were made to accelerate vaccination campaigns to target a broader population. In response to the emergence of the Omicron variant in the 5th wave, stricter international travel restrictions and monitoring of travellers from affected areas were enforced. Practices including increased testing and timely isolation of cases were emphasized. The government considered administering booster doses to enhance immunity, particularly for those who had received their primary vaccination.

Furthermore, we analyzed the Ct values of COVID-19 cases in particular in the 5th wave were predominantly by the Omicron variant, which was associated with an increased transmission rates. The Ct data indicated that younger individuals, irrespective of gender, had lower Ct values, indicative of severity of infection. The significance of low Ct values lies in their correlation with increased transmission rates. A lower Ct value signifies a higher concentration of the virus in the patient's sample, suggesting a more robust and infectious viral presence. Individuals with lower Ct values may experience more severe symptoms, potentially leading to increased respiratory activities that release a greater number of viral particles into the surrounding environment. Consequently, these factors contribute to the efficiency and persistence of virus transmission.

In conclusion, our observations revealed a higher prevalence of COVID-19 among males, primarily because male family members often work outside the home and have more community interactions than females. Additionally, we noted that individuals between 19 and 39 years were more susceptible to infection. Previous reports have shown that a significant proportion of young adults were affected in most districts of Punjab [33].

Limitations of our study are as follows: First, there is the unavailability of data on clinical symptoms and outcomes of the tested cases. The Ct values were only available for the 5th wave, which made comparing each variant's severity and transmission dynamics across all the waves difficult.Second, due to the unavailability of mobility data, we can only hypothesize that the increased positivity rates were because of paties arriving in Lahore from different parts of Punjab. However, for final analysis, the availability of mobility data is critical. Third, longitudinal data on viral laod was not avialbale due to which the exact rate of viral replication, the duration of shedding, and the potential for transmission could not be accurately determined. Finally, the data used in this study was only taken from one laboratory.

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Evolution of COVID-19 infection in Punjab; trends during five waves of infection in the province of Punjab - BMC ... - BMC Infectious Diseases