Associations of the COVID-19 pandemic with the reported incidence of important endemic infectious disease agents and syndromes in Pakistan

Abstract

Background: Persons in Pakistan have suffered from various infectious diseases over the years, each impacted by various factors including climate change, seasonality, geopolitics, and resource availability. The COVID-19 pandemic is another complicating factor, with changes in the reported incidence of endemic infectious diseases and related syndromes under surveillance.

Methods: We assessed the monthly incidence of eight important infectious diseases/syndromes: acute upper respiratory infection (AURI), viral hepatitis, malaria, pneumonia, diarrhea, typhoid fever, measles, and neonatal tetanus (NNT), before and after the onset of the COVID-19 pandemic. Administrative health data of monthly reported cases of these diseases/syndromes from all five provinces/regions of Pakistan for a 3-year interval (March 2018-February 2021) were analyzed using an interrupted time series approach. Reported monthly incidence for each infectious disease agent or syndrome and COVID-19 were subjected to time series visualization. Spearman's rank correlation coefficient between each infectious disease/syndrome and COVID-19 was calculated and median case numbers of each disease before and after the onset of the COVID-19 pandemic were compared using a Wilcoxon signed-rank test. Subsequently, a generalized linear negative binomial regression model was developed to determine the association between reported cases of each disease and COVID-19.

Results: In late February 2020, concurrent with the start of COVID-19, in all provinces, there were decreases in the reported incidence of the following diseases: AURI, pneumonia, hepatitis, diarrhea, typhoid, and measles. In contrast, the incidence of COVID was negatively associated with the reported incidence of NNT only in Punjab and Sindh, but not in Khyber Pakhtunkhwa (KPK), Balochistan, or Azad Jammu & Kashmir (AJK) & Gilgit Baltistan (GB). Similarly, COVID-19 was associated with a lowered incidence of malaria in Punjab, Sindh, and AJK & GB, but not in KPK and Balochistan.

Conclusions: COVID-19 was associated with a decreased reported incidence of most infectious diseases/syndromes studied in most provinces of Pakistan. However, exceptions included NNT in KPK, Balochistan and AJK & GB, and malaria in KPK and Balochistan. This general trend was attributed to a combination of resource diversion, misdiagnosis, misclassification, misinformation, and seasonal patterns of each disease.

Keywords: COVID-19; Incidence; Infectious disease outbreaks; SARS-CoV-2.

Fig. 1

Monthly number of reported cases of various infectious diseases or syndromes in Pakistan from March 2018 to February 2021 and cases of COVID-19 from March 2020 to February 2021

Fig. 2

Monthly number of reported cases of acute upper respiratory infection (AURI) and COVID-19 in five provinces/regions of Pakistan from March 2018 to February 2021

Fig. 3

Monthly reported cases of pneumonia and COVID-19 in five provinces/regions of Pakistan from March 2018 to February 2021

Fig. 4

Monthly reported cases of hepatitis and COVID-19 in five provinces/regions of Pakistan from March 2018 to February 2021

Fig. 5

Monthly reported cases of diarrhea and COVID-19 in five provinces/regions of Pakistan from March 2018 to February 2021

Fig. 6

Monthly reported cases of typhoid and COVID-19 in five provinces/regions of Pakistan from March 2018 to February 2021

Fig. 7

Monthly reported cases of measles and COVID-19 in five provinces/regions of Pakistan from March 2018 to February 2021

Fig. 8

Monthly reported cases of NNT and COVID-19 in five provinces/regions of Pakistan from March 2018 to February 2021

Fig. 9

Monthly reported cases of malaria and COVID-19 in five provinces/regions of Pakistan from March 2018 to February 2021