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Background Healthcare workers (HCWs) fighting against the COVID-19 pandemic are under incredible pressure, which puts them at risk of developing mental health problems. This study aimed to determine the prevalence of depression, anxiety, and stress among HCWs responding to COVID-19 and its associated factors. Methods A multi-country cross-sectional study was conducted during July–August 2020 among HCWs responding to COVID-19 in nine Eastern Mediterranean Region (EMR) countries. Data were collected using an online questionnaire administered using KoBo Toolbox. Mental problems were assessed using the Depression, Anxiety, and Stress Scale (DASS-21). Results A total of 1448 HCWs from nine EMR countries participated in this study. About 51.2% were male and 52.7% aged ≤ 30 years. Of all HCWs, 57.5% had depression, 42.0% had stress, and 59.1% had anxiety. Considering the severity, 19.2%, 16.1%, 26.6% of patients had severe to extremely severe depression, stress, and anxiety, respectively. Depression, stress, anxiety, and distress scores were significantly associated with participants’ residency, having children, preexisting psychiatric illness, and being isolated for COVID-19. Furthermore, females, those working in a teaching hospital, and specialists had significantly higher depression and stress scores. Married status, current smoking, diabetes mellitus, having a friend who died with COVID-19, and high COVID-19 worry scores were significantly associated with higher distress scores. Conclusions Mental problems were prevalent among HCWs responding to COVID-19 in EMR. Therefore, special interventions to promote mental well-being among HCWs responding to COVID-19 need to be immediately implemented.

Background This study aimed to compare knowledge, attitude and practice (KAP) regarding COVID-19 between public health workers (PHWs) attended field epidemiology training program (FETP-trained) and those who did not attend FETP (non-FETP trained). Methods Multi-country cross-sectional survey was conducted among PHWs who participated in COVID-19 pandemic in 10 countries at EMR. Online questionnaire that included demographic information, KAP regarding COVID-19 pandemic was distributed among HCWs. Scoring system was used to quantify the answers, bivariate and Multivariate analysis performed to compare FETP-trained with non-FETP trained PHWs. Results Overall, 1337 PHWs participated, with 835 (62.4%) Conclusions FETP-trained are having better KAP than non-FETP PHWs. Expanding the intermediate level, maintain the Rapid Response training and introduce the laboratory component are recommended to maximize the benefit from FETP. Infection control, antimicrobial resistance and coordination are areas where training should include.

Objective To molecularly characterise the relationship between Epstein-Barr virus (EBV) genotypes and Pashtun ethnicity. Methods The cross-sectional study was conducted from November 2018 to December 2019 after approval from the Gomal University, Dera Ismail Khan, Pakistan, and comprised blood samples from transgender sex workers who were seropositive for human immunodeficiency virus-1 and seronegative for human immunodeficiency virus residing in two cities of Khyber Pakhtunkhwa province and Islamabad, the federal capital. Formalin-fixed paraffin-embedded (FFPE). Samples were collected from the partner institute along with the patients data, but without any follow-up from the study subjects which was purely on the basis of physical availability. β-globin gene and EBER-1(EBV encoded small RNA-1) were amplified for qualitative assessment and existence of Epstein-Barr virus. Characterisation of EBNA-2 (EBV Nuclear Antigen-2 was done through nested polymerase chain reaction. Results Of the 80 subjects, 40(50%) each were seropositive and seronegative individuals. The overall mean age was 28±6.917 years. Among the seropositive group, 38(95%) were homosexual and 2(5%) were heterosexual. Among the seropositive group, 16(40%) had Epstein-Barr virus genotype 1 and 6(15%) had genotype 2, while co-infections were found in 2(5%) subjects. In the seronegative group, 36(90%) subjects had Epstein-Barr virus genotype 1, while there was no case of genotype 2 or co-infection. EBV-2 genotypes with HIV seropositivity showed strong association (p=0.005). Amplification for the EBER-1 gene was done in all the 80(100%) samples. Conclusions Epstein-Barr virus EBV genotype 1 was found to be the most frequent type, while genotype 2 and co-infections were detected in only seropositive samples.

BACKGROUND Globally, there is a growing need for public health professionals skilled in preventing and responding to the surge of emerging and re-emerging infectious diseases. This is particularly important to the Eastern Mediterranean countries that are facing emergencies in addition to the increased public health risks of unprecedented scale during the COVID-19 pandemic. Public health professionals are instrumental in responding to the COVID-19 pandemic in terms of detecting and monitoring new cases, conducting investigations, tracing contacts, ensuring patients are being tested, applying isolation and quarantine protocols, providing up-to-date information, educating the community, and producing statistics and models to track disease progression. OBJECTIVE This study aims to compare knowledge, attitude, and practice (KAP) regarding COVID-19 between public health workers (PHWs) that attended the Field Epidemiology Training Program (FETP trained) and those who did not attend FETP (non-FETP trained). METHODS A multicountry cross-sectional survey was conducted among PHWs who participated in the COVID-19 pandemic in 10 countries in the Eastern Mediterranean Region. An online questionnaire that included demographic information and KAP regarding the COVID-19 pandemic was distributed among PHWs. The scoring system was used to quantify the answers; bivariate and multivariate analyses were performed to compare FETP-trained with non-FETP–trained PHWs. RESULTS Overall, 1337 PHWs participated, with 835 (62.4%) CONCLUSIONS FETP-trained participants had better KAP than non-FETP–trained PHWs. Expanding the intermediate level, maintaining the rapid response training, and introducing the laboratory component are recommended to maximize the benefit from the FETP. Infection control, antimicrobial resistance, and coordination are areas where training should be included.

BACKGROUND The establishment of empirical evidence in the Eastern Mediterranean Region necessitates the implementation of wide-scale studies to describe the demographic, clinical features, and severity profile of patients with COVID-19. OBJECTIVE This study aims to assess the patterns of COVID-19 severity and mortality in seven countries, and to determine the risk factors of COVID-19 severity and mortality. METHODS This multicountry study was based on a retrospective review of medical records of hospitalized patients confirmed to have COVID-19. This study includes data from Iraq, Pakistan, Sudan, Somalia, Morocco, Egypt, and Yemen. All demographic and clinical data were extracted from hospital records (paper files) by trained data collectors. RESULTS A total of 4141 patients were included in this study from seven countries. Comorbidities were reported by nearly half of the patients, with hypertension (n=1021, 24.7%) and diabetes (n=939, 22.7%) being the most common. Older age, diabetes mellitus, hypertension, and heart diseases were significantly associated with COVID-19 severity and mortality. Ever smoking and renal diseases were significantly associated with severity but not mortality, while male gender, respiratory diseases, and malignancy were significantly associated with mortality but not severity. CONCLUSIONS The study confirms the role of comorbidities and demographic features on the severity and mortality of COVID-19. Understanding the contributing factors ensures attentive care and informs clinical management of patients with poorer prognoses in the early stages of diseases.

BACKGROUND COVID-19 became a pandemic rapidly after its emergence in December 2019. It belongs to the coronavirus family of viruses, which have struck a few times before in history. Data based on previous research regarding etiology and epidemiology of other viruses from this family helped played a vital role in formulating prevention and precaution strategies during the initial stages of this pandemic. Data related to COVID-19 in Pakistan were not initially documented on a large scale. In addition, due to a weak health care system and low economic conditions, Pakistan’s population, in general, already suffers from many comorbidities, which can severely affect the outcome of patients infected with COVID-19. OBJECTIVE COVID-19 infections are coupled with a manifestation of various notable outcomes that can be documented and characterized clinically. The aim of this study was to examine these clinical manifestations, which can serve as indicators for early detection as well as severity prognosis for COVID-19 infections, especially in high-risk groups. METHODS A retrospective observational study involving abstraction of demographic features, presenting symptoms, and adverse clinical outcomes for 1812 patients with COVID-19 was conducted. Patients were admitted to the four major hospitals in the Rawalpindi-Islamabad region of Pakistan, and the study was conducted from February to August 2020. Multivariate regression analysis was carried out to identify significant indicators of COVID-19 severity, intensive care unit (ICU) admission, ventilator aid, and mortality. The study not only relates COVID-19 infection with comorbidities, but also examines other related factors, such as age and gender. RESULTS This study identified fever (1592/1812, 87.9%), cough (1433/1812, 79.1%), and shortness of breath (998/1812, 55.1%) at the time of hospital admission as the most prevalent symptoms for patients with COVID-19. These symptoms were common but not conclusive of the outcome of infection. Out of 1812 patients, 24.4% (n=443) required ICU admission and 21.5% (n=390) required ventilator aid at some point of disease progression during their stay at the hospital; 25.9% (n=469) of the patients died. Further analysis revealed the relationship of the presented symptoms and comorbidities with the progression of disease severity in these patients. Older adult patients with comorbidities, such as hypertension, diabetes, chronic kidney disease, and asthma, were significantly affected in higher proportions, resulting in requirement of ICU admission and ventilator aid in some cases and, in many cases, even mortality. CONCLUSIONS Older adult patients with comorbidities, such as hypertension, diabetes, asthma, chronic obstructive pulmonary disorder, and chronic kidney disease, are at increased risk of developing severe COVID-19 infections, with an increased likelihood of adverse clinical outcomes.

Background Inadvertent delays in access to appropriate therapeutic interventions in high-risk group coronavirus disease 2019 (COVID-19) patients contribute to mortality in patients with severe/critical disease presentation. Objectives The aim of this study was to determine the effect of timely admission to the hospital on mortality of patients with severe/critical COVID-19. Another secondary aspect of this study was to observe the efficacy of time-dependent use of corticosteroids on mortality of critical/severe COVID-19 patients. Methods Clinical data of 659 patients with severe/critical COVID-19, admitted to four major tertiary care hospitals from the Islamabad-Rawalpindi region of Pakistan was retrospectively collected from a period February–August 2020. Multivariate logistic regression analysis was carried out to determine the predictors of mortality in severe/critical COVID-19 patients. Results Out of a total of 659 patients, 469 (71.2%) patients died. Age > 60 years, presence of hypertension, heart disease and kidney disease along with late admission (>5 days) were significant predictors of mortality in patients with severe/critical COVID-19. Conclusions The study highlights the importance of well-timed provision of appropriate medical interventions control COVID-19-associated mortality.

SARS-CoV-2 is known to cause severe bilateral pneumonia and acute respiratory distress syndrome or COVID-19 in patients, which can be debilitating and even fatal. With no drugs or vaccines available yet, a wide range of treatment regimens used are being repurposed. The need of the hour is to analyze various currently available regimens and devise a treatment plan that is most effective for COVID-19. Here we describe the case of a 68-year-old man with hypertension and diabetes, exhibiting symptoms of cough and shortness of breath, who presented at the emergency department of our hospital. Chest computed tomography revealed bilateral ground glass opacities that were indicative of COVID-19, and a computed tomography score of 24 was indicative of severe pulmonary pneumonia. He tested positive for COVID-19. His treatment regimen included the use of convalescent plasma, oxygen therapy, steroids, high-dose antibiotics, broad-spectrum antiviral remdesivir, and anti–interleukin-6 monoclonal antibody (Tocilizumab) at various stages of the disease. Oxygen supplementation was required at the time of admission. The patient initially developed a cytokine release storm, and oxygen supplementation was initiated to manage his condition. Supportive care and multiple treatment regimens were used to successfully recover the patient’s health. With a rapid increase in number of confirmed cases worldwide, COVID-19 has become a major challenge to our health care system. With no available vaccines currently, the establishment of a combination of therapeutic drugs that effectively reduce disease progression is of utmost importance.

BACKGROUND Since the first reports of COVID-19 infection, the foremost requirement has been to identify a treatment regimen that not only fights the causative agent but also controls the associated complications of the infection. Due to the time-consuming process of drug discovery, physicians have used readily available drugs and therapies for treatment of infections to minimize the death toll. OBJECTIVE The aim of this study is to provide a snapshot analysis of the major drugs used in a cohort of 1562 Pakistani patients during the period from May to July 2020, when the first wave of COVID-19 peaked in Pakistan. METHODS A retrospective observational study was performed to provide an overview of the major drugs used in a cohort of 1562 patients with COVID-19 admitted to the four major tertiary-care hospitals in the Rawalpindi-Islamabad region of Pakistan during the peak of the first wave of COVID-19 in the country (May-July 2020). RESULTS Antibiotics were the most common choice out of all the therapies employed, and they were used as first line of treatment for COVID-19. Azithromycin was the most prescribed drug for treatment. No monthly trend was observed in the choice of antibiotics, and these drugs appeared to be a random but favored choice throughout the months of the study. It was also noted that even antibiotics used for multidrug resistant infections were prescribed irrespective of the severity or progression of the infection. The results of the analysis are alarming, as this approach may lead to antibiotic resistance and complications in immunocompromised patients with COVID-19. A total of 1562 patients (1064 male, 68.1%, and 498 female, 31.9%) with a mean age of 47.35 years (SD 17.03) were included in the study. The highest frequency of patient hospitalizations occurred in June (846/1562, 54.2%). CONCLUSIONS Guidelines for a targeted treatment regime are needed to control related complications and to limit the misuse of antibiotics in the management of COVID-19.

The COVID-19 outbreak started as pneumonia in December 2019 in Wuhan, China. The subsequent pandemic was declared as the sixth public health emergency of international concern on January 30, 2020, by the World Health Organization. Pakistan could be a potential hotspot for COVID-19 owing to its high population of 204.65 million and its struggling health care and economic systems. Pakistan was able to tackle the challenge with relatively mild repercussions. The present analysis has been conducted to highlight the situation of the disease in Pakistan in 2020 and the measures taken by various stakeholders coupled with support from the community to abate the risk of catastrophic spread of the virus.

BACKGROUND The coronavirus outbreak initiated as pneumonia caused by a novel virus in the city of Wuhan, China in late December 2019. The outbreak was declared as the sixth public health emergency of international concern (PHEIC) on January 30, 2020 by the WHO and later termed as a pandemic. OBJECTIVE Pakistan was thought to be one of the hotspots for coronavirus spread due to it sharing borders with China, having a populace of 204.65 million, its broken healthcare infrastructure, and weak economy. we here intend to overview the measures taken by Pakistani authoraties. METHODS Online research methods (ORMs) were used to collect information/instructions generated date-wise by Pakistani authorities and were compared to the outcomes. RESULTS Even in the presence of all these problems the Pakistani government was able to tackle the problem with relatively mild repercussions CONCLUSIONS This short communication aims to aid in emphasizing the current situation in a nutshell and the measures taken by the Government of Pakistan along with support from general population to abate the risk of catastrophic spread of the virus.

UNSTRUCTURED SARS-CoV-2 is known to cause severe bilateral pneumonia and acute respiratory distress syndrome or COVID-19 in patients, which can be debilitating and even fatal. With no drugs or vaccines available yet, a wide range of treatment regimens used are being repurposed. The need of the hour is to analyze various currently available regimens and devise a treatment plan that is most effective for COVID-19. Here we describe the case of a 68-year-old man with hypertension and diabetes, exhibiting symptoms of cough and shortness of breath, who presented at the emergency department of our hospital. Chest computed tomography revealed bilateral ground glass opacities that were indicative of COVID-19, and a computed tomography score of 24 was indicative of severe pulmonary pneumonia. He tested positive for COVID-19. His treatment regimen included the use of convalescent plasma, oxygen therapy, steroids, high-dose antibiotics, broad-spectrum antiviral remdesivir, and anti–interleukin-6 monoclonal antibody (Tocilizumab) at various stages of the disease. Oxygen supplementation was required at the time of admission. The patient initially developed a cytokine release storm, and oxygen supplementation was initiated to manage his condition. Supportive care and multiple treatment regimens were used to successfully recover the patient’s health. With a rapid increase in number of confirmed cases worldwide, COVID-19 has become a major challenge to our health care system. With no available vaccines currently, the establishment of a combination of therapeutic drugs that effectively reduce disease progression is of utmost importance.

Background Globally, there is a growing need for public health professionals skilled in preventing and responding to the surge of emerging and re-emerging infectious diseases. This is particularly important to the Eastern Mediterranean countries that are facing emergencies in addition to the increased public health risks of unprecedented scale during the COVID-19 pandemic. Public health professionals are instrumental in responding to the COVID-19 pandemic in terms of detecting and monitoring new cases, conducting investigations, tracing contacts, ensuring patients are being tested, applying isolation and quarantine protocols, providing up-to-date information, educating the community, and producing statistics and models to track disease progression. Objective This study aims to compare knowledge, attitude, and practice (KAP) regarding COVID-19 between public health workers (PHWs) that attended the Field Epidemiology Training Program (FETP trained) and those who did not attend FETP (non-FETP trained). Methods A multicountry cross-sectional survey was conducted among PHWs who participated in the COVID-19 pandemic in 10 countries in the Eastern Mediterranean Region. An online questionnaire that included demographic information and KAP regarding the COVID-19 pandemic was distributed among PHWs. The scoring system was used to quantify the answers; bivariate and multivariate analyses were performed to compare FETP-trained with non-FETP–trained PHWs. Results Overall, 1337 PHWs participated, with 835 (62.4%) Conclusions FETP-trained participants had better KAP than non-FETP–trained PHWs. Expanding the intermediate level, maintaining the rapid response training, and introducing the laboratory component are recommended to maximize the benefit from the FETP. Infection control, antimicrobial resistance, and coordination are areas where training should be included.

The IFNL4 gene is negatively associated with spontaneous and treatment-induced clearance of hepatitis C virus infection. The activity of IFNλ4 has an important causal role in the pathogenesis, but the molecular details are not fully understood. One possible reason for the detrimental effect of IFNλ4 could be a tissue-specific regulation of an unknown subset of genes. To address both tissue and subtype specificity in the interferon response, we treated primary human hepatocytes and airway epithelial cells with IFNα, IFNλ3 or IFNλ4 and assessed interferon mediated gene regulation using transcriptome sequencing. Our data show a surprisingly similar response to all three subtypes of interferon. We also addressed the tissue specificity of the response, and identified a subset of tissue-specific genes. However, the interferon response is robust in both tissues with the majority of the identified genes being regulated in hepatocytes as well as airway epithelial cells. Thus we provide an in-depth analysis of the liver interferon response seen over an array of interferon subtypes and compare it to the response in the lung epithelium. Supplementary information The online version of this article (doi:10.1038/gene.2015.23) contains supplementary material, which is available to authorized users.

Background: The strong association of transgender community with sex work has put them at a higher risk of contracting sexually transmitted infections. We, for the first time, attempted to investigate the prevalence of Epstein- Barr virus genotypes in transgender sex workers of Pakistan. Methods: Blood samples of 40 HIV-1 seropositive transgender sex workers were screened out for Epstein-Barr virus detection and genotyping by extracting genomic DNA from all whole blood samples. Blood samples of 46 HIV seronegative transgender sex workers were also characterized for comparison. Information regarding, age, number of sex partners, sexual habits, etc. were collected on study-designed pro forma. Β-globin and EBER-1 were amplified to assess the quality and presence of EBV DNA. Analysis of EBNA-2 genotyping was done by nested PCR. Results: Among HIV-seropositive TSW's, EBV genotype determination was found in 60% of cases, of which, 62.5% and 29.16% were EBV-1 and EBV-2 respectively, while a coinfection of 8% was also observed. Among HIV-negative individuals, 78% were EBV-1, whereas EBV-2 genotype and co-infections were absent. All non-typable samples were amplified for the EBER-1 gene in both populations, confirming EBV genome in the samples. Conclusion: EBV-1 was the most common genotype of EBV in both HIV seropositive and seronegative samples, while EBV-2 and co-infection were observed only in HIV seropositive individuals.

The functional receptor for type III interferons (IFNs) is a heterodimer of IFNLR1 and IL10R2. IFNLR1 is expressed in a highly tissue specific manner, with epithelial and liver tissue as the prime expressing tissues in humans. However, knowledge about the molecular pathways responsible for regulating the expression of IFNLR1 is yet unknown. In this study, various bioinformatics tools were used to predict the scores of signal peptides of IFNλR1 and IFNαR1, which was considered as an important difference in the expression of both receptors or participation in regulating the IFNLR1 gene. In silico study revealed that the signal peptide of IFNαR1 had more potential than the signal peptide of IFNλR1 but changing the signal peptide of wild type IFNλR1 with the signal peptide of IFNαR1 in wet lab had barely shown any differences. Selective expression of IFNλR1 was considered to be a plus point towards the targeted anti-viral activity of IFNλs but artificial control on its expression will surely make IFNλs a better drug with enhanced activity. The results of this study may help us in contributing some understanding towards the mechanisms involved in the selective expression of IFNLR1 and exceptionalities involved.

The IFNL4 gene is a recently discovered type III interferon, which in a significant fraction of the human population harbours a frameshift mutation abolishing the IFNk4 ORF. The expression of IFNk4 is correlated with both poor spontaneous clearance of hepatitis C virus (HCV) and poor response to treatment with type I interferon. Here, we show that the IFNL4 gene encodes an active type III interferon, named IFNk4, which signals through the IFNkR1 and IL-10R2 receptor chains. Recombinant IFNk4 is antiviral against both HCV and coronaviruses at levels comparable to IFNk3. However, the secretion of IFNk4 is impaired compared to that of IFNk3, and this impairment is not due to a weak signal peptide, which was previously believed. We found that IFNk4 gets N-linked glycosylated and that this glycosylation is required for secretion. Nevertheless, this glycosylation is not required for activity. Together, these findings result in the paradox that IFNk4 is strongly antiviral but a disadvantage during HCV infection. The IFNL4 gene is a recently discovered type III interferon, which in a significant fraction of the human population harbours a frameshift mutation abolishing the IFNλ4 ORF. The expression of IFNλ4 is correlated with both poor spontaneous clearance of hepatitis C virus (HCV) and poor response to treatment with type I interferon. Here, we show that the IFNL4 gene encodes an active type III interferon, named IFNλ4, which signals through the IFNλR1 and IL-10R2 receptor chains. Recombinant IFNλ4 is antiviral against both HCV and coronaviruses at levels comparable to IFNλ3. However, the secretion of IFNλ4 is impaired compared to that of IFNλ3, and this impairment is not due to a weak signal peptide, which was previously believed. We found that IFNλ4 gets N-linked glycosylated and that this glycosylation is required for secretion. Nevertheless, this glycosylation is not required for activity. Together, these findings result in the paradox that IFNλ4 is strongly antiviral but a disadvantage during HCV infection

Interferons (IFNs) are an integral part of the immune system, which upon stimulation results in recruitment of cytokines for viral clearance. IFNs have been characterized as potent antiviral agents that which can reduce viral titer and have been found to act as critical mediators for tumor regression in few cases. During the course of time Hepatitis C virus (HCV) has evolved and influence IFN efficiency through various pathways. Rapidly occurring amino acid substitutions in HCV’s core protein, sequence homology with protein kinase (PKR), increased numbers of quasi-species and wild-type Interferon sensitivity determining region (ISDR) strains are linked with an inefficient response to IFN therapy. This article describes the pharmacodynamics of IFNs with an aim to decipher the possible involvement of HCV proteins in subverting these responses. We hereby discuss IFN-based therapies targeting the host and viral genetic factors, since they have a strong impact in determining the efficacy of an IFN in HCV infected host.

Background Transgender males are at high risk for sexually transmitted diseases including AIDS caused by the notorious Human Immunodeficiency Virus (HIV), yet little consideration is given by the policy makers, researchers and non-governmental organizations (NGOs) towards this sensitive issue in Pakistan. Methods In this study, we have investigated the prevalence of HIV infection among 306 transgender males with a median age of 29 years (range 15–64 years) residing in Rawalpindi, Pakistan. Rapid HIV antibody-screening methods including the strip test and Enzyme Linked Immuno-absorbent tests were employed to detect HIV antibodies among the subjects. For further confirmation, Polymerase Chain Reaction (PCR) was carried out. Statistical analytical techniques utilized included logistic regression and chi-square. Results HIV-1 was found to be the predominant viral subtype. PCR confirmed 21.6% (Confidence Interval 0.17-0.26) of the respondents were reported being HIV positive. 15.7% of the transgender men who shave at home and 13.7% of the transgender men who were educated below 5th grade were found to have HIV. Conclusion This study shows a very high prevalence of HIV among transgender males. Unawareness among these individuals about the ramifications of this infection owes largely to lack of education. The spread rate is alarming and HIV epidemic is imminent if awareness is not widespread.