Pakistan’s battle against adenoviral conjunctivitis and its economic implications

Apart from devastating systemic attacks on humans by adenovirus, it has gained great attention from ophthalmologists as a potential cause of an epidemic of conjunctivitis globally. Being more prevalent among all conjunctivitis, a significant rise in viral conjunctivitis had been observed, particularly in summers from July to August, while bacterial incidence was high in winter from December to April1. Matted eyelids due to purulent discharge and lack of itching in bacterial conjunctivitis are labeled as differentiating symptoms from viral conjunctivitis2. Manifestations of viral conjunctivitis include red or pink eye, watery discharge, irritation, lid swelling, and punctate keratopathy, progressing to corneal scarring and visual loss3. Usually, supportive care with artificial lubricants, topical steroids, and repeated cold washings are advised by clinicians for symptomatic relief, but oral or topical antiviral drugs (i.e. acyclovir and ganciclovir) could be used to limit the duration of active infection2. The ubiquitous adenovirus exists in different types (i.e. 4, 7, 8, 9, and 37) and species (B, D, and E), of which type 8 and species D are familiar with outbreaks. A high transmission rate of up to 50% has been reported not only by human-to-human but also from infected medical equipment such as slit lamps, tonometers, and eye drops. 65.22% of adenovirus infections are usually contracted from ophthalmology clinics4. Annually, 20 million people in the United States of America (USA) suffer from adenovirus attributed to its highly contagious nature3. Significant statistics from countries like China (39.8%), Turkey (44%), and Pakistan (75%) are also supportive of its high prevalence rate5–7. Currently, Pakistan, especially the province of Punjab, had an outbreak of adenoviral conjunctivitis affecting 86 133 people by 28 September 2023 with an average of 13 000 incidence rate per day8. Adenoviral epidemics had been reported in Germany, Russia, and Spain, while Canada and Michigan had the first epidemic of adenovirus in human history in 1934. These epidemics were evident in crowded places, that is, schools, hospitals, army camps, and among medical students4. Epidemics significantly burden the economy and increase the costs of its control and management. Economics-related issues arise either directly or indirectly. Direct economic crisis results from delay in diagnosis, increasing the risk of vector transmission and wide spread of disease. Various management strategies and high-cost diagnostic tools such as polymerase chain reaction (PCR) and nucleic acid amplification test (NAAT) burden the economy. A US-based statistical evaluation has a direct cost of $396.04 per person per month (PPPM) among patients with infectious conjunctivitis compared to $289.63 PPPM in non-conjunctivitis controls. Indirect factors affecting the economy include job furlough, effective time wastage, productivity loss, and suspended routine activities of family members. The estimated loss of the amount of $105.42 PPPM was determined only for the job loss due to infectious conjunctivitis9. An adenoviral outbreak in the neonatology department of a tertiary care hospital in Argentina had a significant impact on the economy. The hospital paid a cost of $205 000 for the isolation of the neonatal ICU (NICU), the building of new wards, extra incentives for healthcare workers (HCWs), and referrals of high-risk pregnant women to other hospitals10. The COVID-19 pandemic has imposed detrimental effects on Pakistan’s economy by raising unemployment and affecting transportation, tourism, business, and education. A serious economic shock of decline in remittances from $22.9 billion (2019) to $17 billion (2020) was observed during the COVID-19 pandemic11. By the end of 2021, remittances were increased to $ 31 billion, a 40% improvement over 201912. The cost of $5200 used for the prevention of the malaria outbreak in Pakistan prevented only 588 malaria cases13. Similarly, the HIV and dengue epidemics had a great impact on the economy of Pakistan14. WHO had recommended a health fund of $34 per capita; however, the government of Pakistan assigns only $4.2 per person health expenditure, resulting in multiple challenges for the population of Pakistan, especially in dire health situations especially during an epidemic of adenoviral conjunctivitis15. Controlling vector transmission, cost-effective management of active infection, health education, and raising the health budget could be the fundamental ways to combat adenoviral conjunctivitis in critical economies. Preventive strategies such as hand washing, avoidance from touching infected eyes, inanimate subjects like towels, doors, books, clothing, etc., and self-isolation during the active phase of infection could help in reducing vector transmission and further contraction of outbreaks. Medical instruments used by ophthalmologists must be disinfected periodically with a povidone-iodine solution. Implementation of preventive measures could help in dealing with economic crises at societal and national levels3. Ongoing outbreaks could be efficiently handled with minimal economic implications by educating the general population via various social and print media platforms. Cost-effective diagnosis and treatment should be devised at the government level and followed by clinicians. More than $ 3 million was saved by Johns Hopkins Medicine through the cost-effective use of PCR in adenoviral conjunctivitis. Effective treatment might be useful in reducing the escalation of economic stress. Hence, only cost-effective investigations and treatment options should be promoted to support the economies16. Vaccines were formulated against adenovirus types 4 and 7; however, adenovirus type 8 is the most common cause of conjunctivitis. Now, the government must collaborate with international organizations to develop a vaccine, thus reducing its chain of transmission and preventing it from becoming a pandemic. Vaccines against this ocular virus will help prevent blindness3. As per WHO recommendation, the government must strengthen the health sector economically to overcome any epidemics or pandemics such as COVID-19 in the future. Anti-inflammatory and immunoglobulin-based advanced therapies must be cost-effective for the general population of Pakistan. The government should play a key role in legislation and its executions to prevent this outbreak beyond the borders. Ethical approval Ethics approval was not required for this editorial. Consent Informed consent was not required for this editorial. Sources of funding No financial support was acquired for this article. Author contribution M.I., H.J., and M.J.T.: conceived the idea; M.I., W.T., H.J., and A.Y.: retrieved the data, wrote up the letter; A.A., W.T., M.M.F., and M.J.T.: reviewed and provided inputs. All authors approved the final version of the manuscript. Conflicts of interest disclosure The authors declare no conflicts of interest. Research registration unique identifying number (UIN) 1. Name of the registry: not applicable. 2. Unique identifying number or registration ID: not applicable. 3. Hyperlink to your specific registration (must be publicly accessible and will be checked): not applicable. Guarantor Mohammed Mahmmoud Fadelallah Eljack; Teaching Assistant, Community Department, University of Bakht Alruda, Ad Duwaym, Sudan; MBBS, University of Bakht Alruda, Ad Duwaym, Sudan; P. O. Box 1311, Ad Duwaym 12556; https://orcid.org/0000-0002-2370-9368; E-mail: [email protected]; Mobile number: +249964656914. Provenance and peer review Not commissioned, externally peer-reviewed. Data availability statement The material datasets used and/or analyzed during this study are available from the corresponding author upon reasonable request.

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