Pink eye is at it again in Pakistan; is it a condition to be worried about?

Introduction Pink eye, medically known as ʻconjunctivitisʼ, is one of the most common causes of eye redness1. Pink eye is the inflammation of the conjunctiva mainly caused by infectious microorganisms or noninfectious irritants. The irritation or infection leads to the dilation of the conjunctival vessels, presented as the classical edema and hyperemia of the conjunctiva1. Pink eye is often seen in emergency departments, primary healthcare facilities, and urgent care settings. Approximately 80% of cases of pink eye are diagnosed by healthcare professionals in medical fields other than ophthalmology, such as pediatricians and nurses2. The prevalence of pink eye varies across different populations, influenced by age, sex, and seasonal variations. The statistical analysis of the reported cases in the emergency department resulted in the bimodal distribution. The highest incidence of the disease was observed in children aged 0–4 years, while the second peak occurred among women at 22 years and men at 28. Moreover, the disease’s prevalence within the same age group fluctuated based on the time of year3. Between summer and spring, allergic conjunctivitis accounts for ~15–40% of pink eye cases. At the same time, the period from December to April sees most cases related to bacterial conjunctivitis4,5. Research conducted in Pakistan, involving 388 patients over 5 months, revealed that ~75% of pink eye cases were attributed to adenovirus infection, while around 18% were caused by bacterial infections6. Another research study involving schoolchildren in Karachi revealed that ~19% of cases were related to allergic conjunctivitis. Furthermore, the study found a clear association between advancing age and an increased likelihood of developing allergic conjunctivitis7. A new surge in pink eye cases has recently been reported in Pakistan in 2023, notably in the highly populated Punjab province. Health authorities in Pakistan have reported a substantial increase, with 394 795 individuals contracting the disease, including 10 269 cases recorded in the last 24 h alone8. The sudden rise of pink eye cases in Punjab, Pakistan, is worrisome and requires immediate attention. Identifying affected groups and healthcare providers is crucial for resource allocation and prevention. This article therefore aims to examine the pink eye outbreak in Pakistan thoroughly. It will investigate the outbreak’s causes, risk factors, and patterns. Additionally, the paper will provide suggestions on how to effectively control the outbreak and offer recommendations for future public health initiatives in Pakistan to reduce the impact of future attacks in the country. Reasons for the current surge of pink eye in Pakistan Pink eye is often referred to as a highly infectious condition. It can be spread through contact with the discharge from infected eyes or by touching surfaces contaminated with this discharge and then touching your own eyes. It can also be transmitted through direct contact, such as by shaking hands or sharing towels, and by being close to an infected patient who coughs or sneezes9. Approximately 35% of conjunctivitis cases are contracted from close friends10. In Pakistan, most outbreaks of this disease are caused by viruses where close-knit communities are common and the rapid transmission of the virus is a major concern. About 80% of the total viral pink eye cases are associated with the adenovirus and the most recent outbreak is also being attributed to this virus. The primary manifestations of ocular adenoviral infection are epidemic keratoconjunctivitis, followed by pharyngoconjunctival fever11. Adenovirus is highly contagious and is most frequently transmitted in classrooms or offices. There is a significant risk of an epidemic of adenoviral conjunctivitis occurring in ophthalmology wards because it often spreads through the use of contaminated ophthalmic instruments and eye solutions12. The transmission risk is further elevated because adenovirus can persist on environmental surfaces for an extended period, up to 4–5 weeks13. It remains viable even in the presence of various physical and chemical agents, as well as under unfavorable pH conditions. For instance, adenovirus is resistant to lipid solvents due to the absence of lipids in its structure. Its infectivity is at its peak within a pH range of 6.5 to 7.4; however, the virus can endure pH levels ranging from 5.0 to 9.014. Moreover, adenovirus may remain infectious even after being frozen. Efforts and challenges to control pink eye in Pakistan The Islamabad Healthcare Regulatory Authority (IHRA) has implemented precautionary measures to curb the rapid spread of the disease15, but these measures are often disregarded by schoolchildren. Consequently, the disease is frequently observed among students. Karachi, in particular, is at high risk for an outbreak of this highly contagious disease due to its humid climate, especially during the current monsoon season, which supports the survival of the infectious agents. According to an ophthalmologist at Karachi’s largest public-sector tertiary hospital, the deteriorating air quality (currently with an Air Quality Index (AQI) score of >100) due to limited rainfall in the city has also contributed to the spread of not only pollutants but infections as well16. Furthermore, a study has suggested that the proximity of a residence to both a river and a temporary garbage dump can impact the occurrence of this disease. Residences situated near rivers and temporary waste disposal sites tend to have inadequate sanitation practices. River water has the potential to contaminate well water, commonly used for daily purposes. Additionally, the presence of temporary garbage dumps near residential areas adds to the overall unclean environment10. When combined with poor hygiene and densely populated areas, these environmental factors make Karachi, a city near the sea, an ideal location for an outbreak. The outbreak of pink eye has posed a serious threat to public health and education in Pakistan. In response to the escalating situation, the health authorities in Pakistan took various measures to control and prevent the spread of the infection. The Primary and Secondary Healthcare Department in Punjab issued a public advisory that outlined safety protocols for the general public. The advisory urged people to use hand sanitizer, avoid touching their eyes without proper hand hygiene, and refrain from using items that had come into contact with infected individuals17. The health department also advised infected individuals to use recommended eye drops and clean their eyes with tissues. Applying cold water was also suggested to alleviate discomfort18. The health authorities also implemented school closures as a precautionary measure to curb the transmission of the virus among children. The interim Chief Minister of Punjab declared a 1-day holiday for all government schools in the province19. Later, the Punjab government extended this decision by directing both government and private schools to remain closed from Thursday through Sunday20. This was intended to reduce the exposure of students and teachers to the infection and allow them time to recover. The efforts to control pink eye in Pakistan were aimed at protecting public health and minimizing the impact of the outbreak on social and economic activities. However, challenges remained in ensuring compliance with the safety guidelines and providing adequate treatment for the affected population. Moreover, there was a need for more awareness and education on the causes, symptoms, and prevention of pink eye among the public. The outbreak also highlighted the importance of strengthening the health system and improving sanitation and hygiene standards in Pakistan. Implications of pink eye in Pakistan Generally, health conditions have implications for an individual, society, and the entire world. The pink eye could have a lot of implications for the Pakistani population. The pink eye could have physical, emotional, and economic implications for the Pakistani population. Pink eye can cause inflammation in the cornea that can affect the vision of the affected person1 and, as a result, could hinder the functionality, mobility, and daily activities of the affected person. Pink eye can cause both short-term and long-term psychological problems such as depression, insomnia, etc. due to unnecessary fears and isolation, and if care is not taken, the affected person can commit suicide. Pink eye can reduce the economic productivity of Pakistan. Individuals affected with pink eye tend to focus on getting well before resuming work. Prolonged hospital stays due to pink eye can also contribute to the economic burden in Pakistan. Money spent on the management of this disease is another contributing implicating factor. Recommendation From the findings so far on the pink eye in Pakistan, it is a condition to be worried about. To mitigate pink eye in Pakistan, all hands must be on deck. This implies that the Pakistani government and the citizens must work together to fight this infection. The current management of conjunctivitis is symptomatic and should be limited to general measures, such as cold compresses and artificial tears with antihistamines, mast cell stabilizers, etc21, which we urge the Pakistani government to provide in abundance and at cheaper prices for easy use and availability for everyone with the infection. The WHO recommended that antimicrobial agents should not be indicated for the treatment of pink eye unless there is an aggregated microbial infection and steroidal anti-inflammatory medications, for example, prednisolone, should not be used as they significantly increase viral replication as well as eye drops containing antibiotics should not be used21. For this reason, all healthcare providers in Pakistan especially those in the primary and secondary health facilities must take note of this strictly and also educate the general public about it. Again, we urge healthcare providers in Pakistan should only use isolation to limit contact with cases during the active period of the infection and take precautions regarding exudates and secretions. They should restrict contact with cases while the disease is active. Even though no vaccine prevents all types of conjunctivitis; however, there are vaccines to protect against some viral and bacterial diseases that are associated with conjunctivitis, such as; Rubella, Chickenpox, Measles, Shingles, Pneumococcal, and Haemophilus influenzae type b (Hib)22, which we urge the Pakistani government and health authorities to make available for the Pakistani population. To prevent future outbreaks of pink eye in Pakistan, we urge the Pakistani government to strengthen its collaborations with the international community including the WHO, the Food and Agriculture Organization of the United Nations (FAO) and the World Organization for Animal Health (OIE), in order word, Joint Tripartite23. Through collaborations, surveillance for the timely detection of outbreaks of pink eye in Pakistan would adequately guide control measures of the infection in the country. Public health surveillance has been shown to represent the first phase of the overall public health approach to various disease outbreaks24. Collaboration would also help the health authorities in Pakistan to investigate contacts and sources of pink eye and determine if there has been a common source of infection in any part of the country. Another advantage of collaboration is to strengthen laboratory capacity for confirmation of the diagnosis of pink eye in Pakistan especially through funding opportunities, novel medical diagnostic kits, research opportunities, vaccines, etc. especially for the ophthalmologists in Pakistan regarding eye diseases in general. For the masses in Pakistan, we advise them to comply with the general measures such as frequent hand washing with soaps and water, avoiding unnecessary touching of their eyes, avoiding sharing towels, etc. as well as reporting early to a nearby hospital for any suspected signs and symptoms of pink eye and related diseases. Moreso, we urge healthcare providers in Pakistan to always wear gloves and gowns for patient care and use personal protective measures. They should also wash their hands before and after providing care to an individual with probable or laboratory-confirmed conjunctivitis. In addition, they should always disinfect furniture and medical equipment to avoid contamination of other patients and/or staff in the healthcare facility. Finally, the Pakistani health authorities should step up mass campaigns and awareness towards the prevention of eye diseases on radio/television stations, including social media platforms like Facebook, Twitter, and Linked, Twitter. etc. as these would go a long way in improving the knowledge, attitude, and perception of the Pakistani about eye diseases, including pink eye. Conclusion As Pakistan witnessed another outbreak of pink eye in 2023, we urge the Pakistani government including healthcare providers and the general public in Pakistan to take drastic measures to mitigate the spread of the disease through judicious use of recommended medications, precautions, as well as collaborations with international bodies and organizations to put an end to this debilitating disease in the country. We believe that pink eye should be mitigated in Pakistan. Ethical approval Not applicable to this correspondence. Consent Not applicable to this correspondence. Sources of funding All authors received no funding to this correspondence. Author contribution M.O.O. and M.F.: conceptualization; M.O.O.: manuscript preparation, project administration, software, visualization, writing – review and editing, and supervision; A.I.A. and S.C.U.: funding acquisition; M.F.: investigation. All authors contributed in resources, validation, writing – original draft, and final approval of manuscript for publication. Conflicts of interest disclosure None to be declared. Research registration unique identifying number (UIN) Name of the registry: not applicable. Unique identifying number or registration ID: not applicable. Hyperlink to your specific registration (must be publicly accessible and will be checked): not applicable. Guarantor Malik Olatunde Oduoye. E-mail: [email protected], https://orcid.org/0000-0001-9635-9891 Data availability statement Not applicable to this work. Provenance and peer review Not commissioned, externally peer-reviewed.