Why Pakistan's Youth Faces Heightened COVID-19 Risk
Exploring the scientific and sociological factors behind Pakistan's alarming youth infection rates during the pandemic
The COVID-19 pandemic has rewritten global health paradigms, often characterized as a grave threat primarily to the elderly and those with underlying conditions. However, in Pakistan, a startling and counterintuitive narrative emerged—one where the youth population became disproportionately affected. This article delves into the scientific and sociological reasons behind this alarming trend, exploring the unique intersection of viral evolution, socioeconomic realities, and public health policies that placed Pakistan's young generation squarely in the path of the pandemic. Through a detailed examination of key research and experimental data, we unravel the complex factors that made the country's demographic dividend its potential Achilles' heel during this global crisis.
Globally, COVID-19 severity and mortality were strongly correlated with advanced age. Pakistan, a country with a median age of just 22.8 years and over 50% of its population under 30, might have expected a milder outbreak based on international age-risk profiles 8 . Yet, data from the first wave revealed a starkly different reality: a shocking 50-60% of all confirmed infections were occurring in individuals aged 18-49 years, with a particularly alarming 35-45% of cases concentrated in the 18-39 age bracket 1 . This pattern suggested a significant departure from global norms and pointed to factors unique to the Pakistani context.
A significant proportion of Pakistani youth are engaged in daily-wage labor, public transportation, and customer-facing roles in the informal economy. A nationwide lockdown was economically devastating for this demographic, forcing many to continue working in high-risk environments to survive, thereby increasing their exposure 1 .
Crowded urban centers and large, intergenerational families made effective social distancing nearly impossible. An infected young person, often asymptomatic or mildly symptomatic, could easily become a superspreader within their own household, passing the virus to more vulnerable older relatives 1 .
Genomic surveillance played a crucial role in understanding the virus's behavior. A study sequencing SARS-CoV-2 genomes from the first wave in Pakistan found evidence of higher genetic entropy (a measure of genetic diversity and mutation rate) compared to strains from other parts of the world. This higher diversity suggested a rapidly evolving virus within the population, which can have implications for transmission, severity, and even vaccine efficacy. The study identified strains from the G and S clades circulating early on, with mutations noted in key genes like the Nucleocapsid (N) and Spike (S) protein . This constant evolution meant the virus was actively adapting to its new, young host population.
A critical study evaluating rapid diagnostic tests (RDTs) highlighted a major challenge in surveillance. The research tested over 33,000 suspected patients, confirming 100 positive cases via the gold-standard RT-PCR method. When these confirmed positive samples were tested using two types of RDTs, the results were concerningly poor 3 :
| Test Type | Overall Sensitivity | Sensitivity in Males | Sensitivity in Females | Sensitivity in Children |
|---|---|---|---|---|
| Nasopharyngeal Swab RDT | 52% | 53% | 58% | 25% |
| Saliva-based RDT | 21% | 21% | 23% | 0% |
This significant rate of false negatives, especially in saliva-based tests, meant many infected individuals, particularly the youth who might prefer less invasive testing methods, were being missed. This allowed them to unknowingly continue spreading the virus, skewing both the understanding and containment of the outbreak.
A pivotal retrospective study analyzed a massive dataset from the Aga Khan University Hospital, one of Pakistan's largest testing facilities, to understand testing and positivity trends across demographics between February 2020 and February 2022 4 .
The researchers reviewed 470,249 RT-PCR tests. The data was analyzed in phases corresponding to Pakistan's pandemic waves. They employed multivariate regression models to assess independent associations between COVID-19 positivity and variables like age, gender, and time period, while adjusting for co-variates.
The study's findings were profound:
of tests performed on individuals aged 21-40 years
Higher odds of testing positive for individuals over 80 years compared to children 0-10 years
| Age Group | Percentage of Total Tests | Adjusted Odds Ratio (aOR) for Positive Test |
|---|---|---|
| 0-10 years | 4.4% | Reference (1.0) |
| 11-20 years | 8.6% | Increased |
| 21-30 years | 25.2% | Increased |
| 31-40 years | 22.9% | Increased |
| 41-50 years | 15.1% | Increased |
| 51-60 years | 10.4% | Increased |
| 61-70 years | 6.3% | Increased |
| 71-80 years | 3.8% | Increased |
| >80 years | 2.6% | 2.5 (95% CI: 2.3–2.7) |
Gender Findings: After adjusting for age and pandemic phase, the positivity rates between males and females were found to be the same, suggesting that the observed differences in case numbers were largely driven by the disparity in testing rates rather than a biological difference in susceptibility 4 .
Understanding the pandemic required a diverse array of scientific tools. Here are some of the essential reagents and materials used in the studies cited 3 4 :
| Reagent/Tool | Function | Example from Research |
|---|---|---|
| RT-PCR Assays | Gold standard for detecting active SARS-CoV-2 infection by amplifying viral RNA. | Roche Cobas 6800 SARS-CoV-2 assay; USFDA-approved Seegene Allplexâ„¢ 2019-nCoV Assay (triple target: E, N, RdRp genes). |
| RNA Extraction Kits | Isolate and purify viral RNA from patient samples (e.g., nasopharyngeal swabs) for downstream testing. | QiaAmp RNA minikit (Qiagen). |
| Next-Generation Sequencing (NGS) Library Prep Kits | Prepare genetic material for sequencing to track viral mutations and lineages. | Nextera XT DNA Library Prep Kit (Illumina); TruSeq Stranded Total RNA Library Prep Kit (Illumina). |
| Rapid Diagnostic Tests (RDTs) | Lateral flow assays for quick detection of viral antigens (less sensitive than PCR). | Lepu Medical (China) nasopharyngeal and saliva-based antigen test kits. |
| Enzyme-Linked Immunosorbent Assay (ELISA) Kits | Detect antibodies (IgG/IgM) in blood serum, indicating past infection or immune response. | Used in seroprevalence studies (not detailed in provided results but critical for overall understanding). |
| Viral Transport Media (VTM) | Preserve specimen integrity during transport from collection site to laboratory. | Used for all nasopharyngeal swab samples. |
| Bioinformatics Software (BCFtools, SnpEff, PhyML) | Analyze genetic sequence data, call variants, annotate mutations, and build phylogenetic trees. | Used to identify SNVs, calculate entropy, and determine viral clades (e.g., G, S) circulating in Pakistan. |
of respondents had adequate knowledge about COVID-19
had a good perception of the virus
Despite the challenges, studies revealed a surprisingly high level of knowledge and good perception regarding COVID-19 among the educated public. One large cross-sectional survey of 1,200 respondents found that 93.3% had adequate knowledge (mean score 6.59/8) and 85.6% had a good perception (mean score 4.29/5) of the virus. Social media (42.9%) and electronic media (41%) were the primary sources of information 5 9 .
However, dangerous misconceptions persisted. Nearly half (46%) of respondents in one survey believed COVID-19 could be a bioweapon, and there was widespread confusion about the efficacy of preventive measures like thermal scanners 9 . This highlights the critical need for continuous, targeted public health messaging to combat misinformation, a battle that is particularly crucial for an engaged and connected youth population.
The vulnerability of Pakistan's youth to SARS-CoV-2 was not a simple matter of biological susceptibility but a complex syndemic—a synergy of biological, social, and economic factors. High exposure rates due to economic necessity, crowded living conditions, early limitations in testing, and the virus's own evolving characteristics converged to create a perfect storm.
Campaigns must be designed specifically for the youth, leveraging the social media platforms they use, to effectively promote vaccination and combat misinformation.
Providing social safety nets for daily-wage workers and low-income families is not just an economic imperative but a critical public health intervention, enabling effective isolation and quarantine.
Strengthening laboratory capacity and ensuring access to accurate and affordable testing across the country is essential for effective surveillance and rapid response.
Continuous monitoring of viral evolution remains crucial to track the emergence of new variants and guide vaccine and therapeutic strategies.
Protecting Pakistan's future means protecting its youth. Learning from the hard lessons of the COVID-19 pandemic is the first step toward building a more resilient and equitable health system capable of shielding its most valuable asset—its next generation—from the next health crisis.