Estimation of COVID-19 burden in Egypt
Authors: Mohamed Hassany, Wael Abdel-Razek, Noha Asem, Mohamed AbdAllah, Hala Zaid
Journal: The Lancet Infectious Diseases (2020)

We read with interest the Correspondence by Ashleigh Tuite and colleagues.1Tuite AR Ng V Rees E et al.Estimation of the COVID-19 burden in Egypt through exported case detection.Lancet Infect Dis. 2020; (published online March 26.)https://doi.org/10.1016/S1473-3099(20)30233-4Summary Full Text Full Text PDF Scopus (32) Google Scholar We thank them for their interest in estimating the coronavirus disease 2019 (COVID-19) burden in Egypt. However, their model-based calculations used the number of patients known on March 6, and the numbers of patients and deaths are continuously changing. Attempting to reach a more up-to-date estimate of the expected number of patients in Egypt, we used other assumptions according to real-life data. The rapid spread of COVID-19, which started in China, led to its characterisation as a pandemic by WHO on March 11.2WHOCOVID-2019 situation report—51.https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200311-sitrep-51-covid-19.pdf?sfvrsn=1ba62e57_10Date: 2020Date accessed: March 31, 2020Google Scholar On Feb 14, Egypt announced its first COVID-19 case.3WHOCOVID-2019 situation report—26.https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200215-sitrep-26-covid-19.pdf?sfvrsn=a4cc6787_2Date: 2020Date accessed: March 31, 2020Google Scholar Thereafter, Egypt scaled up preventive measures, with a partial lockdown starting on March 25. RT-PCR was done in nasopharyngeal swabs from symptomatic patients and contacts of confirmed cases traced in the preceding 2 weeks. In patients with a high rate of suspicion, the test was repeated after 48 h. Screening at airports included body temperature and clinical assessment and the use of a rapid diagnostic test for anti-severe acute respiratory syndrome coronavirus 2 IgM and IgG. Deaths from influenza-like illness were also reviewed. As of March 31, Egypt announced 710 COVID-19 cases and 46 related deaths (fatality rate 6·48%, 95% CI 4·78–8·55).4WHOCOVID-2019 situation report—71.https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200331-sitrep-71-covid-19.pdf?sfvrsn=4360e92b_4Date: 2020Date accessed: March 31, 2020Google Scholar We acknowledge that, in the absence of open screening, this could be an underestimation of the total number of patients and an overestimation of the fatality rate. To estimate the expected disease burden in Egypt, we used fatality rates in the USA and Germany, because they applied open screening, and in regional countries with conditions similar to those of Egypt (Algeria, Bahrain, Iran, Israel, Jordan, Saudi Arabia, Lebanon, Morocco, Palestine, Qatar, Tunisia, Turkey, and United Arab Emirates). On the basis of WHO's report on March 31,4WHOCOVID-2019 situation report—71.https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200331-sitrep-71-covid-19.pdf?sfvrsn=4360e92b_4Date: 2020Date accessed: March 31, 2020Google Scholar the fatality rate of all reported countries ranged from 0·7% to 11·8%. We deduced a factor by dividing our fatality rate by the global rate and those of the listed countries. This factor was then multiplied by our number of identified cases to estimate the expected total number (table).TableEstimated number of patients with COVID-19 in EgyptNumber of patients with confirmed COVID-19*As of March 31, 2020.Number of deaths related to COVID-19*As of March 31, 2020.Fatality rate, % (95% CI)Expected number of patients with COVID-19 in Egypt (95% CI)Egypt710466·48% (4·78–8·55)..Germany71 6907741·08% (1·01–1·16)4261 (3377–5241)USA185 15937732·04% (1·97–2·10)2257 (1720–2886)USA and Germany256 84945471·77% (1·72–1·82)2598 (1974–3331)Region†Includes Algeria, Bahrain, Iran, Israel, Jordan, Saudi Arabia, Lebanon, Morocco, Palestine, Qatar, Tunisia, Turkey, and the United Arab Emirates.68 93632814·76% (4·60–4·92)966 (738–1233)Global854 01342 0064·92% (4·87–4·96)935 (697–1222)COVID-19=coronavirus disease 2019.* As of March 31, 2020.† Includes Algeria, Bahrain, Iran, Israel, Jordan, Saudi Arabia, Lebanon, Morocco, Palestine, Qatar, Tunisia, Turkey, and the United Arab Emirates. Open table in a new tab COVID-19=coronavirus disease 2019. In conclusion, the expected total number of patients with COVID-19 in Egypt, as of March 31, could be in the range of 710–5241 patients. Notably, the exclusion of patients who have not acquired the infection from the reporting country could have decreased these numbers. Additionally, the listed countries do not share the same curves of spread or deaths, stages of the epidemic, or steps of interventions. We declare no competing interests. HZ is the Minister of Health and Population of Egypt. MH and WA-R contributed equally. Estimation of the COVID-19 burden in Egypt through exported case detectionIn December, coronavirus disease 2019 (COVID-19) emerged in Wuhan, China, causing a pandemic that continues to spread globally.1 86 countries have reported cases.2 As of March 6, 2020, Egypt has reported three cases of COVID-19; however, at least 14 cases have been exported from Egypt to four countries.3 The burden of infection in Egypt, therefore, might be substantially larger than reported. We estimated the potential burden of COVID-19 in Egypt using the approach of Fraser and colleagues.4 Full-Text PDF Estimation of COVID-19 burden in EgyptThe foundation of any estimation process is the use of independent unbiased samples. However, when attempting to estimate Egypt's burden of coronavirus disease 2019 (COVID-19) by studying exported cases, Ashleigh Tuite and colleagues1 established neither independence nor absence of bias for the cases used in their study. This approach is especially problematic in the light of widespread news of a tourist cruise ship in Egypt exporting COVID-19 across the world through hundreds of tourists who were onboard during the timeframe used by Tuite and colleagues in their Correspondence. Full-Text PDF Estimation of COVID-19 burden in EgyptI read with interest the Correspondence by Ashleigh Tuite and colleagues,1 and I respectfully disagree with the methods used by the authors and their conclusion. Full-Text PDF Estimation of COVID-19 burden in Egypt – Authors' replyWe thank Mohamed Hassany and colleagues, Ahmed Negida, Tarek Sahmoud, and Khaled Elmeleegy for raising their concerns about our modelling study. We would like to reiterate that the number of confirmed cases of coronavirus disease 2019 (COVID-19) in every country worldwide (Egypt included) is an underestimate of the true burden of illness, regardless of the screening programmes in place. Although we are aware that all modelling studies have limitations, we believe that it is important to rely on multiple sources of information to have a more accurate reflection of the so-called ground truth. Full-Text PDF Estimation of COVID-19 burden in EgyptTo estimate the burden of coronavirus disease 2019 (COVID-19) in Egypt, Ashleigh R Tuite and colleagues1 used the same model of exported case detection used by Fraser and colleagues for the H1N1 outbreak in Mexico.2 However, Tuite and colleagues neither clarified nor verified the assumptions of this exported case-detection model. First, the authors used data from the UN World Tourism Organization (UNWTO) on the average length of stay in Egypt by tourists (11·6 days), which is not accurate for the following reasons: we contacted UNWTO to verify the most recent estimates, and the average length of stay by tourists in Egypt was 11·6 days in 2018, 7·78 days in 2017, 6·1 days in 2016, 9 days in 2015, and 10 days in 2014, with no estimates available for February, 2020; the UNWTO estimates combine the length of stays of domestic and international tourists, including visitors from several countries other than the USA, Canada, France, and Taiwan; and for Egypt, a country with rapid changes in the political, economic, and tourism fields, it would be inaccurate to confidently consider these incomplete statistical data for the present model of February, 2020. Full-Text PDF