Estimation of COVID-19 burden in Egypt
Authors: Ahmed Negida
Journal: The Lancet Infectious Diseases (2020)

To estimate the burden of coronavirus disease 2019 (COVID-19) in Egypt, Ashleigh R Tuite and colleagues1Tuite 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 used the same model of exported case detection used by Fraser and colleagues for the H1N1 outbreak in Mexico.2Fraser C Donnelly CA Cauchemez S et al.Pandemic potential of a strain of influenza A (H1N1): early findings.Science. 2009; 324: 1557-1561Crossref PubMed Scopus (1585) Google Scholar 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. Second, Tuite and colleagues' model assumes that the population mixing in Egypt is equally likely between Egyptian residents and tourists and that tourists and Egyptian residents are at equal risk of infection, which is not correct for the following reasons: Egyptian population demographics are different from those of the USA, Canada, France, and Taiwan, particularly regarding life expectancy and population age groups, a well known risk factor for symptomatic COVID-19 infections; and Egypt is an agricultural country, with tourism destinations in Egypt, as reported on the official website of the ministry of tourism, being related to either Ancient Egypt or the coastal areas.3Egyptian Tourism AuthorityThis is Egypt.http://www.egypt.travelDate: 2020Date accessed: March 27, 2020Google Scholar Most tourism destinations are in special locations far away from residential places and have low population densities. Therefore, we cannot assume that population mixing in Egypt is equally likely between Egyptian residents and tourists because several high-density residential cities do not have tourists. Third, Tuite and colleagues' model focused on 1 month, from Feb 6 to March 6, 2020. By Feb 6, the four countries (USA, Canada, France, and Taiwan) had officially reported a total of 36 confirmed COVID-19 cases (table). Therefore, we cannot rule out the opposite possibility that some of these COVID-19 cases were infected before arriving in Egypt. What makes this scenario possible is that Egyptian authorities applied COVID-19 airport screening for travellers from China alone but not from other countries, owing to insufficient resources (as reported by the WHO office in Egypt). Another observation is that most of the early confirmed Egyptian cases were reported in Luxor and Aswan, two major tourism destinations in Egypt.TableDate and travel history of the first confirmed COVID-19 case in the USA, Canada, France, and TaiwanDateTravel historyTotal number of confirmed COVID-19 cases until Feb 6, 2020USAJan 20, 2020Returned from Wuhan, China12CanadaJan 27, 2020Returned from Wuhan, China5FranceJan 24, 2020Returned from China6TaiwanJan 21, 2020Returned from China13Total....36COVID-19=coronavirus disease 2019. Open table in a new tab COVID-19=coronavirus disease 2019. On the basis of these points, I argue that Tuite and colleagues' model is not accurate and might not be suitable to estimate the burden of COVID-19 in Egypt. Besides, we cannot rule out the possibility that COVID-19 cases in Egypt were imported from other countries. I am a consultant and advisor biostatistician for Clinart MENA and MRSClin and the founder and chairman of the Medical Research Group of Egypt, a major non-governmental clinical research society in Egypt. 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 EgyptWe read with interest the Correspondence by Ashleigh Tuite and colleagues.1 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. Full-Text PDF