Egypt’s COVID-19 contradiction

[newcastle]

By
Mada Masr
December 3, 2020

After a rush of coronavirus patients overwhelmed Egypt’s healthcare system in the spring, the official number of new COVID-19 cases in the country calmed over the summer. Yet, the decline in new cases was not mirrored in the country’s daily number of deaths.

As a result, Egypt’s overall death rate throughout the course of the coronavirus pandemic is the seventh highest in the world.

According to doctors on the front lines of Egypt’s response to the virus, international observers, and former and current government officials who spoke to Mada Masr, the trend is being produced by Egypt’s testing policies.

Sources explain that the death rate recorded by the Health Ministry is inflated: samples analyzed outside of the Health Ministry’s Central Labs are excluded from the official daily count so that large numbers of daily cases are unaccounted for, while government protocol allows PCR tests at the Central Labs only for patients with the severest of symptoms.

Egypt had a fairly quiet summer in terms of case rates, according to Health Ministry figures. After a peak in June, when 1,774 cases were recorded in a single day, the Health Ministry’s daily reports showed a steady decline. Egypt’s epidemiological curve hit its nadir in late August with 89 cases recorded in a day and continued to hover around the same level until the number of cases eventually began to climb again in mid-October, with the government officially announcing the onset of Egypt’s second wave in recent weeks.


Despite the plateau in the new case rate over the summer, the death rate continued to climb.

Based on data released by Egypt’s government and collated by Mada Masr, in comparison to global data published by the John Hopkins University, Egypt’s overall death rate over the course of the pandemic is 5.79 percent; more than double the global rate of 2.36 percent. Between the first recorded case in Egypt and the national peak in late June, the death rate was 4.32 percent. But between early July, when daily recorded cases began to decrease, and now, the national death rate has shot up to eight percent, compared to the global rate of 1.82 percent over the same period.

Over the summer, the death rate continued to incline upward until it exceeded nine percent over the period between early August and the end of November, compared to the global rate of 1.73 percent, making Egypt’s death rate for that period among the highest in the world.

There is no reason to believe that the higher death rate is due to a shortfall in the health service. After being overwhelmed in June by the rising number of patients requiring isolation or other medical services, hospitals became less crowded and the pressure on them lightened over the summer, allowing them to provide better healthcare. In May, the government gave the green light to private hospitals to provide care to COVID-19 patients, which presumably relieved pressure on the overall healthcare system as well. Worldwide, death rates have declined for a variety of reasons, including doctors gaining experience in learning how to treat the disease better.

Some light may be shed on these seemingly contradictory figures by examining the government’s testing policy, a crucial strategic component of any country’s efforts to tackle the coronavirus according to the United States’ National Institutes of Health, which stresses testing “asymptomatic and pre-symptomatic individuals” as “key to interrupting the spread.”

Yet, according to four doctors, who agreed to speak with Mada Masr on condition of anonymity due to concerns about retaliation, the Health Ministry’s protocol places significant restrictions on when PCR tests can be administered to patients suspected of having COVID-19.

The coronavirus can be detected through three kinds of tests, the most common of which is the PCR test. Although the test is not 100 percent accurate, the doctors who spoke to Mada Masr said it remains the most reliable and efficient thus far. While “the reported rate of false negatives is as low as two percent and as high as 37 percent, the false positive rate […] should be close to zero,” according to an article published on the Harvard School of Medicine’s website.

In the early stages of the outbreak in Egypt, it appeared as though the Health Ministry’s containment scheme was working well, and it received praise from the World Health Organization. According to a diplomatic source who is well informed on how the WHO makes its assessments, this was because Egypt initially implemented the same infrastructure it used — to great success — in the campaign to eradicate Hepatitis C. “The tracking system was fine when Egypt was recording 200 to 300 cases per day,” says the source, who spoke on condition of anonymity.

But as the disease spread, the ministry adopted a more conservative approach to PCR testing. Ministry doctors were instructed to rely on other lab tests and imaging methods to assess the probability of a patient having contracted the virus. Although PCR results are the only information the ministry uses to compile its official tally of daily cases, access to a conclusive PCR test in Egypt is dependent on a complex set of conditions.

It is hard to discern a clear picture of how many PCR tests the Health Ministry is conducting based on the scarce information available. On November 7, Nancy al-Gendy, the administrative director of the ministry’s Central Labs, said that around 10,000 tests per day are being analyzed across the country’s labs. Just three days later she was quoted as saying that the ministry’s Central Labs were receiving around 3,500 swabs a day.

According to data provided by the government to the WHO, and published by The New York Times, Egypt runs 953 tests per 100,000 people — a remarkably low level of testing when compared to other countries in the region. Jordan, for example, conducts 20,540 tests per 100,000 people. Similarly, the rates in Iraq and Libya are significantly higher than in Egypt at 7,554 and 5,421, respectively.


A combination of requirements that limits the number of ministry approved tests and the exclusion of any PCR testing outside of the ministry’s Central Labs from the daily count has resulted in low numbers of reported cases in Egypt. According to a former official at the ministry’s preventative medicine department, officially recorded cases are at best a fifth of the actual number of people who have contracted COVID-19.

As per the Egyptian Health Ministry’s official protocol released in June, a swab is taken for a PCR test when a patient is experiencing mild to severe symptoms or when home isolation is not possible. If the symptoms are mild, the patient is instructed to isolate at home. If their test comes back negative, they are tested again 48 hours later. If positive, they are to be taken to one of the hospitals designated for isolation of coronavirus cases.

However, the doctors told Mada Masr that the protocol was not adhered to after the official number of cases began to exceed 1,000 per day.

PCR testing in Egypt is reserved only for patients experiencing pneumonitis and symptoms of respiratory failure, according to the doctors. “Since day one of the outbreak, the Health Ministry has advised prudence in PCR testing,” says a doctor who works at the Abbaseya Fever Hospital.

Instead of PCR analyses, doctors are expected first to rely on a raft of other methods to diagnose most patients. Suspected cases are admitted to the hospital’s monitoring room — essentially a clinic for patients who exhibit symptoms of fever, coughing or shortness of breath. A doctor writes down their symptoms and orders a blood test and chest X-ray. If the blood test and X-ray indicate a COVID-19 infection — displaying a low white cell count or signs of pneumonitis — the doctor may recommend a PCR.

Still, the patient is not guaranteed a PCR test. After the first request for a PCR, the patient is referred to an internal medicine practitioner for a second assessment. The second doctor can either approve the request or order a chest CT scan for further assessment.

If a PCR test is eventually approved, a swab is taken and sent to the Central Labs. The patient’s information as well as their imaging and testing results are reported to the emergency and crisis room at their local directorate for health affairs. Only then does the case make it into the official daily toll. Any cases diagnosed by any other means are not included.

As pointed out by a member of the Higher Education Ministry’s Scientific Committee, as well as by a source who works at an international organization that observes Egypt’s efforts to combat the virus, patients with late-stage symptoms are more likely to die. If testing is mostly limited to these patients, Egypt’s comparatively high death rate makes sense.

The Health Ministry has been adamant in excluding all tests run outside of its own labs from the official count. According to a former Health Ministry official who is currently a professor at Ain Shams University’s Faculty of Medicine, the ministry does not recognize positive cases unless they are conducted by the Central Labs. “If a citizen gives a swab at – let’s say – the Ain Shams Specialized Hospital […], their test comes back positive and they call 105 to get the care they need, the operator would insist on redoing the test at a Central Lab,” the official explained to Mada Masr. The daily toll of cases, therefore, does not include tests run by labs at most university hospitals, Armed Forces hospitals, or any other labs that do not fall under the Health Ministry’s auspices.

The same is true of tests conducted in the private sector. Initially, the ministry refused to authorize the private sector to conduct coronavirus testing at all. This changed in mid-June when the Higher Education Ministry gave permission for a drive-thru testing center to be opened at Ain Shams University, with a statement posted on the Cabinet’s official Facebook page announcing that the service was a “collaboration” between Prime Speed Medical, the Higher Education Ministry and the reference laboratory affiliated with it. Ahmed al-Geidy, the technical director of Prime Speed Medical who spoke to Mada Masr in July, said that the company does not supply any test results to the Health Ministry. An official source at the Health Ministry’s central laboratories also told Mada Masr at the time that the Health Ministry does not recognize the lab’s test results.

As for private hospitals, they may conduct swabs and send them for testing to the Central Labs, but do not have official clearance to test samples in their own labs, Health Minister Hala Zayed explained at the time.

While the official position remains the same, over the past few months several private labs have been conducting PCR tests on demand for a fee ranging between LE1,500 and LE3,000. Anyone can call a company like Speed Lab or Al Mokhtabar for a technician to come to the patient’s home to take a swab, with the results returned one or two days later. Since private labs are not officially authorized to conduct independent tests, there is no evidence to suggest the results are reported to the Health Ministry and included in the official count.

The increase in Egypt’s death rate is evident from the contrast between death rates during the months of rapid spread (March, April, May and June) and during the months where the number of cases ebbed (July, August, September and October).


On the other hand, more testing would lead to a higher number of officially recorded cases without a corresponding marked rise in the number of deaths. This would in turn likely reduce the death rate when compared to the total number of cases. This can be seen statistically even as the number of daily tests remained constant over the last month: as the second wave begins and the number of cases increases, the death rate decreases.


As to the government’s reasons for placing such stringent restrictions on testing, the diplomatic source told Mada Masr that since the beginning of the outbreak, Egypt’s authorities have worked to cultivate an image that the country remains a “safe place” for tourism and investment. Yet, the testing strategy has caused an inflation in the official death rate recorded, potentially undermining that very image.

In early November, as the second wave of the coronavirus pandemic hit Egypt, the Health Ministry’s Scientific Committee to Combat Coronavirus convened to discuss the issue. “A number of countries have imposed complete lockdowns,” Prime Minister Mostafa Madbuly remarked during the meeting — issuing a stern warning to citizens that ignoring precautions could “force us to revert back to some tough decisions” which “may inflict economic damage on a lot of people.”

[newcastle]

Madr Masr is, of course, a frequent publicist of articles critical of Egypt.

There is, however, no denying the basic statistics highlighted...as the underlying table demonstrates.

https://www.worldometers.info/coronavir ... meAdvegas1?