In the early days of March, the Health Ministry’s handling of the new coronavirus that has since swept the world was business as usual. Egypt had recorded three confirmed COVID-19 infections since announcing the first case in mid-February, including an Egyptian who had returned from abroad. No one had died from the virus yet.
Like any other communicable disease, COVID-19 was handled by the ministry’s preventive medicine department, which wrote periodic reports for Health Minister Hala Zayed about developments in other countries, as well as the World Health Organization’s updates and recommendations.
Zayed had just made a six-day trip to the Chinese capital of Beijing, where she expressed Egypt’s official solidarity in fighting the virus.
Everything changed on March 6, the day she returned to Egypt. Twelve confirmed cases were in one location: Egyptian workers aboard a Nile cruise in Luxor that had arrived from Aswan. The discovery marked a turning point in the response of the Health Ministry — and later the state — to the threat posed by COVID-19.
“The increased sense of danger was not only due to the number of cases jumping suddenly from three to 15,” says an official in the Health Ministry with direct knowledge of the ministry’s efforts to curtail the new coronavirus. “Until then, we were dealing with isolated cases. But Luxor was the first infection cluster.”
Zayed moved quickly, raising the ministry’s internal response level and forming an operations room to centralize the response to the virus on the same day she returned. Mohamed Hassany, the minister’s assistant for public health, was tapped to lead the operations room. The preventative medicine department that had been in charge of the file was now flanked by health officials from a host of other health departments, including curative care, ambulance and pharmaceutical affairs departments alongside representatives from external state bodies, including the Interior Ministry, the General Intelligence Service and Administrative Control Authority.
“We can consider March 6 as the first day of Egypt’s confrontation with COVID-19,” says the Health Ministry official, putting us in the middle of the fourth week of the ministry’s escalated response.
In describing the ministry’s response to Mada Masr over the last few weeks, the official has often reached for military metaphors, peppering their speech with words such as “war.” In the official’s account, the days following the formation of the operations room saw Egypt fighting the outbreak with a “limited army” and “few capabilities.” However, that army began mobilizing, training its troops for battle on several fronts amid a barrage of new infections.
Following its relatively late formation, the operations room needed to work on several issues at once: isolate and treat the known infected cases, while examining those who had come in contact with them; build a system to identify, trace and manage new cases; import testing kits from abroad and prepare the ministry’s labs scattered across the country to carry out tests; assess beds, equipment and staffing needs in public hospitals for different outbreak scenarios; create a diagnostic and treatment protocol; and design awareness and press releases to limit new infection.
The operations room was inundated with practical tasks and yet still had to continually brief Zayed and the Cabinet in order to guide other state bodies’ response to the pandemic’s threat.
The ministry designated 27 hospitals, one for each governorate, to diagnose and quarantine suspected cases. It prepared another six hospitals as quarantine centers for cases that had tested positive. Additional staff in a call center, outsourced and located in Giza’s Smart Village, were trained to answer inquiries and reports of potential cases with a doctor overseeing every 20 agents.
But the priority for the command room was to contain the outbreak in Luxor before it got out of control.
“Luxor was lucky, so to speak,” the Health Ministry official says. “It was the first and only outbreak cluster at the time, so it received all of our attention and capabilities.”
Medical teams were quickly dispatched to Luxor and Aswan, accompanied by a WHO delegation. The team tested everyone who had been exposed to positive cases, as well as those who had potentially been exposed: family members, work colleagues and neighbors. The ministry’s teams then conducted tests on a random sample of those who had been on a Nile cruise or stayed in a docked hotel boat, tourists and workers alike.
“We ran 400 tests and only one came out positive,” the official says. “So we decided to change our strategy.”
About a week after the Luxor outbreak, the operations room made a decision that remains controversial. Faced with the fact that Egypt, like most countries, doesn’t have the necessary capacity to conduct large-scale testing, the government decided to ration tests, running them only on cases that fit the COVID-19 “case definition” specified by the ministry’s scientific committee.
Under the ministry’s new policy, only those who showed symptoms after being in contact with a known positive case or arriving from a country with a high infection count would be tested. This would leave cases of asymptomatic transmission outside the ministry’s purview. The call center started advising more callers who hadn’t shown symptoms to stay home and self isolate. Fever and chest hospitals prioritized critical cases: those with chronic diseases and the elderly.
“It’s not that we don’t have the money to buy the tests,” the official says. “But Egypt is standing in a long queue, which includes the United States and all of Europe, to acquire testing kits.”
Egypt has the capacity to conduct 200,000 tests, according to a March 27 report written by a WHO technical support mission. Zayed, the health minister, said on March 25 that Egypt has so far conducted 25,000 tests.
The official contends that the ministry’s decision remains correct, even after the WHO updated its advice to governments to “test, test test,” in addition to enacting social distancing policies, on March 16.
“On the contrary, [the decision] rectified the mistake of wasting our limited medical and human resources, exhausting teams and squandering test kits,” the official says. “We’re saving our resources for critical times.”
But does the rationing of tests mean there could be a high number of infections that the ministry doesn’t know about? Those in the operations room believe that it is unlikely given the results of the 5,000 tests that had been conducted before test rationing began.
The individuals tested by that point included family members and people exposed to positive cases; health workers in hospitals where cases were confirmed; workers who were required to be tested before traveling to Gulf countries (before these countries closed travel with Egypt) and walk-ins who requested to take the test at government labs before the decision was made to ration tests.
“We treated these tests as close to a random sample of 5,000 people and studied the results, of which the vast majority were negative,” the official says. “More importantly, we managed to trace the index case for confirmed infections.”
The ministry’s ability to trace infection chains to their source, what is called the index case, is the main reason behind the relative confidence displayed by officials and the WHO. This continued ability to identify index cases puts Egypt in what the WHO terms as the local transmission stage.
According to the Health Ministry official, Egypt has moved from a stage where most cases were imported from outside Egypt to local transmission over the past month. However, the official contends that Egypt hasn’t reached the community transmission stage — which the WHO defines as an inability to relate confirmed cases through chains of transmission for a large number of cases.
In the eyes of the official, this means there are not a large number of unaccounted for cases. “If we get cases of individuals who haven’t been exposed to any known positive case and who haven’t traveled to a country with an outbreak, then we can say that there are infections that we’re not aware of,” the official says.
The ministry has also instructed health bureaus, tasked with issuing death certificates across Egypt, to flag cases in which the cause of death is similar to flu symptoms, a measure aimed at helping identify undiagnosed COVID-19 cases.
To suppress uncounted cases, the Health Ministry would hypothetically have to enlist patients’ families, neighbors, doctors, nurses and the media as co-conspirators, the official says. “Practically, it is impossible to hide cases, even if the ministry wanted to do so.”
Today, things seem more orderly inside the ministry compared to the first days of the operation room’s establishment, according to the official. Instead of the Whatsapp group used in the early days, the operations room communicates over an interface that links it to hospitals and the call center. Suspected cases are seamlessly referred to the operations room, where officials from the gathered departments start taking actions within their respective fields of speciality.
When the official speaks about Egypt’s current position, there is a measured sobriety. “[The rate of infection is] rising at an acceptable level: 2.5 new infections against every confirmed case. The death rate was low before rising to 5 percent of all positive cases,” the official says. “Despite all that, everyone in the ministry is expecting the inevitable jump in numbers, when we’ll most likely reach the community transmission stage.”
There are plenty of reasons to worry about the coming days. The leadership of the operations room includes a number of ministry officials who designed and implemented the comprehensive national screening and treatment campaign for hepatitis C over the past three years. While this gave them experience in monitoring, investigating and following cases, it also made them deeply aware of poor infection control conditions in hospitals and health units.
For example, a study conducted by the Health Ministry and the WHO last year found that about half the health workers surveyed suffered an average of four needlestick injuries per year. According to a 2002 World Health Report, 2 million out of 35 million healthcare workers worldwide, approximately 5 percent, suffer needlestick injuries per year.
Such conditions would pose a formidable challenge should the number of patients needing hospital care surge. That could force the ministry to admit COVID-19 patients at all hospitals, which would increase the rate of infection among medical staff.
“We started sending ambulances to transport suspected cases from their homes, and we’ve asked people not to go to hospitals on their own” to limit infections, he said.
Yet the biggest cause for concern inside the ministry is the loose implementation of social distancing. The operations room’s main adversary now is Cairo’s metro, which transports about 3.5 million people daily and is still operating from 6 am to 7 pm, until it closes as part of the nationwide nightly curfew.
The closure of cafes, restaurants, movie theaters and shopping malls was among the ministry’s initial recommendations. However, there was a lag in implementing the decision. There was also a delay in the decision to suspend flights in the early, crucial stage, given that 80 percent of confirmed cases were tourists or people exposed to tourists.
However, the official asserts that there is not a feeling that the government is stalling in following the ministry’s recommendations. “Honestly, this is the usual response time for the Egyptian state given the number of bodies involved and the level of coordination between them,” the official says.
Officials are trying to strike the delicate balance between warning citizens of what’s coming and fueling a state of panic. Their new strategy was tested in the Belqas region of the Daqahlia governorate, where two Egyptians who were exposed to a European tourist died in the village of Samaheya. The minister imposed a lockdown of the village and put 300 families under medical supervision for two weeks, and sanitized the village’s streets and buildings.
“All we did was to classify the village as a high-risk location and put it under supervision due to the two deaths and 10 infections found there,” the official says. Nonetheless, the decision to quarantine the village spurred a rumor that the whole Belqas area had become an epicenter for the disease, a rumor that only dissipated after the quarantine period elapsed.
Today, it’s hard to imagine that it’s been only three weeks since the outbreak on the Luxor Nile cruise and the establishment of the operations room. Cases have risen from 15 to over 700 in that period, with at least 46 people dying due to complications from the disease. COVID-19 cases have been confirmed in 25 of Egypt’s 27 governorates, the lone exceptions being North Sinai and New Valley, according to the official. The rash of exceptional measures taken so far have given the ministry official a degree of comfort, but they remain insufficient, in the official’s view, to stop the spread of the disease.
“Egypt is no different than any other country, in the sense that we will probably witness, in the coming few days, a rise to the peak of the infection curve,” the official says. “But these coming ten days will also determine if infections will start going down or if things will go out of control like we see in Italy.”