Estimation of COVID-19 burden in Egypt

To 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. 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.³ 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.

Table.

Date and travel history of the first confirmed COVID-19 case in the USA, Canada, France, and Taiwan

	Date	Travel history	Total number of confirmed COVID-19 cases until Feb 6, 2020
USA	Jan 20, 2020	Returned from Wuhan, China	12
Canada	Jan 27, 2020	Returned from Wuhan, China	5
France	Jan 24, 2020	Returned from China	6
Taiwan	Jan 21, 2020	Returned from China	13
Total	..	..	36

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.