Commentary: Challenges of COVID-19 screening of healthcare workers in Egypt and the Eastern Mediterranean region

The Eastern Mediterranean region has been severely affected by COVID-19. Countries have suffered from wave 3 of the COVID19/SARS-CoV-2 virus, after the first wave started in China and the second wave started in Europe. Good-quality data are lacking on the precise extent of infection. However, conditions that favour spread include large populations living in overcrowded cities (in Egypt especially given it is a country of close to 100 million people), inadequate healthcare and lack of transparency and accountability of governments.¹

Mostafa et al.² report SARS-CoV-2 prevalence among >4000 healthcare staff in one of the largest facilities in Egypt—the Ain Shams University Health System (ASUHS), comprising 12 hospitals and health centres with a large number of healthcare workers (HCWs). During the early phase of the pandemic, 4.2% of staff were found to be carrying the virus. The number of SARS-CoV-2-infected HCWs is small (170), which limits the interpretation of findings from this study. Nevertheless, there are some striking findings. The large proportion of staff with SARS-CoV-2 who were asymptomatic (68.2%) means it is likely that many who are infectious will continue to work in hospitals and potentially and unknowingly expose fellow HCWs and patients to SARS-CoV-2. Further, 54.1% of those infected do not recall coming into contact with an infected individual. This has important implications regarding isolation decisions in Egypt and other nearby countries. Clearly, symptom-based isolation will lead to the absence of much-needed HCWs who may not have SARS-CoV-2, without protecting against spread from the majority of virus-positive staff who are asymptomatic.

This study by ASUHS in response to SARS-CoV-2 is a good first step. However, these findings likely underestimate the full extent of SARS-CoV-2 spread among Egyptian HCWs. The authors did not report the participant-response rate. It is possible that many HCWs were deterred by the study protocol, including the testing procedures, and those with who had respiratory symptoms may be especially under-sampled due to absence from work because of sickness or other factors. There is an important context here: the Egyptian government has detained nine HCWs for reporting about SARS-CoV-2 or complaining about their risks to SARS-CoV-2 exposure.³ There is also widespread stigma associated with being infected,⁴ which has applied particularly keenly to Egyptian physicians.⁵ These responses seriously undermine efforts to contain the pandemic and fear of persecution or social shaming might have prevented many from coming forward and participating, although there was an assurance about anonymity. The data about the prevalence of infections among HCWs in Egypt, including those at ASUHS, are not publicly available, otherwise it would have made comparisons and country-wide data available for a better interpretation of the findings from the study.

The study found that those who wear gowns are more likely to have a positive test, but it also might be that they are at higher risk because of their clinical duties and this is the reason for the gown-wearing. There is no measure reported in the paper of rates of infection in the community, although the authors write that they suspect most of the transmission in this workforce is from the community. However, the participants (98% of them) reported contact of cases was in the workplace, not in the community.

Data on SARS-CoV-2 in the general population from official reports from Egypt are based on very limited testing and are kept confidential and not accessible to researchers. The Minister of Health admitted that the official figures were likely to be an under-count and the true number of cases may be 7-fold higher.⁶ Recent SARS-CoV-2 data for Saudi Arabia include >300 000 cases in a population of 33 million (around 0.9% prevalence) and Qatar with close to 120 000 cases in a population of 2.7 million (around 4.4% prevalence), whereas, for Egypt, the crude prevalence proportion is only 0.1% based on recent data.⁷ All the factors of overcrowding, low income, low education and fragmented and unprepared health systems that are present in the region are risk factors in Egypt for the spread of SARS-CoV-2.

The authors should be commended for their efforts to highlight the exposure to risk of infection among HCWs but the findings must be interpreted in light of the socio-political challenges that apply to SARS-CoV-2 in Egypt and the region. The results cannot be compared directly to those from countries like the Netherlands, where the spread of SARS-2-CoV is lower than that in Egypt but the reported prevalence of infections among HCWs is higher (6%). Amongst HCWs in the UK, the prevalence has been as great as 14–20% when the population prevalence was estimated to be ∼0.08%.⁸

It is important that further studies are carried out in Egypt and other countries in the Eastern Mediterranean to provide a more complete picture of infection rates amongst HCWs and other vulnerable populations. Equally important would be a call to share results and data (after protecting the identity of individuals) of SARS-CoV-2 between countries to provide researchers with the opportunity to develop evidence-based policies on how to combat this deadly pandemic as well as learn how to deal with future ones.

Conflict of interest

None declared.