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Rebound or second wave?
Published in Ahram Online on 11 - 08 - 2020

With the coronavirus accelerating worldwide, passing 20 million infections this week, according to a John Hopkins University case tracker, several countries have once again started imposing lockdown measures over worries of a second wave of infections.
Egyptians are no less worried even though a sense of complacency in recent weeks set in after the daily toll of coronavirus cases fell below 150 individuals a day for four consecutive days last week, marking the lowest single-day record — 112 cases on Tuesday — since April. The daily figures throughout this week witnessed a slight rebound as they once again crossed the 150-patient mark.
Egypt detected 178 coronavirus cases on Sunday, bringing the total number of confirmed infections nationwide to more than 95,000 since the detection of the first case in the country in mid-February.
The Health Ministry said that it had recorded 26 new deaths on Monday 10 August, bringing the total number of fatalities from the respiratory virus to 5,035.
Despite being a tenuous increase, the feeling of anxiety among the public was recently amplified due to the health minister's call for the necessity of adhering to preventive measures in anticipation of a spike in coronavirus cases, and the ministry's decision to re-open dozens of isolation hospitals nationwide that had been closed earlier as a result of the decline in numbers.
Health Minister Hala Zayed urged the public on Sunday to adhere to the preventive and precautionary measures during the current “cautionary period” in anticipation of an increase in the number of coronavirus infections, especially following the increased gatherings that took place during last week's Eid Al-Adha holiday.
Also on Sunday, Mohamed Taleb, head of Al-Nagila Hospital, Egypt's first makeshift isolation hospital, told DMC TV that “there is an expectation of a second wave that will be more aggressive than the first one,” forcing the minister to order isolation hospitals to operate again.
Hossam Hosni, head of the Health Ministry's Scientific Committee to Combat Coronavirus, on Monday ruled out that Egypt had entered a second wave. In a TV interview he warned citizens that “the epidemic still exists” and that the recent increase in infections is due to “the lack of caution taken by citizens”.
Two months ago, in the wake of Eid Al-Fitr, the Islamic religious feast at the end of Ramadan and which is usually marked by family gatherings, coronavirus infection rates increased noticeably in Egypt. Officials at the time said the hike could have been attributed to reckless behaviour and a disregard of protective measures in place.
Furthermore, in Eid Al-Adha, which came a month after Egypt gradually began lifting its coronavirus restrictions, there were no restrictions placed on movement in the form of a suspension of transport or a travel ban between governorates as was the case in Eid Al-Fitr. Given the lenient procedures and the decreasing number of infections, both of which reassured the public, Egyptians took the opportunity of the five-day Eid Al-Adha holiday to again congregate and celebrate while others headed to summer resorts to spend their holiday.
Islam Anan, an epidemiology specialist and a pharmaeconomics lecturer at Misr International University, said that there was a false sense of security among the public that led to a lack of awareness and non-compliance with the preventative measures, including a reduction in the wearing of masks.
As long as there are people infected with the coronavirus, even a small number, there will be room for infections to occur, said Anan. He said he did not believe this was a second wave because that is expected in the fall or winter, according to global forecasts.
“The slight increase in numbers is likely to be a rebound of the first wave,” Anan told Al-Ahram Weekly, predicting that any rebound will be felt strongly and not in the epicentre of the outbreak — Cairo and Giza — that saw the highest infection rates during the peak of the first wave.
A rebound usually witnesses a 20 per cent increase in infections due to the exhaustion of susceptible individuals, he argued.
The Weekly visited Al-Abbasiya Fever Hospital, Egypt's first major frontline facility in combating coronavirus, and found the rise in infection rates reflected on the ground.
“The number of infections began to increase again following the Eid Al-Adha holiday,” an emergency doctor at the hospital said on Sunday. Though the doctor, who spoke on condition of anonymity, refused to give the exact numbers, he said “the number of patients has significantly increased and we are currently working much more compared to the period before the Eid holiday.”
Inside Al-Abbasiya Fever Hospital's Virus Lab, an analysis doctor echoed a similar fact, citing the number of daily positive PCR test results. “During the low-number phase prior to the Eid holiday we used to have from three to seven positive PCR results daily, but currently we get from 13 to 15 positive swabs,” the doctor said.
Such PCR results are considered relative evidence of increasing infections given that the main dependence now in diagnosis is CT scans, not PCR tests, the analysis doctor said.
In June, the Health Ministry started using clinical examination results, CT scans, and laboratory analyses to identify suspected cases of coronavirus in parallel with PCR tests.
“Only the critical cases, which are the minority, are diagnosed through PCR tests while the majority of cases are diagnosed through CT scans. However, the ministry's daily toll is only linked to the PCR positive tests regardless of the number of positive cases diagnosed by CT scans,” the fever hospital's analysis doctor told the Weekly.
Anan confirmed the same fact by saying that the ministry's daily toll is merely related to the PCR tests which are currently performed only on patients suffering from severe respiratory symptoms who represent from five to seven per cent of the total number of patients.
“Hence, we should consider the ministry's daily toll a sample size of the universe,” he said.
Higher Education and Scientific Research Minister Khaled Abdel-Ghaffar said on 21 May that the true number of coronavirus infections in Egypt could be over 71,000, even though the Health Ministry had only recorded 14,229 confirmed infections at the time. Those numbers, according to Abdel-Ghaffar, were based on a hypothetical model that assumes that the official recorded cases are fivefold lower than the actual numbers.
Because so little is known about the novel coronavirus, Anan says, all explanations remain hypotheses.
He said the difference between a rebound and second wave could be determined using several ways.
One way is to apply a different health policy by moving from reactive testing to proactive testing which has been implemented in the UAE, Germany and the United States. Proactive testing means conducting random swabs of citizens on the street through which the percentage of increase can be evaluated, and a warning signal can be received early.
“It [the proactive testing] is the ideal solution, however, reality says that it cannot be done in Egypt,” he stated.
In order to boost accuracy and get closer to the actual numbers, Anan says, there is a need for every hospital to register the number of patients who have been diagnosed by CT scans in an electronic record for the ministry even if these numbers are not announced.
“There is no such electronic registry so far in Egypt compiling all the cases. Home isolation patients who receive coronavirus medication at home should have such electronic records to register themselves online,” said Anan.
Because symptoms that are being presented are weaker than before, some families currently prefer to treat infected members at home. Earlier in June, under Egypt's treatment protocol at that time, mild Covid-19 patients were treated at home or in university hostels in an attempt to free up beds for critical cases in overwhelmed state-run isolation hospitals.
With the relaxing of lockdown measures, Anan believes that what matters the most now is to adapt to the new normal by remaining committed to all preventive measures and to remember that even one sick individual can start a new wave of infections like what happened in China's Wuhan, the epicentre of the coronavirus.
The government said in late July that it may resort to adopting the strict preventative measures that it had imposed earlier to fight the coronavirus, including shutting down activities, if the infection rate rises again.

*A version of this article appears in print in the 13 August, 2020 edition of Al-Ahram Weekly

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