Frequently Asked Questions
COVID-19: To what extent is Tunisia able to overcome the crisis ?
- Can you introduce yourselves? Do you have social or political objectives?
We are a group of independent Tunisian Health professionals with diverse academic and professional experiences in the field of public health in Tunisia and abroad. We have tried to provide our analysis based on our expertise in the field of public health and epidemiology to contribute to the response implemented by Tunisia to face the current COVID19 outbreak.
Jaber Belkhiria is a Veterinarian and an Epidemiologist. He works for the One Health Institute at the University of California Davis on novel diseases such as the coronavirus.
Oussam Zekri is a global health consultant currently working on the management of disability programs in West & Central Africa. He is a DMD and holds a Master in Health Administration with a focus on Health Policy and Management from the University of South Carolina.
Amine Ghrabi is a medical doctor who studied and worked in Tunisia, and is currently pursuing a MSc in Global Health Policy at the London School of Economics (LSE).
2. What is the purpose of the article?
The main purpose was to analyze the current strategies taken to mitigate the impact of COVID-19 and raise awareness about potential epidemiological scenarios. In this article, we have specifically evaluated the impact of the current 28-days lockdown on the evolution of the epidemic.
3. Are we really going to see 15,000 deaths and 300,000 cases by August?
This scenario is possible in case the 28-days nation-wide lockdown is totally lifted on 20 april 2020 and life returns to normal without any preventive measures or an elaborated preparedness response ( increased ICU capacity or a mass testing strategy for example). However, we are confident that follow up decisions aiming to reduce these numbers will be taken.
With regard to the frequency of symptomatics and CU cases, the model adopted as a reference the rates of ICU cases by age group, according to the data presented by Ferguson et al. Thus, the intensive care admission rate (% of ICU cases) varies between 5% for the 0–9 year age group and 70.9% for patients over 80 years of age. Note also that these rates were applied by taking into account the distribution of age categories in the general Tunisian population.
We are also aware that some factors that we did not take into consideration (because they might be still unknown and/or difficult or impossible to quantify) might affect those results. As mentioned in the paper, no model is perfect, and numbers are predictive, not fact. And we are open to critics and additional input to improve the current model.
4. Some have accused you of providing false information to try to cause panic in the country, especially since the number of cases recorded with the virus so far is very far from the numbers you mentioned. Also, Ministry of Health officials assert that the peak of the virus cannot be determined now. How do you respond to this matter?
The main purpose was to analyze the current strategies taken to mitigate the impact of COVID-19 and raise awareness about potential epidemiological scenarios. In this article, we have specifically evaluated the impact of the current 28-days lockdown on the evolution of the epidemic.
We are also aware that some factors that we did not take into consideration (because they might be still unknown and/or difficult or impossible to quantify) might affect those results. As mentioned in the paper, no model is perfect, and numbers are predictive, not fact. And we are open to critics and additional input to improve the current model.
The peak cannot be determined but can be estimated. These estimations are really important for decision makers as they can help have a vision on previous impacts and help decide future ones. COVID-19 isn’t the first infectious disease scientists have modeled — Ebola and Zika are recent examples. These in fact helped avoid terrible scenarios and help establish effective prevention measures.
5. Can the health system in Tunisia tolerate thousands of people infected with Coronavirus? What is the solution to reduce the spread of the virus in Tunisia?
Clearly, the current health system can be overwhelmed with this novel COVID19 outbreak. Therefore, its capacities (especially more ICU beds) need to be strengthened to ensure that needed care is provided to as many patients as possible. Without such an expanded capacity more lives will be lost. Simultaneously, the internal coordination between involved stakeholders has to be improved and the engagement with the general public has to be more efficient through interactive and transparent communication.
The current lockdown is a good step to delay the epidemic through time, but this measure alone will not totally stop the virus from spreading. It is our responsibility as citizens to avoid spreading the virus by washing hands and using masks. Everyone can play a role in avoiding the transmission by keeping physical distancing, using protective masks, washing hands and sharing relevant information on social media (no fake news).
6. In your prediction curves, the ICU cases (intensive care patients) represent the majority of hospitalized cases. Doesn’t this ignore the epidemiological profile of hospitalized patients?
First, it should be noted that the two curves in Figure 3 are plotted on a logarithmic scale (see curve with a non-logarithmic scale below). Second, at any given time, the total population of the intensive care unit (ICU cases) should not be interpreted as a proportion of the hospitalized population, since these are separate conditions in two groups.
7. Why should acceleration continue? Aren’t we already seeing a deceleration?
“Containment reduces interactions between susceptible and infected. We therefore reduce the number of people who can be infectious because they will either heal or die. The dynamics of the disease will therefore be slowed down once the containment is lifted since there are less infectious people but also less susceptible people but also (in comparison to the initial suspect population). With confinement, the dynamics of the disease are slower, and therefore we have to wait a little longer to reach the threshold that indicates the end of the epidemic. But the most important thing to understand with containment is that even if the duration of the epidemic is longer, the number of people affected by the virus is decreasing (and therefore also the deaths). ” Ref
8. Doesn’t the disease heal in 2 to 4 weeks depending on the severity. How do you explain that the number of sick cases continues to accumulate as if patients don’t recover?
You can see in Figure 2 the evolution of new symptomatic cases over time. However, Figure 3 represents the evolution of the cumulative number of symptomatic cases over time.
9. Do Tunisian decision makers have reliable information to counter the propagation of the virus?
The key message to keep in mind is that it is important to follow measures taken by the government to avoid transmission. Social distancing and confinement are key to slow down the epidemic and thus to give time to prepare for worst case scenarios.
10. How do you assess the decision to put Tunisia in lockdown?
We are currently observing the positive impact of the early lockdown decision. The number of newly confirmed cases and number of deaths have started to slowly decrease. This has delayed the outbreak and saved valuable time that can be invested in improving the health system’s capacity to absorb a potentially higher number of patients. Clearly, the decision to go through a lockdown was not easy to take but we cannot imagine a scenario where this decision would not have been taken.
11. What other strategies would have been possible?
Hypothetically, two other options would have been possible. First option: not having a lockdown and targeting and isolating only infected patients (following South Korea model). Second option: not having a lockdown and not testing suspected patients.
12. Should the lockdown continue?
A longer lockdown could definitely reduce the spread of the disease to the point of stopping the infection. At the same time, strategic interventions to prepare for the potential impact of future transition from lockdown should be initiated and properly implemented. All these actions would require additional socio-economic sacrifices.
13. What are the political obstacles to implementing a good strategy?
Public trust is the major political obstacle for an effective strategy implementation.
14. Who makes the political decisions?
The government had been granted special powers recently, and he is now able to issue decree-laws of legislative character aiming to control the spread of the virus and without referring to the parliament.
15. Are there any additional measures that the government should take now?
Strengthen the health system’s capacities (especially more ICU beds), improve internal coordination between involved stakeholders, and engage with the general public through a more interactive and transparent communication.
16. What is the role of the citizens in this pandemic?
Moreover, it is on us as Tunisians to make our responsibilities as citizens to avoid spreading the virus by washing hands and using masks. Everyone can play a role in avoiding the transmission by keeping physical distancing, using protective masks, washing hands and sharing relevant information on social media (no fake news). It is also important to respect the current lockdown measures.
17. It was reported earlier that there are symptoms similar to Coronavirus in some Tunisians a few months ago. Can we say that the Tunisians acquired what is called the “herd immunity”? Which led to the few injuries recorded in the country?
There is no scientific evidence that Tunisians have acquired immunity to SARS-COV 2 from previous infections.
18. In the event that the quarantine is reduced, can Tunisia be exposed to another wave of Coronavirus, as has happened in some countries? What is the correctness of the disease returning to those recovering from it?
Scientists worldwide are assessing the effectiveness of an immunity post COVID infection.
They are also assessing possibilities for second waves.
19. How do you comment on the assertion of the French Professor, Luc Montagnier, that the Corona virus was mistakenly removed from a Chinese laboratory during the search for an AIDS vaccine? In other words, is a virus a result of normal development, or was it made in a laboratory?
To our knowledge there is no scientific evidence that SARS-COV2 has been made in a lab.
20. When do you expect the end of the Coronavirus in the world? Especially in light of the talk about the ability of this virus to develop itself continuously (there is talk now about the presence of 40 mutations of the virus)?
There is no clear date to the end of this pandemic. However, this is not the first nor the last epidemic to happen. Humanity had taken hits in the past from epidemics but was always able to stand up stronger and better prepared. We have to learn to cope with uncertainty
