<h3 style="text-align: justify;">The national situation of COVID-19</h3>
As of June 17, Egypt has officially recorded a total of 49,219 coronavirus cases. The number of daily reported cases continued to rise until May 31, started to decline on June 1 before rising again starting from June 4 (Figure 1)<a href="#_edn1" name="_ednref1">[i]</a>.
<img style="display: block; margin-left: auto; margin-right: auto;" src="http://api-aps.aucegypt.edu/uploads/tinymce/1595887673imageFigure 1.png" alt="" width="500" height="272"> By definition, the daily figures show historical data for an average of 5-6 days prior to the day of reporting (the incubation period of the disease according to the World Health Organization) (WHO, 2020). Therefore, the decline suggests a positive impact of applying a relatively stricter curfew during Eid Vacation, from May 24 to May 31.
This unrealistic reported rate of growth renders traditional data collection methods less useful in contact tracing and reacting to the spread of the virus. The Ministry of Health relies on their conventional methods of data collection which only account for the PCR confirmed positive cases, leaving most cases unreported due to the limited clinical capacity and the scarcity of PCR diagnostic tests under their conservative testing protocols.
<h3 style="text-align: justify;">Geographic distribution of COVID-19 cases</h3>
On May 2, the World Health Organization (WHO) published data of the spatial distribution of confirmed positive cases across governorates. In a <a href="https://www.youtube.com/watch?v=6Dx96TaU8Bg&amp;feature=emb_title" target="_blank" rel="noopener">press conference</a> on May 31, the Minister of Health announced that 60% of the confirmed positive cases are in the Greater Cairo Region. <a href="https://www.shorouknews.com/news/view.aspx?cdate=31052020&amp;id=8a1ff347-f47d-409c-8966-139133add158&amp;fbclid=IwAR014cEzieSDqcWIyQTPKfpeJRTrlyXBJmalSHnyYDNfF1CYTRp_T6L2X8I" target="_blank" rel="noopener">Shorouk News</a> followed up with a quantified report of the distribution of cases over the 27 governorates. However, the Ministry shows no intentions to release the geographic distribution data regularly.
<h3 style="text-align: justify;">Beyond contact tracing is a capacity crisis</h3>
Based on phone interviews with health professionals in Egyptian public hospitals,<a href="#_edn2" name="_ednref2">[ii]</a> the Egyptian Ministry of Health relies on their nationwide network of hospitals to collect data of COVID-19 tested suspects using a unified data form. Data reporting follows a hierarchical flow in which the assigned hospitals report the collected data to the governorate-level Directorate of Health, which finally reports to the Ministry.
Currently, the data collected of COVID-19 suspected cases include demographic data, communication data (i.e. mobile numbers), detailed address information of residence and work and short-term international travel history. All data points are collected traditionally in string text formats which limits the potentials of any meaningful and timely spatial analysis of the virus spread patterns.
The process of dealing with suspected cases severely lacks coordination among the hospitals assigned to dealing with COVID-19 cases, even within the same Governorate. The challenge materializes in many instances when patients are diagnosed in a hospital but cannot get hospitalization service due to unavailability of resources. In such cases, fully occupied hospitals can not direct the patient to other pre-identified hospitals as they have no access to hospitalization-capacity information in other healthcare facilities. These circumstances allocate the massive burden of finding hospitalization on the patients themselves.
The Ministry of Health has also launched a smartphone application that enables users to report suspected cases, whether themselves or others, by providing necessary information for diagnosis to determine the probability of infection. The system then directs users to the next steps they should take. The application can also send alerts to users whenever they are close to or are at a location where infected cases are present to help them take the necessary precautions (Ahram Online, 2020).
However, the percentage of households with access to smartphones is as low as 49%. This percentage even falls to just 29% in rural areas (CAPMAS, 2018). Realistically, such applications are likely to exclude many vulnerable members who lack access to technology. Additionally, there is no evidence on the value provided by this application until now.
According to the WHO, contact tracing is the process of identifying, assessing, and managing individuals who have been exposed to a disease to prevent onward transmission (WHO, 2015). However, the process is highly reliant on the accuracy of data and the number of respondents. For an effective response, the number of responders must increase rapidly, and without this level of response, the number of cases cannot be anticipated (Wong, et al., 2016).
Hence, efforts should be directed towards community-based monitoring, similar to the system followed in tackling the Ebola virus in Liberia and Sierra Leon, starting 2014. This approach relies on monitoring urban/rural agglomerations instead of individuals; thus, enabling community-based preventive decision-making (such as curfews and restrictions of inter-community travel) and need-based resource allocation to tackle the healthcare capacity crises.
<h3 style="text-align: justify;">The role of GIS in tackling COVID-19</h3>
Geographic Information Systems (GIS) platforms and spatially-aware digital surveys are globally used to monitor, predict and tackle the spread of COVID-19.
In Europe and the US, teams of researchers have started mass population surveys using simple questionnaires to detect impending hotspots and create a spatially-aware early warning system (SEWS) (Halfbinger, 2020. Healthcare Departments use GIS dashboards to geographically monitor confirmed cases of COVID-19 with demographic and statistical indicators. The indicators include hospitalization indicators and use residence data to produce a heatmap rendering the most affected geographies and the spatial distribution of performed tests. (Figure 2) shows the spatial distribution of confirmed positive cases in Florida based on the zip code (Florida Department of Health, 2020).
<img style="display: block; margin-left: auto; margin-right: auto;" src="http://api-aps.aucegypt.edu/uploads/tinymce/1595887646imageFigure 2.png" alt="" width="500" height="272">
<h3 style="text-align: justify;">Proposal: Healthcare-capacity geostatistical platform</h3>
In Egypt, public healthcare planning and allocation of resources are performed exclusively by the central government. Therefore, a multi-level geostatistical platform is proposed to geographically monitor the virus in lights of the healthcare capacity available. The platform consists of two main data collection components that contribute to the Central Information Platform, as follows:
<h3 style="text-align: justify;">Geostatistical COVID-19 platform</h3>
The first component is a GIS database and dashboard of confirmed COVID-19 positive cases. This would allow flagging hotspots where high numbers of positively diagnosed cases live, work, or regularly visit. This framework can enable targeted resource allocation for the hotspots in the short term and future spread forecasting using data of population densities and mobility patterns.
The objectives for a successful GIS system would be to monitor the spatial distribution and intensity of spread, define the profoundly affected and under-equipped areas to supply with sufficient medical resources and inform localized preventive decision-making.
To serve the objectives, a multi-staged framework is proposed:
<ol style="text-align: justify;">
<li>Digitally collect daily data on the available capacity in healthcare facilities, including medical equipment, healthcare workers and the remaining/needed capacity for additional cases.</li>
<li>Digitize all historical records of COVID-19 confirmed positive cases.</li>
<li>Create a data collection tool that enables collecting all relevant demographic and geographic data in a unified and structured digital format to be used by healthcare officials.</li>
</ol>
<h3 style="text-align: justify;">Spatial Early Warning System (SEWS)</h3>
The second component is a survey launched across multiple decentralized channels to reach a statistically significant portion of the population in all geographic areas and collect data on where more citizens or health workers self-report an increased prevalence of symptoms. The aggregation of such data by pre-determined geographic regions across time would allow flagging hotspots where a higher than average percentage of citizens report symptoms, leading to an early warning signal.
This component is only possible by tackling the challenges of the low population access to technology and the frequently reported inefficiency of the national COVID-19 hotline.
To build the system, a multi-channel platform is proposed to allow the biggest portion of the population to self-report symptoms, consisting of a web-based chatbot, a Facebook Messenger chatbot, an effective mobile application and functional local-level hotlines.
The objectives for a successful spatial early warning system (SEWS) would be:
<ol style="text-align: justify;">
<li>Predict surges in cases days in advance.</li>
<li>Forecast high-risk areas in Egypt to lead spatial allocation of medical resources.</li>
<li>Maintain a steady rate of self-reporting across time until the pandemic subsides.</li>
</ol>
<h3 style="text-align: justify;">Central information platform</h3>
Data from the two components would be aggregated by location, time, demographics and shared in aggregate form with the Egyptian Ministry of Health, Health-Researchers and Practitioners through the GIS database and dashboard. Data would be shown in a heatmap resembling the <a href="https://www.definitivehc.com/resources/covid-19-capacity-predictor">COVID-19 Capacity Predictor</a>, similar to the one developed for the US by Definitive Healthcare, as shown in (Figure 3).
<img style="display: block; margin-left: auto; margin-right: auto;" src="http://api-aps.aucegypt.edu/uploads/tinymce/1595887746imageFigue 3.jpg" alt="" width="700" height="380">
The aforementioned heatmaps would be rendered through two different versions:
<ol style="text-align: justify;">
<li>A web platform for decision-makers on local and national levels. The platform would contain features such as (i) Geo-temporal filtering that allows live monitoring of the outbreaks and the remaining/needed resources in any specific geographic area (ii) Report generation from correlating administrative, population and infected cases datasets to provide insights for informative analyses.</li>
<li>A simplified version of the web platform for citizens. The platform would include up-to-date information on the available healthcare capacity within a reachable distance, accompanied by all contact details for timely and accurate patient consultation activities.</li>
</ol>
Prerequisites for a successful and widely accepted pandemic management framework
The utmost objective of the system would be creating a long-term and efficient framework for epidemic/pandemic outbreak management. Therefore, an active partnership between all relevant stakeholders would be required in all stages of development, testing and deployment of tools. Active engagement of the local healthcare authorities and empowering them to advise and even enforce local-level preventive measures would maximize the potentials of the system.
A paradigm shift is required in healthcare management by focusing on: a) the geographic distribution of healthcare capacity (equipment and personnel), b) responsiveness to the specific needs of different urban and rural agglomerations and c) the systematic coordination between healthcare facilities as a separate stream of work (which is equally important to clinical work).
<hr>
<a href="#_ednref1" name="_edn1">[i]</a> Worldometers.info. Data was verified by the author using the records of Ministry of Health on June 8. <a href="#_ednref2" name="_edn2">[ii]</a> Interviews were conducted with health professionals in Cairo, Giza and Menofeya.
<hr>
Refreneces
<ul>
<li style="text-align: justify;">
Ahram Online. (2020, April). <a style="color: #333333;" href="http://english.ahram.org.eg/NewsContent/1/64/367263/Egypt/Politics-/Egypts-health-ministry-launches-coronavirus-mobile.aspx">Egypt's health ministry launches coronavirus mobile application.</a> Ahram Online.
</li>
<li style="font-size: 10pt;">
CAPMAS. (2018). Household Income, Expenditure and Consumption Survey. Central Agency for Public Mobilization and Statistics.
</li>
<li style="font-size: 10pt;">
Florida Department of Health. (2020, April). <a style="color: #333333;" href="https://fdoh.maps.arcgis.com/apps/opsdashboard/index.html#/8d0de33f260d444c852a615dc7837c86">Florida's COVID-19 Data and Surveillance Dashboard. </a>Florida Department of Health, Division of Disease Control and Health Protection.
</li>
<li style="font-size: 10pt;">
Halbfinger, D. (2020, April). <a style="color: #333333;" href="https://www.nytimes.com/2020/04/01/world/middleeast/coronavirus-detection-surveys.html">How Are You Feeling? Surveys Aim to Detect Covid-19 Hot Spots Early. </a>New York Times.
</li>
<li style="font-size: 10pt;">
Rizk, R., &amp; Abou-Ali, H. (2016). Out of Pocket Health Expenditure and Household Budget: Evidence from Arab Countries. The Economic Research Forum (ERF).
</li>
<li style="font-size: 10pt;">
WHO. (2020, April). <a style="color: #333333;" href="https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200402-sitrep-73-covid-19.pdf?sfvrsn=5ae25bc7_4#:~:text=The%20incubation%20period%20for%20COVID,occur%20before%20symptom%20onset.">Coronavirus disease 2019 (COVID-19) Situation Report &ndash; 73.</a> World Health Organization.
</li>
<li style="font-size: 10pt;">
WHO &amp; CFC. (2015). <a style="color: #333333;" href="https://www.who.int/csr/resources/publications/ebola/contact-tracing/en/">Implementation and management of contact tracing for Ebola virus disease.</a> World Health Organization.
</li>
<li style="font-size: 10pt;">
Wong., V, Cooney., D, &amp; Bar-Yam Y. (2016). Beyond Contact Tracing: Community-Based Early Detection for Ebola Response. PLOS Currents Outbreaks(1). doi: 10.1371/currents.outbreaks.322427f4c3cc2b9c1a5b3395e7d20894.
</li>
</ul>

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