Authors: Dr. Jaber Belkhiria , Dr. Amine Ghrabi and Dr. Oussama Zekri

FAQ

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The COVID-19 pandemic is currently expanding across low and middle income countries (LMICs). While Tunisia has been managing a lingering political instability, regional disparities and high levels of youth unemployment over the recent years, the country is also currently put to the test. The expected socio-economic disruptions will inevitably have an impact on the country’s stability. Tunisian political leaders are now faced with making choices between economic prosperity and the preservation of human life.

Although ranked second among best health care systems in Africa (Health Care index), the Tunisian health care structure remains fragile and unequally distributed geographically. The public sector is the primary healthcare provider with 31 936 beds, accounting for 87% of hospital bed capacity. There are around (500) ICU beds distributed across the country among the public and private sector. The country has also been undergoing a striking epidemiological change with an important decline in communicable diseases and an increase in non-communicable diseases. Dealing with epidemics is a novel experience and the country is clearly not prepared. The last epidemic of this scale goes back to 1850 when the Cholera outbreak resulted in the deaths of 6 000 people just in the capital (Tunis). The Tunisian medical body is preparing to provide healthcare for as many patients as possible, but challenges are starting to arise.

Certainly, the COVID-19 pandemic is a valuable opportunity to assess the Tunisian health system’s performance and to emerge with relevant reforms for a more efficient and reinforced one. This paper evaluates Tunisia’s response to its COVID-19 outbreak in light of the existing limitations and future challenges.

Tunisia’s current response to COVID-19

When the first confirmed case was recorded outside of China –the epicenter of the outbreak– on 13 January 2020, the Tunisian government put in motion its response strategy based on a containment paradigm. This involved identifying imported COVID-19 cases, and both tracing and isolating exposed contacts. All passengers arriving from China were screened at major entry points and advised to self-isolate. Suspected cases within the general population were centrally monitored by the Health Emergency Medical Service (SAMU) using its 190 hotline and a rapid intervention team. Meanwhile, the media and the public remained abreast of developments through official press briefings.

The initial preventive strategy enabled authorities to capitalize on time. Experts continued to monitor the global COVID-19 epidemiological map while the Ministry of Health (MoH) administrators adjusted to the leadership of the newly appointed government. The adopted vertical implementation approach failed to gather the needed buy-in among the population as limited awareness campaigns were rolled out and the general public was not informed of potential future scenarios.

On 2 March 2020, an individual who recently travelled from Italy self-reported having symptoms and was confirmed as the first COVID-19 case in Tunisia. Shortly after, the government applied stringent control measures for passengers arriving from Italy. The announcement of patient zero did not discourage people from gathering in large crowds. As an example, roughly 50 000 supporters attended the African Champions League football game between local Esperance and Zamalek of Egypt on 6 March, in Tunis. Even if there was no clear evidence on the impact of such a major public gathering on the spread of the virus, it must be said that the 7th confirmed COVID-19 case, that was recorded by the MoH, is a Tunisian fan who attended the first leg of Zamalek vs Esperance on 28 February, in Cairo.

While patient zero had been identified through the established referral pathways, another case in point was a Tunisian-French citizen who tested positive just after arriving in Tunisia and decided to fly back to France instead of putting himself in self-quarantine. Clearly, relying on passengers’ willingness to self-quarantine was a major flaw in the government’s initial strategy. Soon after, the government gradually accelerated its response to COVID-19. Decision-makers opted for the closure of maritime borders and a significant reduction of flights with specific countries affected by COVID-19 outbreaks: Italy, France, Germany, The United Kingdom, and Egypt. Airlines started a large operation to repatriate Tunisian nationals abroad with requirements of automatic quarantine procedures upon return. Furthermore, the first announced social distancing measures were extended to suspension of all collective prayers and the early closure of restaurants and cafes.

On 16 March, the Tunisian Head of Government announced the adoption of the following measures: closure of land, air and sea borders, a ban on all public gatherings, and a reduction of daily office hours to five hours. These were followed by a Presidential Decree for a nationwide 6 PM to 6 AM curfew. At that time only 24 positive COVID-19 cases were recorded, out of which 14 were imported cases. These early measures were justified by their potential impact on controlling the spread of the virus across the country. Ultimately, a general lockdown was decided by the President of Tunisia following the National Security Council meeting on 20 March.

Simultaneously, the government announced a TND 2.5 Billion socio-economic package ($0.8 billion, 2% of Gross Domestic Product) in support of vulnerable households. To finance this package, Tunisia had to revisit its priorities with international donors. A $2.8 billion Extended Fund Facility (EFF) loan agreed with the IMF in 2016 was closed, and Tunisia pursued the IMF’s Rapid Financing Instrument (RFI) to request a $400 million loan deal to address the fiscal and economic impact of the epidemic.

Aside from these relatively proactive measures, authorities and political leaders kept calling Tunisian citizens to act responsibly in support of the state’s efforts by fully complying with specific self-isolation and social distancing requirements. Daily press conferences held by the MoH not only provided the media and the public with the latest information and updates regarding the epidemiological situation across the country but were also an opportunity to reiterate calls for compliance with government directives. Nevertheless, some social gatherings including wedding ceremonies and private parties continued to take place in a business as usual manner in some regions of the country. Consequently, another Presidential Decree was enacted to restrict the movement of people and to limit gatherings to a maximum of three persons. And yet, crowds were still largely reported through social media platforms.

A centralized testing strategy had been implemented to test all suspicious cases and contacts of confirmed cases in one single hospital in Tunis. Several political actors and other stakeholders, such as the national professional order of medical doctors, publicly advocated for a mass testing strategy that expands to all public and private healthcare facilities. Therefore, the government strategy attracted widespread criticism from the public, allowing all types of self-proclaimed public health experts to join the public outcry, warning about the dangerous consequences of a restricted testing strategy. Fearful reactions and extreme panic among health workers at Habib Bourguiba University Hospital on 23 March upon admission of a suspicious COVID-19 patient revealed a worrying lack of coordinated communication and preparedness to properly handle a vastly growing number of cases in the following weeks.

The way forward

As of 7 April 2020, a total of 623 COVID-19 positive cases and 23 related deaths were officially confirmed by the Ministry of Health.

In theory, the following three elements play a key role in the total number of COVID-19 related deaths:

1 The number of ‘susceptibles’: individuals who do not have an immunity to SARS- COV2. If 70 to 80% of the population is immune to the virus, either by directly getting infected or by acquiring passive immunity through vaccination, then the epidemic will end. This is the concept of herd immunity. Since vaccination is not yet an option, the scientific community is already considering the possibility of secondary infection waves until all susceptibles get immune.

2 The infection rate: frequency of occurrence of new instances of infection within a population during a specific period. Infection requires direct contact with an infected individual or an indirect transmission through contaminated surfaces. An Infected person may be symptomatic (showing signs of the disease) or asymptomatic (no signs of the disease). Asymptomatic individuals are harder to detect and can unknowingly spread the virus to susceptibles. Methods to reduce infection rates can be conducted via the quarantine of asymptomatic infected individuals identified through mass testing (South Korean example) or by putting the entire population in strict confinement until the epidemic fades away (Italian example). Testing will help monitor the incidence of infection and inform on geographic clusters among other indicators. However, both options will come at a cost. The confinement’s socio-economic consequences cannot be sustained by many LMICs. As the economy slows down, the government will still have to subsidize and/or offer alternatives to economically fragile segments of the population. Massive testing needs rigorous planning and allocation of significant human resources to laboratory testing in addition to effective quarantine and monitoring of confirmed positives. It must be sustained during the entire epidemic and that comes at a high financial cost.

3 The health system capacity: an efficient healthcare system with a high capacity to identify and provide appropriate and accessible care to those who need it. This means that the general population has equitable access to trained workforce and equipped hospitals with enough beds and ICUs across the country. A higher health system capacity would increase chances of recovery, thus reducing total death rates. Short-term additional needs for hospital beds and ICUs would require significant adjustment of the current supply chain and health financing arrangements to purchase additional equipment and set up temporary hospitals. Purchasing medical equipment has become problematic as demand is very high and manufacturers are out of stock. Moreover, the global supply chain being temporarily disrupted will impact the arrival of such equipment intended to meet the local demand.

Disease modeling has become an important tool to better understand the epidemic evolution following the country’s demographic, healthcare system and sanitary restrictions put in place to slow/stop the disease. The predictive model used is tailored to the Tunisian context in order to inform decision making. The model was based on confirmed COVID-19 related deaths which is considered to be the most reliable information available. Details are presented here.

Disclaimer: No model is perfect, and numbers are predictive, not fact.

This compartmental model is built on theoretical individual movements between different compartments with rates specific to COVID-19 (Figure 1). All these transitions between compartments are characterized by various factors related to the virus (infection rate R0) or the populations (demographics, health conditions, and social interactions). This model only considers differences in age distribution across the Tunisian general population.

Figure 1 Transition between the different compartment used in the epidemiological model

Figure 2 shows the evolution of the epidemic drivers from March to October 2020, taking into consideration the current nationwide 28-days lockdown (in vertical dashed lines) enforced since 22 March.

Figure 2: Evolution of the epidemic drivers [March-October 2020].

In August of this year, Tunisia is expected to have its epidemic peak (i.e. highest number of symptoms). During this critical month, over 300 000 people are expected to be infected, with approximately 60 500 showing symptoms, 10 000 will need to be hospitalized, out of which 2 500 will need to be transferred to ICUs. These numbers will start to decrease once the peak of August passes.

Figure 3 contrasts the predicted cumulative numbers of infected persons (yellow line), hospitalized persons (blue line), and deaths (black line). In this figure, the cumulative number of confirmed cases (yellow dots) and deaths (black dots) were extracted from the MoH official daily reports.

Figure 3: Evolution of the cumulative numbers of infected persons, hospitalized persons and deaths.

The model estimates that the number of deaths will reach 10 000 to 15 000 individuals by October 2020. Up to now, the confirmed numbers of COVID19-related deaths have been following the predicted numbers. In the context of the current 28-days lockdown (in vertical dashed lines), this model shows a reduction in the slope of the epidemic. This also means that the epidemic will be progressing with relatively reduced acceleration. With the current measures, it must be acknowledged that the cumulative confirmed cases only represent the tip of the iceberg, as it is still inferior to the cumulative number of infected individuals in the population (the total number of symptomatic and asymptomatic). Once the lockdown is lifted (20 April 2020), the cumulative number of cases and fatalities will keep increasing until September 2020, when it will start to plateau out.

Figure 4 highlights the expected needs for hospital beds: Standard beds (blue line) and ICU beds (pink line) through time.It is assumed that Tunisia’s ICU capacity is 500 ICU beds which are 100% dedicated to COVID-19 cases (in other words not accounting ICU patients with other health conditions).

Figure 4: Evolution of hospital needs over time.

Starting from June, Tunisia is expected to reach the saturation of its ICU beds capacity. This saturation might lead to sudden increase in death rates (not accounted for by this model).

The peak of the epidemic is now expected in August 2020. The 28 days lockdown will not stop the epidemic, but will delay it through time. Valuable time has already been gained by adopting this early-stage measure that relatively flattened the epidemic curve. However, this lockdown cannot be extended indefinitely given its socio-economic impact. It is thus vital to efficiently invest the time gained in improving the health system response capabilities and preparedness according to the best scientific evidence available.

Mass testing could be considered as a relevant option only if regulated in a way that maximizes the general public benefit. The Tunisian government is currently contemplating lockdown exit options and considering moving away from a targeted testing strategy. In fact, mass testing at early hotspots has shown to be effective and strong advocates are lobbying to scale up testing to both public and private laboratories. However, offering equitable access to this diagnostic tool remains questionable if it were to be led by a market-driven approach. Moreover, considering how poorly the government handled the quarantine of returning passengers at the beginning of the epidemic, there are valid concerns about the Tunisian government’s capability to enforce strict self-isolation on infected individuals if solely relying on people’s good will.

A more aggressive approach to enforce social distancing is required during the next few weeks. Health experts and policy-makers must improve their communication with the public through more efficient use of messaging channels. As the virus continues to spread, it is crucial to ensure the population’s proper understanding of the rationale behind the temporary disruption of social and economic life. It is also important to constantly promote basic preventative practices from regular hand washing to avoiding crowds and contact with the vulnerables and the sick. Starting to adopt such large-scale healthy habits would be highly useful once the lockdown is lifted. These are beneficial behavioral changes that will be acquired and carried on beyond the current health crisis.

Expanding hospital capacity is a more strategic and sustainable investment compared to large-scale testing. The model clearly shows that Tunisia will reach its hospital capacity threshold in June 2020. Undoubtedly, an overwhelmed healthcare system will result in a dramatic increase in the rate of mortality. Therefore, existing hospitals have to be reconfigured and additional supplies, particularly ICU beds and ventilators, must be made available. Immediate investments must prioritize the enhancing of hospitals capacity in order to deliver critical care in ICUs with enough ventilators and personal protective equipment. In the absence of such expanded capacity, more lives will be lost.

Tunisia’s response to its own COVID-19 outbreak has been undermined by its ongoing economic and political challenges. Mostly, Tunisians have been united to stem the epidemic’s impact on their lives, putting aside their political tense disagreements. Yet, thin citizenship considerations quickly dented this sense of collective solidarity in the face of the emergency. In this context, the state’s response to the crisis faced vivid criticism across the public sphere despite its gradual nature. Overall, Tunisia’s efforts have been scattered resulting in a non-sufficient response. The creation of an independent public health agency with a clear mandate and appropriate prerogatives will provide the finest protection against future outbreaks and epidemics.