THE COVID-19 FORECAST IN NORTHWEST SYRIA: The Imperative of Global Action to Avoid Catastrophe

  1. Mahmoud Hariri
  2. Wael Obaid
  3. Hazem Rihawi
  4. Salah Safadi
  5. Mary Ana McGlasson

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Abstract

Introduction

There is limited research on how the COVD-19 pandemic will affect countries with weakened health systems and particularly those in conflict. Syria’s protracted conflict has strained its health systems and caused fragmentation. In this study, we focus on northwest (NW) Syria, where recent violence has driven almost one million civilians (of the 4.17 million in the area) from their homes between December 2019 and March 2020. The area is challenged by overcrowding, inadequate WASH, shelter and insufficient healthcare services. Internationally promoted measures (social distancing, self-isolation, quarantine, lockdown) are not impossible. We model outcomes, according to three scenarios, should there be a COVD-19 outbreak. We aim to 1. Predict the numbers of cases, including severe and critical ones, and deaths. 2. Identify critical time points when the health system capacity is overwhelmed due to COVID-19.

Methodology

Using the WHO COVD-19 Essential Supplies Forecasting Tool (COVID-ESFT) and data from the Health Information System Unit on population and health facility capacity and utilization in northwest Syria, we generate predicted numbers of cases, deaths and health care needs according to three scenarios. Scenario One assumes a medium doubling rate (every 4 days) and a medium clinical attack rate (20% of the population). Scenario Two assumes a fast doubling rate (every 3.2 days) and a medium clinical attack rate (20% of the population). Camp-population Scenario assumes a very fast doubling rate (every 2.3 days) and a medium clinical attack rate (20% of the population). Scenarios One and Two apply to the total population of 4.17 million and for 8 weeks from the first case while Camp-population Scenario applies only to the 1.2 million internally displaced persons (IDPs) in camps and tented settlements and for 6 weeks from the first case. For each scenario, we identify critical time-points when the health system capacity is overwhelmed assuming a highly conservative estimate that 50% of regular hospital (ward) and ICU beds can be occupied by COVID-19 patients.

Results: Scenario One

Predicts 16,384 cases (0.4% of the total population), of which 2,458 are severe and 819 are critical, and 978 deaths in the first 8 weeks. Scenario Two predicts 185,364 cases (4.4% of the population), of which 27805 are severe and 9268 are critical, and 11,066 deaths in the first 8 weeks. Camp-population Scenario predicts 240,000 cases (20% of the IDP population) of which 36,000 are severe and 12,000 are critical and 14,328 deaths in the first 6 weeks. With only 2,429 inpatient beds and 240 ICU beds (98 with adult ventilators, 62 with paediatric ventilators) in northwest Syria, ward and ICU bed capacities will be overwhelmed within 4–7 weeks. The Camp-population Scenario will see the earliest critical time-points.

Conclusion and recommendations

Should a COVID-19 outbreak occur in NW Syria, projected cases and deaths will be particularly severe among IDPs. Health system capacity will be overwhelmed within a short period after the first case in camp settings. There is need for further research to account for additional variables that can impact projections. However, it is urgent for international community to mobilize efforts and resources to support community-based measures, increase testing, strengthen health system capacity.

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  1. ScreenIT

    SciScore for 10.1101/2020.05.07.20085365: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    NIH rigor criteria are not applicable to paper type.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    This study has several limitations that need to be addressed in future research. This forecasting report uses globally reported estimates for key parameters such as doubling rate, attack rates and case-fatality rates. It is possible for the situation in NW Syria to be different, either negatively or positively, thus substantially altering projections. This necessitates repeating these projections based on actual figures during an outbreak as has been done in other settings. Our study did not use age-specific projection (such as CFR). The COVID-ESFT does not incorporate population-specific factors, such as population age structure, prevalence of comorbidities particularly chronic conditions, and population density, and health system factors, such as bed availability and health workforce readiness, both of which can affect epidemic outcomes. As such, our findings should be considered basic and further modeling is needed to take such factors into account. Unfortunately, there is limited prior research on COVID-19 in similar conflict-affected settings23 to guide such modeling and epidemic projections. The COVID-ESFT considers an exponential growth model, which does not reflect a real epidemic curve that is seen in epidemics and pandemics. Furthermore, the COVID-ESFT only projects an estimate for the first six to eight weeks of an outbreak from the first case. Should an outbreak occur, real-time epidemiological data would be incorporated into the model to provide better forecastin...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

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  2. Version published to 10.1101/2020.05.07.20085365 on medRxiv