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Published online 7 August 2020
Muriel T. Zaatar, assistant professor of biology at University of Balamand Dubai, outlines the UAE’s efforts to protect its population against the spread of COVID-19, and how to gauge its success.
The first cases of COVID-19 in the United Arab Emirates (UAE) were confirmed on January 29, 2020. Starting with a family arriving to the country from China, where the virus was first declared, cases began multiplying and accelerating.
The government, via the Ministry of Health and Prevention (MoHaP) and the National Emergency Crisis and Disaster Management Authority (NCEMA), began monitoring the evolution of the disease and implementing measures to limit its spread. On March 8, schools and universities were closed and distance learning was adopted. The government provided soft guidelines to limit transmission in the public and private sectors. But the acceleration of cases in the UAE, the rampant spread in other countries, and the World Health Organization (WHO) declaration of a pandemic led to stricter measures. This included the closure of borders and the suspension of all passenger and transit flights on March 25. On March 26, mobility within the country was restricted with a night curfew and a disinfection programme, which was scaled up to a total curfew with stricter restrictions on movement from April 4 until April 23. The lockdown was later eased, while a night-time curfew remained.
Numbers during curfew
Despite these strict measures and their economic cost, the number of diagnosed cases continued to climb. In early April 2020, the UAE embarked on a mass testing strategy, with the number of tests spiking (figure 1) close to a high of 60,000 tests per day. This allowed authorities to detect more infected individuals and could explain why numbers were rising despite the strict measures.
Following a peak of 994 daily diagnosed cases on May 22, the number of cases began to decline despite an increase in the number of tests conducted and the casting of a wider net to look for infections. The ratio of positive tests to overall tests conducted, also known as the rate of positivity, is the indicator that matters and is central to understanding infection dynamics. A decline of the rate of positivity is an encouraging indicator that correlates with measures put in place in preceding weeks. The rate of positivity in the UAE continued to drop from highs of 3% in May to an average below 1% in July.
Takeaway message 1: It is important to conduct enough tests in order to identify infected individuals, and to follow the rate of positivity to assess the impact of the measures taken and the dynamics of the infection.
Keeping things under control
At the time of writing this article, many countries are witnessing a renewed spike of diagnosed cases. This could very well happen in the UAE as well when measures are relaxed. To keep things in check, testing, isolating and tracing are vital. We cannot stop the pandemic if we do not know who is infected.
In that regard, the UAE has continued with its strategy of mass testing, achieving some of the highest levels in the world (#1 in the Arab World, #5 worldwide - 531,488 per million population)2. So far, more than five million tests have been conducted with roughly two million planned for the coming two months for a population of 9.9 million. In the Gulf region, Bahrain and Qatar have also conducted a high number of tests and, along with the UAE, are in the top 20 testing nations worldwide.
In addition to testing and isolating, MoHaP launched a nationwide contact tracing campaign, encouraging people to download the UAE’s official COVID-19 testing and contact tracing app Alhosn.
Finally, the objective of any country is to keep the number of active cases below healthcare capacity. To this end, the UAE has set up field hospitals, like the one at the Dubai World Trade Centre.
As a result, the daily number of recoveries in the UAE started to exceed the number of newly diagnosed cases at the beginning of June 2020 (figure 2). The recovery rate in the UAE stands close to 90%, in line with the high average of other Gulf Cooperation Council (GCC) countries.
The high recovery rate is a good sign, especially when it is coupled with a low fatality rate. In the UAE, the fatality rate has been lower than 1% since mid-May and is now at 0.6%. Bahrain, Oman and Qatar are leading in terms of low fatality rates (figure 3).
Takeaway message 2: Testing, isolating and tracing while ensuring optimal healthcare system readiness to maintain high recovery and low fatality rates are key to keep viral spread under control.
A closer look at relaxation measures
On May 12, the WHO advised that, before reopening, rates of positivity in testing should remain at 5% or lower for at least 14 days3. This target is based on the experience of countries that have driven their case numbers down and largely stopped viral spread. Low positivity rates, along with the other parameters detailed above, are an important benchmark to gauge progress against the pandemic.
With the improvement in the indicators and given the high economic cost of the measures, the UAE partially lifted the curfew and relaxed the restrictions on movement on June 24. The government also announced the reopening of airports and shopping malls with limited restrictions.
However, NCEMA emphasized the importance of avoiding gatherings, practicing social distancing, and wearing masks and gloves when going out.
What’s next for the UAE’s infection curve?
Clearly, the number of active cases has been dropping (figure 4), but is the worst behind us? To try to answer this, we need to forecast how this curve will evolve. Many statistical models have been developed to put a horizon on when the curve will flatten. One model (figure 5) that caught our interest is a forecasting model, initially developed for applications in economics. This model exploits the experience of countries/regions in which the epidemic occurred early on, to refine forecasts and parameter estimates for locations in which the outbreak took place later in time. The model generates a 60-day projection of the number of active cases4.
The vertical dashed lines in figure 5 indicate the forecast origin. The circles indicate actual infections. The solid lines after the forecast origin represent medians of the forecasted distribution. The grey shaded bands indicate potential probabilities of deviation with most probabilities falling within the dark grey band.
The level of uncertainty (the dark and light grey bands) is still relatively high for Bahrain, Kuwait, Oman, and Saudi Arabia. The UAE and Qatar have less uncertainty and their medians are headed towards a flattening of the curve around October 2020. This low uncertainty is explained by the way the model is built, which relies on the experience of other countries at a similar stage of their curve and is driven by the positive measures that are put in place.
The new norm
A safe and effective human vaccine is currently not available for COVID-19, but 24 candidate vaccines are under clinical evaluation5. The UAE has launched phase III trials for Sinopharm's COVID-19 vaccine6. In addition, many countries, including the UAE, Saudi Arabia, Kuwait and Qatar, have submitted expressions of interest to protect their populations and those of other nations through joining the COVAX facility, which guarantees rapid, fair and equitable access to COVID-19 vaccines worldwide7. Until such access is provided, most people are not protected and are vulnerable to the virus.
It is obvious from the numbers and the forecast of active COVID-19 infections that the measures adopted by the UAE have paid off. While the curve seems to be headed towards flattening sometime in October 2020, citizens and residents are advised not to let down their guards to ensure that this projection materializes. Things could quickly change.
In this context, the UAE is educating and adopting a posture that all citizens are responsible. It has launched the hashtag #We_are_all_responsible to remind people that personal protective actions (physical distancing, personal hygiene, and wearing masks) are priorities.
*Dr. Muriel Tahtouh Zaatar is an assistant professor of biology at the University of Balamand Dubai - Dubai Investments House. She has a PhD in immunology-physiology and the biology of organisms from Lille I University, France. She is a regular member of the American Association of Immunologists, has numerous publications, and received multiple awards in the field of life sciences. This article is a collaboration with Dr. Bassam Mahboub, a consultant pulmonologist and head of the pulmonary medicine unit at Dubai Health Authority, where he is leading the innovation hub for care model innovation. He is American Board certified in internal medicine, pulmonology, allergy and clinical immunology. He also has an MBA from Wolverhampton University, UK. Professor Elie Tamer, the Louis Berkman Professor of Economics at Harvard University Cambridge provided guidance during the writing of this article. Professor Tamer's research is in econometrics and empirical industrial organization. He is a fellow of the Econometric Society, and a former co-editor of Econometrica and Quantitative Economics. He is also an editor of the Journal of Econometrics in the United States.