Current situation · Current situation • COVID-19 transmission, as captured by reported cases, has started to level (Figure 1), while deaths have stayed steady for the last two

WHO EMRO Region Model updates for September 11, 2020

covid.healthdata.org Institute for Health Metrics and Evaluation

IHME’s latest COVID-19 forecasts indicate that the WHO Eastern Mediterranean Region (EMRO) will reach nearly 165,847 deaths by January 1. If mask wearing in public increases to 95%, there will be nearly 97,293 deaths, and about 68,554 lives could be saved.

Current situation

• COVID-19 transmission, as captured by reported cases, has started to level (Figure 1), while deaths have stayed steady for the last two weeks at around 350 deaths per day. Deaths have been declining since early July but seem to be leveling now with the possibility of rising again due to the rise in cases in August (Figure 2a).

• About 16% of deaths in the region are among those aged 45 or under (Figure 2b). • Examination of effective R (the number of new infections caused by each infection) on August 28 based on the

combined analysis of data on cases, hospitalizations, and deaths suggests that transmission is increasing in four countries: Iraq, Oman, Libya, and Palestine (Figure 3).

• The percent of the population infected with COVID-19 is still very low, with the highest rates observed in Iran, Iraq, Oman, Saudi Arabia, and Kuwait (Figure 4).

• The fraction of infections being detected has risen just a little during the epidemic, with the fraction of infections detected and reported as confirmed cases less than 7.5%. This rate has not improved in the past month (Figure 5).

• Countries with daily death rates over 1 per million are Iraq, Iran, Libya, and Oman (Figure 6).

Trends in key drivers of transmission (mobility, mask use, testing, and seasonality)

• Social distancing mandates have stayed relatively constant over the last week, with Lebanon in a two-week partial lockdown. Somalia is the only country with no mandates (Table 2 and Figure 7).

• Mobility – measured by app use on smartphones including Android and Apple IOS – has increased since early April, with a slight decline around the two major Islamic Holidays (Figure 8a). Mobility is now about 12% less than the baseline in January. It remained stable the past couple of weeks but shows some signs of slight decline lately. However, we expect the relaxation of mandates in the region will tend to increase mobility through September. The lowest levels of mobility are currently seen in Saudi Arabia (Figure 8b). A caution about our estimate of mobility is that due to the use of smart devices, we may have overestimated the decline in mobility, as wealthy people are more likely to reduce their mobility.

• Despite mask mandates in the EMRO region, mask use has declined to less than 40% (Figure 9a). The highest mask use is in the Gulf countries, but it is less than 30% in Afghanistan, Yemen, Palestine, Sudan, Egypt, Libya, and Tunisia (Figure 9b).

• COVID-19 testing rates have leveled in the region but are still below 45 per 100,000 (Figure 10a). The highest rates of testing are now in UAE (Figure 10b).

Projections

• Our estimate of cumulative deaths for EMRO has decreased to 165,847 deaths by January 1. It was 171,958 deaths in our last release (September 3). As of today, there have been about 54,451 COVID-19 deaths in the region. Our estimates suggest 111,396 deaths from now until January 1 (Figure 12).

• If a herd immunity strategy is pursued, we estimate 202,149 deaths in the region by January 1 (Figure 12). • We expect that the daily death rate will start increasing in the coming week and will reach 3,700 deaths per day

by January 1 (Figure 13). • These forecasts assume that countries will on average re-impose a package of social distancing mandates when

the daily death rate reaches 8 per million. Our current projections show that several countries will re-impose

WHO EMRO Region Model updates for September 11, 2020

covid.healthdata.org Institute for Health Metrics and Evaluation

mandates by January 1. In November, mandates are expected in Iraq, Palestine, Syria, and Morocco. Mandates are expected in Oman, Egypt, Libya, and Lebanon in December (Figure 15).

• If mask use were increased to 95% – the level observed in Singapore and several countries in Latin America – the projected number of deaths would be nearly 97,293 deaths, and about 68,554 lives could be saved. This is about a 62% reduction in the number of deaths expected between now and January 1 (Figure 12 and 13).

• By the week of January 1, COVID-19 is expected to be the fifth-leading cause of death in EMRO (Table 3).

EMRO-specific notes

• A caution for EMRO: since many of the countries have unrest or wars, the chance of under-reporting of cases and deaths due to lack of testing and poor vital registration is very high. Our current estimates do not include excess mortality.

• Some countries in the region have reported very few deaths, and they have peaked and are declining (Pakistan, Saudi Arabia, and Egypt). In addition to the under-reporting issue, it is possible that previous coronavirus infections are resulting in immunity to COVID-19. It is also possible that the size of contact networks is smaller in EMRO than in the West, or that “super spreaders” were removed from the pool (i.e., death or immunity of key “connectors” in a community such as a store employees, etc.).

Model updates

The large increase in daily deaths expected in late November and December is driven by continued increases in mobility, declines in mask use, and – most importantly – seasonality. We estimate the likely impact of seasonality by examining the trends in the Northern and Southern Hemisphere. For example, Southern Hemisphere countries such as Argentina, Chile, southern Brazil, and South Africa had much larger epidemics than expected based on mobility, testing, and mask use. The statistical association between COVID-19 transmission rates and pneumonia seasonality patterns is strong in our data and is the basis for our estimate of the magnitude of the seasonal increase that is expected.

Clinical experience suggests that case management of COVID-19 has improved through oxygenation/ventilation methods and the use of dexamethasone and remdesivir. This improved management would manifest itself as a reduction in the infection-fatality rate at each age. We have looked for statistical evidence of this shift in two ways. First, we have examined the COVID-19 admission-fatality rate – the number of deaths divided by hospital admissions. To date, the admission-fatality rate has remained constant since April. This could be explained by two possible factors. First, it is possible that there is no change in the infection-fatality rate. Second, it is possible that the infection-fatality rate has declined because hospitals are admitting only more severe patients over time, and performing better triage. However, we have looked at the directly measured infection-fatality rate using seroprevalence studies. To date we have not detected any statistically significant decrease in the infection-fatality rate. We will continue testing on a regular basis for statistical evidence of the infection-fatality rate declining, but we do not see it based on our sero-positive analyses yet.

Eastern Mediterranean Region MODEL UPDATES

COVID-19 Results Briefing: the Eastern Mediterranean Region

Institute for Health Metrics and Evaluation (IHME)

September 11, 2020

This briefing contains summary information on the latest projections from the IHME model on COVID-19 inthe Eastern Mediterranean Region. The model was run on September 11, 2020.

Model updates

Updates to the model this week include additional data on deaths, cases, and updates on covariates.

covid19.healthdata.org 1 Institute for Health Metrics and Evaluation

Eastern Mediterranean Region CURRENT SITUATION

Current situation

Figure 1. Reported daily COVID-19 cases

0

5,000

10,000

15,000

20,000

Apr May Jun Jul Aug SepMonth

Cou

nt

Daily cases



Table 1. Ranking of COVID-19 among the leading causes of mortality this week, assuming uniform deathsof non-COVID causes throughout the year

Cause name Weekly deaths RankingIschemic heart disease 15,912 1Neonatal disorders 7,028 2Stroke 6,729 3Lower respiratory infections 3,385 4Road injuries 2,935 5Cirrhosis and other chronic liver diseases 2,806 6Chronic kidney disease 2,501 7Diabetes mellitus 2,403 8Diarrheal diseases 2,386 9Chronic obstructive pulmonary disease 2,315 10COVID-19 2,211 11

Figure 2a. Reported daily COVID-19 deaths and smoothed trend estimate

0

200

400

600

May Jun Jul Aug Sep

Dai

ly d

eath

s



Figure 2b. Estimated cumulative deaths by age group

0.0

2.5

5.0

7.5

10.0

12.5

<5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 99Age group

Sha

re o

f cum

ulat

ive

deat

hs, %

Figure 3. Mean effective R on August 28, 2020. The estimate of effective R is based on the combined analysisof deaths, case reporting and hospitalizations where available. Current reported cases reflect infections 11-13days prior so estimates of effective R can only be made for the recent past. Effective R less than 1 meansthat transmission should decline all other things being held the same.

<0.87

0.87−0.9

0.91−0.93

0.94−0.96

0.97−0.99

1−1.02

1.03−1.05

1.06−1.08

1.09−1.12

>=1.13



Figure 4. Estimated percent infected with COVID-19 on September 08, 2020

<1

1−1.9

2−2.9

3−3.9

4−4.9

5−5.9

6−6.9

7−7.9

>=8

Figure 5. Percent of COVID-19 infections detected. This is estimated as the ratio of reported COVID-19cases to estimated COVID-19 infections based on the SEIR model.

0

5

10

15

Feb Mar Apr May Jun Jul Aug Sep

Per

cent

of i

nfec

tions

det

ecte

d

African Region

Region of the Americas

South−East Asia Region

European Region

Eastern Mediterranean Region

Western Pacific Region



Figure 6. Daily COVID-19 death rate per 1 million on September 08, 2020

<1

1 to 1.9

2 to 2.9

3 to 3.9

4 to 4.9

5 to 5.9

6 to 6.9

7 to 7.9

>=8


Eastern Mediterranean Region CRITICAL DRIVERS

Critical drivers

Table 2. Current mandate implementation

All

gath

erin

gs r

estr

icte

d

All

none

ssen

tial b

usin

esse

s cl

osed

Any

bus

ines

ses

rest

ricte

d

Mas

k us

e

Sch

ool c

losu

re

Sta

y ho

me

orde

r

Trav

el li

mits

Yemen

United Arab Emirates

Tunisia

Syrian Arab Republic

Sudan

Somalia

Saudi Arabia

Qatar

Palestine

Pakistan

Oman

Morocco

Libya

Lebanon

Kuwait

Jordan

Iraq

Iran (Islamic Republic of)

Egypt

Djibouti

Bahrain

Afghanistan

Mandate in place No mandate



Figure 7. Total number of mandates

Yemen

United Arab Emirates

Tunisia

Syrian Arab Republic

Sudan

Somalia

Saudi Arabia

Qatar

Palestine

Pakistan

Oman

Morocco

Libya

Lebanon

Kuwait

Jordan

Iraq

Iran (Islamic Republic of)

Egypt

Djibouti

Bahrain

Afghanistan


# of mandates

0

1

2

3

4

5

6

Mandate imposition timing



Figure 8a. Trend in mobility as measured through smartphone app use compared to January 2020 baseline

−50

−25

0

Jan Feb Mar Apr May Jun Jul Aug Sep

Per

cent

red

uctio

n fr

om a

vera

ge m

obili

ty

African Region



European Region



Figure 8b. Mobility level as measured through smartphone app use compared to January 2020 baseline(percent)

=<−50

−49 to −45

−44 to −40

−39 to −35

−34 to −30

−29 to −25

−24 to −20

−19 to −15

−14 to −10

>−10



Figure 9a. Trend in the proportion of the population reporting always wearing a mask when leaving home

0

20

40

60

Jan Feb Mar Apr May Jun Jul Aug Sep

Per

cent

of p

opul

atio

n

African Region



European Region



Figure 9b. Proportion of the population reporting always wearing a mask when leaving home on September08, 2020

<30%

30 to 34%

35 to 39%

40 to 44%

45 to 49%

50 to 54%

55 to 59%

60 to 64%

65 to 69%

>=70



Figure 10a. Trend in COVID-19 diagnostic tests per 100,000 people

0

50

100

150


Test

per

100

,000

pop

ulat

ion

African Region



European Region



Figure 10b. COVID-19 diagnostic tests per 100,000 people on September 03, 2020

<5

5 to 9.9

10 to 24.9

25 to 49

50 to 149

150 to 249

250 to 349

350 to 449

450 to 499

>=500



Figure 11. Increase in the risk of death due to pneumonia on February 1 compared to August 1

<−80%

−80 to −61%

−60 to −41%

−40 to −21%

−20 to −1%

0 to 19%

20 to 39%

40 to 59%

60 to 79%

>=80%


Eastern Mediterranean Region PROJECTIONS AND SCENARIOS

Projections and scenarios

We produce three scenarios when projecting COVID-19. The reference scenario is our forecast of what wethink is most likely to happen. We assume that if the daily mortality rate from COVID-19 reaches 8 permillion, social distancing (SD) mandates will be re-imposed. The mandate easing scenario is what wouldhappen if governments continue to ease social distancing mandates with no re-imposition. The universal maskmandate scenario is what would happen if mask use increased immediately to 95% and social distancingmandates were re-imposed at 8 deaths per million.

Figure 12. Cumulative COVID-19 deaths until January 01, 2021 for three scenarios.

0

50,000

100,000

150,000

200,000

0

50

100

150

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan

Cum

ulat

ive

deat

hsC

umulative deaths per 100,000

Continued SD mandate easing

Reference scenario

Universal mask use

Fig 13. Daily COVID-19 deaths until January 01, 2021 for three scenarios.

0

1,000

2,000

3,000

0

1

2

3


Dai

ly d

eath

sD

aily deaths per 100,000


Reference scenario

Universal mask use



Fig 14. Daily COVID-19 infections until January 01, 2021 for three scenarios.

0

500,000

1,000,000

1,500,000

0

500

1000

1500


Dai

ly in

fect

ions

Daily infections per 100,000


Reference scenario

Universal mask use

Fig 15. Month of assumed mandate re-implementation. (Month when daily death rate passes 8 per million,when reference scenario model assumes mandates will be re-imposed.)

September

October

November

DecemberNo mandates before Jan 1



Figure 16. Forecasted percent infected with COVID-19 on January 01, 2021

<1

1−1.9

2−2.9

3−3.9

4−4.9

5−5.9

6−6.9

7−7.9

>=8

Figure 17. Daily COVID-19 deaths per million forecasted on January 01, 2021 in the reference scenario

<1

1 to 1.9

2 to 2.9

3 to 3.9

4 to 4.9

5 to 5.9

6 to 6.9

7 to 7.9

>=8



Table 3. Ranking of COVID-19 among the leading causes of mortality in the full year 2020. Deaths fromCOVID-19 are projections of cumulative deaths on Jan 1, 2021 from the reference scenario. Deaths fromother causes are from the Global Burden of Disease study 2019 (rounded to the nearest 100).

Cause name Annual deaths RankingIschemic heart disease 827,400 1Neonatal disorders 365,500 2Stroke 349,900 3Lower respiratory infections 176,000 4COVID-19 165,847 5Road injuries 152,600 6Cirrhosis and other chronic liver diseases 145,900 7Chronic kidney disease 130,100 8Diabetes mellitus 125,000 9Diarrheal diseases 124,000 10

Mask data source: Premise; Facebook Global symptom survey (This research is based on survey resultsfrom University of Maryland Social Data Science Center); Kaiser Family Foundation; YouGov COVID-19Behaviour Tracker survey

A note of thanks:

We would like to extend a special thanks to the Pan American Health Organization (PAHO) for keydata sources; our partners and collaborators in Argentina, Brazil, Bolivia, Chile, Colombia, Cuba, theDominican Republic, Ecuador, Egypt, Honduras, Israel, Japan, Malaysia, Mexico, Moldova, Panama, Peru,the Philippines, Russia, Serbia, South Korea, Turkey, and Ukraine for their support and expert advice; andto the tireless data collection and collation efforts of individuals and institutions throughout the world.

In addition, we wish to express our gratitude for efforts to collect social distancing policy information inLatin America to University of Miami Institute for Advanced Study of the Americas (Felicia Knaul, MichaelTouchton), with data published here: http://observcovid.miami.edu/; Fundación Mexicana para la Salud(Héctor Arreola-Ornelas) with support from the GDS Services International: Tómatelo a Pecho A.C.; andCentro de Investigaciones en Ciencias de la Salud, Universidad Anáhuac (Héctor Arreola-Ornelas); Lab onResearch, Ethics, Aging and Community-Health at Tufts University (REACH Lab) and the University ofMiami Institute for Advanced Study of the Americas (Thalia Porteny).

Further, IHME is grateful to the Microsoft AI for Health program for their support in hosting our COVID-19data visualizations on the Azure Cloud. We would like to also extend a warm thank you to the many otherswho have made our COVID-19 estimation efforts possible.


http://observcovid.miami.edu/

Documents

Current situation · Current situation • COVID-19 transmission, as captured by reported cases, has started to level (Figure 1), while deaths have stayed steady for the last two