JMIR Publications

ABSTRACT

Background:

Coronavirus disease 2019 (COVID-19) is caused by Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As of September 7, 2020, a total of 27,314,629 confirmed COVID-19 cases and 893,474 related deaths have been reported worldwide (WHO 2020). In Egypt, a total of 99,863 confirmed COVID-19 cases and 5,530 related deaths have been reported as of September 7, 2020 (WHO 2020). Influenza like Illness (ILI) sentinel surveillance in Egypt started in year 2000 in 8 sentinel sites geographically distributed all over the country. Patients presenting to the outpatient clinics in the participating hospitals with fever and cough within the last 10 days are required to provide throat swabs to be kept in viral transport media (VTM), stored in nitrogen tank at -80 ⁰C and shipped on a weekly basis to the Central Public Health Lab (CPHL) in Cairo for testing for influenza types and subtype by reverse transcription polymerase chain reaction (RT-PCR). Patients’ demographic and clinical data are collected in a special database that is regularly analyzed. Reports with the rate of influenza positivity and prevalent influenza type and subtype is provided to decision makers and relevant stakeholders on a weekly basis. Since the beginning of the COVID-19 pandemic, Egypt Ministry of Health and Population (MoHP) requested adding SARS-CoV-2 to the testing panel in all ILI surveillance sites. Early in the pandemic, CPHL was the only laboratory approved by MoHP for SARS-CoV-2 testing. Accordingly testing for influenza was on hold starting from October 2019 and specimens collected from ILI patients were archived at -70°C for subsequent testing when possible. As the number of COVID-19 patients in Egypt started to decline in August 2020, CPHL set up to test the archived specimens collected by ILI sites for influenza type and subtype, and SARS-CoV-2 by RT-PCR (Viasure Sars-CoV-2 Real Time PCR Detection Kit (CerTest Biotec, Spain). A recent report from CPHL released on 16th August 2020 identified a case with mixed SARS-CoV-2 and Flu-A/H1 viruses infection. This report aims at describing how the case was identified and the patient’s demographic and clinical characteristics and outcomes.

Objective:

This report aims at describing how the case was identified and the patient’s demographic and clinical characteristics and outcomes.

Methods:

Influenza like Illness (ILI) sentinel surveillance in Egypt started in year 2000 in 8 sentinel sites geographically distributed all over the country. Patients presenting to the outpatient clinics in the participating hospitals with fever and cough within the last 10 days are required to provide throat swabs to be kept in viral transport media (VTM), stored in nitrogen tank at -80 ⁰C and shipped on a weekly basis to the Central Public Health Lab (CPHL) in Cairo for testing for influenza types and subtype by reverse transcription polymerase chain reaction (RT-PCR). Patients’ demographic and clinical data are collected in a special database that is regularly analyzed. Reports with the rate of influenza positivity and prevalent influenza type and subtype is provided to decision makers and relevant stakeholders on a weekly basis. Since the beginning of the COVID-19 pandemic, Egypt Ministry of Health and Population (MoHP) requested adding SARS-CoV-2 to the testing panel in all ILI surveillance sites.

Results:

Case presentation Among 510 specimens collected from patients with ILI symptoms from October 2019 to August 2020,29(5.7%) were positive for influenza. Of those, 15(51.7%) had A/H1, 11(38.0%) A/H3, and 3(10.3%) Flu-B. The first case of COVID-19 in Egypt was announced on the 14th of February, whereas the ILI surveillance caught its first COVID-19 case two weeks later announcing the beginning of community transmission of the disease in Egypt. Of the 510 specimens tested, 61 (12.0%) were COVID-19 positive (Figure 1). One case was confirmed for both SARS-CoV-2 and influenza A/H1. The case presented to the outpatient clinic of one of the ILI surveillance sites that serves slum area in Cairo on the 18th of May 2020. She was 21-year-old female student complaining of fever, cough, fatigue, and malaise for two days with no other symptoms or associated comorbidities. She presented with high fever of 40.2°C, her chest was free on auscultation. The patient was swabbed and sent home for treatment, she was given symptomatic treatment in the form of antipyretic, antitussive and oral Cefadroxil 2gm per day. Symptoms persisted for two days followed by full recovery. No investigations were performed as the patient had no lower respiratory tract symptoms. At home, no isolation was done for the case and four out of her five family contacts had mild respiratory symptoms 2-3 days after exposure to the confirmed case. Secondary cases included the two parents (both are 49 years of age), two brothers (9 and 16 years old) all recovered within 2-3 days, except the father who was having hypertension and recovered in two weeks. All her contacts did not seek healthcare and recovered without treatment.

Conclusions:

treatment. Discussion Dual infection of corona viruses and Influenza A viruses was reported before (Jiang 2020). During the current COVID-19 pandemic, co-infection of SARS-CoV-2 and influenza A/H1 was reported from many countries including China, Italy, Iran, and Japan (Wu 2020, D’Abramo 2020, Hashimi 2020, Kondo 2020, Azekawa 2020). The case reported from Egypt was a young female whereas most of the patients reported from other countries were older ages. In a mini-review that describes 37 patients with SARS-CoV-2 and influenza coinfection by D’Abramo et al., it was found that 66.7% of patients were ≥50 years of age, and 56.5% were males (D’Abramo 2020). Most of the cases with co-infection reported from other countries had prolonged course ofthe disease, with all of them admitted to hospital (Wu 2020, D’Abramo 2020, Hashimi 2020, Kondo 2020, Azekawa 2020). While the case reported from Egypt had mild symptoms, she was detected during routine ILI surveillance activities. She had short course of 4 days with home treatment, that is why she had no radiology or blood testing done. Her contacts even had milder symptoms, so they did not seek any medical advice. Most of the cases with co-infection reported had predisposing factors reducing their immunity and many of them required mechanical ventilation and/or ICU admission. It was found that more than 60% of patients with co-infection had comorbidities, 33% needed artificial ventilation, and 29% were admitted to ICU5. Up-to date the case reported from Egypt is the only one with mild upper respiratory symptoms reported from any country. This could be related to her age and gender in addition to the absence of pre-disposing comorbidities. Results of ILI patients testing indicated that more than 80% of cases were negative for both SARS-CoV-2 and influenza. Broader viral testing might be needed to identify the etiology particularly if it would affect patient treatment (Kondo 2020). Conclusion: Egypt is reporting a case of SARS-CoV-2 and influenza A/H1 co-infection with mild ILI symptoms. This finding suggested that co-infection can occur in people of younger ages with no comorbidities. The report showed that patient immunity can overcome both infections leading to full recovery in a short period with no need to medical procedures. ILI surveillance proved effective in detection of the viral causes of patients with ILI symptoms. Broadening of the testing panel is recommended especially if it could guide case management.