"The corridors are no longer safe."
A sentence used by Elham, a nurse at Al Sadr Hospital in Beni Sueif, to describe her fears every time she crossed the hallway to the coronavirus isolation section. It didn’t take long for her fears to become a reality. She developed symptoms, tested positive and was transferred to another hospital to receive the same care she had been providing her patients.
Sayed, a nurse working at the National Cancer Institute, also developed symptoms. He couldn’t get a diagnostic test at his hospital so he had to use his colleague’s car to drive to several hospitals before being able to get tested.
Ghada, a nurse at Ain Shams General Hospital, continued working after being exposed to droplets from a patient. She couldn’t get a test at her hospital as the health ministry’s guidelines stated that only healthcare workers who have symptoms can be tested. When her children started showing symptoms, Ghada finally managed to coordinate with a member of the infection control team to get the PCR test as a regular patient. She and two of her four children tested positive.
This report follows cases of healthcare workers who were infected with Covid-19 and documents how the Egyptian Health Ministry failed to protect public healthcare workers by following incomplete, sometimes contradictory safety protocols and not adopting clear strategies for early detection and limiting of infections amongst public hospitals’ staff.
Ain Shams General Hospital team
according to data by the Central Agency for Public Mobilization and Statistics 2018
According to the World Health Organization (WHO) as a healthcare worker with exposure to the virus, Ghada should have been equipped with the highly effective N95/FFP2 mask. She should have also been given a PCR test after 14 days of self-isolation, based on the Egyptian health ministry’s own guidelines. Ghada says none of this was implemented.
After isolating at home, Ghada developed complications that necessitated her transfer to the hospital. "I self-administered the oxygen. The building security personnel and my colleagues were afraid of me," she remembers.
She still had symptoms when she was called back to work, so she requested a test to confirm her recovery. The hospital denied her request and gave her no choice but to return to work. According to the Health Ministry’s guidelines at the time, 28 days were considered sufficient confirmation for recovery which meant infected healthcare workers returning to work were not tested. Ghada says the hospital did a throat swab test for healthcare workers who were in self-isolation, but they were never shown the results.
The hospital's infection control director, who had tested positive himself, could not be reached for comment. Meanwhile, the head of the nursing team, who preferred to only publish her first initials N.A., agreed that the ministry did not provide a sufficient number of PCR tests.
By mid-April, two months after the first infection in Egypt, the Ministry of Health had not yet announced a unified protocol to deal with infected healthcare workers. It was left up to each hospital’s administration. Meanwhile, Egyptian Minister of Health Hala Zayed announced setting up thirty isolation centers in hospitals across Egypt for Covid-19 patients.
The first unified protocol was issued on April 18. However, according to the doctors syndicate, public hospitals’ healthcare workers in clinics and emergency rooms continued to work without a clear and unified protocol. Doctors and syndicate members said different hospitals and clinics were using different protocols that were inadequate in fighting the pandemic. The syndicate accused the health ministry of being responsible for the death of healthcare workers because of “negligence.”
The Health Ministry database did not have updated numbers for infected healthcare workers until June 1st.
But the ministry’s official records show that the numbers increased from a handful in mid-March to 81 at the beginning of April, about 10 percent of the reported cases in Egypt at the time. The number of infected healthcare workers rose again to 13% by mid-April according to statements by the former WHO official in Egypt, Jan Jabbour.
According to data from the Ministry of Health and Population as of June 3, 2020
Public and central hospitals to serve COVID-19 patients
* Click on the red dots to see the number of hospitals in each governorate
A health ministry statement issued later, on May 25th, said 11 healthcare workers had died of Covid-19 and 291 were infected. A statement with conflicting numbers was issued on the same day by the doctors syndicate putting the number of deaths amongst healthcare workers at 19 deaths and infections at 350. The numbers increased to 160 deaths and over a thousand cases by mid-September, according to Dr. Mohamed Abdel-Hamid, treasurer of the doctors syndicate. By early November, the death toll surpassed 200 and infections 3500, according to Dr. Iman Salama, the rapporteur of the doctors’ syndicate’s social committee.
Estimates by the local syndicate branches show that over 20 percent of healthcare workers were infected in some hospitals. Out of 300 thousand nurses in Egypt, 220 thousand of whom work in public hospitals, 21 thousand were admitted to isolation centers, according to head of the Egyptian nursing syndicate Kawthar Mahmoud.
Over the course of three months, from mid-February to mid-May, this report tracked news of hospital closures in news websites and newspapers, and documented, through official sources, confirmed cases of infection transmission amongst healthcare workers in over 30 hospitals including Ain Shams, Zaytoun Specialist, Al Zahra Al Jamii, Al Shorouk and Banha Al Jamii. According to 30 testimonies, the reasons for the infections included the absence of clear protocols to deal with the pandemic or confusion due to adopting updated protocols that contradicted existing ones. The report also documents 20 cases, through hospital data that included the date of infection, diagnosis and tests taken as well as data issued by the Ministry of Health which followed treatments given to Covid-19 patients.
Sayed, the nurse at the National Cancer Institute, recounts how it all started on March 21 when a child with Covid-19-like symptoms was admitted to the emergency room.
The child was not given a PCR test as there was no protocol in place requiring public hospitals to do so. The health ministry recommends that regular patients, who are not suspected of having Covid-19, be screened by checking their temperatures and any respiratory issues before entering the hospital and requires that they should wear an N95 | FFP2 mask. “They did not provide us with these masks either and we were just told to ‘be careful,’” says Sayed.
We corroborated Sayed’s claims by speaking to fifty workers in twenty hospitals, all of whom confirmed that “personal protective equipment, including medical masks,” were not provided and when available were of poor quality, easy to tear and let air in. This was also confirmed by the syndicate’s statements and letters by the medical equipment division of the Federation of Egyptian Industries.
Sayed requested that his last name be withheld because he says some of the nurses and doctors were threatened by the hospital directors after protesting against the lack of safety measures. He adds that some were even punished by being reassigned to other hospitals temporarily.
Sayed had to use a regular mask when dealing with the suspected case. Soon after, he started experiencing severe pain and high temperature. He couldn’t get an ambulance from his hospital to take him to Al-Munira Hospital, which was designated for suspected Covid-19 cases, so his colleague Mohamad drove him in his car. Mohamad later got infected himself, although he says he cannot confirm that driving Sayed was the cause. “Either I picked it up from the child we admitted in the emergency room, or after that from Sayed. But I know that I definitely passed the infection on to my family.”
There were numerous cases of hospital workers transmitting the disease to their families, including Zain, an accountant at the Nasser Institute Hospital in Cairo, who infected nine members of his family.
His daughter, Hadeer, is a doctor with the infection control team at Bahtim Shubra al-Khaimah Hospital. “Not only did the institute conceal the infection of one of the administrative workers, but it also refused to provide PCR tests to people working in the same office. My father was only allowed to receive blood tests and a CT scan, and accordingly the diagnosis came back as a common cold instead of coronavirus,” she says.
Hadeer adds that the distribution of personal protective equipment to hospital workers was random and depended on availability. She says the priority was given to the teams in closest contact with the virus, such as doctors and nurses in intensive care units.
It was hard for Zain to get a PCR test to confirm he has Covid-19, especially as some governors and towns decided to reduce testing entirely by requiring the signature of two doctors from the hospital’s isolation team or by replacing tests with CT scans and blood tests.
Hadeer managed to have her father and close family members tested by using her personal connections and transferred her father to the isolation unit at Alexandria Hospital and her mother to Qaha Hospital before finding out that she had also been infected along with her siblings, one of her uncles and his family.
Meanwhile, workers in different hospitals were demonstrating and demanding PCR tests for themselves and people they have been in contact with, but with no success.
The Respiratory Disease Hospital in Mansoura in the Dakahlia governorate witnessed one of those demonstrations.
Mona, a nurse at the hospital, remembers what happened. “After nine staff members were infected with corona, we asked for PCR tests for the workers on the same floor. They told us we must have symptoms first. By the time we started having symptoms, the infection had already been transmitted to the nursing staff on another floor.” She says 30 hospital workers ended up going into self-isolation.
“We became a source of infection. The hospital director even gave instructions to ban the nursing staff from entering his office."
The Nurses’ Syndicate confirmed receiving complaints from nurses in different hospitals. Ihab El-Taher, secretary general of the doctors syndicate, criticizes postponing the diagnostic tests till after symptoms appear. “It is wrong to link safety rules to the emergence of symptoms. This meant the team whose goal is to combat the pandemic became a source of transmission of the virus. We have repeatedly called for comprehensive testing of healthcare workers to reduce transmission rates before the development of symptoms, but to no avail.”
The ministry of health issued a number of decisions in March and April to contain the virus. They included suspending work in outpatient clinics, creating infection control departments in hospitals, designating certain routes for suspected cases and conducting daily morning screenings for hospital staff. The guidelines also included designating a “compliance officer” from the hospital's infection control team to ensure the measures were being followed. However, doctors found these measures to be a burden on top of their already hectic schedules and some hospitals did not implement them.
The ministry also announced that the General Administration for Infection Control was the only body authorized to issue statements for combating the virus to avoid confusing and contradictory instructions. It also said that treatment services should partially or completely be stopped if there’s continuous infection amongst the hospital staff, but without specifying the number of cases that would warrant that. The ministry also said healthcare workers should follow a rotation system to limit exposure.
The measures looked good on paper, but in reality were not always clear, effective or followed.
“At the beginning of the crisis, we waited for specialized infection control teams to take over the task of monitoring preventive measures and our safety, but protecting medical staff was not among the ministry’s priorities,” says Karim Mesbah, a doctor and member of the doctors’ syndicate council. Mesbah was shocked by accusations directed at doctors and claims that they didn’t want to work.
This prompted some doctors to threaten to resign in opposition to the "bad procedures" as Khaled Nashaat, a doctor at Al-Shorouk Hospital Khaled Nashaat, puts it. Nashaat refused to complete his assignment at Cairo International Airport in protest against procedures used to diagnose staff members who were in contact with a positive case by using the rapid test instead of a PCR.
Under pressure by the prime minister’s office, the Ministry of Health had to form an inquiry committee to look into the reasons for the collective resignation of doctors at Al-Munira Hospital. The doctors announced their resignation and posted it on their Facebook pages after the death of one of their colleagues, which they blamed on the “bad procedures.”
The rate of infection among medical staff, according to the data of the Ministry of Health until April 2, 2020
Meanwhile, the 31 isolation hospitals and the screening departments at the fever and chest hospitals were following protocols consistent with the recommendations of the WHO. Therefore, when Ilham developed a slight cough, she and her colleagues got tested. Six of them were positive. None of them returned to work until two PCR tests confirmed their recovery.
The isolation hospitals then replaced the PCR tests with rapid antigen tests to detect infections amongst healthcare workers. Dr. Abd al-Rahman Abd al-Latif believes the accuracy of the rapid test does not match that of the PCR test, which is why he decided to self-isolate for 14 days even after his rapid test results were negative.
Al-Taher, secretary of the doctors syndicate, says the ministry was mistaken in switching testing methods. “Every day they come up with something new.”
The reporter tried to contact Khaled Mujahid, spokesperson for the Ministry of Health, but he did not respond. Dr. Ihab Attia, the director general of the Public Administration for Infection Control and Mustafa Ghanima, general manager of Curative Care said they were under strict instructions not to provide any information to the media without permission from the ministry’s spokesperson.
Sayed and Ghada both returned back to work. Meanwhile, fifteen of Ghada’s colleagues were also infected. Another nurse, who preferred to publish only her initials N.R., says, "how do we even know if we’ve recovered from the virus?” N.R. repeatedly asked for PCR tests before returning to work, but couldn’t get one.
“There is no problem in returning to work, but we must make sure that we have recovered first. I am still afraid of hugging my children,” says another nurse at the hospital, G.H.
But two nurses who were interviewed for this report, Fatima and Basma, did not return to work. After developing complications from contracting the virus, they both died.
According to the World Health Organization office in Cairo until mid-April
According to the World Health Organization office in Cairo until mid-April
Head of Preventive Medicine Sector, April
Statement of the Ministry of Health for quarantine chest and fever hospitals, fevers, May 25
Doctors Syndicate statement, May 25
according to the Doctors Syndicate in early November