Tracking of COVID-19 in Libya

We noticed that the article was submitted on 16 March and was published online on 20 March. This was eight days earlier than the offi cial declaration of the fi rst case of COVID-19 in Libya. The author did not report about the required legally mandatory notifi cation of the cases to the local health authorities. This is of a great concern, due to the nature of infection and the fragility of the Libyan HealthCare systems.


Introduction
We read with interest the article entitled "Preliminary epidemiological analysis of suspected cases of corona infection in Libya" published by Dr. Daw MA, 2020. The author acknowledged the declaration of Coronavirus Disease 2019 (COVID-19) pandemic and the diffi culties in application of WHO and CDC measures in confl ict areas such as Libya.

Epidemiological, clinical and laboratory data
We noticed that the article was submitted on 16 March and was published online on 20 March. This was eight days earlier than the offi cial declaration of the fi rst case of COVID-19 in Libya. The author did not report about the required legally mandatory notifi cation of the cases to the local health authorities. This is of a great concern, due to the nature of infection and the fragility of the Libyan HealthCare systems.
There was no information about the time of conducting the research, its place, and eventual admission of the patients to intensive care units. There were no comments about respiratory symptoms especially respiratory rate and/ or dyspnea. Laboratory investigation did not include hypoxia assessment and blood gas results were not reported even for the two patients who died.
Total number of patients were eight, but in reporting about the radiological fi ndings, six patients (75%) had bilateral pneumonia and three patients (38%) had unilateral pneumonia, which make a total of nine different presentations.
We were wondering whether in reality there were fi ndings of unilateral pneumonia in two patients (25%) and multiple mottling in three patients (38%).
The author reported negative results for screening of respiratory viruses. There was no mention of the types of respiratory infections that were looked for. This is of paramount importance as some of the resources required might not be available, and many diseases such as Infl uenza The author reported the death of two patients out of the eight patients (25%). This is particularly a high case fatality rate from COVID-19 in comparison to reported fi gures on other parts of the world. This is of particular concern as, no data was mentioned about associated comorbidities, but the laboratory investigations reported that six patients were diabetics and six were anemic. The number of cases in this study is small, and no conclusive mortality rate can be withdrawn in the time being.
As two patients (25%) passed away, it would be worthy to know if they were patients with ground glass opacity, as it is usually found in the second week of COVID-19 infection. was not confi rmed.

Migration and spread of pandemic
The author had pointed out that migrants going through Libyan shores could endanger southern Europe countries.
However we know that the number of cases are already beyond control in Europe (Italy: >119,000, Spain: >124,000 and USA: >278,000 with mortalities on 4 April that mount to >3,300 in China, >14,600 in Itlay, > 11,700 in Spain and >74000 in USA).
Neither Libya, nor most African countries from where migrants do usually come are implicated in the pandemic until now [1].
The author rightly called for international efforts to be coordinated to fi ght the pandemic. Unfortunately, the shortcomings of the global health system and the low morals levels highlighted the importance of country-based efforts.
Early detection and reporting to local health authority are of primordial importance in such efforts.

Infection pattern and national health authority stand
The offi cial declaration of the fi rst case of COVID-19 in This is in contrast to similar diseases as SARS-CoV, which is mostly infectious during the peak of patient's illness, in a time when they are hospitalized with consequent limited mobility and chances of close contact with their entourage. One study showed that COVID-19 median incubation period is fi ve days, and 97.5% of patients develop symptoms within 11.5 days.
However, very small percent will develop symptoms after 14 days of quarantine [2]. COVID-19 is well known to have a fastspreading nature due to highest viral loads near presentation [3], where high load correlated with patient's severe disease [4]. These fi nding could justify clinical picture in fi rst Libyan case.

Conclusion
In our opinion, we need a confi rmation of COVID-19 cases by evidence-based laboratory and clinical means according to recognized standards. A discussion and reporting of these suspected cases to corresponding health authority, medical staff and public is mandatory in timely manner.
We praise the author for his close and timely follow-up of COVID-19 suspected cases, as this would help optimize management in this group of patients. Low population density in Libya, absence of humidity and very small InterCity's movements, could have a positive role in prevention of infection outbreak [7]. This should not by any mean divert us from the more cost-effective actions that was proved to be effective in China, with national plan comprising the "Four Es" or so called 4E strategy (early detection, early reporting, early isolation, early treatment) especially in the context of the fragile Libyan healthcare system.