Addressing the real trajectory of COVID-19 in the Eastern Mediterranean region - Authors' reply.

Our Correspondence was based on the analysis of available data on the COVID-19 pandemic in the Eastern Mediterranean region. The objectives were to highlight the upsurge in COVID-19 cases since February, 2021, and to alert about the risk of further degradation of the epidemiological situation due to the evolution of key determinants, such as the decreased adherence to public health and social measures, emergence of more transmissible variants, and insufficient vaccination coverage.

Social determinants of health are key factors in the pandemic, and we have clearly acknowledged this point, but until high vaccination coverage has been reached, public health and social measures are the only effective measures to control the spread of SARS-CoV-2. Reasons for the decreasing adherence to public health and social measures include a decrease of trust in governments, a denial of the pandemic among populations, and fatigue due to imposed restrictions.

Most of these reasons are not mentioned by Khuloud Alsaba. There is no evidence that any Eastern Mediterranean region government has denied the pandemic. On the contrary, at the request of governments in the region, WHO has done review missions that include assessment of all aspects of the response, including governance, whole-of-government, and whole-of-society approaches. During the regular ministerial meetings convened by the WHO Eastern Mediterranean region, there has been no COVID-19 denial, although strategic priorities and approaches might vary.

The WHO Health Emergency programme was established to respond to the health needs of vulnerable populations. The Eastern Mediterranean region is home to 43% of people who need humanitarian assistance and the source of 64% of the world's refugees, and where access to basic sanitation and drinking water is denied to 174 million and 84 million people, respectively.

These people are at higher risk of infection by the SARS-CoV-2 virus. However, the lowest COVID-19 incidence and mortality rates are reported in the most fragile countries within the Eastern Mediterranean region (appendix), and no major upsurge of cases has been reported in refugee camps.

The under-reporting of cases and deaths, and the absence of upsurge are due to limited access to health facilities, poorly developed surveillance systems, insufficient testing capacity, restricted international arrivals limiting virus introduction, reduced internal mobility, and demographics.

It is erroneous to think that the spread of COVID-19 can be solely explained by poor social determinants of health and misconduct of governments. According to the WHO COVID-19 dashboard, as of May 18, 2021, the ten countries reporting the highest number of cases included the USA, France, the UK, Italy, Germany, and Spain, all of which have democratic systems and some of the highest gross domestic product in the world.

COVID-19 is a new and complex disease which is still misunderstood, and we are encouraging impartial, collaborative research from experts in virology, epidemiology, vaccinology, sociology, and economy.

We declare no competing interests.