Islamic Republic of Afghanistan

Ministry of Public Health

Monitoring & Evaluation and Health Information System General Directorate

Prevalence of COVID-19 and its Related Deaths in Afghanistan: A

Nationwide, Population-Based Seroepidemiological Study
July 2020

Adopted from:
Version: 1.1
Date: 17 March 2020
Contact: EarlyInvestigations-2019-nCoV@who.int

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Principle Investigator and Co-investigator:

Principle Investigator: Sayed Ataullah Saeedzai

Co-Investigators: Dr. Ahmad Jawad Osmani, Dr. Bashir Noormal, Dr. Mohammad Nadir
Sahak, Dr. Jamaluddin Ahadi, Dr. Hafiz Rasooly, Giti Azim, Bahara Rasoly, Dr. Niaz M.
Achakzai, Dr. Daud Altaf, Dr. Abdul Naser Ikram, Dr. Ahmad Wali Rasekh, Akmal Samsor,
Fatima Arifi

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List of abbreviations:

ANC Antenatal Care

CDC Centers for Disease Control and Prevention

CI Confidence Interval

DHIS2 District Health Information-2

EA Enumeration Area

ELISA Enzyme linked Immuno Sorbent Assay

FDA Food and Drug Administration

GCMU Grant Contract Management Unit

ICU Emergency Center Unit

IRB Institutional Review Board

NGO Non-governmental Organization

NSIA National Statistics and Information Authority

PMO Performance Management Office

PPHD Provincial Public Health Directorates

PNC Postnatal Care

RDT Rapid Diagnostic Test

STATA South Texas Art Therapy Association

USAID United States Agency for International Development

WHO World Health Organization

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Acknowledgment:

The National Survey of Prevalence of COVID-19 and its Related Deaths in Afghanistan have been led
by Monitoring & Evaluation and Health Information System General Directorate in the country. The
main objective of the survey was understanding the COVID-19 infection and death rate in the country.
Hereby, I would like to convey my sincere gratitude from enthusiastic efforts of survey principle
investigator and co-investigators for their dedication in implementing this survey. Moreover, it is
worthy to appreciate from all survey regional Master Trainers, National Statistic and Information
Authority (NSIA) team, World Health Organization (WHO) team, USAID, World Bank, CDC US,
Performance Management Office (PMO), GCMU, ANPHI, all Provincial Public Health Directorates
(PPHDs), Health promotion Department (HPD), all BPHS and EPHS Implementing NGOs, survey
steering committee team, Data management teams for their efforts during the survey. Apparently with
no doubt the efforts undertaken by all the mentioned teams have made implementation of this survey
successful within the given tight deadline.

Additionally, I would also like to express my appreciation to all the participants of the survey for their
consent to participate.

Sincerely

Dr. Ahmad Jawad Osmani

Acting Minister - Ministry of Public Health

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 Table of Contents:
Background: ........................................................................................................................................ 2
Objectives: ....................................................................................................................................... 2
Methodology: ...................................................................................................................................... 3
Sampling Strategy and Sample Size of the Study ......................................................................... 3
Sample Collection for RDT and ELISA: ....................................................................................... 3
COVID-19 IgG/IgM Rapid Test Cassette ................................................................................. 3
Data Collection, Management and Analysis ................................................................................. 4
Quality Assurance from Implementation of the Survey .............................................................. 4
Results: ................................................................................................................................................. 6
Rapid Diagnostic Test (RDT) Results ............................................................................................... 6
RDT results for 18 years or above ................................................................................................ 6
RDT results for 5 to 17 years ........................................................................................................ 8
Conclusions.....................................................................................................................................12
Recommendations ..........................................................................................................................13
Study limitations ............................................................................................................................14
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Background:

The COVID-19 disease has been spreading to 213 countries since start of epidemic in China
(Wuhan). As of 10th August 2020, over 20 million (20,104,418) positive cases have been
detected in all over the world, with more than 7 hundred thousand (735,305) deathsi.
Afghanistan has reported the first case of COVID-19 in Herat province on 24th Feb 2020 who
had travel history to Iran. As of 10th August 2020, Afghanistan has reported 37,162 positive
cases and with 1,328 deathsii.

So far, no vaccine has been introduced and there is no effective and specific treatment for
COVID-19; hence, the countries have recommended non-pharmaceutical measures such as
social distancing, home quarantine, closure of schools and universities, and avoiding gathering
in order to decrease the virus transmission within the society and decrease the burden on
healthcare system. Afghanistan has undertaken the preventive and non-pharmaceutical
measures as soon as the first case of COVID-19 was detected in Herat province.

Case detection and isolation of patients play a key role in prevention of communicable disease
spread as well as COVID-19 patients. So far, the initial focus of the Ministry of Public Health
(MoPH) was on patients with severe disease in order to decrease mortality due to COVID-19
and; as such; the full spectrum of the disease, including the extent and fraction of mild or
asymptomatic infections that do not require medical attention are not clear.

Thus, based on the instruction of H.E the president of Afghanistan, the Ministry of Public
Health has conducted a national survey on estimation of COVID-19 cases and its’ associated
deaths in 9 regions of the country. The study steering committee was established in prior with
participation of representatives from National Statistic and Information Authority (NSIA),
Central Public Health Laboratories (CPHL) and World Health Organization (WHO) and study
protocol was reviewed, given feedback and approved by Institutional Review Board, John
Hopkins University, WHO, CDC, it’s and added among the WHO global unity study.

Objectives:
The primary objectives for this seroepidemiological investigation are as below:
• To determine the magnitude of COVID-19 infection in the general population and age-
specific cumulative incidence, as determined by seropositivity and clinical symptoms
of COVID-19
• To determine the magnitude of asymptomatic or subclinical infections

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 • To determine the deaths rates in different time periods (since March 2019) and COVID-
19 deaths in population
• To identify the leading cause of deaths since March 2020 in Afghanistan

Methodology:

The national seroepidemiological investigation for COVID-19 infection is a population-based,

cross-sectional study. Participants are asked questions regarding demographic information,
signs and symptoms of COVID-19 disease, existing co-morbidities, and deaths in the family
and their cause of death in the past 15 months. In addition the blood serum is collected from
participants for RDT and ELISA tests. It is worth mentioning that for people who are tested
IgM positive during the survey, the survey team have provided home isolation advices to them.
Sampling Strategy and Sample Size of the Study

The seroepidemiological study sample have provided estimates for the whole country, for urban
and rural areas, and for the nine regions. As a national study, it is done in 8 regions of
Afghanistan as well as Kabul province, considered as a separate region making it nine. In this
study two stage cluster sampling is used. In the initial stage, the updated list of Enumerated
Areas (EAs) is used as the study frame, 31- 44 clusters (EAs) are selected randomly per region
by direct support of National Statistical and Information Authority (NSIA); therefore, total
clusters for this study was 360 EAs.

In the second stage, all households in an enumeration area was listed and 16 households per
EA are selected using random sampling table provided by NSIA. In addition, NSIA provided
the maps for all selected EAs with exact boundaries. Age stratification is done in the study;
there was two individuals for RDTs were randomly selected in each household; one from 5-17
years of age and one equal/above 18 years of age. Due to shortage of time and to have valid
data, insecure and inaccessible EAs are not included in the study.

Sample Collection for RDT and ELISA:

COVID-19 IgG/IgM Rapid Test Cassette
Blood samples are collected from two household member randomly (one from 5 to 17 years
and another from equal and above 18 years of age) and are tested using RDTs with results
available within 15 to 20 minutes. The RDTs used in this survey are FDA authorized with
related IgM sensitivity of 95.7%, relative IgM specificity of 97.3%, and relative IgG sensitivity
of 91.8% and relative IgG specificity of 96.4%.

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The blood sample collection for RDTs were two drops of blood by finger prick. As the RDTs
were done in front of the participant, the result of RDT was shared with participants during the
study.
Data Collection, Management and Analysis

Each participant recruited into the investigation are asked to complete a questionnaire which
covered demographic information of household members as well as exposure history, deaths,
and cause of death information in past 15 months starting from March 2019. Before the data
collection, master trainers were designated for each regions and provided 2 days training by
teams from MoPH, NSIA and CPHL. The data collection teams of each province were
introduced by each provinces’ related NGOs and Provincial Public Health Directorates
(PPHDs) and trained by master trainers for two days.
It is worth mentioning that initially 5 days were planned to collect the data; however, due to
security challenges, negotiation with anti-government groups to grant permission for
conducting the survey and geographical distance in some provinces, the data collection took 2
weeks to be completed. The total number of data collection team were 191 teams with
participation of two members (one male and one female) and since there was need for drawing
blood from participants for RDT and ELISA tests, team members consisted of nurses/midwives
or lab technicians. The regional data were entered into DHIS2 system after collection and
quality check was applied on them by other teams. Afterwards the data was transferred into
STATA for data analysis.
In this survey weighted analysis have been applied to adjust for complex survey design.
Sampling weight, non-response weight and post stratification weighting was done using
STATA software. The proportion were calculated and 95% confidence interval and p-value
were adjusted for the survey design.
In order to present the data for current and past infection of COVID-19, the people who have
been tested positive for both IgG and IgM and either IgM or IgG was summed while for current
infection to COVID-19 in the survey, only IgM positivity proportion is reported.
Quality Assurance from Implementation of the Survey
In order to assure the quality of data collection, the data collection teams were monitoring
during their data collection by related master trainers in regions’ capitals as well as, by
surveillance staff in provinces. Before entering the data into the system, the questionnaires
were quality checked and some participants whose phone numbers were available in the
questionnaire, were contacted through phone calls randomly. In addition, for verification of

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RDTs used in the survey, ELISA test will be applied on half of sample size in 9 provinces. It
is worth mentioning that ELISA tests haven’t been performed yet so there might be slight
changes in data results after adjusting the test results with ELISA.

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Results:
Of the 360 clusters planned for this survey, 338 (94%) completed the survey. Similarly, of the total
planned 5760 households, 5177 (90%) households completed the survey. A total of 9,514 household
members in this 338 clusters were interviewed and tested for COVID-19 in this survey. Of the
total respondents, 53.9% were males and 46.1% females. More than three-fourth (79.2%) of
the respondents were from rural areas and 27% in urban areas. The mean age of the respondents
was 27 years with majority being married (79.2%).

The total proportion of COVID-19 positive infection (including all positive results, IgG positive
(past infection) IgM positive (current infection) or both IgG and IgM positive) was 31.5% for
Afghanistan. Kabul Region had the highest proportion of COVID-19 positive infection (53%)
followed by East Region (42.9%), Central Region (36.3%), West Region (34.1%), Northeast
Region (32.4%), Southeast Region (32.2%), North Region (30.7%) and lowest was in Central-
Highland Region (21.1%) followed by South Region (25.8%) (Figure 1).

Figure 1. Proportion of COVID-19 positive infection (including all positive results, IgG positive, IgM positive or both IgG
and IgM positive) among all study age groups (both adults and children)

60.0% 53.0%
50.0% 42.9%
40.0% 36.3% 34.1% 32.4% 32.2% 31.5%
Percent

30.7%
30.0% 25.8%
21.1%
20.0%
10.0%
0.0%
Kabul East Central West NortheastSoutheast North South Central National
highland

Region

Rapid Diagnostic Test (RDT) Results

RDT results for 18 years or above
A total of 5,168 household members of 18 or above were interviewed and tested for the survey.
According to the findings of the survey, the proportion of COVID-19 positive infection among
respondent of 18 years or above was 35.2% and the proportion of COVID-19 negative infection was
64.8% (Table 1). The proportion of COVID-19 positive was 33.9% among males and 37.1% among
females. Likewise, the proportion of COVID-19 positive was 42.3% in urban areas compared to 31.6%
in rural areas (Table 2).

Table 1. Proportion of COVID-19 positive (including all positive results, IgG positive, IgM positive or both IgG and IgM
positive) by RDT among 18 years or above.

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 Region % [Confidence Interval (CI)] P-Value
Central region 45.5 [37.8-53.4] 0.0001
Central highland region 24.9 [17.9-33.7]
East region 49.1 [41.5-56.8]
Kabul region 56.8 [52-62]
Northern region 35.3 [28.1-43.4]
Northeastern region 39.3 [31.9-47.4]
Southern region 26.6 [19-36]
Southeastern region 40.9 [34.4-47.9]
Western region 39.8 [34.8-45.1]
National 35.1 [31-39.5]

Table 2. Proportion of COVID-19 positive by RDT among 18 years or above by area and gender

Areas % [Confidence Interval (CI)] P-Value

Rural Areas 31.7 [26.5-37.4] 0.01
Urban Areas 42.3 [35.7-49.2]
Gender
Males 33.9 [29 -39.2]
Females 37.2 [32-42.6]

Moreover, the survey findings reveal that 2.6% of participants 18 years old or above were IgM positive
(current infection). Southeast region had the highest proportion of IgM positive (7%), followed by
Central region (4.3%), Northeast region (4%), Western region (3.4%), Kabul region (2.7%), Eastern
region (2.5%), Southern region 1.6% and Northern region (1.4%) and it was lowest in the Central
highland region (0.9%) (Table 3).

Table 3. Proportion of IgM positive RDT results by region among 18 years or above

Region % [Confidence Interval (CI)] P-Value

Central region 4.3 [2.4-7.6] 0.0001

Central highland region 1 [0.4-2.3]
Eastern region 2.5 [1.4-4.5]
Kabul region 2.7 [1.4-5]
Northern region 1.4 [0.6-3.4]
Northeastern region 4 [2.1-7.8]
Southern region 1.6 [0.7-3.4]
Southeastern region 7 [3.7-12.9]
Western region 3.4 [1.8-6.3]
National 2.6 [2-3.5]

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RDT results for 5 to 17 years
A total of 4,346 household members aged 5-17 years were interviewed and tested in this survey. Of the
total tested, the proportion COVID-19positive (including all positive results, IgG positive, IgM positive
or both IgG and IgM positive) among 5-17 years old was 25.3%, which was 30.7% in urban areas
compared to 23.4% in rural areas. The proportion of COVID-19 positive among this age group was
24.1% among males and 26.7% among females. More than a quarter (29.2%) of the COVID-19 positive
infection was reported among 15-17 years old. Kabul region had the highest proportion (46.4%) of
COVID-19 positive among participants aged 5-17 years. It was followed by East region (32.4%), West
region (24.5%), South region (24.4%), North region (23%), Central region (21%), Southeast region
(17.6%) and the proportion of IgG and IgM positive was the lowest in the Central highland region
(14.6%) (Table 4).

Table 4. Proportion of COVID-19 positive infection by RDT results by region among 5-17 years
Region % [Confidence Interval (CI)] P-value
Central region 21 [14.5-29.3] 0.04
Central highland region 14.6 [8.6-23.8]
Eastern region 32.4 [26.8-38.6]
Kabul region 46.4 [40.8-521.]
Northern region 23 [16.8-30.8]
Northeastern region 20.9 [15.1-28.2]
Southern region 24.4 [14.5-38]
Southeastern region 17.6 [10.6-27.6]
Western region 24.5 [18.4-31.8]
National 25.3 [20.5-30.8]

Table 5. Proportion of COVID-19 positive infection by RDT results by area and gender among 5-17 years
Areas % [Confidence Interval (CI)]

Rural Areas 23.4 [17.5-30.6]

Urban Areas 30.8 [24.8-37.5]
Gender
Males 24.2 [18.5-31]
Females 27.8 [21.3-33]

The survey findings also reveal that the proportion of IgM positive among participants aged 5-17 was
3.3% (4.1% males and 2.3% females). The highest proportion of IgM positive was reported in the south
region (4.7%), followed by Kabul region (3.5%), West region (3.3%), Central region and Northeast
region (both 2.8%), Southeast region (2.4%), Central highland region (1.6%), East region (1.4%) and
lowest the North region (1.2%). Furthermore, the proportion of IgM positive was 3.7% in rural areas
compared to 2.3% in urban areas during the survey.

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Table 6. Proportion of COVID-19 IgM positive RDT results by region among 5-17 years

Region % P-value
[Confidence Interval (CI)]
Central region 2.8 [1.2-6.3] 0.01
Central highland region 1.6 [0.4-6.6]
Eastern region 1.4 [0.7-3.1]
Kabul region 3.5 [1.6-7.3]
Northern region 1.2 [0.4-3.7]
Northeastern region 2.8 [1-7.6]
Southern region 4.7 [1.6-13.1]
Southeastern region 2.4 [0.8-6.8]
Western region 3.2 [1.7-6]
National 3.3[1.8-6.3]

Discussion
The national COVID 19 morbidity and mortality survey in Afghanistan reveals that about 10
million people (31.5%) had either current or past COVID-19 infection, while about 6 million
adults aged 18 or above and 3 million children aged 5 to 17 years old had either current or past
infection .
The finding of the current survey is consistent with the telephone survey conducted with the
randomly selected samples of 713 health volunteers to estimate the COVID-19 morbidity in
the country. According to the telephone survey, the estimated proportion of the individual with
COVID-19 signs and symptoms was at 49.6%; it is close to the current and past infections in
the most of the regions reported in the current survey.

Furthermore, the CoMo model, developed by the University of Oxford in collaboration with
the World Health Organization and 65 member states, estimated the peak incidence of COVID-
19 in four distinct scenarios: good, bad, very bad, and appropriate. In this model, if the
preventive interventions (in a very bad scenario) are not considered, the peak of COVID-19
was predicted in June 2020, and the COVID-19 infection will infect an estimated 69.6% of the
population with 20,509 death by end 2020.

Table 1: COVID 19 morbidity and mortality data by various source in Afghanistan

Source % of COVID 19 Morbidity Number of COVID 19
Mortality
National COVID 19 31.5% (10 of entire population)
Morbidity and Mortality
Survey
CoMo Model 69.6% 20,509
Telephone Survey 49.6% NA

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 Local Governance NA 9,667
Organization Assessment
Youth Network 725,157 Persons 2,883 in each province
National Surveillance 36,605Persons (12 July 2020) 1038 (12 July 2020)
Data

In communicable disease, one of the main indicators in decision making is estimating the herd
immunity among the population. Herd immunity occurs when a higher proportion of the
population is immunized from an infectious disease, hence, reducing the probability of the
disease transmission from one person to another and the entire population protected from that
disease.
Herd immunity can be achieved either through infecting individuals or vaccinating people. The
levels of herd immunity vary for different diseases, for instance, it is estimated 94% for
measles, which indicates that to build up the herd immunity against measles, 94% of the
population must be immunized for the measles. Determining the country's herd immunity is
directly related to the estimation of Basic Reproduction Number (Ro) of the disease, which
indicates that on average how many person can be infected by one infected person.
Different studies report different herd immunity level based on the COVID-19 R0 of different
contexts. The findings for herd immunity ranged from 43% to 85%. A study conducted by
Randolph and Barreiro indicates that if we consider R0=3 (that is, one person can infect up to
3 others); the required herd immunity is 67 % at the population leveliii.
The study conducted by the Genton and Jeong reveals that the majority of the country's
population have not been infected enough to achieve the herd immunity, and these findings
are confirmed by the report of the lowest COVID-19 morbidity levels from the most countries,
for example Sweden reported an infection rate of 7% by the end of April despite no lockdown;
the mentioned study also states that obtaining the herd immunity by exposing the population
to the disease causes the simultaneous infection of the majority of the population and pave the
way for the second wave of the diseaseiv. According to the John Hopkins University, to build
up the herd immunity against COVID 19, 70% of the population should be immunizedv. While
the study conducted by Kwok and his team estimated herd immunity based on different Ro, in
case of Ro= 1-2, the estimated herd immunity is 50%, for Ro=2-4 (herd immunity= 56.1 to
74.8 %), and for R0> 4 the estimated herd immunity are between 77.9 to 85%vi.
Considering that more young and active people in the community are exposed and infected, the
recent study estimated the required herd immunity in the community higher than 43%vii. Also
Britton and his team estimated herd immunity against COVID-19 between 43% - 60%viii. In

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addition, a study published in the Lancet Magazine, considered Ro = 2.2 in Wuhan, China, an
estimated of 60% of the population needs to be immunized to reach the herd immunityix,
and another study shows that with Ro =2.5 – 3, the required herd immunity expected to be
60-70%x.

Apart from all the studies on herd immunity, on the study conducted by Seow and his team
on antibody decay over time found that the amount of antibodies produced in the body after
contracting the disease will be reduced during 94 daysxi.
Given the results of all the above studies and the existing survey which shows the current and
past COVID-19 infection rate is about 10 million people (31.5%), it can be summarized that
32% of population were infected with the COVID-19 which does not indicate a herd immunity
for the entire country, and most of the population are still at the risk of infection.
As per the findings of this survey, there are differences between provinces and regions; some
provinces have crossed the peak. For instance, in Kabul province, more than half of the
province’s population has achieved the required herd immunity, the lowest reported herd
immunity of 43%, while this proportion is 21 percent in the central highland. As majority of
the populations are still at risk of infection. The preventive measures should be lifted gradually
step by step according to WHO guideline.
Based on the information of countries with a similar context to Afghanistan, if we assume the
Ro = 2 to 3 in the country , the required proportion of COVID-19 infection which is required
to build a herd community is between 56 to 75%; Kabul province with 53% COVID 19
morbidity is in this range. The eastern and central regions with 34 to 42% COVID 19 adult
morbidity are relatively in good position, but the western, northeastern, southeastern, northern,
southern and central highlands regions with less than 35% of morbidity are not in relatively
good condition and not close to the herd immunity.

Current and Number of people at

Minimum % for herd immunity is
Regions Past risk of infection based
reported 43 % and Maximum is
COVID-19 on average of all
reported 85%
Infection reported herd

Based on herd immunity of 43%, immunity

352090(60%)
Kabul 53% Kabul already achieved it. But if we
consider the higher levels , it has not
reached yet
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 Northeast 32.4% Not reached to minimum level of 1164297
herd immunity
Not reached to minimum level of 1227256
North 30.7%
herd immunity

West 34.1% Not reached to minimum level of 1020314

herd immunity
Central 21.1% Not reached to minimum level of 386875
highland herd immunity

Central 36.3% Not reached to minimum level of 579968

herd immunity

East 42.9% Not reached to minimum level of 479674

herd immunity

South 25.8% Not reached to minimum level of 925019

herd immunity

Southeast 32.2% Not reached to minimum level of 925019

herd immunity
National 31.5% Not reached to minimum level of 8462611
herd immunity

In reference to above discussion and evidence, generally the preventive and control measures
in the society should not be lifted at once because only 31.5% of the population have had
current or past infection and the majority of the population have not achieved the necessary
level of immunity against the disease. If disease control policies continue, the health system
can control the level of morbidity of disease. Otherwise, the rate of hospitalization and the need
for ventilator for patients will be increased and subsequently the health system should bear its
high burden.
Conclusions
• The proportion of COVID-19 positive infection is higher in urban areas compared to rural
areas. It means that the COVID-19 spread will be towards rural areas in the coming months,
therefore, there is need to improve health care facilities and services in these areas.
• While there is no difference in the proportion of COVID-19 positive infection by sex, the
infection rate is higher among adults age group than children.
• The COVID-19 morbidity were reported higher in Kabul, East, and central regions.

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• The rate of infection in Afghanistan has not yet reached the level of herd immunity, which
indicates that there are still suspected population in the country that needs for considering
precautionary measures and not lifting them so early.
Recommendations
The recommendations in this report are based on the international evidence and current context
of Afghanistan, and these recommendations are not based on the findings of this survey.
Public awareness and risk communication: Mobilization of the national health system
capacities for public awareness (3,386 public and private health facilities, 40,000 civil servants,
60,000 community health workers and private sector staff); utilize citizen charter network,
Health Shura, school teachers and students, Mullahs; and use of media (Radio & TV).

Health messages: Mandatory use of mask within the workplaces, educational institutions,
shops and other commercial and public areas; enhance immunity level of the population
(level of vitamin D is lower among females) such as use of vitamin D fortified oil increase
utilization of primary health care services (vaccination, ANC, PNC and etc..) for routine
health services disrupted due to COVID-19.

Active surveillance and contact tracing: Strengthening contact tracing and to utilized the
support of all related sectors including private health sector on case detection, sample
collection and referral of the cases; use of school for contact tracing (performance based
payment); electronic data collection on COVID-19 case findings into Flexi Feedback; enhance
the lab capacity (establish COVID-19 diagnostic labs at the regions and provinces, capacity
building of diagnostic labs for public and private labs at the provincial levels, and providing
the required equipment and supply for the diagnostic labs)

Improvement of health care service coverage for COVID-19 patients from village to
national level: Home base care (for mild and moderate cases) by the mobile health teams and
public and private clinics; Hospital based care (for severe and critical cases); to prepare of
national, regional, provincial hospitals and CHCs and private hospitals for severe and critical
cases; to strengthen the Intensive Care Units (ICUs) for critical cases; capacity building of
health care workers (advanced skills); and continuation of other health care packages
particularly maternal and child care.

Preparedness for the winters season: Identify vulnerable areas where the roads and
transportation system are blocked during the winter; provision of oxygen machines and

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ventilators (at district level) and establishment of oxygen production factory (at provincial
level); provision of medicine and primary health care services (Sehatmandi project) for
COVID-19; provision of strategic and essential medicine for primary health services and
COVID-19 patients (the health centers run by MOPH); encouraging and implementing
preventive measures at the national and local levels.

Change in the lockdown/movement restriction measures: Relaxing the

lockdown/movement restrictions measures based on WHO recommendations; gradual opening
of schools and educational institutions (for instances, only secondary and high school or two
to three days per week; availability of active surveillance; availability and implementation of
case detection guideline in the schools; clear guideline for contact tracing); resuming
restaurants and wedding halls activities based on MOPH guidelines (for instance maximum
participants should not be exceed more than 200 guests and keeping social distance of 2 meter
between the tables); gradual resumption of other construction and developmental projects.

Study limitations
1. Time limitation (tight deadline) for the survey implementation
2. Insecurity in certain areas of the survey
3. Inability to use proper household listing and maps of Enumeration Area in the areas where
government lack control over which might have affected the findings
4. To assess the accuracy of the rapid tests, the ELISA tests has not not performed yet, so final
result in this report was not adjusted accordingly which will be adjusted once ELISA is
conducted.

References:

i
Coronavirus Update (Live): Cases and Deaths from COVID-19 Virus Pandemic - Worldometer [Internet]. [cited
Aug 10, 2020]. Available from: https://www.worldometers.info/coronavirus/.

14
ii
MoPH Data warehouse – Dashboard, COVID-19 Afghanistan, retrieved from: https://moph-dw.gov.af/dhis-
web-dashboard/#/ accessed on 10th August 2020

iii
Randolph, H. E., & Barreiro, L. B. (2020). Herd Immunity: Understanding COVID-19. Immunity, 52(5), 737-
741.

iv
Coronavirus Update (Live): Cases and Deaths from COVID-19 Virus Pandemic - Worldometer [Internet]. [cited
Aug 10, 2020]. Available from: https://www.worldometers.info/coronavirus/.

v
JH Bloomberg School of Public. (2020). What is herd immunity and how can we achieve it with COVID-19?
Retrieved from https://www.jhsph.edu/covid-19/articles/achieving-herd-immunity-with-covid19.html

vi
Kwok, K. O., Lai, F., Wei, W. I., Wong, S., & Tang, J. (2020). Herd immunity - estimating the level required to
halt the COVID-19 epidemics in affected countries. The Journal of infection, 80(6), e32–e33.
https://doi.org/10.1016/j.jinf.2020.03.027

vii
US News & World Report.Could threshold for COVID-19 herd immunity be lower than thought? Retrieved
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