Introduction
Despite varying levels of health system infrastructure that reflect on preparedness across the region, Middle East and North Africa (MENA) countries’ overall health management strategies, characterized by strict containment measures enforced early in the outbreak, efficiently controlled the pandemic’s emerging spread in the region. As of June, countries are progressively and carefully getting down to ease restrictions on movement and economic activities and prepare their strategy toward deconfinement.
The MENA region’s governmental authority has taken short aggressive measures to limit the spread of coronavirus disease 2019 (COVID-19) infection by limiting many innumerable individuals’ movements. Their square measure over 800,000 confirmed cases across the MENA region, with a substantial proportion (30%) in Iran. Among Arab economies, the Kingdom of Saudi Arabia has the highest confirmed cases, followed by Qatar and the United Arab Emirates (UAE).
COVID-19 is the second coronavirus that affects the Middle East, following the Middle East respiratory syndrome coronavirus reported in Saudi Arabia in 2012. UAE was the first Middle Eastern country to say a case, following the COVID-19 happening in China. The Middle East faces the dual threats of potential mass virus outbreaks in conflict zones and looming socioeconomic upheaval. Each crisis might have severe humanitarian consequences.
MENA region has reacted preemptively, and this contributed to flattening the curve of infections in their countries. Most of the Arab countries implementing social distancing measures while the virus was still in its infancy. Meanwhile, Saudi Arabia adopted an aggressive approach toward the virus, including a curfew from nightfall to dawn. National capital conjointly adopted alternative radical steps like preventing holy journey to two of Islam’s most religious places—Mecca and Medina.
Outbreak and management of the health crisis
The increasing spread of the coronavirus across countries has prompted many governments to introduce unprecedented containment measures to reduce community impact. These are priority measures enforced by a sanitary situation, which leaves little room for other sectors as health should remain the primary concern.
The containment measures achieved with rapid identification and isolation of suspect or confirmed COVID-19 cases. Associated with strict infection control measures to minimize intrahospital transmission and prevent incapacitation of essential services, the planned response is a continuum and will vary based on the scale and severity of the pandemic.
The first COVID-19 cases in MENA countries observed in the UAE. According to numbers exaggerated sharply within the first few weeks of the happening, the worldwide trend is in line with numbers. However, infection and mortality rates could seem to the point that the pandemic has not hit the region as laborious. The number of COVID-19-related deaths in Arab countries, compared to the population, remains so much below the rates recorded in some European and Asian countries.
These measures will be explained by MENA economies’ swift and early response. Following the pandemic, they introduced strict containment measures beginning within the half of March. Notably, several countries did not wait to own confirmed cases to impose movement restrictions and social distancing measures. For example, Saudi Arabia suspended pilgrimages to Mecca and Medina and barred access to holy sites within the two cities as early as March.
Most countries started closing colleges and nurseries and prohibiting giant public gatherings, together with spiritual ones. Given the pandemic risk, many countries declared a state of national emergency and obligatory stricter containment measures and necessary self-isolation and curfews. All countries have banned entry to foreigners till additional notice, and air traffic has been placed on hold or considerably reduced. Borders stay open for the transport of products and medical instrumentality. Quarantine rules are including severe penalties for noncompliance, starting from fines to jail sentencing, like in Jordan, Saudi Arabia, and the UAE.
As of May, many MENA countries have begun to relax confinement measures bit by bit and set up their exit ways. Deconfinement plans were either progressive, like Lebanon’s five-step reopening set up that started on April 27, or depend on a geographical breakdown between low-risk and speculative regions, because it is that the case in the Asian country that has been divided into white, yellow, and red areas based on the number of confirmed infections and deaths. Algeria, Bahrain, Iraq, Lebanon, Saudi Arabia, and also the UAE have all approved businesses and commercial places to resume activity, at least partly. These measures raise the cases in Kingdom of Saudi Arabia, and they change the plan to strict confinement.
MENA region proposed a plan that leads to the success of its containment ways to approach the deconfinement part. The gradual easing of restrictions has been associated with permanent strict preventive measures. Physical distancing is enforced in most countries, with businesses comply with preventative measures. Face masks have conjointly been mandatory in public places in Bahrain, Morocco, Qatar, and also the UAE, with violators facing significant penalties, together with up to jail.
Challenges to health systems and health sector responses
MENA countries’ containment efforts have proved a diversity of responses in light of the region’s varying levels of health system preparedness.
Over the past 25 years, the Gulf Cooperation Council (GCC) countries have undertaken substantial investments in health-care infrastructure, aboard efforts to extend the number of doctors and nursing personnel. This has considerably improved the standard of health-care services within the GCC. In an assessment of COVID-19 preparedness published in March by the World Health Organization (WHO), where countries were graded on a scale of one to five, with one that means no capacity to retort and five that means sustainable capacity, all GCC countries except Qatar scored either four or five. However, GCC health systems face many challenges as well as vital risk factors associated with lifestyle diseases like diabetes, obesity, and cardiovascular diseases. Especially, diabetes prevalence rates within the region are among the highest worldwide as high as 22% in Kuwait and 18.3% in Saudi Arabia. As diabetes and obesity are reported to be a risk factor for hospitalization and mortality of the COVID-19 infection, this could place an extra strain on GCC health systems’ capacity to respond to the crisis. Another concern is GCC’s significant reliance on expatriate medical hands and foreign medical equipment and supplies, which can be affected by travel and transport restrictions.
Developing MENA economies have suffered from insufficient health resources, shortages of skilled faculty within the health-care system, and lack of enough medical equipment. Total health expenditure per capita in the majority of MENA countries is considerably below average for countries in similar financial gain categories. Moreover, the quantity of physicians per 1000 inhabitants within the region is substantially below the WHO suggested threshold of 4.5 doctors, nurses, and midwives per 1000 population and as low as 0.72 and 0.79 in Morocco and Egypt, respectively.
For countries suffering to maintain basic life requirements and political conflict, the COVID-19 pandemic poses exceptionally fragile and uncoordinated responses in these areas. It lacks the mandatory capability to react to the crisis in terms of medical facilities, equipment, and personnel. In Syria, the WHO estimates that 70% of health-care workers have left the country as migrants or refugees. In comparison, only 64% of hospitals and 52% of primary health-care centers remain fully operational.
MENA governments introduced measures and dedicated specific funds to stop their health systems from being overwhelmed and cut back the fast spread of COVID-19, to support their medical staff and protect the community. Many countries have enhanced the number of critical care units and hospital beds to admit COVID-19 patients, as well as by building dedicated treatment facilities as within the UAE, that performs quite 40,000 tests/day. Governments have conjointly scaled up their testing capability by creating new sites and establishing drive-through testing stations. This has enabled countries to facilitate detection, tracing, and isolation of cases ( Fig. 1 ).
Statistics across the region
As of June 28, 2020, the total number of COVID-19 cases in MENA region reached 800,000. With 235,000 confirmed COVID-19 cases, Iran is the regional epicenter of the new coronavirus, and the country’s case numbers have grown exponentially since March 25, when it had about 24,811 cases. However, as the coronavirus has spread across the region, Iran’s share in the total number of MENA cases has reduced from 86% on March 25 to 30% as of June 28 with a total death cases of 11,408. Middle Eastern governments, led by the GCC, are conducting more intensive health screening operations to identify potential cases of the illness. To date, Saudi Arabia, the second in COVID-19 cases with the total number currently 206,000, has recorded 143,000 recoveries and 1885 deaths related to COVID-19.
The third in the region is Qatar with 99,000 cases followed by Egypt 72,000 cases, it is the worst-hit country in terms of case numbers outside Iran and the GCC.
While health experts have warned that the easing of restrictions could cause a second wave of COVID-19 in the country, most of the countries’ government says it must resume activity to buoy its sanction-hit economy ( Fig. 2 ).
To date, 610,00 individuals in the MENA region have recovered from COVID-19 with 76% of the total cases, while 19,400 individuals have died of the illness.
Governments’ strategic responses
Following the confirmation of the first cases of COVID-19 within the MENA region, national governments quickly adopted measures to strengthen institutional coordination by making interministerial structures.
Other measures include the creation of technical and scientific committees in charge of monitoring and evaluating the progress of the situation and anticipating the direct and indirect repercussions of COVID-19. For example, the Tunisian government has created a National COVID-19 Monitoring Authority, gathering senior officials from all ministries, with the aim of “imposing full compliance with measures to fight the virus.” The authority will also ensure the coordination between the National Committee against the coronavirus, headed by the Presidency of the Government, and the regional committees against natural catastrophes. It will also be in charge of “monitoring the regularity of the supply of basic products, the distribution of social assistance to poor families or families without income, as well as the referral of recommendations to the national committee to combat COVID-19 to adopt the necessary measures to contain the virus”.
Many governments also adopted measures to ensure the continuity of public services in countries where confinement measures were imposed. Teleworking arrangements and online tools have been developed to facilitate the ongoing functioning of public administration. Jordan and Morocco developed practical manuals on teleworking, outlining crucial advice and tips to facilitate its use. Morocco also created a series of new digital delivery services that aim to reduce the exchange of paper documents, thus limiting the risk of COVID-19 transmission via papers.
In the Gulf region, the authority enhances teleworking for most of the government sectors and provides an online portal to strengthen the confinement.
Multiple categories rapidly took place on a large scale for the pandemic, including infection control; intensive care unit (ICU) bed surge capacity; adequate staffing of physicians, nurses, and respiratory therapists; complicated ethical dilemmas; and staff wellness. Procedures to deal with these problems were created and enforced together with nursing, respiratory therapist, and hospital leadership.
Patient characteristics
Age is a strong risk factor for severity, complications, and death. Patients in the Middle East with no reported underlying medical conditions had an overall case fatality of 0.9% similar to international figure. Patients with comorbidities encounter higher case fatalities: those with cardiovascular disease, those with diabetes, and chronic respiratory disease, or cancer, prior stroke, chronic lung disease, and chronic kidney disease have all been associated with increased severity and adverse outcomes. Serious heart conditions, including heart failure, coronary artery disease, congenital heart disease, cardiomyopathies, and pulmonary hypertension, may put people at higher risk for severe illness from COVID-19. People with hypertension may be at an increased risk for severe illness from COVID-19 and should continue to take their medications as prescribed. At this time, people who have only underlying medical condition like hypertension are not considered to be at higher risk for severe illness from COVID-19.
Accounting for differences in age, prevalence of the underlying condition, and mortality associated with COVID-19 reported in the Middle East country till now has been similar to reports from the United States and China.
The typical course of the disease
Most patients admitted to the ICU have similar presentations with fever, difficult breathing, and cough as a classic triad that can be associated with other nonspecific symptoms of generalized malaise, myalgia, and diarrhea.
Typically, patients started to be symptomatic after day 5 with the progressive difficulty of breathing and desaturation to < 90% (detected by pulse oximeter), and in day 10, high requirement of oxygen using high-flow nasal cannula, BiPAP, is the next feature for most of the patients. Response to different therapy and self-proning has different effects but usually show initial response. By the end of 2 weeks, most of the patients who didn’t improve become intubated with a classic presentation of acute respiratory distress syndrome (ARDS).
Lung compliance earlier may not be compromised but within 1 week of intubation mostly dropped to less than 20. Multiple studies are currently running to support these data ( Fig. 3 ).
Clinical challenges
Currently, there are no drugs or other therapeutics approved by the U.S. Food and Drug Administration or recommended by WHO to prevent or treat COVID-19. Current clinical management includes infection prevention and control measures and supportive care, including supplemental oxygen and mechanical ventilatory support when indicated and most of the available drugs included under investigational clinical trial.
Multiple clinical challenges arise with the pandemic everywhere across the Middle East countries, and it dictates special precautions to maximize patient outcomes and minimize the chance to spread the disease to intensive care practitioners.
A comprehensive airway management policy was adapted from rapidly evolving international recommendations. These procedures ensured that the most experienced staff would attempt intubation using a video laryngoscope and rapid sequence induction (RSI). To improve efficiency and optimize patient care, a critical care physician, when identified a patient who required intubation, that physician notified the COVID-19 intubation team. Preparations included obtaining induction, sedation, and vasopressor medications; ensuring the use of appropriate personal protective equipment (PPE) for this high-risk procedure (impervious gown, goggles, or welder’s mask, gloves, head covers, and papers); the team moving the patient to a negative-pressure room for intubation. The initial team included an anesthesiologist, a critical care nurse, and a respiratory therapist. Patients as per recommendations should be intubated using RSI and a video laryngoscope. The multidisciplinary critical care team then moved the patient to the intensive care unit (ICU).
Additional methods evolved due to an increased number of hospital admissions and intubations, by involving two anesthesia airway groups covering 24 h a day, 7 days a week, dedicated to COVID-19 intubations. This team brought with them the acceptable PPE and a video-assisted intubation device. Hospital pharmacologists created virtual RSI kits to be easily accessed on each floor. Finally, a peri-intubation team led by certified registered nurse anesthetists assumed the role of coordinative peri-intubation procedures, as well as gathering medications and staff and transporting patients to the negative-pressure room before intubation and also to the ICU after intubation.
Role of infectious disease consultants
Given the highly infectious nature of the disaster and the rapidly evolving therapeutic landscape, infectious disease consultants instantly established a dedicated COVID-19 team. This team consults on every critically sick patient with COVID-19 daily to review infectious disease parameters and advice regarding therapies (antiviral and antimicrobial) and trying detection of patients susceptible to cytokine storming syndrome and propose innovative therapies. Moreover, they show evolving therapeutic trials ( Table 1 ).
