The Pandemic of COVID-19 in Eastern Mediterranean Region: Selected Outcome Parameters

Background: Despite the passage of eight months since the start of COVID-19 pandemic, it still represents a major public health problem at global, regional and national levels. Objective: To present comparative outcome indicators and time trends for the pandemic among countries in the Eastern Mediterranean Region and to discuss possible determinants behind such trends. Methods: We used data on all newly reported cases of COVID-19 infection from the start of the pandemic in each EMR country till the 5 of August, 2020. Three sources of data were used: the World Health Organization Websites and two private website reporting cases of world countries. Numbers were directly abstracted from these sources and Excel programme functions were used to make graphic presentations. Verification of numbers were made with data reported by health authorities in these studied countries. Results: As on August 5,2020 countries of the Eastern Mediterranean Region varied substantially in scale of the incidence rate per million population (from highest of 38939.1 in Qatar to lowest of 54.2 in Syria), the case fatality (closed case fatality ratio) ranged from lowest of 0.2% in Qatar to the highest of 37.0% in Yemen. Cause-specific mortality rate ranged from 1.1 to 212.5 per million population in Jordan and Iran respectively. Testing policy was the main determinant of reported cases. Despite the decline in the scale of daily cases, none of the countries has reached a stage of clear exit (zero cases). Conclusion: Most of the countries are experiencing a pattern of accelerated pandemic and are heading towards declining trend. Few are experiencing continued rise or resurgence and threats to re-emerge are impending. Reopening is a real challenge and careful scientific evidence based exit might be possible.


Introduction
espite the passage of long time since the start of COVID-19 pandemic in the countries of Eastern Mediterranean Region 1,2 the outlook of the pandemic at global level still not clear yet. The number of cases and resulting fatalities are increasing and almost all countries are fighting the virus. A number of countries have shown some features of evident containment after rapid spread of infection like China, South Korea, Italy, Spain, France, Turkey, United Kingdom, Germany and most other European countries but resurgence cannot be excluded and actually is evident. 3,4 The United States, Russia, Brazil, India, Peru and Mexico and many others, are examples of countries experiencing severe wave of cases and deaths and occupying top ranks in reported cases. [3][4][5] Countries in the Eastern Mediterranean Region (EMR) are among many countries in which the pandemic started as modest daily cases but most of these countries experienced escalation with time. Some of them could succeed in suppressing the epidemic curve. Until now and after nearly six months of the start of case reporting in EMR countries, Iran has witnessed exponential increase very early in the course of the pandemic, some other countries are reporting substantial number of cases in recent weeks like Saudi Arabia, Qatar, Egypt, Oman, United Arab Emirates, Morocco and Iraq. The remaining countries showed modest time trend but some of them are potentially at risk of rapid increase of cases and consequently deaths resulting from coronavirus infection. EMR countries showed clear variation in the extent of risk of infection, case fatality and recoveries. 5 The reasons for these substantial variations across the world countries and within EMR are not clear. We propose that social behavior and population response could be one reason. Initial pool of infection and reluctance to take decisive counteraction as early as the start of the pandemic are additional reasons for the rapid escalation of the disease. Herd immunity and environmental conditions are other possible reasons. Also under-detection of mild cases could be an additional explanation at least for some of these countries. It is hoped that EMR countries will pass this pandemic without entering a phase in which the health care systems are severely overridden by cases similar to what happened in some Asian and European Countries. 6 However, the measures against the COVID-19 pandemic in the foreseeable future may need extensive reconsideration to encompass not only health aspects but also the consequences of the epidemic on population living and country economics. 7,8 A careful planning to COVID-19 exit is needed but this must be based on thorough analysis of the situation. In this article we took the initiative to monitor the dynamics of the pandemic in EMR countries and compile data on cases, deaths and recoveries from various sources including national reports, World Health Organization websites and private websites. This study was planned to document basic epidemiological features of COVID-19 in the early months of the pandemic. Specifically, it was intended to present comparative indicators including time trend for the pandemic outcomes among these countries and to discuss possible determinants behind such trends.

Method and Sources of data
The data used in this article covered the period from the onset of the pandemic in various countries in EMR to August 5, 2020. For the epidemic curves, the time period was extended to the 9 th of August to complete the data for the last week. Data were obtained from sources containing the daily new cases of COVID-19 reported by various government agencies and Ministries of Health in the region supported by the World Health Organization Websites 3,4 and two private websites reporting cases for EMR and other world countries. 5,9 The use of multiple sources facilitated the cross checking and matching of numbers reported in different sources. Consistency was almost complete among the sources used. Numbers of cases were fed into an Excel sheet and graphs were made using the Excel functions. A case of COVID -19 was defined according to specific criteria adopted by various countries in accordance with the World Health Organization definitions. In general a case denotes a person with a positive nasal or throat swab Polymerase Chain Reaction Test (PCR). The triggers for the test were clinical features suggestive of the disease, contact with cases, active case detection and history of travel to other affected countries. Data on population of each country were obtained from World meters for population. 10 The statistical analysis covered: a. Epidemiological outcome measurement including four parameters: Incidence rate (IR): The number of reported cases per 1,000,000 populations up to 5August 2020. Overall case fatality ratio (OCFR): The number of deaths among COVID-19 reported cases up to 5 August divided by all reported cases up to 5 August 2020. Case fatality ratio for closed cases (Closed CFR): The number of deaths among COVID-19 cases reported up to 5August 2020 divided by summation of deaths and recoveries over the same time period. Cause-specific mortality rate (CSMR): The number of deaths during a specified period of time per million population.

b. Comparative curves were prepared to display characteristics of COVID-19 epidemic curves in EMR Arab countries
To smooth the curves, we used weekly instead of daily reported cases. Twelve countries, in addition to Iraq, were compared. They were grouped arbitrarily into two groups based on the extent of weekly reported cases in each country. A high incidence countries included Iraq, Kuwait, Saudi Arabia, Bahrain, Qatar, UAE, Oman, Egypt and Morocco. A low incidence countries included Jordan, Lebanon, Tunisia and Palestine.

c. We attempted to explore the effects of certain variables on the incidence rate of COVID-19.
We hypothesized that incidence rate of COVID-19 infection is determined by a number of factors such as tourist activities, foreign short term workers, international air travel to countries with high infection transmission, the population structure and behavior, population density, the median age and the intensity of testing for infection practiced by each country. We got some data on a number of these hypothesized determinants where multiple regression analysis was carried out to identify predictors of incidence rate. The dependent variable was the incidence rate of COVID-19 as reported cases per million population as of August 5, 2020. The predictors for each country were population density per Km, median age, proportion of elderly over 65 years old, and the number of tests per million population. The sample countries for this analysis were the EMR 22 and 25 other countries. The latter were added to improve the efficiency statistical analysis and to broaden the coverage of countries in different contents. A systematic random sample was drawn from the list of countries covered in Corona World meters .3 during April 2020

Pandemic outcomes in EMR
Selected epidemiological parameters on the situation of COVID-19 infection in the EMR countries after almost six months from the start of the pandemic are  (Table-1). The extent of the incidence rate, the case fatality ratio and the cause specific mortality rate varied substantially among different countries. Compared with the average regional values of 2193.5 per Million population. Twelve countries (Afghanistan, Jordan, Egypt, Lebanon, Libya, Morocco, Pakistan, Somalia, Sudan, Syria, Tunisia and Yemen) have incidence rates below the regional average. The other ten countries all have incidence rates above the regional average. With respect to case fatality ratio, ten countries (Afghanistan, Egypt, Iran, Iraq, Lebanon Libya, Somalia, Sudan, Syria, Tunisia and Yemen) have ratios above the regional averages of 2.6% and 3.1% for overall and closed ratios. The regional causespecific mortality rate was 57.7 per Million population. Eight countries exceeded the regional figure for the CSMR (Bahrain, Djibouti, Iran, Iraq, Kuwait, Oman, Qatar and Saudi Arabia). In this section we attempt to understand the dynamics of the pandemic in selected Arab EMR countries. (Figures 1and 2) show that most of the Arab EMR countries have experienced slowly increasing weekly cases followed by escalation and then a recent decline. The rise in Iraq continued until now and no indication of curve flattening or decline is evident yet. Recent resurgence is also seen in Oman and Morocco.   (Table-2), presents detailed data on incidence rates and four presumed determinants of the incidence rate.  (Table-3), shows the results of a step-wise multiple regression analysis carried out to predict incidence rate using data in (Table-1 0.002) and independent predictor of incidence rate of COVID-19 infection in EMR countries and in All countries listed in (Table-2). The average number of tests per million population could explain just under one fifth (Adjusted R 2 = 0.17) of the variability in the reported incidence rates of COVID -19.

Discussion
The COVID-19 infection started in China late December 2019 and then rapidly spread to almost all countries in the World. 1,11 The pandemic have imposed severe threat to the life and wellbeing of the population in terms of morbidity, mortality, social life and economic consequences in many countries. In some countries the situation represents a real challenge to the health care system. 6 In the EMR countries, great variations do exist in incidence and fatality rates, and hence in policy to respond to the pandemic. 12,13 Despite that the scale of the pandemic in the Arab state members of EMR started modest in general terms but threats of escalation were witnessed in some countries. As of August 5, the incidence rate of COVID-19 varies widely in Arab countries. Qatar experienced the highest incidence rate so far. Bahrain, Kuwait, Saudi Arabia, Oman, United Arab Emirates, Iran, Iraq and Djibouti have relatively high rates but less than Qatar. All the remaining countries have lower incidence rates. This variation in incidence rate is not unique to EMR Arab countries but rather it is a phenomenon prevailing in all regions in Asia and Europe in particular. 14 Among the determinants of reported incidence rate are the scale of testing for COVID-19 reported by each country. Definitely this is not the only determinant and future research need to explore in-depth analysis for additional determinants and protective factors. The same variation does exist in case fatality ratio for all cases and for closed cases as shown in (Table-1). Some countries like Yemen, Sudan, Iran, Tunisia, Egypt, Syria, Somalia, Afghanistan and Iraq experienced relatively high CFR. Bahrain, Djibouti, Qatar and Palestine experienced very low case fatality ratios. Most of the EMR Arab countries have case-fatality ratios higher than those initially reported in China. 15 The variation in the CFR should reflect at least two things. First, the severity of detected cases. Second, the effectiveness of the health care system in managing the epidemic situations and severe and critical cases. Countries with high active case detection activities are expected to have lower proportion of severe and critical cases and less fatal outcomes. This is evident in Gulf countries which exhibit higher rates of testing and case detection and lower case fatality ratios. Despite all these indicators, exit from COVID-19 pandemic in EMR countries is not easily anticipated yet. Most EMR countries did not pass a definite peak of the pandemic. Even the countries which showed some decline after peaking are now experiencing resurgence The implication of such epidemiological situation is that EMR countries might be in a rather difficult situation to manage exit from COVID-19 pandemic within the short future. To attempt reopening is a real challenge and needs intensive discussion among various parties about the means, indicators and preparedness to unexpected developments and the risk of second wave of infection. 16 A strategy of four specific public health principles (Monitoring infection status at population level, community acceptance and engagement in any easing or restrictive measures, public health capacity and measures and health system capacity) proposed by Rawaf et al 7 is worth using as a base for reopening towns and cities. Failure to recognize that may lead to unexpected flare up of the pandemic in short time after apparent relief. 13

Limitation of the Study
The study could have been much better if it secured contributions from other participant coauthors from other EMR countries in this study. This imposed some limitation on the direct use of available data in different countries and the use of other expertise. The fast moving numbers of the pandemic made authors in a hurry to prepare and close the manuscripts. At the time of its publication, some of the findings might become inconsistent with the prevailing situation. This does not undermine the value of continuing research given the nature of pandemics and rapid changes with the passage of time. The data used in this article were carefully checked across various sources to ensure consistency.

Conclusions
Most of the EMR countries have experienced a pattern of accelerated pandemic and peaks. Most are heading towards decline. Only few experience some definite decline in the scale of reported cases but threats to re-emerge are impending. Reopening is surrounded with real challenges and careful scientific evidence based exit might be possible.