Unique challenges to control the spread of COVID-19 in the Middle East

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Pleasecitethisarticleinpressas:BalochZ,etal.UniquechallengestocontrolthespreadofCOVID-19intheMiddleEast.JInfectPublic Health(2020),https://doi.org/10.1016/j.jiph.2020.06.034

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ContentslistsavailableatScienceDirect

Journal

of

Infection

and

Public

Health

j o u r n al ho me p ag e :h t t p : / / w w w . e l s e v i e r . c o m / l oc a t e / j i p h

Unique

challenges

to

control

the

spread

of

COVID-19

in

the

Middle

East

Zulqarnain

Baloch

a,1

_,

_Zhongren

_Ma

a,1

_,

_Yunpeng

_Ji

a,b

_,

_Mohsen

_Ghanbari

c,d

_,

_Qiuwei

_Pan

a,b

_,

Waleed

Aljabr

e,∗

a_Biomedical_Research_Center,_Northwest_Minzu_University,_Lanzhou,_China

b_Department_of_{Gastroenterology}_and_Hepatology,_Erasmus_{MC-University}_Medical_Center,_Rotterdam,_The_Netherlands c_Department_of_{Epidemiology,}_Erasmus_{MC-University}_Medical_Center,_Rotterdam,_The_Netherlands

d_Department_of_Genetics,_School_of_Medicine,_Mashhad_University_of_Medical_Sciences,_Mashhad,_Iran e_Research_Center,_King_Fahad_Medical_City,_Riyadh,_Saudi_Arabia

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received2May2020

Receivedinrevisedform19June2020 Accepted28June2020 Keywords: COVID-19 MiddleEast Challenges

a

b

s

t

r

a

c

t

TheCOVID-19pandemicisspreadingatunprecedentedpaceamongtheMiddleEastandneighboring countries.Thisregionisgeographically,economically,politically,culturallyandreligiouslyavery sensi-tivearea,whichimposeuniquechallengesforeffectivecontrolofthisepidemic.Thesechallengesinclude compromisedhealthcaresystems,prolongedregionalconﬂictsandhumanitariancrises,suboptimal lev-elsoftransparencyandcooperation,andfrequentreligiousgatherings.Thesefactorsareinterrelatedand collectivelydeterminetheresponsetothepandemicinthisregion.Here,wein-depthemphasizethese challengesandtakeaglimpseofpossiblesolutionstowardsmitigatingthespreadofCOVID-19.

Having not forgotten the panic of the Middle East Respi-ratory Syndrome coronavirus(MERS-CoV), its new counterpart severeacute respiratorysyndromecoronavirus2 (SARS-CoV-2), thecausativeagentofcoronavirusdisease2019(COVID-19),has landedintheMiddleEast.AtJune14,2020,therewere778,147 casesand18,027deathsofCOVID-19recordedacrosstheMiddle East.Althoughthecasenumberwaslowcasesintheearlydaysof theoutbreak,ithasspeededatunprecedentedpacelateronand affectingalltheMiddleEastcountries(Fig.1).Thiscouldreflectthe levelsofpreparednessandresponseplansimplementedlocallyin MiddleEastcountries.TheMiddleEastliesatthejunctureofEurasia andAfrica,andconstitutesanimportantpillarinshapingmodern civilizationsandreligions.Itisgeographically,economically, politi-cally,culturallyandreligiouslyaverysensitivearea.Unfortunately, thewholeregionhasbeenthecenterforwarsandconflictsoverthe pastyears.Thesecomplexitieshaveimmenseimpactonbreading, respondingandmitigatingepidemics[1].Ofnote,Iranistheearly epicenterwiththehighestnumberofconfirmedCOVID-19cases anddeathsintheMiddleEastregion,followedbyTurkey,Saudi

∗ Correspondingauthorat:ResearchCenter,KingFahadMedicalCity,P.O.Box. 59046,Riyadh11525,SaudiArabia.

E-mailaddress:waljabr@kfmc.med.sa(W.Aljabr).

1 _These_authors_contributed_equally_to_this_work.

Arab,QatarandEgypt(Fig.2).Giventherapidspreadof COVID-19,weaimtoemphasizetheuniquechallengesofcontainingthe epidemicinthisregionandtotakeaglimpseofpossiblesolutions.

Theimbalancedandweakenedhealthcaresystems

Healthcaresystems withintheMiddle Eastconstitutea high degreeof variability withregardstoaccessibility, capacity, and qualityamongdifferentcountries.ThePersianGulfregionacquires signiﬁcantwealthfromtheoilindustryandhasdevelopedtheir healthcare systems [2]. Withinthese countries, there is a two-tieredhealthcaresystemstructurewithpublicandprivatestreams ofﬁnancingandservicedelivery.WHOhashighlightedthecrucial roleofearlydetectionofCOVID-19casestointerruptthespread, whereastherequiredexpertiseanddiagnosticcapacitycould dif-fertremendouslyamongdifferenthealthcareproviders[3].Thus, itisessentialfortheauthoritiestoensureequalandrapidaccess todiagnosisandtreatmentofCOVID-19regardlessofnationalities, ethnicities,religionsandbeliefs.

The healthcare systems in non-oil-producing countries are largelyunderdevelopedandwerefurtherweakeneddueto pro-longedconflictsandwars.Violentattacksonhealthcarefacilities andhealthworkersduringconflictsdestroyessentialhealth ser-vicesthataremostneededduringthetime[4].TheSyrianconflict

https://doi.org/10.1016/j.jiph.2020.06.034

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Fig.1. COVID-19averageweeklycasesanddeathsinMiddleEastRegion.

Fig.2. TotalnumberofconﬁrmedCOVID-19casesanddeathsfrom29/01/2020to14/06/2020indifferentcountriesoftheMiddleEastregion. hasbeenmarkedbyfrequentandintenseattacksagainst

health-carefacilities[5].TheongoingYemenwarhasledtoonly45%of thetotalhealthcarefacilitiestobefunctional.Alessonlearntfrom theconﬂictsintheDemocraticRepublicoftheCongoisthat fre-quentlyattackinghealthcareworkersandEbolatreatmentcenters hasgravelyexacerbatedtheEbolaoutbreaks[6].

ThegeopoliticalcontextinPalestineresultsinlimitedfreedom ofmovementandeconomicstabilitycausingmajorchallengesfor

healthcaresystemmaintenance[7].InIran,althoughthehealthcare systemhasbeendeveloped,economicsanctionsjeopardizesocial determinantsofhealthandaccesstomedicationandhealthcare[8]. TherapidgrowingnumberofCOVID-19casesinIranisthreating theoverwhelmedhealthcaresystembutsanctionsfurtherlimitthe accesstoemergencymedicalsupplies.Rapidandadequateaccess tohealthcareisessentialforcontrollingtheepidemicbutalsofor minimizingseverepatientoutcomes[9].

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Fig.3. MassgatheringsinIslam.(A).PilgrimsattheGreatMosqueofMecca,inSaudiArabia.TheritualofTawafwalkingseventimescounterclockwisearoundtheKaaba,a buildingatthecenteroftheGreatMosqueofMecca,isperformedbyalltheUmrahandHajjpilgrims.(B).thecityQominIranisconsideredholybyShiaMuslims.Itattracts aroundtwentymillionpilgrimseveryyear.

Riskoflargeepidemicsinhumanitariancrises

Besidesweakeninghealthcaresystems,warsand conflictsin theMiddleEasthavealsoledtolarge-scalehumanitariancrises. BecauseoftheSyrianCivilWar,13.5outof22millionSyriancitizens requirehumanitarianassistance.Ofthese,fivemillionhavebeen placedinrefugeecampsestablishedinTurkey,Lebanon,Jordan, Egyptandothercountries[10].TheconditionsinYemenhave con-tinuouslydeterioratedsinceviolencebrokeoutinearly2015.Over fourmillionpeoplehavebeenforcedtofleetheirhomes,andmore than80%ofthepopulation(24million)isinneedofhumanitarian assistance[11].Since2016,Yemenhasexperiencedalarge-scale choleraepidemic,affectingmorethan1.2millioncasesandover 2500deaths[12].

EmergingevidenceindicatesthatSARS-CoV-2isverycontagious [13].Conﬂicts-drivenpopulationmigrationwilllikelyincreasethe riskofSARS-CoV-2transmission.Human-to-humantransmission mainlyoccursviadroplets orclosecontacts[14]. Thusthehigh populationdensityinrefugeecampsandalackofsanitationand hygiene areprone towidespreadof thevirus[15]. A subsetof COVID-19patientsdevelopdiarrhea andshedvirusesintofeces [16,17]. This hasmajor implications pointing to possible fecal-oraltransmission[18].Thus,itisrecommendedtocloselymonitor whetherthis routeoftransmissionmayoccurinrefugeecamps wherehave poorwater, sanitationandhygiene services.Efforts must be made to minimize the risks of provoking large-scale COVID-19epidemicsinthesettingsofhumanitariancrisis.

Levelsoftransparency,communicationandcooperation

Recallingtheimportantcommunicationlessonsfromthe pre-vious SARS outbreak, transparent communication is key to an effectiveresponsetoCOVID-19outbreak.Becauseofcultural, eth-nical and religious differences, non-inclusive governments and humanitariancrises,thelevelsoftransparentcommunicationare clearlysuboptimalinthisregion[19].

Twofactorsareofconcernasobstaclesfortransparent commu-nicationandcooperation,includingreligionandethnicityoriented diversification and conflicts. Severalmajor religions have their ownoriginsintheMiddleEast,includingJudaism,Christianityand Islam.Arabsconstitutethemajorityofethnicpopulationfollowed byPersian,Turk,Azeri’s,Kurds,Jews,Copts,GreekCypriots, Assyr-iansandIraqiTurkmen.Thesedifferenceshaveprimarilyinflamed theinstabilityandconflictoftheregion.EvenwithintheIslamic countries,theconflictinYemenbetweenSaudi-backedSunniand Iran-backedShiasectshascausedthemosthorrifichumanitarian disasterinmodernhistory.Moreover,thegovernmentsarealsonot transparentenoughwiththeirpeoplebecauseofthepoliticaland

religioushierarchiesandprioritizationintheMiddleEastcountries. Infact,SARS-CoV-2doesnotdiscriminatenationalities,ethnicities andreligions.Transparentcommunicationandjointeffortsareat thecoreofeffectivemeasuresforcontrollingtheongoingCOVID-19 epidemic.

Religiousmassgatheringsimposeriskofsuperspreading

events

MassgatheringsdeﬁnedbyWHOareplannedorspontaneous eventsthat gathersubstantial numbersof attendees,and these eventsareassociatedwithmajorpublichealthchallenges[20].This isparticularlyrelevant tothepotentialsuperspreadingof SARS-CoV-2.TheoutbreakinChinacoincidedwithamassivepopulation movement,becauseoftheChineseLunarNewYearholiday[21].A massiveannualpotluckbanquetfor40,000familiesheldinWuhan inthemiddleofJanuarywassuspectedasanexacerbationofthe outbreak in theepicenter. Analysisofnine gatheringsfor meal orholidayvisithasindicatedthatsuperspreadingeventstendto occurduringtheseclosecontacts[22].Duringareligious gather-ing,asuperspreadereventthataChurchattendeeinfectednearly 40peoplehasoccurredinKoreaandsubstantiallytriggeredpublic panic.

InIslam,therearetheﬁve-times-dailyritualprayersanda con-gregationalprayeroneveryFridayinmosques,wherelargenumber ofworshipersgathers.Ofmoreconcernsarethelarge-scale pilgrim-ages.SaudiArabiacontinuouslyreceivesmanymillionsofUmrah pilgrimsand2–3millionHajjpilgrimsataspecialseasonofeach yearfromover180countries(Fig.3A).Respiratoryinfectionsare themostcommonillnessamongpilgrims,andtheassociated mor-talityrateduringHajjhasbeenreportedas2.4%[23].InIran,the earlyCOVID-19caseswererecordedinQom(Fig.3B),acitythat attractsmillionsofpilgrimsfromcountriesincludingLebanon,Iraq, Bahrain,Yemen,KuwaitandPakistan.ManyoftheinitialCOVID-19 casesintheMiddleEastandneighboringcountriesarerelatedto thetravelhistorytoQomorothercitiesofIran,andmostofthem arepilgrims.

Aspilgrimsconcentratingonreligiousrituals,thereareclose contactsamongworshipersandinsufﬁcientself-protective mea-sures,andthereforeamplifytheriskoftransmissionandpotential super spreadingof SARS-CoV-2[24]. Thegovernments of Saudi Arabia,IranandIraqaretakingheavymeasuresonregulatingthe attendanceofcongregationalprayersandpilgrimagestomitigate therisks.Inthisrespect,werecommendtheauthoritiestoactively communicatewithreligionscholarsandleadersofthereligious communitiestofacilitatedecision-makingandpolicy implemen-tation.

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Conclusion

Facing the spread of COVID-19 in the Middle East, there are major challenges to contain this epidemic. These include compromised healthcare systems, prolonged regional conflicts andhumanitarian crises,suboptimal levelsoftransparency and cooperation,andfrequentreligiousgatherings.Thesefactorsare interrelatedandcollectivelydeterminetheresponse tothe epi-demicinthisregion.Thereisnosimplesolution,buttoleverage the communication and cooperation between political leaders, healthcareauthorities,religionscholarsandthegeneralpublicis certainlyimportant.Immediateeffortsshouldbededicatedto pos-siblylifteconomicsanctionsandtoendviolenceandconflict.For moreeffectiveresponsetotheepidemic,wecalltoestablishan independentandneutralinternationalworkinggroupspecifically dedicatingtoCOVID-19,withparticularfocusonareaswith con-flictsandhumanitariancrises.Thisneworganizationshouldwork closelywithallUnitedNationsagencies,allthehumanitarian orga-nizations,andthelocalhealthcareauthoritieswithsupportofthe internationalcommunity.Finally,weshalluniteandensure com-mitmentfromallpartiestocontaintheepidemic,asthereareno physicalorvirtualbordersforSARS-CoV-2tocross.

Funding

The work was supported by the Ministry of Education of Chinafor anInnovativeResearchTeam inUniversity grant(No. IRT17R88;toZ.M.). Competinginterests Nonedeclared. Ethicalapproval Notrequired. References

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