Coronavirus Pandemic A review of the prevalence of COVID-19 in the Arab world

Introduction: Coronavirus disease 2019 (COVID-19) is a rapidly spreading disease worldwide. It is a real test for all health authorities including Arab countries. In this review, we aimed to assess the prevalence of COVID-19 in the Arab world. In addition, to compare the findings of this study with other top affected countries. Methodology: We searched for official websites from the Ministries of Health and other official sources in all 22 Arab countries. Medline, Science Direct and Google Scholar websites were also used to search for COVID-19, 2019 novel coronavirus, SARS-CoV-2 and coronavirus. The time period was from 1 January 2020 to 31 May 2020. Results: As of May 31, 2020, COVID-19 has caused 290,428 confirmed cases, 3,696 deaths and 157,886 cured cases in all Arab countries. In terms of confirmed cases, Saudi Arabia followed by Qatar, UAE, Kuwait and Egypt have the highest reported cases. However, the total number of deaths was dominant in Egypt, followed by Algeria, Saudi Arabia, Sudan and UAE. In comparison to other non-Arab countries and confirmed cases, Arab countries come fourth after USA, Brazil and Russia. In terms of death, the Arab world is not listed as the top ten affected countries as only scored eight deaths per million have been recorded. Conclusions: Most Arab countries took some serious early steps to minimize the outbreak of COVID-19. At the moment, controlling the source of infection, the route of transmission and taking care of infected patients are the main challenges for health authorities in all Arab countries.


Introduction
As of May 31, 2020, coronavirus disease 2019 (COVID-19) has caused 6,057,853 confirmed total cases, 371,166 deaths and 2,847,539 cured cases in 213 countries and territories over six continents [1]. COVID-19 is a rapidly spreading disease. The first official announcement of coronavirus by the Wuhan Municipal Health Commission in China was on 31 December 2019 [2]. In about two months later (March, 11, 2020), World Health Organization (WHO) declared COVID-19 as a pandemic.
Previous exposures of coronaviruses to humans were prominent in 2003 and 2012 with severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV), respectively. Many studies suggest that bats could be the main source of severe acute respiratory syndrome -coronavirus 2 (SARS-CoV-2) [3][4][5]. A recent study revealed that COVID-19 has a 96.2% genome sequence similarity with Bat CoV RaTG13 [6]. Moreover, bats are also considered to be the usual pool of a wide variety of coronaviruses including SARS-CoV-like and MERS-CoV-like viruses [7]. SARS-CoV-2 is a positive-sense, single-stranded RNA virus belonging to the genus Betacoronavirus [8]. Although SARS-CoV-2 shares about 79% of its genome sequencing with SARS-CoV, it is much more transmissible [9].
Coughing and sneezing are believed to be the main transmission mode of SARS-CoV-2 between humans. Several studies revealed that close contacts with COVID-19 patients are at high risk of infection [10,11]. A recent study revealed that the virus was detected in feces, suggesting that SARS-CoV-2 may be transmitted by the fecal route [12]. People who are more susceptible to COVID-19 include the elderly [13] and patients with hypertension, diabetes, respiratory system disease and cardiovascular disease [14]. The most common clinical features of COVID-19 include fever, cough, sore throat, headache, fatigue and breathlessness. It is important to note that these symptoms can also be found with other diseases. In some cases, patients can progress to pneumonia, respiratory failure and finally death [15]. In general, the incubation period of the disease is 3-7 days, but no longer than two weeks [16]. Currently, there is no cure for SARS-CoV-2 and vaccines are not yet available. However, there are many COVID-19 vaccine candidates being conducted under different stages of trials [17].
The Arab league consists of 22 Arab countries distributed as 12 in Asia and 10 in Africa. These countries combined to have a total area of over 5 million square miles. The Arab league was created to unite the Arab countries politically and to represent the interests of the people. However, the health system and resources available differ from one country to another. COVID-19 is a real test for health authorities in all Arab countries. In this review, we aimed to assess the prevalence of COVID-19 patients in the Arab world from January to May 2020 and to compare these findings with other affected countries.

Methodology
Medline, Science Direct and Google Scholar websites were used to search for COVID-19, 2019 novel coronavirus, SARS-CoV-2, coronavirus and in combination with Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi Arabia (SA), Somalia, Sudan, Syria, Tunisia, United Arab Emirates (UAE) and Yemen. In addition, Google website was used to search for official websites and announcements from the Ministries of Health in all Arab countries and other official sources such as WHO. The time period was from 1 January 2020 to 31 May 2020. Inclusion criteria include official information in clinically diagnosed COVID-19 in English or Arabic. Exclusion criteria include unofficial information regarding COVID-19 in all Arab countries, language restrictions to English or Arabic only and unspecified date and location of the information or suspicion of duplicate information. The following information was collected from each Arab country: first announced cases, number of confirmed, death and cured cases monthly, gender, average age, preventive methods, total population and testing methods used. The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [18]. The data were analyzed using the Statistical Package for the Social Sciences (SPSS) software version 23 (SPSS Inc., Chicago, IL, USA). Results are presented as numbers, percentages and means.

Results
Our research produced 301 records. After removing the duplicate records, 196 records were obtained. In addition, 82 records were excluded as they were irrelevant to our study. The suitability of 114 records were further assessed and 90 records were removed according to the following reasons: (i) 67 records were not suitable, (ii) 14 showed brief reports, (iii) 8 were letters to editors and (iv) one record was not up to date. Finally, 24 records were included in the analysis [1,.
The total Arab population who live in Arab countries is 435,648,763. The first Arab country to officially report the presence of COVID-19 was UAE with five cases on January, 29, 2020. Egypt was the second Arab country and the first Arab-African country to declare the presence of COVID-19 on February, 14, 2020. All Arab countries utilized real-time polymerase chain reaction (Real-time PCR) as the testing method for SARS-CoV-2. Results are obtained in about four to five hours following nasal and nasopharyngeal swabs.
Statistically COVID-19 cases show that Arab countries are ranked fourth after USA, Brazil and Russia. In terms of total deaths, Arab countries come in the second last, before Chile. UAE performed 2,110,493 molecular tests for SARS-CoV-2 whereas Yemen conducted only 120. Other parameters which include total tests, tests per million, population and average age are summarized in Table 4.

Discussion
Currently, COVID-19 is the number one threat on human health worldwide, resulting in serious challenges for governments and healthcare workers in regards to its spread, treatment and prevention. For this reason, the urge to understand the disease behavior and how any preventive or controlled measures might have influenced such spread is necessary. Therefore, the current review aimed to assess the prevalence of COVID-19 patients in the Arab world and to compare them with other affected countries from January to May 2020. To our knowledge, we are the first to summarize the numbers of confirmed, death and cured cases monthly compared to the total population and testing method in the 22 Arab countries.
COVID-19 greatly pressurized the health care system due to the high numbers of cases and deaths in many countries. Strategies and measures to reduce the spread of COVID-19 included the lockdown of major cities, full suspension of flights, university and school closure, social distancing, suspension of events, provision of free-of-charge health care to all patients, and launching of COVID-19 active screening in the highly infected areas [42]. Moreover, quarantine was also implemented as it is recommended by the WHO to be the most effective intervention strategy for preventing the spread of the virus [43,44]. The timing and restrictions of these strategies varies from one country to another, which subsequently affected the number of confirmed and death cases overtime as discussed below.
Although the first Arab country to officially report confirmed cases was UAE (5 cases; January, 29, 2020), Kuwait showed the highest cases, followed by Bahrain, UAE and Iraq in February. The highest reported cases in these countries were synchronous with Iran which reported its first case of COVID-19 on 19 February 2020 and continue to become among the most severely affected countries as of 18 May 2020 [45]. Many Arabs especially in the Gulf Cooperation Council region considered Iran as a central attraction for religious and personal reasons [46]. On the other hand, Egypt was the second Arab country and the first Arab -African country to declare the presence of COVID-19 on February 14, 2020. Having said that, the cases did not increase in number in that month and thus was not among the Arab countries with highest cases. The geographic location and the self-sufficiency of labor and other resources might limit or reduce the entry of travelers from China at the beginning of the pandemic. This theory might be also applicable to other Arab countries, which reported zero cases in February.
All Arab countries reported increasing number of confirmed cases except in Morocco and Tunisia. However, the increase in confirmed cases varied from one country to another based on the preventive and controlled measures used by each country. Some countries delayed in applying these measures resulting in an increase in COVID-19 cases and further spreading of the disease. Surprisingly countries such as Iraq, Sudan, Somalia, Lebanon, Palestine, Yemen, Libya and Syria showed less than 0.025% of confirmed cases despite implementing less restricted measures. The unstable political status of these countries might have played a major role for such percentage. Their health care system is already suffering from lack of resources and proper policies. In addition, the lack of accurate and frequent testing, financial support and most importantly documentation, all these could have led to the underestimation of reported cases. Other stable countries, which showed similar or less percentage of confirmed cases, could be due to their geographic location and interaction with the outside world such as Mauritania and Comoros.
The trend of death cases among all Arab countries revealed some discrepancies as demonstrated in Table  2. For example, although Saudi Arabia showed the highest number of confirmed cases with 85261 but their death rate percentage (0.59%) is less than in Egypt (3.83%), which showed 24985 confirmed cases. Irrespective of the initially low percentage of confirmed cases, countries undergoing civil wars such as Syria and Yemen showed the highest percentage of death cases with 23.77% and 24.84%, respectively. On the other hand, countries with strong health care system and proper adhered policies in handling the pandemic showed very low percentages of death cases such as Oman, Qatar and Bahrain with 0.42, 0.07 and 0.17%, respectively. Thus, the political status and the health care system might affect the spread of infection and patients' management.
All Arab countries showed a scaling trend of cured cases of COVID-19 regardless of the above-mentioned factors that previously influenced the confirmed and death cases in these countries. The period of such cases was either longer or shorter and slower or faster depending on certain criteria set by each country. For example, cured cases can be determined by either using laboratory tests similar to the detection test or by the absence of symptoms. The nature of COVID-19 indicated that some of its symptoms such as coughing required long time to disappear. For that reason, reporting of the confirmed cured cases takes longer.
Despite recent data showing that COVID-19 has killed more than 371,166 people worldwide, the Arab countries have recorded the lowest number of deaths. When comparing these 22 countries to the rest of the world, they are ranked fourth place after USA, Brazil and Russia, as their total population is higher (435, 648,763). Based on the average age (26.77 years), the Arab world is considered to be the youngest among the rest, indicating why the disease is considered to be less aggressive and subsequently leading to less death rate (eight deaths per million). This was also true for India, which harbors young population (28 years) and subsequently less death (four deaths per million). These findings are in line with other similar reported results in Italy, China and United States that have associated COVID-19 deaths to be more common in older adults than younger persons [47][48][49]. Mexico has also a young population but their death cases are huge compared to the above two young countries (77 deaths per million). This could be explained by different theories including (i) the genetic makeup of this population (ii) the preventive and controlled measures that were immediately used to handle the pandemic and (iii) the health care system that has a great impact on these percentages. In the absence of vaccine or specific drugs for COVID-19, reducing the spread and transmission of the infection is the best protective approach that any country must follow [50].
Several limitations of our study are worth noting. First, difficulty of obtaining data. Second, short time span of study, of five months as this may miss the events leading to more useful data. Third, the absence of gender and age information in many Arab countries did not allow us to perform many comparisons and estimate the risk factors. Fourth, the lack of relevant studies in many Arab countries. All these limiting factors could be justified that COVID-19 is a new disease and requires more time for preparation and analysis. Fifth, many non-Arab nationalities work in those Arab countries and most of those evaluated data did not distinguish Arabs from non-Arabs. Finally, many patients who were asymptomatic or had mild symptoms and who were treated at home, might not be included in those data.

Conclusions
With all the variations detected among the Arab countries in either their political status, preventive and controlled measures, policies and/or the health care system, progression in handling the COVID-19 is still manageable. The total scale and severity of COVID-19 cases in all the Arab countries is still considered to be at low risk and is ranked fourth due to the strict and serious early measures taken to minimize this outbreak. Currently strategies such as minimizing the source of infection, the route of transmission and taking care of infected patients remain as the main challenges for health authorities in all Arab countries in controlling the COVID-19 pandemic.