Tackling COVID-19 in the Eastern Mediterranean Region
Authors: Ahmed Salim Al-Mandhari, Richard J Brennan, Abdinasir Abubakar, Rana Hajjeh
Journal: The Lancet (2020)

COVID-19 has substantially impacted the Eastern Mediterranean Region (EMR), home to nearly 700 million people across 22 diverse countries. Since the first reported confirmed case in January, 2020, 3 611 352 confirmed COVID-19 cases and 91 738 deaths were reported in the region as of Nov 17, 2020.1World Health Organization Regional Office for the Eastern MediterraneanCOVID-19 situation in the region—total reports. Situation as of 17 November.http://www.emro.who.int/health-topics/corona-virus/index.htmlDate: 2020Date accessed: November 17, 2020Google Scholar Most countries saw fairly slow transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the early months of the pandemic but in May, as social measures, such as restrictions and partial or full lockdowns, were relaxed during the holy month of Ramadan, disease transmission accelerated.2Walker PGT Whittaker C Watson OJ et al.The impact of COVID-19 and strategies for mitigation and suppression in low- and middle-income countries.Science. 2020; 369: 413-422Crossref PubMed Scopus (526) Google Scholar, 3WHOCoronavirus disease 2019 (COVID-19) situation report—102 and 163.https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reportsDate: 2020Date accessed: November 12, 2020Google Scholar After a small reduction in the summer, cases increased in late August as disease surged in countries, such as Jordan and Tunisia, where transmission had been low earlier in the year and resurged in other countries, such as Bahrain and Oman.3WHOCoronavirus disease 2019 (COVID-19) situation report—102 and 163.https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reportsDate: 2020Date accessed: November 12, 2020Google Scholar Several factors can explain the regional COVID-19 trends and inform more effective disease control. First, the early implementation of public health and social measures, starting mid-March, proved effective, including non-pharmaceutical individual and societal interventions to control COVID-19.4WHOConsiderations for implementing and adjusting public health and social measures in the context of COVID-19. Interim guidance.https://www.who.int/publications/i/item/considerations-in-adjusting-public-health-and-social-measures-in-the-context-of-covid-19-interim-guidanceDate: 4 November 2020Date accessed: November 12, 2020Google Scholar All countries closed schools and non-essential businesses, imposed travel restrictions, and partial or full lockdowns,5ACAPSCOVID 19 Government Measures Database.https://www.acaps.org/covid19-government-measures-datasetDate: 2020Date accessed: November 12, 2020Google Scholar and community mobility decreased substantially.6GoogleGoogle COVID-19 community mobility report.https://www.google.com/covid19/mobility/Date: 2020Date accessed: November 12, 2020Google Scholar But as these measures were eased, community mobility resumed and was only 19% below pre-COVID-19 levels by mid-July.6GoogleGoogle COVID-19 community mobility report.https://www.google.com/covid19/mobility/Date: 2020Date accessed: November 12, 2020Google Scholar Second, restrictions on mass gatherings and pilgrimages had an important role. In Iran, cases initially occurred in Qom, a destination for religious pilgrimages, which soon became an epicentre, and within 15 days all 31 provinces in Iran reported cases. By early April, 12 EMR countries reported SARS-CoV-2 transmission associated with mass gatherings and pilgrimages. In response, new measures were taken including the closures of mosques and the suspension of Friday and church prayers and the Umrah.7Saudi Press AgencyMinistry of Hajj and Umrah: Hajj 1441H is decided to take place this year with limited number of pilgrims from all nationalities residing in Saudi Arabia. Saudi Press Agency, June 22, 2020https://www.spa.gov.sa/viewfullstory.php?lang=en&newsid=2100951Date accessed: November 12, 2020Google Scholar Third, migrant workers drove SARS-CoV-2 transmission during the early months of the pandemic in those countries where they constitute a large proportion of the population. The Gulf countries, which have the highest testing rates, also have the highest COVID-19 regional attack rates; in these countries, 62–90% of COVID-19 cases occurred among migrant workers early on,8Gambrell J 2 Mideast countries have highest confirmed virus rates. Associated Press, July 23, 2020https://apnews.com/fe5909abd3a01d5d77f65a556183050dDate accessed: November 12, 2020Google Scholar attributed partly to overcrowded living conditions.9Hutton J Coronavirus exposes vulnerabilities of world's migrant workers.The Straits Times. 26 May 2020; https://www.straitstimes.com/world/middle-east/virus-exposes-vulnerabilities-of-worlds-migrant-workersDate accessed: November 12, 2020Google Scholar Finally, among the eight EMR countries affected by conflict and humanitarian emergencies—Afghanistan, Iraq, Libya, the occupied Palestinian territory, Somalia, Sudan, Syria, and Yemen—COVID-19 attack rates are substantially lower than in other countries in the region (median 73 cases per 100 000 population vs 1343 cases per 100 000).10OCHAGlobal humanitarian overview.https://www.unocha.org/sites/unocha/files/GHO-2020_v9.1.pdfDate: 2020Date accessed: November 12, 2020Google Scholar This lower attack rate might be due to restricted international arrivals limiting virus introduction, reduced internal mobility, the demographics of these countries,11Central Intelligence AgencyCountry comparison: median age. CIA World Factbook, 2020https://www.cia.gov/library/publications/the-world-factbook/fields/343.htmlDate accessed: November 12, 2020Google Scholar and fewer tests in conflict-affected countries than in other EMR countries (median 291 tests per 100 000 vs 15 279 per 100 000).12WHOEastern Mediterranean Regional Office COVID-19 dashboard.https://app.powerbi.com/view?r=eyJrIjoiN2ExNWI3ZGQtZDk3My00YzE2LWFjYmQtNGMwZjk0OWQ1MjFhIiwidCI6ImY2MTBjMGI3LWJkMjQtNGIzOS04MTBiLTNkYzI4MGFmYjU5MCIsImMiOjh9Date: 2020Date accessed: November 17, 2020Google Scholar Observations from community and health facilities in conflict-affected countries suggest that laboratory testing capacity or under-reporting of cases is unlikely to solely explain these lower attack rates. The main challenges to the COVID-19 response in the EMR include information sharing, expanding public health measures, protecting health workers, achieving behaviour change, ensuring continuity of essential health services, and establishing reliable supply chains. Although the effectiveness of country-specific COVID-19 responses varies, certain best practices in the region have been important. Decisive leadership and whole-of-government and whole-of-society approaches are central to an effective response.13Obaid Al Saidi AM Abikar Nur F Al-Mandhari AS et al.Decisive leadership is a necessity in the COVID-19 response.Lancet. 2020; 396: 295-298Summary Full Text Full Text PDF PubMed Scopus (71) Google Scholar Most countries established high-level national multisectoral coordination mechanisms and developed national plans that covered the nine pillars of the WHO COVID-19 Strategic Preparedness and Response Plan (panel).14WHOCOVID-19 Strategic Preparedness and Response Plan—operational planning guidelines to support country preparedness and response.https://www.who.int/publications/i/item/draft-operational-planning-guidance-for-un-country-teamsDate: 2020Date accessed: November 12, 2020Google Scholar For surveillance, countries leveraged existing systems, including routine influenza surveillance and polio infrastructure. Nonetheless, reporting of epidemiological data to WHO as per the International Health Regulations (2005) and application of the WHO case definition have often been unreliable and incomplete. Although all 22 countries can test for SARS-CoV-2, laboratory capacities, testing strategies, and testing rates vary widely—eg, from 33 to 146 343 tests per 100 000 population in EMR countries. Contact tracing is generally insufficient and not yet scaled up. All EMR countries have designated health facilities to manage COVID-19 cases, mostly of severe disease. Treatment protocols vary from supportive treatment to complex regimens, including compassionate drug use outside of clinical trials.15Pooladanda V Thatikonda S Godugu C The current understanding and potential therapeutic options to combat COVID-19.Life Sci. 2020; 254117765Crossref PubMed Scopus (64) Google Scholar Health workers accounted for 7–10% of COVID-19 cases during the 3 months of the pandemic in the EMR and outbreaks among these workers contributed to acceleration of the pandemic.16Hendawi H Coronavirus: Egypt orders enquiry into doctor's death as separate wards open for medics.The National. May 26, 2020; https://www.thenational.ae/world/mena/coronavirus-egypt-orders-inquiry-into-doctor-s-death-as-separate-wards-opened-for-medics-1.1024891Date accessed: November 12, 2020Google Scholar Inadequate infection prevention and control (IPC) programmes and poor IPC compliance are important contributing factors, especially considering that ten countries had no pre-existing national IPC structures. On the basis of WHO recommendations, all EMR countries subsequently prioritised and invested more in IPC practices through training, monitoring, and provision of personal protective equipment.17Saqlain M Munir MM ur Rehman S et al.Knowledge, attitude, practice and perceived barriers among healthcare professionals regarding COVID-19: a cross-sectional survey from Pakistan.J Hosp Infect. 2020; 105: 419-423Summary Full Text Full Text PDF PubMed Scopus (323) Google Scholar As the pandemic evolved, risk communications and community engagement faced challenges, such as widespread so-called pandemic fatigue.18Radwan R Virus-weary Saudis at risk of succumbing to "pandemic fatigue". Arab News.https://www.arabnews.com/node/1728231/saudi-arabiaDate: Sept 2, 2020Date accessed: November 12, 2020Google Scholar COVID-19 knowledge and risk perception vary across the region; use of masks ranges from 6% to 83% across EMR countries.19Honarvar B Lanjarani KB Kharmandar A et al.Knowledge, attitudes, risk perceptions, and practices of adults toward COVID-19: a population and field-based study from Iran.Int J Public Health. 2020; 65: 731-739Crossref PubMed Scopus (148) Google Scholar, 20Al-Hanawi MK Angawi K Alshareef N et al.Knowledge, attitude and practice toward COVID-19 among the public in the Kingdom of Saudi Arabia: a cross-sectional study.Front Public Health. 2020; 8: 217Crossref PubMed Scopus (481) Google Scholar, 21Institute for Health Metrics and EvaluationMask use in WHO regions.http://www.healthdata.org/infographic/mask-use-who-regionsDate: 2020Date accessed: November 12, 2020Google Scholar The socioeconomic impacts of COVID-19 response measures have been substantial, with gross domestic product projected to decline by 4·7% across the EMR in 2020 and by 13% in conflict-affected countries.22International Monetary FundFive charts that illustrate COVID-19's impact on the Middle East and Central Asia.https://www.imf.org/en/News/Articles/2020/07/14/na071420-five-charts-that-illustrate-covid19s-impact-on-the-middle-east-and-central-asiaDate: July 16, 2020Date accessed: November 12, 2020Google Scholar WHO recommends risk assessment before the easing of COVID-19 response measures, but some countries struggled to make such assessments while mitigating economic impacts, and often decisions were not adequately informed by public health data.23WHOConsiderations in adjusting public health and social measures in the context of COVID-19. Interim guidance.https://www.who.int/publications-detail-redirect/considerations-in-adjusting-public-health-and-social-measures-in-the-context-of-covid-19-interim-guidanceDate: 16 April 2020Date accessed: November 12, 2020Google ScholarPanelNine pillars of the WHO COVID-19 Strategic Preparedness and Response Plan•Country-level coordination, planning, and monitoring•Risk communication and community engagement•Surveillance, rapid response teams, and case investigation•Points of entry, international travel, and transport•National laboratories•Infection prevention and control•Case management•Operational support and logistics•Maintaining essential health services and systems •Country-level coordination, planning, and monitoring•Risk communication and community engagement•Surveillance, rapid response teams, and case investigation•Points of entry, international travel, and transport•National laboratories•Infection prevention and control•Case management•Operational support and logistics•Maintaining essential health services and systems The COVID-19 pandemic has compromised delivery of essential health services (EHS) in the region, as countries repurposed health systems to respond. About 75% of EHS had some level of disruption in 13 countries, mostly affecting routine immunisations, dental services, rehabilitation services, and family planning.24WHOIn WHO global pulse survey, 90% of countries report disruptions to essential health services since COVID-19 pandemic.https://www.who.int/news-room/detail/31-08-2020-in-who-global-pulse-survey-90-of-countries-report-disruptions-to-essential-health-services-since-covid-19-pandemicDate: Aug 31, 2020Date accessed: November 12, 2020Google Scholar Countries are now increasingly prioritising continuity of EHS, using WHO's operational guidance.25WHOEssential health services.https://www.who.int/publications/i/item/10665-332240Date: June 1, 2020Date accessed: November 12, 2020Google Scholar In addition, the pandemic has exposed the fragility of the medical supply chain; there have been shortages of personal protective equipment, ventilators, and diagnostics in all EMR countries. WHO and partners established the COVID-19 Supply Chain System that managed distribution of supplies to more than 160 countries. WHO's EMR logistics hub in Dubai, central to this system, had managed 376 shipments to 109 countries by Nov 17, 2020. In conflict-affected countries there are insufficient resources for an effective response, with inadequate planning, limited public health and hospital capacity, and difficulties with implementing physical distancing and hand and personal hygiene in overcrowded settlements for displaced persons.26Favas C Guidance for the prevention of COVID-19 infections among high-risk individuals in camps and camp-like settings. London School of Hygiene & Tropical Medicine, March 31, 2020https://www.lshtm.ac.uk/sites/default/files/2020-04/Guidance%20for%20the%20prevention%20of%20COVID-19%20infections%20among%20high-risk%20individuals%20in%20camps%20and%20camp-like%20settings.pdfDate accessed: November 12, 2020Google Scholar The most pressing challenges remain balancing the easing of COVID-19 control measures while maintaining suppression of SARS-CoV-2 transmission, scaling up public health measures, tackling COVID-19 fatigue, and establishing a platform for distribution of eventual COVID-19 vaccines. Countries in the EMR must heed the advice of the independent Global Preparedness Monitoring Board: show responsible leadership, engage citizens, build strong systems for health security, and ensure sustained investment and strong governance of preparedness for health emergencies.27Global Preparedness Monitoring BoardA world at risk: annual report on global preparedness for health emergencies.https://apps.who.int/gpmb/annual_report.htmlDate: 2019Date accessed: November 12, 2020Google Scholar ASA-M is the WHO Regional Director for the Eastern Mediterranean. We declare no competing interests.