COVID-19 in the Arab countries: Three-year study

Introduction

On March 11, 2020, the World Health Organization (WHO) declared coronavirus disease 2019 (COVID-19) as a pandemic. COVID-19, which is caused by severe acute respiratory syndrome-coronavirus (SARS-CoV-2), is a highly contagious virus.¹ In the last three years, COVID-19 has infected and killed millions of people around the world, including those in Arab countries. When COVID-19 started in the first period of 2020 and the polymerase chain reaction (PCR) tests were not available, fever, dry cough, sore throat, headache, fatigue, and breathlessness were the common symptoms for COVID-19 patients. However, many people with COVID-19 remain asymptomatic but can transmit SARS-CoV-2 to others.^2,3

In the past, vaccines have saved lives, avoided illness and infection, and been evaluated as effective health interventions.⁴ In fact, WHO has shown that vaccines are safer than treatment.⁵ COVID-19 vaccines reduce the risk of illness, hospitalization, and death from COVID-19. A study showed that the mean percentage of death with one dose was 11.55% compared to 4.31% after the second dose of any type of approved vaccine.⁶ Globally, it has been estimated that about eight billion doses of the COVID-19 vaccine have been distributed to reduce the rate of COVID-19.⁷ Comprehensively, the COVID-19 vaccination saved approximately 20 million lives during its first year of distribution.⁸ As of January 1, 2023, more than 5.51 billion people worldwide have received a dose of a COVID-19 vaccine, which corresponds to approximately 71% of the world population, and fully vaccinated about 66%.⁹

A recent study in Qatar concluded that deaths attributable to SARS-CoV-2 vaccination are extremely rare.¹⁰ They reported that the death rate among the vaccinated persons with a high probability of relationship to SARS-CoV-2 vaccination was 0.34 per 100,000 vaccine recipients, while the death rate among the vaccinated persons with either high or intermediate probability of relationship to SARS-CoV-2 vaccination was 0.98 per 100,000. In line with this study, the United States Centers for Disease Control and Prevention identified only nine deaths from 14,980 reports of death among more than 589 million vaccine doses between December 14, 2020, and June 6, 2022.¹¹

On the other hand, WHO has identified many different variants of SARS-CoV-2 including Alpha, Beta, Omicron, Gamma, Delta, Eta, Iota, Kappa, Zeta, and Mu. On 26 November 2021, WHO declared the Omicron variant, known as lineage B.1.1.529, a variant of concern.¹² It was first identified in Botswana and South Africa.¹³Although the Omicron variant (B.1.1.529) causes less severe symptoms, it is more contagious and spreads faster than any previous variant. Many studies reported that this variant causes reinfection, and may escape the immune system’s defenses, and two doses of vaccination appeared to be less effective.^14–16 However, some studies show that boosters can provide protection against Omicron infection.^17–19 Unfortunately, these variants and probably others will continue to emerge as long as SARS-CoV-2 remains.

The development of vaccines is usually a lengthy and complex process. However, in order to stop the transmission of COVID-19, vaccine development has been accelerated.^20,21 Despite unequal vaccine distribution, vaccine hesitancy, and waning immunity, billions of vaccine doses have been administered worldwide. One of the major causes of vaccine hesitancy and delay in vaccination is the concern about adverse effects.²² As of December 29, 2022, WHO approved 11 COVID-19 vaccines including Sinopharm, Sinovac, Bharat Biotech, Moderna, Pfizer/BioNTech, Oxford/AstraZeneca, Serum Institute of India, Janssen/Johnson & Johnson, Novavax, Serum Institute of India, and CanSino.²³

The Arab world contains 22 countries, distributed 12 in Asia and 10 in Africa. Language, history, traditions, and culture are shared by Arab countries.²⁴ However, the healthcare systems and availability of resources differ from one Arab country to another. Previously, we published two review papers. The first was a 5-month COVID-19 data in all Arab countries from January 1, 2020, to May 31, 2020, and concluded that most Arab countries took some serious early steps to minimize the outbreak of COVID-19.²⁵ The second one was a one-year from February 2020 to February 2021, and we concluded that among the Arab countries, Qatar, Bahrain, and Lebanon showed the highest number of recovered, confirmed, and deaths per million population, respectively. The number of confirmed and death cases among Arab countries triggers significant worries about morbidity and mortality related to COVID-19, respectively.²⁶ We have been following COVID-19 from the beginning in each Arab country. In the present study, we aimed to assess further the prevalence of COVID-19 in the Arab world from January 2020 to December 2022 and to compare these findings with other significantly affected countries.

Methods

We used the WHO, World COVID-vaccinations tracker, Worldometer, and Ministries of Health official websites to search for COVID-19 data in 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. The period covered was from January 2020 to December 2022. The inclusion criterion was official information about clinically diagnosed COVID-19 in English or Arabic. The exclusion criterion was unspecified date and location of information, or suspicion of duplicate information. The data were collected monthly and verified with the data in the Worldometer. The following information was collected from each Arab country: total population, median age, number of monthly confirmed, death, and recovered cases, the total number of COVID-19 tests, and COVID-19 vaccine rates (first and second). The data for the topmost 15 affected countries were extracted from the Worldometer at the same time as the data for the Arab countries. Ethical approval and written informed consent were not required for this type of study. Data were analyzed using the IBM SPSS Statistics (RRID:SCR_016479) software version 25 (SPSS Inc., Chicago, IL, USA). Results are presented as numbers, percentages, and means.

Results

By January 01, 2023, the total Arab population who live in Arab countries was 449,809,846. Egypt recorded the highest population among all Arab countries, followed by Sudan, and Algeria with 106,156,692, 45,992,020, and 45,350,148, respectively. The highest median age was seen in the UAE, followed by Qatar, and Bahrain with 38.4, 33.7, and 32.3 years, respectively. Whereas the lowest median age was seen in Sudan at 18.3 years. The total number of COVID-19 tests in all Arab countries was 362,542,626. The UAE recorded the highest number of tests per million population (PMP) with 19,632,329, followed by Bahrain (5,960,320), and then Oman (4,695,724). The people in Qatar and the UAE have received two doses of the COVID-19 vaccine equally to about 99% whereas those in Yemen received only 3% for both doses (Table 1).

The total number of COVID-19 cases in all Arab countries was 14,218,042 and of those, 173,544 (1.2 %) were deceased and 13,384,924 (94%) were recovered. Jordan, Qatar, Kuwait, Palestine, and Lebanon recorded the highest number of reported cases PMP with 261,404, 164,032, 151,138, 131,568, and 118,957, respectively. Yemen recorded only 383 cases PMP. Based on the evaluation of three years from January 2020 to December 2022, the trend showed that the first quarter of 2022 had the highest number of confirmed COVID-19 cases in all Arab countries with 3,235,665 cases. In the same quarter period, 11 Arab countries scored their highest number of COVID-19 confirmed cases (Table 2).

Deaths PMP were dominant in Tunisia, Jordan, Palestine, Lebanon, and Libya with 2,430, 2,116, 1,073, 1,052, and 914, respectively. The trend demonstrated that the third quarter of 2021 had the highest number of deaths in all Arab countries with 31,275 cases. In the same quarter period, five countries had the highest number of COVID-19-related deaths (Table 3).

Bahrain, Jordan, Kuwait, Qatar, and Palestine showed the highest number of recovered cases PMP with 307,175, 258,944, 147,542, 134,455, and 131,528, respectively. The trend showed that the first quarter of 2022 had the highest number of recovered cases in all Arab countries with 3,261,712 cases. In the same quarter period, 10 countries had the highest number of recovered cases (Table 4).

In comparison to the topmost 15 affected countries, the Arab world ranked 16 as it had the lowest overall incidence PMP of 31,609. The data on total deaths PMP showed that India had the lowest number of deaths with only 377 cases followed by the Arab world with 386 cases. The United States recorded the highest number of deaths with 3,339 cases. In terms of the total number of tests for SARS-CoV-2, Arab countries ranked eleventh with 805,990 tests PMP. The highest number of tests PMP was conducted by Spain (10,082,298) and the lowest was by Brazil (296,146). Arab countries showed the youngest median age followed by India with 28.7 years as its median age. Conversely, Japan had the oldest median age of 48.6 years, however, it had fewer COVID-19 deaths per million populations with 456 cases. It is worth mentioning that six of the top 15 affected countries are from Europe. France was the worst country (after South Korea) as it recorded 599,471 cases PMP and ranked first. Other parameters, which include total tests and population, are also compared (Table 5).

Discussion

The present study aimed to assess the prevalence and the impact of the COVID-19 pandemic in 22 Arab countries and compare them with other significantly affected countries from January 2020 to December 2022. COVID-19 confirmed cases increased exponentially in the first quarter of 2021 due to the influenza season with Jordan demonstrating the highest number of cases followed by Lebanon. A dramatic increase in COVID-19 confirmed cases occurred in the third quarter of 2021 due to the emergence of the Delta variant,²⁷ which peaked in Iraq with a total number of 665,730. Another reason for the spike increase is the slow uptake of the vaccine in many countries of the world, including Arab countries.²⁸ For example, only 20% of the population in Iraq had received single/double doses of the COVID-19 vaccine. In addition, people in several countries, such as Iraq, refused to take the vaccine, which in turn, might have played a role in accelerating the number of COVID-19 confirmed cases.²⁹ Furthermore, the re-opening of schools and businesses, people returning from holidays and social mixing subsidized the escalation in the COVID-19 confirmed cases at the end of summer and the start of winter of 2021.²⁷ The situation was further aggravated by the economic disturbance in some of these countries hence, they had a compound crisis; COVID-19 and economic disruption.³⁰

Preventive measures taken by countries during the pandemic affected the spread of the COVID-19 virus. During the first, second, and third quarters of 2020, the pandemic was under control in most Arab countries mostly due to the implementation of extreme precautionary measures. The major measures include land, sea, and air route closure, nighttime or all-day curfew and lockdown, school and universities closure, worship places closure, prohibition of gatherings, closure of shops, malls, beaches, public parks, and gardens, cancellation of all cultural and sports events, festivals, seminars, and scientific meetings, and suspension of work in all government and private sectors.^31–33A study conducted in Saudi Arabia showed that preventive measures had an enormous effect in reducing the number of expected confirmed cases of COVID-19 from 437,096 cases to an observed number of 28,656 at the beginning of the second quarter of 2020.³⁴ Because of the economic crisis in some countries like Jordan, some of these measures were diminished in the fourth quarter of 2020, leading to an increase in COVID-19 cases.³⁵

During the first quarter of 2022, which was a shockwave, the Arab countries recorded the highest number of confirmed COVID-19 cases ever reported between 2020 and 2022. The total number of cases was 3,235,665, with Jordan reporting the highest number of cases at 630,811. The potential reason for the spike is the occurrence of the Omicron variant that had affected the death rate and increased hospitalization.³⁶ On the other hand, the pandemic had intense consequences on the economy of many countries. Therefore, to revive the economy, different approaches were taken such as the period of isolation of the infected people was reduced and guidelines on PCR testing of suspected COVID-19 cases became more restrictive.³⁵ Subsequently, there was a dramatic decrease in the confirmed cases in the second quarter of 2022, which continued to decline until the end of the year. Both the third-fourth quarters of 2021 and 2022 demonstrated a similar wave but with a lesser rate of confirmed COVID-19 cases in 2022. This could be due to the higher vaccine coverage in that year emphasizing the importance and the impact of vaccination intake.³⁷ Despite the full vaccination coverage in Qatar (99%), among Arab countries, Qatar was reported with the highest number of confirmed cases of COVID-19 in the fourth quarter of 2022 with a total number of 37,730. The conceivable reason could be that Qatar was hosting the World Cup 2022 with no COVID-19 restrictive measures required to enter the country, which had strikingly increased the social gathering and thus, increased COVID-19 confirmed rates.³⁸

Among Arab countries, such as the Gulf Cooperation Council (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the UAE) and Morocco, with over 60% of their population fully vaccinated, showed a sharp decrease in the death rate PMP in the last quarter of 2021 (Table 3). However, the first quarter of 2022 retained a death peak, which disappeared by the second quarter of the same year, probably because of the fast-spreading Omicron variant wave. Countries like Yemen, Syria, Iraq, and Sudan showed a low percentage of vaccination, a low number of tests, and surprisingly low deaths PMP (Tables 1 and 3). Political instability and a weak healthcare system that depends on outside humanitarian aid could be attributed to a lack of regular testing and continued poor documentation of COVID-19 status.²⁵

Jordan, as an example of an Asian country, experienced the first wave of viral spread during the fourth quarter of 2020, lasted until January 2021, and resulted in a great increase in accumulative confirmed and death cases. Before the first wave started, epidemiological status was under control, but by early September 2020 some restrictions were removed, e.g., land boundaries were opened for export/import goods from neighboring countries, universities opened doors for registration, and people started to take the crisis less seriously.³⁵ The second wave in Jordan was led by the fast-spreading UK variant that started in January 2021 continued until May 2021 and peaked in March 2021. The Indian Delta strain spread in Jordan during the second quarter and beginning of the third quarter of 2021, but the epidemiological data did not show any peak due to vaccination or naturally acquired immunity.³⁵ The third and fourth waves, from October 2021 until January 2022 and January 2022 to March 2022, respectively, started as the government halted many preventive measures due to economic stress. Both waves were led by the Omicron variant.³⁵

Tunisia, as an example of an African country, started to record positive cases in early March 2020, however by June 2020, the government could control the situation by applying preventive measures, which resulted in zero cases between 4^th and 12^th June. In July 2020, borders opened and clear slackening in sticking with preventive measures by people resulted in the second wave, which affected the country. March 2021 was the start of the third wave in Tunisia, which was highlighted by severe cases and a high transmission rate, caused by the Alpha variant after the fourth wave, which was led by the Delta variant that occurred in May 2021. During this period, Tunisia got a high rate of deaths PMP (Table 3). The Omicron variant of concern was the cause of the fifth wave by the end of 2021, so the country experienced another peak of death during the first quarter of 2022. These waves attributed to a large number of deaths. Tunisia has the highest number of deaths PMP among Arab countries. The economic crisis in addition to political problems made it difficult for the government to control COVID-19 and this in turn, resulted in the delay of the introduction and dissemination of COVID-19 vaccines.³⁹

Studying the trend of recovered cases is a useful indication of the health status and the health system in these countries. It is also a good tool to be used in terms of applying certain restrictions such as the duration of lockdown. From January 2020 to December 2022, all Arab countries showed various numbers of recovered cases of COVID-19. Such variation depended initially on the number of infected cases and on a broader scope, the severity of infection, treatment, patient immunity, vaccination, and other political and health factors.³⁷ Although some data were missing on the number of recovered cases for some countries, Bahrain, followed by Jordan, Kuwait, and Qatar showed the highest among all Arab countries. Whereas, Syria, Sudan, Somalia, and Yemen showed the lowest number of recovered cases, which may be explained by the unstable political status and subsequently the weakness of the healthcare system. Over time and based on the registered cases, the trend of recovered cases started at a low, reached a high peak, and eventually declined. This trend is common in such pandemics and the mode of spreading such infection had been observed in the previous pandemic.⁴⁰ The bell-shaped trend in certain countries such as Palestine, given all collected data, are accurate, and helped tremendously in managing the pandemic crisis in terms of lockdown, financial and social impact, and predicting the coming waves of the mutant viruses.

The effect of a complete vaccination regimen on the recovered cases was not consistent among Arab countries. As mentioned previously, Qatar had the highest percentage of the vaccinated population but was not the top-rated country in the recovered cases. Such observation does not exclude the importance of vaccination effect on these cases rather than additional factors that might have contributed to this outcome.

A recent study showed the effectiveness of the vaccine in preventing SARS-CoV-2 infection and its symptoms. In addition to other mitigation strategies, vaccine campaigns could have a great impact on the number of confirmed and recovered cases.⁴¹ Although quarantine was one of the most important measures in controlling the spread of the epidemic,⁴² such a theory changed once the right vaccine was used. Quarantine controls the disease by the large fraction of pre-symptomatic and asymptomatic transmission, unlike the vaccine that eliminates the virus and reduces its symptoms in many cases.

During the recent pandemic, vaccination campaigns have proven their effectiveness to control the disease and reduce the severity of its symptoms. Certain tactics were used to enhance public awareness and acceptance of vaccine during these campaigns. One of the most effective tactics was to address public opinions of vaccine safety and efficacy by disseminating accurate information through authorized channels. This information was in different languages to reach out all in the community. Community engagement and healthcare guidance were also helpful. During the vaccination process, the uptake of vaccine was enhanced by removing any obstacle that might delay such a process. For example, setting up vaccination centers in different locations with an easy access and quick appointment. These centers had big area to accommodate more people at each time. Community outreach existed for those who could not go to these centers.⁴³ Unfortunately, many countries had anti-vaccine groups that were affecting the vaccination campaigns badly. Those groups influenced the decision of several people on taking the vaccines and subsequently affecting the control of the disease. Changing the culture and the mentality of certain groups in societies will be the first and biggest challenges for vaccination campaigns in any pandemic in the future. Altogether, the authors hypothesized that vaccination campaigns influenced the number of confirmed and recovered cases in these Arab countries despite the impact of other related factors. It is very important to open new insights in the research of vaccine discovery and more time and effort should be spent in this area.

Recently, Hoxha and coworkers analyzed COVID-19 data from 164 different countries and concluded that higher COVID-19 vaccination rates are associated with lower COVID-19 mortality rates and that there is a tendency for more vaccinations and fewer deaths per 1,000 cases with increasing country income levels.⁴⁴ Notably, Both Qatar and UAE represent as the highest income countries in the Arab world. The UAE recorded the same percentage of the vaccinated population as Qatar, and both demonstrated low number of deaths. Research conducted in the UAE regarding the inactivated BBIBP-CorV (Sinopharm) vaccine revealed that its efficacy against severe COVID-19 outcomes was 80% for hospitalization, 92% for critical care admission, and 97% for preventing death.⁴⁵ In addition, a study conducted in Morocco on the long-term efficacy of the inactivated BBIBP-CorV vaccine revealed a decrease in effectiveness, dropping from 88% to 64% six months after vaccination.⁴⁶ Furthermore, in Qatar, a different study demonstrated that the efficacy of BBIBP-CorV vaccine against SARS-CoV-2 infections decreased gradually, with a more rapid decline observed after the fourth month. This decline resulted in about 20% protection at five to seven months following vaccination. However, the vaccine’s efficacy remained nearly 96% effective in preventing hospitalization and death six months after vaccination.⁴⁷

Compared with the 15 topmost affected countries in the world, the Arab world experienced a lower number of cases and deaths PMP (Table 5). It also performed fewer tests than its population. South Korea, Japan, Argentina, Brazil, Vietnam, and India also performed a lesser number of tests than their populations. Conversely, the six European countries (France, Germany, Italy, UK, Spain, and Russia), Australia, the United States of America, and Turkey have performed tests more than their populations. A similar result was observed for most European countries by November 2022, where the number of tests exceeded the number of residents.³⁷ The diagnostic testing strategy and mass screening including the screening of asymptomatic people is a major strategy in controlling the spread of the virus.⁴⁸ Hence, testing procedures such as PCR is a tool used to detect and record both confirmed and death cases.⁴⁹ It is possible that such countries that performed fewer tests than their populations could have resulted in recording fewer confirmed cases and deaths. Furthermore, it has been suspected that the smaller number of tests carried out could be a reason for the reduced spread of the virus and the slowing down of the spread of the infection. However, the analysis conducted by Hisaka et al., (2020) concluded that extensive PCR testing might be effective in reducing the number of deaths and that further studies are required to verify this hypothesis.⁵⁰

A previous study reported that older age plays a vital role in influencing the severity of COVID-19 disease and negative clinical outcomes than the younger population.⁵¹ With this, the lower deaths PMP as observed in both the Arab world (386 cases) and India (377 cases) could be attributed to the low median age of 26 and 28.7 years, respectively. By contrast, this claim contradicts why Japan with the highest median age of 48.6 years in the top 15 affected countries also recorded a low number of deaths PMP (456 cases).

Studies have reported that in response to the COVID-19 pandemic, all 44 Muslim countries including the Arab world and Turkey, mainly implemented mitigation strategies to control the virus.^52,53 The main aim of implementing a mitigation strategy is to reduce the number of death tolls by focusing on the medical care of severe cases and relying on social distancing and quarantine to flatten the curve of epidemic impact and burden on hospitals.⁵⁴ Stringent measures included the suspension of all airline flights, cancellation of Umrah, and down-scaling of the pilgrimage to Mecca.⁵² Other countries that mainly responded with mitigation strategies included the United States, and European countries.^54,55 Mitigation measures are adopted immediately once the containment strategies (strict lockdowns) fail to isolate the infected individuals due to the widespread infection in the community or until vaccines are developed.⁵⁶ Hence, there is a clear indication that countries vary widely in their response to the COVID-19 impact and that these differences could be partially explained by many factors such as the economic and cultural situation, governmental policies, medical capacities, the age and genetic variation between ethnic groups in a population.⁵⁰

Due to surge in COVID-19 patients during the pandemic and the demand to increase medical services accordingly, field hospitals were launched and effectively operated in several Arab countries like the KSA, UAE, Tunisia, and Jordan.^57–60 For example, in the KSA, the Ministry of Health established four field hospitals in high-risk areas with a capacity of +1100 beds each.⁵⁷ This expansion in health infrastructure during a short time of pandemic would strengthen the health care system for any future surge of infectious disease. In response to the pandemic, electronic disease surveillance has been improved in several Arab countries. This was highly contributed to detect, monitor, response, control and prevent disease. Also, it allowed decision maker to implement any necessary measure based on the collected data. In Saudi Arabia, the Saudi Data and Artificial Intelligence Authority (SDAIA) developed the Tawakkalna App which was used to monitor individual movement during quarantine and give notifications to users when they have been in an area of positive cases, and to prove vaccination status.⁶¹ In Oman, Tarassud Plus platform was used as a hub for the same purposes.⁶² One of the implications of COVID-19 crisis was the hesitancy toward vaccination. Articles showed that the prevalence of vaccination hesitancy found to be 5.4%-63.8% in Saudi Arabia, 12%-79% in Egypt, 10.4%-80.1% in Jordan, 26%-57.3% in Qatar and 47% in Algeria.⁶³ This hesitancy was related to many factors including fear about side effect, insufficient time for vaccine testing, concerns on safety and effectiveness of vaccination.^63,64 Information that was acquired online through nonscientific resources found to increase this hesitancy.⁶³ Studies recommended that the dissemination of information should be through scientific/governmental websites.^65,66 Educational campaigns through television and social media are recommended to inform the public of the benefits of COVID-19 vaccine.⁶⁷

The healthcare system in Arab countries focused on treating COVID-19 patients, leading to the postponement of some non-urgent surgeries and outpatient appointments. Telemedicine was employed to reduce the burden on in-person facilities through virtual clinics, as seen in Saudi Arabia.⁵⁷ Additionally, several Arab countries, including Oman and Saudi Arabia, provided a 24/7 toll-free hotline for inquiries and support throughout the pandemic.^57,62 During the COVID-19 pandemic, digital technologies emerged as a crucial field to ensure public safety, health, and the continuation of commercial and social activities. According to the Arab Information and Communication Technology Organization (AICTO) platform, many Arab countries developed technology projects in response to the situation. For instance, Jordan launched two initiatives during the pandemic: “You are not with us, we are with you” to enhance psychological health, and “Mouneh” for shopping.⁶⁸ Saudi Arabia’s digital infrastructure supported society with 19 apps and platforms during the pandemic, facilitating public services in health, education, economy, telecommunications, and other sectors. Examples include “Mawid” and “Sehhaty” for health services, and “Ein,” a unique app for transitioning public schools to e-learning.⁶⁹

Conclusions

Although the number of confirmed, death, and recovered cases of COVID-19 have greatly reduced in the last quarter of 2022 in most Arab countries, further efforts to address the need to re-campaign on COVID-19 vaccines and raise awareness programs about boosters must be implemented. COVID-19 has had a relatively smaller impact on Arab countries than on other countries that have been significantly affected.