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

Background Twenty-two Arab countries share a common language, history, and culture. Nevertheless, governmental policies, healthcare systems, and resources differ from one Arab country to another. We have been following Coronavirus (COVID-19) from the beginning in each Arab country. In the present study, we aimed to assess the prevalence of COVID-19 in the Arab world and to compare these findings with other significantly affected countries. Methods Websites of the World Health Organization, World COVID-vaccinations tracker, Worldometer, and Ministries of Health were used to extract COVID-19 data in all Arab countries between the period January 2020 to December 2022. Results All Arab countries had 14,218,042 total confirmed COVID-19 cases, 13,384,924 total recovered cases and 173,544 total related deaths. The trend demonstrated that the third quarter of 2021 recorded the highest death toll and the first quarter of 2022 recorded the highest number of confirmed and recovered cases. Compared to the top 15 affected countries, the Arab world ranked last as it had the lowest overall incidence per million population (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. 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, many Arab countries still need to re-campaign about COVID-19 vaccines and raise awareness programs about boosters. COVID-19 has had a relatively smaller impact on Arab countries than on other countries that have been significantly affected.


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 the past, vaccines have saved lives, avoided illness and infection, and been evaluated as effective health interventions. 4n fact, WHO has shown that vaccines are safer than treatment. 5COVID-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. 6Globally, it has been estimated that about eight billion doses of the COVID-19 vaccine have been distributed to reduce the rate of COVID-19. 7Comprehensively, the COVID-19 vaccination saved approximately 20 million lives during its first year of distribution. 8As 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. 10They 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 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. 12It 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. 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. 20,21Despite 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. 22As 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. 23e Arab world contains 22 countries, distributed 12 in Asia and 10 in Africa.Language, history, traditions, and culture are shared by Arab countries. 24However, 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. 25The second one was a one-year from February 2020 to February 2021, and we REVISED Amendments from Version 2 The title has been slightly modified.
The population of Mauritania has been modified and subsequently the countries in Table 1 have been reordered.Two additional paragraphs have been added to the discussion section.
Few sentences have been rephrased.
Any further responses from the reviewers can be found at the end of the article 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. 26We 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.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. 28or 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. 29Furthermore, 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. 27The situation was further aggravated by the economic disturbance in some of these countries hence, they had a compound crisis; COVID-19 and economic disruption. 30eventive 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.2][33] A 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. 34Because 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. 35ring 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. 36On 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. 35Subsequently, 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. 37Despite 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. 38ong 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. 35The 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. 35The 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. 35nisia, 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. 39udying 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. 37Although 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. 40The 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. 41Although 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. 43nfortunately, 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. 44Notably, 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. 45In 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. 46Furthermore, 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. 47mpared 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. 37The diagnostic testing strategy and mass screening including the screening of asymptomatic people is a major strategy in controlling the spread of the virus. 48Hence, testing procedures such as PCR is a tool used to detect and record both confirmed and death cases. 49It 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. 50previous 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. 51With 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. 52,53The 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. 54Stringent measures included the suspension of all airline flights, cancellation of Umrah, and down-scaling of the pilgrimage to Mecca. 52Other countries that mainly responded with mitigation strategies included the United States, and European countries. 54,55itigation 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. 56Hence, 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][59][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. 57This 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. 61In Oman, Tarassud Plus platform was used as a hub for the same purposes. 62One 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. 63This hesitancy was related to many factors including fear about side effect, insufficient time for vaccine testing, concerns on safety and effectiveness of vaccination. 63,64Information that was acquired online through nonscientific resources found to increase this hesitancy. 63Studies recommended that the dissemination of information should be through scientific/governmental websites. 65,66Educational 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. 57Additionally, several Arab countries, including Oman and Saudi Arabia, provided a 24/7 toll-free hotline for inquiries and support throughout the pandemic. 57,62During 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. 68Saudi 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

Strengths and limitations
A key strength of this study is its comprehensive follow-up and collection of COVID-19 data in each Arab country for three consecutive years.In addition, accurate monthly data were obtained from the Ministry of Health in each country and verified with the Worldometer data for COVID-19.However, there are a few limitations in our study.First, no distinction was made between Arabs and non-Arabs in the reported health data since many non-Arabs work in Arab countries.Second, COVID-19 hospitalizations are lower after being fully vaccinated, so many patients might not be included in these statistics.Third, many Arab countries lack information about COVID-19 vaccine boosters.Fourth, the lack of gender and age data in numerous Arab countries prevented us from conducting thorough comparisons and assessing potential risk factors.Finally, this study could not identify an association between COVID-19 related deaths and comorbidities due to the absence of risk factors such as hypertension, diabetes, respiratory system disease, and cardiovascular disease in the data extracted.

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.The authors obtained accurate monthly data from the official websites of the Ministry of Health in each country in addition to verifying those against the data from the websites of the WHO, World COVID-vaccinations tracker, and Worldometer for COVID-19.The abstract, introduction, and methods were well written, clear, and appropriate to the research topic.I would like to suggest enriching the discussion with this subtitle: "Implications for clinical practice and public health practice".
Here are some elements for the respected authors to consider as relevant to the study aim:-Strengthen Healthcare Infrastructure: Examples 1: Invest in healthcare infrastructure, including hospitals, and medical supplies, to ensure preparedness for future pandemics.Example 2: Enhance the capacity of healthcare systems to accommodate a surge in patients during emergencies.

1.
Improve Disease Surveillance: Example 1: Develop and maintain robust surveillance systems to detect and monitor infectious diseases promptly.Example 2: Enhance the sharing of data and information among Arab countries and with international health organizations.

2.
Promote Vaccination Campaigns: Example 1: Implement comprehensive and equitable vaccination campaigns to achieve herd immunity against COVID-19 and future infectious diseases.Example 2: Combat vaccine hesitancy through targeted public health messaging and education.

3.
Enhance Telemedicine and Digital Health: Example 1: Expand telemedicine and digital health services to improve access to healthcare and reduce the burden on in-person facilities.Example 2: Ensure the privacy and security of electronic health records and telemedicine platforms.

4.
Prepare for Variants: Example 1: Develop strategies to monitor and respond to emerging variants of concern, including the rapid adjustment of vaccines and therapeutics.Example 2: Invest in genomic sequencing capabilities for timely variant detection.

5.
Strengthen Public Health Messaging: Example 1: Enhance public health communication strategies to provide accurate and timely information to the public during health crises.Example 2: Address misinformation and disinformation through targeted campaigns.

6.
Invest in Research and Development: Example 1: Allocate resources for research into infectious diseases, epidemiology, and vaccine development to better prepare for future pandemics.Example 2: Foster collaboration between academia, industry, and public health agencies.

7.
Prepare for Healthcare Workforce Challenges: Example 1: Develop contingency plans for healthcare workforce shortages during health emergencies.Example 2: Support the mental health and well-being of healthcare workers.

8.
Improve International Collaboration: Example: Foster regional and international collaboration in disease surveillance, response, and research.Example 2: Participate in global initiatives to ensure equitable access to vaccines and treatments.

9.
Health Equity and Vulnerable Populations: Example 1: Prioritize health equity in policies and interventions, addressing disparities that affect vulnerable populations.Example 2: Ensure access to healthcare and social support for marginalized communities. 10.
The following 4 articles below may be helpful in writing up or re-writing these points, if you agree on them, or additional points to be additional take-home messages for the readers.
These are 2 additional online resources:-  Understanding the epidemiology of COVID-19 in the Arab world and comparing it to the world could help researchers and decision-makers explore the best ways to deal with COVID-19 and may provide lessons for a more effective response to public health emergencies in the future.However, there are some suggestions to improve the article.
1-Type of the study: Is this a review article or an original research?Based on the article's methodology and structure, this article is considered original (research article).The authors extracted primary/secondary data (raw data) from online websites and then analyzed and interpreted the data.In contrast, a review article or paper is based on other published articles.
Review articles generally summarize the existing literature on a topic in an attempt to explain the current state of understanding of the topic.Therefore, this is not a review article because the authors did not base their methodology on a review of previous studies/research.The authors should reconsider this part!2-Suppose this article is considered an original study, which it appears to be.In that case, it is preferable to change the word "review" in the title to another word, for example, "study," so that the title is: "COVID-19 in the Arab countries: A three-year study" or "COVID-19 in the Arab countries: A study after three years".Please remove the phrase "the coronavirus".
8-In the "Methods" section, please provide the link/reference for each website if possible (Worldometer...).

9-
The exclusion criterion was unofficial information regarding COVID-19 in all Arab countries ,...This phrase (unofficial information regarding COVID-19 in all Arab countries) should be removed because it is known from the inclusion criteria (exclusion criteria are not the opposite of inclusion criteria).13-The people in Qatar and the United Arab Emirates ... have [ 1] Use the abbreviation: the UAE.Population or demographic characteristics such as age was also identified as a potential factor that may have influenced infection and death rates.We demonstrate in the discussion section that the ability of "healthcare systems to respond promptly against the COVID-19" such as implementing strict lockdown measures and mitigation strategies significantly reduced confirmed cases and fatalities.We also show in the discussion that countries that employed heavy testing protocols revealed higher number of cases and that under-reporting could have played a role in countries that did not employ large-scale testing.
Taking into account the possible influence of variables including climate, public health initiatives, and alterations in population behavior, how were seasonal fluctuations in COVID-19 incidence and death taken into account in the analysis? 1.

Response
According to the data of COVID-19 fluctuations, the spikes of Covid-19 were connected to the spread waves but not the climate.For example, in Tunisia, the peaked deaths were in the third quarter of 2021 which is considered as hot climate whereas in Lebanon the peaked deaths were in the first quarter of 2021 which is considered as a cold climate.According to the public health initiatives (e.g.vaccination) and positive alteration in population behaviors, we mentioned in the paper how these two factors affected the decrease in the death's numbers.
Could you provide further details about any possible biases or confounding factors, such as variations in healthcare access, population demographics, or government response tactics, that would affect how these cross-regional comparisons are interpreted? 1.

Response
This is very good question, however, population demographics such as gender and age are not reported.Thus, we have added the following sentence as a limitation: The Regarding the access to healthcare facilities during COVID-19 crises, this information is not available in all Arab countries.We know that GCC countries offered free medical treatment and vaccinations to all residents but this information is missing in other Arab countries.
According to the manuscript, vaccination campaigns were a major factor in the decline of COVID-19 cases, fatalities, and hospital admissions in Arab nations.Can you offer more proof or analysis to back up this claim, such as comparisons of COVID-19 results before and after vaccination campaigns or research on the efficacy of vaccines? 1.

Response
Our results did not study the comparison of COVID-19 before and after vaccination campaigns.As suggested, the following paragraph has been added in the discussion section: Research conducted in the United Arab Emirates 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. 46In 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. 47Furthermore, 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. 48w were public opinions of vaccine safety and efficacy, vaccine hesitancy, and disinformation addressed during the vaccination campaign discussion?Were any tactics put in place to enhance vaccination uptake and remove obstacles to access? 1.

Response
The following sentence has been added in the discussion section: 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. 44he benefits of publishing with F1000Research: Your article is published within days, with no editorial bias • You can publish traditional articles, null/negative results, case reports, data notes and more • The peer review process is transparent and collaborative • Your article is indexed in PubMed after passing peer review • Dedicated customer support at every stage • For pre-submission enquiries, contact research@f1000.com

©
2024 A. Alrasheedi A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.The author(s) is/are employees of the US Government and therefore domestic copyright protection in USA does not apply to this work.The work may be protected under the copyright laws of other jurisdictions when used in those jurisdictions.Ahmad A. Alrasheedi Department of Family and Community Medicine, College of Medicine, Qassim University, Buraydah, Al Qassim Region, Saudi Arabia Overall, this study is excellent and worth accepting as the authors evaluated the spread of the COVID-19 pandemic in a critical region, the Arab world, over three years (2020-2022).

5 - 6 -
In the second sentence of the "Introduction" section, which years? 2020-2022 or 2021-2023; please specify!The reference No. 5 is old (2004).Is there any recent one?7-In paragraph 4 of the "Introduction" section, please remove the phrase "the coronavirus."To be "… many different variants of SARS-CoV-2, including …".Also, in this statement: as long as the coronavirus SARS-CoV-2 remains.
lack of gender and age data in numerous Arab countries prevented us from conducting thorough comparisons and assessing potential risk factors.Regarding the government response tactics, we have already mentioned in the discussion section that: During the first, second, and third quarters of 2020, the pandemic was under control in most Arab countries 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.

Table 1 .
Features of the Arab countries related to COVID-19 from January 2020 to December 2022.

Table 2 .
The trend of quarterly COVID-19 confirmed cases in all Arab countries from January 2020 to December 2022.

Table 3 .
The trend of quarterly COVID-19 death cases in all Arab countries from January 2020 to December 2022.

Table 4 .
The trend of quarterly COVID-19 recovered cases in all Arab countries from January 2020 to December 2022.
COVID-19: Coronavirus.Q: Quarter.SA: Saudi Arabia.UAE: United Arab Emirates.PMP: per million population.Countries ranked based on the highest number of recovered cases PMP.

Table 5 .
Comparison of COVID-19 prevalence between the Arab world and the top 15 affected countries from January 2020 to December 2022.ResultsBy 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,and32.3years,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 (Table1).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 (Table2).
COVID-19: Coronavirus.PMP: per million population.Countries ranked based on the highest number of confirmed cases PMP.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 (Table3).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 (Table4).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 (Oxf).2022; 3: 100258.PubMed Abstract|Publisher Full Text|Free Full Text 67.Abu Farha RK, Alzoubi KHKhabour OF-, et al.: Exploring perception and hesitancy toward COVID-19 vaccine: A study from Jordan.Hum.Vaccin.Immunother.2021; 17(8): 2415-2420.PubMed Abstract|Publisher Full Text|Free Full Text 68.COVID-19 -Arab ICT Initiatives.(n.d.).AICTO.[Accessed May 19 2024].Reference Source 69.Hassounah M, Raheel H, Alhefzi M: Digital Response During the COVID-19 Pandemic in Saudi Arabia.J. Med.Internet Res.2020; 22(9): e19338.

Is the topic of the review discussed comprehensively in the context of the current literature? Yes Are all factual statements correct and adequately supported by citations? Yes Is the review written in accessible language? Yes Are the conclusions drawn appropriate in the context of the current research literature? Yes Competing Interests:
1-WHO's response to COVID-19 in the Eastern Mediterranean Region Independent review by Dalberg Advisors February 2023 https://cdn.who.int/media/docs/default-source/evaluationoffice/who-s-response-to-covid-19-in-the-emr---independent-review_february-Nocompeting interests were disclosed.

3 -
In the "conclusions" section of the Abstract, Confirmed what?Confirmed cases or confirmed deaths.A word is missing!4-In the first line of the "Introduction" section, which coronavirus is?It is the novel coronavirus, or as it is named, SARS-CoV-2.In contrast, the disease caused by this virus is called COVID-19.I suggest it be written as "… declared coronavirus disease 2019 (COVID-19) as …".
10-The following information was collected from each Arab country: total population, median age, number of monthly confirmed,... Confirmed what?Please make it clear.
Rephrasing the sentence to be clear, I suggest, "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)."Always add "the" before UAE, USA, and UK while mentioned in the text.

14 - Table 1 :
Please identify the abbreviations in the table (Add footnotes), even if they have already been mentioned in the text.Please check the population number of Mauritania.15-Table2: define the abbreviations in the table (Add footnotes): UEA, SA, and PMP, as well as for other tables.Also, in column 10 (Q1-22), some numbers are not uniform in the way they are written.16-Inthe"Discussion"section,New Year season New Year season?Do you mean influenza season, where URTIs, including coronaviruses, increase?17-Anotherreasonfor the spike increase is the slow uptake of the vaccine in many countries.Which countries? of the world, including Arab countries or in many Arab countries?18-During the first, second, and third quarters of 2020, the pandemic was under control in most Arab countries due to ... Using the probability form, such as "mostly due to" or "probably because," is better.19-Thefirstquarter of 2022 was a shockwave as it was recorded with the highest-ever number of COVID-19 confirmed cases with 3,235,665 peaked by Jordan with a total number of 630,811.To be clearer, I suggest you rephrase it to be: "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." 20-Qatar was reported with the highest number of confirmed cases of COVID-19 in the fourth quarter of 2022 Suggesting to rephrase by adding among Arab countries.21-Inparagraphno. 12, ...Australia, USA, and Turkey have performed tests more than their populations.DEFINE USA: please write the United States of America.22-In the "Strengths and limitations" section, However, there are a few limitations in our review.study or review?This will depend on your classification.23-Although the number of confirmed, death, and subsequently recovered cases of... Confirmed what?Please make it clear.

Is the topic of the review discussed comprehensively in the context of the current literature? Yes Are all factual statements correct and adequately supported by citations? Yes Is the review written in accessible language? Yes Are the conclusions drawn appropriate in the context of the current research literature? Yes Competing Interests:
No competing interests were disclosed.

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
https://doi.org/10.5256/f1000research.156102.r247533policy"