Variation in COVID-19 among Eastern Mediterranean Region countries: A comparative study

Ahmed Hassan Albelbeisi Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, International Campus (TUMS-IC), Tehran, Iran https://orcid.org/0000-0002-9638-1260 Ali Albelbeisi In-service Health Education, European Gaza Hospital, Ministry of Health, Palestine Abdel Hamid El Bilbeisi (  abed_az@hotmail.com ) Department of Clinical Nutrition, Faculty of Pharmacy, Al Azhar University of Gaza, Palestine dFaculty of Pharmacy, Al Azhar University of Gaza, Palestine https://orcid.org/0000-0001-8870-8326 Amany El A Faculty of Pharmacy, Al Azhar University of Gaza, Palestine Mahmoud Taleb Faculty of Pharmacy, Al Azhar University of Gaza, Palestine


Introduction
Coronavirus disease 2019 (COVID-19) is a possibly severe acute respiratory infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). 1  Health Organization (WHO) has declared the coronavirus (COVID-19) outbreak as a global pandemic. 3 Now, COVID-19 spreads in 216 Countries, areas and territories among the world which have been reported 7, 410, 510 con rmed cases and 418, 294 con rmed deaths till to 12 June 2020. 4 It is assuming that COVID-19 are initiate from bats. 5 Person-to-person spread has been established in public and health settings. 6 According to CDC, COVID-19 can spread through respiratory droplets formed when an infected person sneezes or coughs, touching a surface or body that has the virus on it. 7 The Eastern Mediterranean Region includes 22 member states, with a population of approximately 583 million. 8,9 In the Eastern Mediterranean Region countries, as of 12 June 2020 more than 737000 cases have been con rmed and more than 16000 death cases. The twenty-two countries of the Eastern Mediterranean Region were classi ed according to the World Bank income class as the following: Four low income countries (Afghanistan, Somalia, Syria, and Yemen), seven lower-middle income countries (Djibouti, Egypt, Morocco, Pakistan, Palestine, Sudan, and Tunisia), ve upper-middle income countries (Iran, Iraq, Jordan, Lebanon, and Libya) and six high-income countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates). 10 Understanding the disease patterns among the Eastern Mediterranean Region countries could inform public health and policy strategies to alleviate the continuing spread of COVID-19 disease. In this study, we aimed to examine variation of COVID-19 in different income class countries of the Eastern Mediterranean Region.

Data collection
The total number of each country population are collected from. 11 COVID-19 reported cases, death cases, total number of tests and test per million are collected from. 12 Six-day data are selected for the present study.

Study parameters
Five parameters such as the percentage of variation COVID-19 con rmed cases, the percentage variation number of deaths, death rate per 1000 con rmed cases, the percentage of variation death rate per 1000 con rmed cases, and tests per one million.

Statistical analysis
Descriptive statistical analyses were done to calculate the percentage of variation COVID-19 con rmed cases, the percentage of variation number of deaths, death rate per 1000 con rmed cases, the percentage of variation death rate per 1000 con rmed cases, and tests per one million in 11 June 2020 and 6 June 2020.

Results
3.1. The percentage variation of COVID-19 con rmed cases 3.1.1. Low-income countries Table 1 demonstrated that, among the four low-income countries (Afghanistan, Somalia, Syria, and Yemen), all countries reported increase number of con rmed cases and the percentage of increase in COVID-19 con rmed cases were range from 31.2% in Syria (the highest) to 9.8% in Somalia (the lowest); the rest of other countries were 17.1%, 22.6% for Afghanistan and Yemen respectively. Table 2 demonstrated that, among the seven lower-middle income countries (Djibouti, Egypt, Morocco, Pakistan, Palestine, Sudan, and Tunisia), all countries reported increase number of con rmed cases except Tunisia, and the percentage of increase in COVID-19 con rmed cases were range from 27.2% in Pakistan to 0.0% in Tunisia; the rest of other countries were 21.8%, 8.2%, 5.5%, 4.9%, and 4.7% for Egypt, Sudan, Djibouti, Palestine, and Morocco respectively. Table 3 demonstrated that, among the ve upper-middle income countries (Iran, Iraq, Jordan, Lebanon, and Libya), all countries reported increase number of con rmed cases and the percentage of increase in COVID-19 con rmed cases were range from 53.5% in Libya to 6.2% Lebanon; the rest of other countries were 50.2%, 11.9%, 6.3% for Iraq, Jordan, and Iran respectively. Table 4 demonstrated that, among the six high-income countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates), all countries reported increase number of con rmed cases and the percentage of increase in COVID-19 con rmed cases were range from 24.6% in Oman to 7.1% in United Arab Emirates; the rest of other countries were17.3%,15.6%, 11.7%, 10.6% for Saudi Arabia, Bahrain, Qatar, and Kuwait respectively.

Low-income countries
The results demonstrated that among the four low-income countries, two countries reported increase the percentage of COVID-19 number of deaths (Afghanistan, and Yemen); the percentage of variations range from 30.3% in Afghanistan, followed by Yemen 22.3% to 0.0% in Somalia and Syria (Table 1).

Lower-middle income countries
The results demonstrated that, among the seven lower-middle income countries, all countries reported increase the percentage of COVID-19 number of deaths except Tunisia and Palestine, the percentage of variations range from 42.3% in Djibouti to 0.0% in Tunisia and Palestine; the rest of other countries were 21.8% 14.9%, 11.7%, 1.4% for Pakistan, Egypt, Sudan, and Morocco respectively ( Table 2).

Upper-middle income countries
The results demonstrated that, among the ve upper-middle income countries, all countries reported increase the percentage of COVID-19 number of deaths except Jordan and Libya, the percentage of variations range from 43.7% in Iraq to 0.0% in Jordan and Libya; the rest of other countries were 6.9%, 4.6% for Lebanon and Iran respectively (Table 3).

High-income countries
The results demonstrated that among the six high income countries, all countries reported increase the percentage of COVID-19 number of deaths, the percentage of variations range from 41.7% in Bahrain to 4.0% in United Arab Emirates; the rest of other countries were 35.3%, 26.8% 23.6%, 9.8% for Qatar, Saudi Arabia, Oman, and Kuwait respectively (Table 4).

Low-income countries
The results demonstrated that among the four low-income countries, In 6 June 2020, the results demonstrated that among the four low-income countries, death rate range from 230.3/1000 in Yemen to 16.7/1000 in Afghanistan; the rest of other countries were 48.0/1000, 35.8/1000 for Syria and Somalia respectively. In 11 June 2020, the results demonstrated that among the four low-income countries, death rate range from 230.1/1000 in Yemen to 18.6 /1000 in Afghanistan; the rest of other countries were 36.6/1000, 33.8/1000 for Syria and Somalia respectively (Table 1).

Lower-middle income countries
In 6 June 2020, the results demonstrated that among the seven lower-middle income countries, death rate range from 59.0/1000 in Sudan to 6.2/1000 in Djibouti, the rest of other countries were 45.1/1000, 36.7/1000, 25.5/1000, 20.6/1000, 6.5/1000 for Tunisia, Egypt, Morocco, Pakistan, and Palestine respectively. In 11 June 2020, the results demonstrated that among the seven lower-middle income countries, death rate range from 60.9/1000 in Sudan to 6.2/1000 in Palestine; the rest of other countries were 45. 3.4. The percentage of variation death rate per 1000 con rmed cases

Low-income countries
The results demonstrated that among the four low income countries, three countries reported decrease the percentage of COVID-19 death rate / 1000 (Somalia, Syria, and Yemen), the decrease range from 23.8% in Syria, followed by 5.6% in Somalia and .09 in Yemen. Afghanistan data reported increased the percentage of COVID-19 death rate by 11.4% (Table 1).

Lower-middle income countries
The results demonstrated that among the seven lower-middle income countries, four countries reported decrease the percentage of COVID-19 death rate / 1000 (Egypt, Morocco, Pakistan, and Palestine), the decrease range from 5.4% in Egypt, followed by 4.6% in Palestine to 3.1% in Morocco and 4.4% in Pakistan. Djibouti and Sudan data demonstrated increase the percentage of COVID-19 death rate / 1000, for Tunisia there is no change in the percentage of COVID-19 death rate ( Table 2).

Upper-middle income countries
The results demonstrated that among the ve upper-middle income countries, all countries data reported decrease the percentage of COVID-19 death rate / 1000 except Lebanon increased by 0.4%, the decrease range from 34.9% in Libya, Followed by 10.6% in Jordan to 1.6% in Iran, followed by 4.6% in Iraq (Table   3).

High-income countries
The results demonstrated that among the six high-income countries, United Arab Emirates, Oman, and Kuwait data reported decrease the percentage of COVID-19 death rate by 2.8%, 2.2%, 1.2% respectively. On the other hand, Qatar, Bahrain, and Saudi Arabia data reported increase the percentage of COVID-19 death rate by 21.0%, 17.6%, 8.8% respectively (Table 4).

Low-income countries
The results demonstrated that among the four low-income countries, the tests per one million range from 1381 in Afghanistan to four in Yemen; data not available for Somalia and Syria (Table 1).

Lower-middle income countries
The results demonstrated that among the seven lower-middle income countries, the tests per one million range from 40880 in Djibouti to 9 in Sudan, the rest of other countries were 10550, 8809, 4849, 3667, 1321 for Morocco, Palestine, Tunisia, Pakistan, and Egypt respectively ( Table 2).

Upper-middle income countries
The results demonstrated that among the ve upper-middle income countries, the tests per one million range from 25216 in Jordan to 1714 in Libya, the rest of other countries were15145, 14261, and 8704 for Lebanon, Iran, and Iraq respectively (Table 3).

High-income countries
The results demonstrated that among the six high-income countries, the tests per one million range from 265687 in the United Arab Emirate to 26092 in Oman, the rest of other countries were 237420, 99959, 77368, and 29966 For Bahrain, Qatar, Kuwait, and Saudi Arabia respectively (Table 4).

Discussion
The current study ndings showed signi cant variations between the Eastern Mediterranean Region countries in the number of deaths, death rate per 1000 con rmed cases and tests per one million. The substantial variation in the rates for COVID-19 in Eastern Mediterranean Region countries is concerning.
The low-income countries appeared more vulnerable compared to high-income countries. After six days, all countries data demonstrated increase in percentage of COVID-19 con rmed cases except Tunisia, the increasing range from 53.5% in Libya, followed by Iraq 50.2% to 4.7% in Morocco, followed by Palestine with 4.9%. Majority of countries data demonstrated increase in percentage of COVID-19 deaths cases number except ve countries (Somalia, Syria, Palestine, Jordan, and Libya), the increasing range from 43.7% in Iraq, followed by Djibouti 42.3% to 1.4% in Morocco, followed by United Arab Emirate with 4%.
Death rate per 1000 con rmed cases among Eastern Mediterranean region countries range from 230.1 in Yemen, followed by Sudan with 60.9 to 0.92 in Qatar, Followed by Bahrain with two. In term of percentage change in death rate per 1000, fourteen countries (Somalia, Syria, Yemen, Egypt, Morocco, Pakistan, Palestine, Iran, Iraq, Jordan, Libya, Kuwait, Oman, and United Arab Emirates) demonstrated, decrease in percentage death rate per 1000, the decreasing range from 34.9% in Libya , followed by Syria with 23.8% to .09 in Yemen , followed by Kuwait with 1.2%; seven countries (Afghanistan, Djibouti, Sudan, Lebanon, Bahrain, Qatar, and Saudi Arabia) demonstrated, increase in percentage death rate per 1000, the increasing range from 35.5% in Djibouti to 0.4% in Lebanon. Only Tunisia country has constant death rate per 1000.
The results demonstrated that among the Eastern Mediterranean Region countries, the tests per one million range from 265687 in United Arab Emirate, followed by Bahrain with 237420 to 4 in Yemen, followed by Sudan with 9 / M. Data not available for Somalia and Syria. The low-income countries, which has the highest death rate per / 1000 had the lowest tests for COVID-19 than other countries in the Eastern Mediterranean region. Yemen had the highest death rate 230.1 per / 1000, and the lowest number of tests 4 / M. In spite of that, the world and WHO was uni ed to ght against COVID-19, the low-income countries should not be alone with this pandemic. Hence then global alert should be helping these countries and particular plans have to be employed. These must include screening tests, COVID-19 virus, specially detection of corona by blood quick tests or swabs which to be mandatory employed, the basic needs such as gloves, masks and sanitizers which de cient in these countries, and also, quarantine places for suspicious cases.

Conclusion
The current study ndings showed signi cant variations between the Eastern Mediterranean Region countries, the substantial variation is concerning. The low-income countries appeared more vulnerable compared to high-income countries; the low-income countries should not be alone with this pandemic. Hence then global should be helping these countries and particular plans have to be employed. These must include screening tests COVID-19 virus.

Declarations Con icts of interest
None of the authors have con icts of interest to report.

Funding
This research did not receive any speci c grant from funding agencies in the public, commercial, or notfor-pro t sectors.