One-year Review of COVID-19 in the Arab World

The coronavirus disease 2019 (COVID-19) has affected almost every country worldwide, including all 22 Arab countries. To the best of our knowledge, this is the first study to follow the prevalence of COVID-19 in all Arab countries. In this review, we aimed to assess the 12-month prevalence of COVID-19 in Arab countries and to compare these findings with other significantly affected countries. World Health Organization, Worldometer, and Ministries of Health websites were used to search for COVID-19 data in all Arab countries. The period covered started from February 2020 to February 2021. In all Arab countries, the median age of the population was 26.25 years. As of March 01, 2021, the total number of confirmed COVID-19 cases in all Arab countries was 4,259,756. Bahrain, Qatar, Lebanon, Kuwait, and United Arab Emirates had the highest reported number of confirmed COVID-19 cases per million population. The total number of COVID-19 deaths was 72,950, with predominance in Lebanon, followed by Tunisia, Jordan, Palestine, and Iraq. In comparison with the topmost affected countries, and based on both the highest number of confirmed and deaths per million population, Arab countries ranked second last before India, with 9,646 and 165 cases, respectively. Among the Arab countries, Qatar, Bahrain, and Lebanon showed the highest number of recovered, confirmed, and death cases per million populations, respectively. The number of confirmed and death cases among all Arab countries triggered significant worries about morbidity and mortality of COVID-19, respectively. However, the younger population in Arab countries may have contributed to fewer COVID-19 deaths in comparison with the topmost affected countries.


INTRODUCTION
The coronavirus disease 2019 (COVID-19) is a highly transmittable viral infection. By August 16, 2021, it had infected 207,995,820 people and caused 4,374,966 deaths worldwide. 1 COVID-19 is caused by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), 2 a positive-sense, single-stranded ribonucleic acid virus belonging to the genus Betacoronavirus. 3 Betacoronavirus also includes SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV), which have caused SARS and MERS in 2003 and 2012, respectively. 4 Although SARS-CoV-2 shares approximately 79% of its genome sequencing with SARS-CoV, it is much more infectious. 5 The clinical hallmarks of COVID-19 include fever, dry cough, sore throat, headache, fatigue, and breathlessness. In some cases, COVID-19 could progress to pneumonia, hypoxemia, acute respiratory distress syndrome, septic shock, blood clotting dysfunction, multiple organ failure, and finally death. 6 However, many people with COVID-19 remain asymptomatic. 7 Coughing and sneezing are the main modes of transmission of SARS-CoV-2 between humans. Several studies have reported that direct contact with patients with COVID-19 are at high risk of infection. 8,9 Although almost everyone is vulnerable to this virus, older people and those with hypertension, diabetes, respiratory system disease, cardiovascular disease, and cancers are more susceptible to COVID-19. 10,11 The prevalence of COVID-19 in children is low. 12,13 Several studies have reported that men are more susceptible to COVID-19 and die of COVID-19 compared with women. 14 -16 The recent introduction of COVID-19 vaccines such as those developed by Pfizer-BioNTech, Moderna, Oxford-AstraZeneca, Johnson & Johnson, Gamaleya, CanSino, and Sinopharm hopes to reduce the incidence of COVID-19 and protect more people. However, the insufficient production, late arrival of COVID-19 vaccines, and the unwillingness of many people to be vaccinated are other concerns in many countries. Those who are hesitant to receive COVID- 19 vaccination are afraid about the vaccine safety. 17,18 Thus, many countries have launched COVID-19 vaccination campaigns. 19 The Arab world contains 22 countries, distributed as 12 in Asia and 10 in Africa. The Arab league was formed to unite Arab countries politically and to represent the interests of the people. 20 However, sex, race, socio-economic classes, layout, and healthcare systems differ from one Arab country to another. Previously, we published 5-month COVID-19 data in all Arab countries (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. 21 In the present study, we aimed to assess further the prevalence of COVID-19 in the Arab world from February 2020 to February 2021 and to compare these findings with other significantly affected countries.

METHODS
We used World Health Organization, Worldometer, and Ministries of Health 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 February 2020 to February 2021. The inclusion criterion was official information of clinically diagnosed COVID-19 in English or Arabic. The exclusion criterion was unofficial information regarding COVID-19 in all Arab countries, language restrictions to either English or Arabic, unspecified date and location of information, or suspicion of duplicate information. The following information was collected from each Arab country: total population, median age, date and number of the first announced cases, number of monthly confirmed, death, and recovered cases, and total number of COVID-19 tests. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software version 23 (SPSS Inc., Chicago, IL, USA). Results are presented as numbers, percentages, and means.

RESULTS
The total Arab population who lived in Arab countries during the study period was 441,622,903. The first Arab country to have officially reported the presence of COVID-19 was UAE, with five cases on January 29, 2020. Egypt was the second Arab country and the first Arab-African country to declare the presence of COVID-19 on February 14, 2020. Comoros, which is an island nation, was the last of the Arab countries to declare the presence of COVID-19 on April 30, 2020. Palestine reported the highest number of its first announcement of COVID-19 with seven cases (May 03, 2020). All Arab countries used real-time polymerase chain reaction (RT-PCR) as the testing method for SARS-CoV-2. UAE performed the highest number of RT-PCRs with 3,076,021 tests per million population, followed by Bahrain and Qatar with 1,777,047 and 547,744, respectively ( Note that five cases of January 2020 were added to February 2020 in UAE. SA, Saudi Arabia; UAE, United Arab Emirates.
One-year Review of COVID-19 in the Arab World Alwahaibi et al.   Other parameters, which include confirmed cases, cases per million, recovered cases, tests per million, and population, are also presented in Table 5.

DISCUSSION
Although many Arab countries applied early serious measures to control the infection of COVID-19 such as suspension of flights and many events, distance learning, lockdown of major cities, physical distancing, quarantine, and wearing of facial masks, COVID-19 is still rapidly increasing. 22 -23 However, because of economic crisis, many Arab countries, as with other global countries, lifted the restrictions before the satisfactory reduction of confirmed cases and deaths. 24 This method could lead to higher numbers of mortality and morbidity. In this study, we have been following COVID-19 cases in all Arab countries since the pandemic started. The number of confirmed COVID-19 cases has continued to increase gradually in most of the studied countries and peaked in July 2020. The possible reason for that peak was that many countries had reopened shopping malls, private businesses, and offices at full capacity. 25 In August 2020, the trend of confirmed COVID-19 cases showed a decline in most of the Arab countries, except in Syria, Algeria, Libya, Oman, Tunisia, Morocco, Iraq, and Lebanon. This is because many countries reimposed extra restrictions and preventative measures to contain the peak, such as banning international flights, suspending Umrah, and cancelling Hajj for the first time in SA since 1932. 23,26,27 Noticeably, Iraq recorded the highest number of confirmed, death, and recovered cases and showed a dramatic increase in the number of confirmed COVID-19 cases starting from July 2020. The possible explanations are the lack of medical support and the relaxation of both curfews and movement restrictions by the authorities. 28 Despite the air travel ban in Iraq, allowing Iraqi citizens to enter the country without restrictions may have contributed to the escalation of COVID-19 cases. 29 The partial reopening of the border between Iraq and Iran for foodstuff trading has also contributed to the increase in COVID-19 cases. 30 In December 2020, Europe reported a new COVID-19 variant, 30 which could likely be one of the reasons for the increasing prevalence of confirmed COVID-19 cases in many countries observed in January and February 2021.
Since the beginning of the COVID-19 crisis, the total daily death in Arab countries was the highest in November 2020, followed by a fluctuation between a slight decline and increase. This might be attributed to several factors: (i) improvement of medical management and coordinated efforts of the health system; (ii) medical caregivers became more familiar in dealing with the crisis and alleviating patients' suffering; (iii) community awareness and education on COVID-19 prompted immediate efforts in seeking medical treatment to decrease disease severity; (iv) use of drugs such as remdesivir, tocilizumab, and baricitinib increased the quality of medical care 31 -33 ; and (v) increased number of tests and testing methods contributed to the reduction of the overall death rate, as high numbers of tests enabled healthcare providers to quickly detect and assess more cases with mild symptoms or even asymptomatic cases and therefore can request individuals with positive results to remain in isolation for time. Apart from the medical care management system, governmental restriction strategies such as online education, bans on gatherings, quarantine for travelers, travel restrictions, maintaining physical distance, and staying at home limited viral transmission and led to a drop in positive cases and, thus, a decrease in the number of deaths. 34 Although COVID-19 continues to be a big threat to the world, the number of recovered cases is considered extremely high. Usually, healthy individuals assumed by their strong immunity can tolerate the flu-like symptoms of COVID-19. Nevertheless, very few rare cases of healthy young individuals have died from this pandemic without any clear reason. 35 Several factors might affect how the human body's immune defense system reacts to the virus. At the    39 Several studies have considered that older age influences the severity of COVID-19 with often more negative clinical outcomes compared with the younger population. 40 -42 The Arab world, followed by India, has the youngest median age, and this could partly explain the lower number of deaths per million population than recorded in the 13 top-affected countries. Surprisingly, Mexico also had a significantly young median age of 29.3 years compared with Germany (median age ¼ 47.8) but recorded 1430 deaths per million, whereas Germany, which has probably much better healthcare, had a much lower number of deaths per million, i.e., 842. This study has some limitations. First, some potential risk factors, such as signs and symptoms, gender, age, death causes, medications, duration of hospital admission, and other confounders (hypertension, diabetes, respiratory system disease, and cardiovascular disease), which can be associated with confirmed, death, and recovered cases of COVID-19 were unavailable. Second, many patients who were asymptomatic or had mild symptoms and who were treated at home might not be included in these data. Third, many non-Arab nationals work in Arab countries, and most of the published data did not distinguish Arabs from non-Arabs. Finally, while data of tests per million are instructive of demonstrating increasing testing capacity, it is unknown whether some countries record the number of people tested or the total number of tests performed, as some people may require more tests to obtain accurate results.

CONCLUSION
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 trigger significant worries about morbidity and mortality related to COVID-19, respectively. However, a younger Arab population in the world may contribute to fewer COVID-19 deaths in comparison with the topmost affected countries worldwide.

Declaration of conflict of interest
None