Coronavirus Disease 2019 (COVID-19) Pandemic in the Kingdom of Saudi Arabia: Mitigation Measures and Hospitals Preparedness

Abstract

Coronavirus disease 2019 (COVID-19) is currently causing a world pandemic. The Kingdom of Saudi Arabia (KSA) reported its first case on the 2nd of March 2020. Due to its potential rapid dissemination within the public and a large probability of a countrywide outbreak, along with the country’s experience in battling another similar coronavirus the Middle East Respiratory Syndrome Coronavirus (MERS-CoV), the KSA was amongst the leading bodies in the world for its swift community action and hospital preparedness.

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© 2020 Journal of Nature and Science of Medicine | Published by Wolters Kluwer - Medknow 155
Review Article
IntRoductIon
In December 2019, a cluster of patients with pneumonia
was linked to a seafood wholesale market in Wuhan, China,
which led to the discovery of a new betacoronavirus,[1]
on January 7, 2020, named severe acute respiratory
syndrome-coronavirus-2 (SARS-CoV-2)[2] that causes
coronavirus disease-2019 (COVID-19). With its novelty and
rapid national and international spread on January 30, 2020,
the World Health Organization International Health Regulation
emergency committee declared the disease a Public Health
Emergency of International Concern. It was declared as a
worldwide pandemic[3] on March 11, 2020. At the time of this
writing, it has infected 862,234 individuals in 180 countries
with 178,836 recoveries and 42,404 deaths with an overall
estimated case fatality rate of 4.9%.[4] The KSA currently has
1720 cases with 264 recoveries and 16 deaths. We review the
different mitigation measures and hospital preparedness for
COVID-19 within the KSA.
communIty contaInment and mItIgatIon measuRes
Different mathematical simulation models have demonstrated
that within a city with a population of almost 5 million people,
with the median cumulative number of SARS-CoV-2 infections
at 80 days after conrming 100 cases in the community with
an assumption that 7.5% of infections were asymptomatic, and
with a basic reproduction number (R0) of 2.5, there would be
an estimated 1207,000 cases,[5] but this would be reduced to
258,000 cases when different interventions at the community
level are implemented. Several community measures would
help delay the spread of the pandemic as was shown with
the total lockdown of Wuhan city.[6] Key strategies on the
community level include cancellation of planned events and
suspension of events with super-spreader potential;[7] use of
social-distancing measures to reduce direct and close contact
between people in the community; travel restrictions, including
reduced ights and public transport and route restrictions
without compromising essential services; voluntary home
quarantine of members of household contacts; changes to
funeral services to minimize crowd size and exposure to
body uids of the diseased;[8] and clear communication from
Coronavirus Disease‑2019 Pandemic in the Kingdom
of Saudi Arabia: Mitigation Measures and Hospital Preparedness
Mazin Barry1, Leen Ghonem2, Aynaa Alsharidi1, Awadh Alanazi1, Naif H. Alotaibi1, Fatimah S. Al‑Shahrani1, Fahad Al Majid1, Ahmed S. BaHammam3,4
1Department of Internal Medicine, Infectious Disease Unit, College of Medicine, King Saud University, 2Department of Pharmacy, King Saud University Medical City,
Riyadh, Saudi Arabia, 3Department of Medicine, University Sleep Disorders Center and Pulmonary Service, King Saud University, Riyadh, Saudi Arabia, 4The Strategic
Technologies Program of the National Plan for Sciences and Technology and Innovation in the Kingdom of Saudi Arabia(08‑MED511‑02), Saudi Arabia
Coronavirus disease-2019 is currently causing a world pandemic. The Kingdom of Saudi Arabia (KSA) reported its rst case on March 2,
2020. Due to its potential rapid dissemination within the public and a large probability of a countrywide outbreak, along with the country’s
experience in battling another similar coronavirus (the Middle East respiratory syndrome–coronavirus), the KSA was among the leading bodies
in the world for its swift community action and hospital preparedness.
Keywords: Coronavirus disease-2019, Kingdom of Saudi Arabia, Middle East respiratory syndrome coronavirus
Address for correspondence: Dr.Mazin Barry,
Department of Internal Medicine, Head Infectious Disease Unit, College of
Medicine, King Saud University, P.O. Box2925, Riyadh 11461, Saudi Arabia.
E‑mail:mbarry@ksu.edu.sa
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For reprints contact: reprints@medknow.com
How to cite this article: Barry M, Ghonem L, Alsharidi A, Alanazi A,
Alotaibi NH, Al-Shahrani FS, et al. Coronavirus disease-2019 pandemic
in the Kingdom of Saudi Arabia: Mitigation measures and hospital
preparedness. J Nat Sci Med 2020;3:155-8.
Abstract
Submission: 01-04-2020 Acceptance: 02-04-2020
Published: 02-07-2020
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Barry, et al.: COVID-19 Pandemic in Saudi Arabia
Journal of Nature and Science of Medicine ¦ Volume 3 ¦ Issue 3 ¦ July-September 2020
156
national and international health authorities, to ensure veried
information and avoid fake news, rumors, and panic.[9] Mass
gatherings and events such as citywide festivals, religious
gatherings, cultural celebrations, scientic conferences, and
large political events should be restricted. Respiratory infections
such as inuenza and now like COVID-19 are commonly
transmitted at a high rate within such large gatherings.[10] On
February 27, 2020, all visits to Mecca and Medina to perform
Umrah and visit the holy mosques have been suspended,
irrespective of nationality, visa type, or residence status.
Travelers are not permitted entry to the KSA with Umrah visas.
Religious gatherings, including daily congregational prayers
and Friday weekly congregational prayer in local mosques,
have been suspended, and the transmission of COVID-19 in
the country – to date – has been low.
The KSA also suspended operations in many government
agencies starting March 16, 2020. All schools and universities
are temporarily closed with remote teaching through virtual
learning platforms. Operation of many markets and malls
is suspended; gatherings in parks, beaches, and resorts are
prohibited. Restaurants are closed except for take-away
service. Pharmacies and grocery stores remain open to serve
customers through governmental assigned online delivery
applications and systems.
All international ights, both incoming and outgoing, were
suspended from March 15, 2020. All domestic ights, as
well as inter-urban bus, taxi, and train transportation, were
all suspended beginning on March 21, 2020. On March 26,
2020, travel between regions of the KSA became prohibited.
A nationwide 7 p.m.–6 a.m. curfew remains in effect for the
entire country; the cities of Riyadh, Mecca, and Medina are
under a 3 p.m.–6 a.m. curfew. The curfew remains in effect for
21 days beginning on March 23, 2020, with limited exceptions
for life and safety.[11] Such lockdowns would help alleviate
health-care system overload.
All international passenger trafc, whether by air, land, or sea,
has been suspended. All tourist travel is currently suspended.
Persons who have been in China, Hong Kong, Taiwan,
Macao, Iran, the United Arab Emirates, Kuwait, Bahrain,
Lebanon, Syria, Egypt, Iraq, Italy, and South Korea in the
previous 14 days are not to be permitted to enter or transit
the country, irrespective of visa or residency status. Travel
to/from mainland China has been suspended. The causeway
between the KSA and Bahrain and land borders between
the KSA and the United Arab Emirates, Kuwait, and Jordan
are restricted to commercial trafc only. All movement into
and out of the city of Qatif in the Eastern Province has been
suspended [Figure 1].[12] Temperature screening of all airline
passengers was also in effect, with travelers arriving from
outside the KSA, including Saudi citizens and residents, will be
placed in health isolation for 14 days following their arrival.[12]
All these decisive measures for the COVID-19 pandemic will
likely prove effective.
The ongoing evaluation of extensions or relaxations of these
measures should take into account testing, contact tracing, and
localized quarantine of suspected cases.[13] Transmission of
COVID-19 can be determined by models that simulate localized
clusters throughout the country and estimate their likely
coverage by testing, given the number of test kits available
nationally per day. Pooled testing methods in which multiple
samples (e.g., from a common household, or a local cluster of
up to 64 people — the limit of pool sample accuracy) are pooled
Figure 1: Conformed cases of coronavirus disease‑2019 in Saudi Arabia and mitigation measures(adapted from the Saudi Health Council)
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Barry, et al.: COVID-19 Pandemic in Saudi Arabia
Journal of Nature and Science of Medicine ¦ Volume 3 ¦ Issue 3 ¦ July-September 2020 157
to be tested spontaneously, and all individuals are quarantined if
the sample comes back positive; this could be useful to multiply
the effect of restricted testing capacity, which is likely to be vital
in determining whether such interventions could be successful
in efciently suppressing COVID-19 spread.[14]
HospItal pRepaRedness
The KSA has a unique position among the rest of the world
by dealing with a similar coronavirus infection: the Middle
East respiratory syndrome-coronavirus (MERS-CoV) that has
been epidemic in the country since 2013 with ongoing sporadic
cases.[15] Infection Prevention and Control (IPC) has been scaled
up across the country since then, and in response to COVID-19,
the Saudi Central Board for Accreditation of Healthcare
Institutions has updated its essential standard requirements
for MERS to include COVID-19.[16] Currently, the Ministry
of Health designated 25 hospitals for COVID-19-infected
patients,[12] amounting to 80,000 hospital beds and 8000
intensive care unit (ICU) beds; in addition, 2200 beds have
been allocated for isolation of suspected and quarantined
cases.[17]
At a hospital level, robust, transparent collaboration between
vital hospital departments is crucial in preparedness, with clear
leadership from hospital management, IPC, internal medicine
and infectious disease departments, pharmacy, critical care
and emergency departments, nursing staff, and microbiology
department. Such collaboration is a keynote essential in facing
pending pandemic diseases.[18]
In anticipation of the pandemic which can stress bed capacity,
medical equipment, and health-care personnel (HCP),
health-care facilities (HCFs) must be ready – to its best
capabilities – by developing strategies for large patient
volume and complex care, attempting to cohort patients
within certain areas, limiting the number of exposed staff,
and conserving medical supplies. This can be challenging,
especially with a limited number of airborne infection
isolation rooms and ICU beds in any given hospital.[19]
Therefore, staff should be divided into different teams that
would care exclusively for COVID-19 patients – when
possible – with backup medical teams in case of infected
staff; this should take into account the incubation period of
the disease of 14 days.[20]
Patients should be discharged, slowing the rate of usual
bed admissions, delaying elective procedures, and reducing
visitation hours, while ensuring ongoing care for most needed
patients (e.g., immunocompromised and posttransplant) with
advancements in technology and virtual telemedicine;[21]
this has been quickly implemented by many HCFs through
web-based and smartphone application services, including
home medication carrier delivery; this led to a great
reduction in overall patient volume within these facilities.
Respiratory illness visual triage at all hospital entry points
for staff, visitors, and patients has also been immediately
implemented.[16]
HCFs must protect and support HCP on the front lines,
and they should receive training on proper donning and
dofng of personal protective equipment, t testing of N95
masks, use of powered air-purifying respirators, and basic
infection prevention practices such as hand hygiene and clear
understanding of the evolving case denition for COVID-19.[12]
Rates of equipment use, inventories of all stored items, and
a stable supply chain should be maintained. Extended use
or limited reuse of N95 respirators may be necessary. Viral
transport mediums, nasopharyngeal swabs, and COVID-19
polymerase chain reaction (PCR) kits should be in high supply
to keep up with the high demand.
Overtime and extended hour compensations for overstretched
staff should be determined and communicated early to all staff,
with a robust mental support program for workers as such
stressful conditions could exacerbate mental conditions and
or cause posttraumatic stress disorder.[22] Some HCFs have
developed hotlines for HCPs for direct, immediate access to
psychiatrists.
Exposure to COVID-19 with plans outlining the management of
HCP regarding work restrictions and quarantine requirements
must be developed; staff with upper respiratory tract infections,
even without a fever, should not come into work. Log-in and
log-out sheet of staff entering rooms of infected patients should
be recorded. HCFs must dene strategies to allocate health-care
resources with plans for contingency and crisis standards that
layout a legal and ethical framework, in addition to developing
a robust, transparent, and open communication policy.[23]
Another important aspect is the disease dynamic itself. Due
to COVID-19 presenting as any other respiratory infection,
lack of specic signs and symptoms including fever, with
a sensitivity of one single nasopharyngeal PCR early in
the disease of 70%,[24] nosocomial transmission will be
challenging. Testing for all respiratory viruses including
SARS-CoV-2, inuenza, parainuenza, respiratory syncytial
virus, human metapneumovirus, and other coronaviruses,
including MERS-CoV, would not only help in establishing a
diagnosis, but also help make the work environment safer for
clinicians and help detect occult COVID-19 infections that
would otherwise be missed.[25] Such infected patients without
putting into account the severity of their illness and by using
proper isolation precautions (single rooms, contact precautions,
droplet precautions, airborne precautions when appropriate, and
plus eye protection) for patients with respiratory syndromes
regardless of the initial viral test results, might protect staff if a
patient is subsequently diagnosed with COVID-19. Health-care
providers who used these precautions will be considered
minimally exposed and will be able to continue working.[26]
It would require one mildly symptomatic patient, a HCP, or
a visitor to ignite a hospitalwide catastrophe. A tight robust,
efficient preparedness system with vigilant observation,
modication, communication, and transparency is key in
preventing such possible scenarios.
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Barry, et al.: COVID-19 Pandemic in Saudi Arabia
Journal of Nature and Science of Medicine ¦ Volume 3 ¦ Issue 3 ¦ July-September 2020
158
Financial support and sponsorship
Nil.
Conflicts of interest
There is no conicts of interest.
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