|Year : 2020 | Volume
| Issue : 3 | Page : 155-158
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
1 Department of Internal Medicine, Infectious Disease Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Pharmacy, King Saud University Medical City, Riyadh, Saudi Arabia
3 Department of Medicine, University Sleep Disorders Center and Pulmonary Service, King Saud University, Riyadh; The Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation in the Kingdom of Saudi Arabia (08.MED511.02), Saudi Arabia
|Date of Submission||01-Apr-2020|
|Date of Acceptance||02-Apr-2020|
|Date of Web Publication||02-Jul-2020|
Department of Internal Medicine, Head Infectious Disease Unit, College of Medicine, King Saud University, P.O. Box 2925, Riyadh 11461
Source of Support: None, Conflict of Interest: None
Coronavirus disease-2019 is currently causing a world pandemic. The Kingdom of Saudi Arabia (KSA) reported its first 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
|How to cite this article:|
Barry M, Ghonem L, Alsharidi A, Alanazi A, Alotaibi NH, Al-Shahrani FS, Al Majid F, BaHammam AS. Coronavirus disease-2019 pandemic in the Kingdom of Saudi Arabia: Mitigation measures and hospital preparedness. J Nat Sci Med 2020;3:155-8
|How to cite this URL:|
Barry M, Ghonem L, Alsharidi A, Alanazi A, Alotaibi NH, Al-Shahrani FS, Al Majid F, BaHammam AS. Coronavirus disease-2019 pandemic in the Kingdom of Saudi Arabia: Mitigation measures and hospital preparedness. J Nat Sci Med [serial online] 2020 [cited 2021 May 18];3:155-8. Available from: https://www.jnsmonline.org/text.asp?2020/3/3/155/282983
| 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, on January 7, 2020, named severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-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  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%. 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 confirming 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, 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. Key strategies on the community level include cancellation of planned events and suspension of events with super-spreader potential; use of social-distancing measures to reduce direct and close contact between people in the community; travel restrictions, including reduced flights 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 fluids of the diseased; and clear communication from national and international health authorities, to ensure verified information and avoid fake news, rumors, and panic. Mass gatherings and events such as citywide festivals, religious gatherings, cultural celebrations, scientific conferences, and large political events should be restricted. Respiratory infections such as influenza and now like COVID-19 are commonly transmitted at a high rate within such large gatherings. 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 flights, both incoming and outgoing, were suspended from March 15, 2020. All domestic flights, 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. Such lockdowns would help alleviate health-care system overload.
All international passenger traffic, 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 traffic only. All movement into and out of the city of Qatif in the Eastern Province has been suspended [Figure 1]. 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. All these decisive measures for the COVID-19 pandemic will likely prove effective.
|Figure 1: Conformed cases of coronavirus disease-2019 in Saudi Arabia and mitigation measures (adapted from the Saudi Health Council)|
Click here to view
The ongoing evaluation of extensions or relaxations of these measures should take into account testing, contact tracing, and localized quarantine of suspected cases. 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 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 efficiently suppressing COVID-19 spread.
| 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. 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. Currently, the Ministry of Health designated 25 hospitals for COVID-19-infected patients, 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.
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.
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. 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.
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; 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.
HCFs must protect and support HCP on the front lines, and they should receive training on proper donning and doffing of personal protective equipment, fit 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 definition for COVID-19.
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. 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 define 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.
Another important aspect is the disease dynamic itself. Due to COVID-19 presenting as any other respiratory infection, lack of specific signs and symptoms including fever, with a sensitivity of one single nasopharyngeal PCR early in the disease of 70%, nosocomial transmission will be challenging. Testing for all respiratory viruses including SARS-CoV-2, influenza, parainfluenza, 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. 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.
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, modification, communication, and transparency is key in preventing such possible scenarios.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al
. A novel coronavirus from patients with pneumonia in China, 2019. N
Engl J Med 2020;382:727-33.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al
. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
WHO Director-General's Opening Remarks at the Media Briefing on COVID-19–11 March 2020. World Health Organization; 11 March, 2020.
Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). Available from: https://coronavirus.jhu.edu/map.html
. [Last retrieved on 2020 Apr 01].
Koo JR, Cook AR, Park M, Sun Y, Sun H, Lim JT, et al
. Interventions to mitigate early spread of SARS-CoV-2 in Singapore: A modelling study. Lancet Infect Dis 2020. S1473-3099(20)30162-6. doi: 10.1016/S1473-3099(20)30162-6. [Epub ahead of print].
Heymann DL, Shindo N. COVID-19: What is next for public health? Lancet 2020. 395(10224):542-545. doi: 10.1016/S0140-6736(20)30374-3.
Qualls N, Levitt A, Kanade N, Wright-Jegede N, Dopson S, Biggerstaff M, et al
. Community mitigation guidelines to prevent pandemic influenza – United States, 2017. MMWR Recomm Rep 2017;66:1-34.
Markel H, Lipman HB, Navarro JA, Sloan A, Michalsen JR, Stern AM, et al
. Nonpharmaceutical interventions implemented by US cities during the 1918-1919 influenza pandemic. JAMA 2007;298:644-54.
Pandey A, Atkins KE, Medlock J, Wenzel N, Townsend JP, Childs JE, et al
. Strategies for containing Ebola in West Africa. Science 2014;346:991-5.
Ebrahim SH, Ahmed QA, Gozzer E, Schlagenhauf P, Memish ZA. Covid-19 and community mitigation strategies in a pandemic. BMJ 2020;368:m1066.
Saudi Center for Disease prevention and Control. Novel Corona Virus (2019-nCoV) Infection Guidelines V1.2. Kingdom of Saudi Arabia: Saudi Center for Disease Prevention and Control Ministry of Health; March, 2020.
Prem K, Liu Y, Russell TW, Kucharski AJ, Eggo RM, Davies N, et al
. The effect of control strategies to reduce social mixing on outcomes of the COVID-19 epidemic in Wuhan, China: A modelling study. Lancet Public Health 2020. pii: S2468-2667(20)30073-6.
Colbourn T. COVID-19: Extending or relaxing distancing control measures. Lancet Public Health 2020. pii: S2468-2667(20)30072-4. doi: 10.1016/S2468-2667(20)30072-4. [Epub ahead of print].
Barry M, Al Amri M, Memish ZA. COVID-19 in the shadows of MERS-CoV in the Kingdom of Saudi Arabia. J Epidemiol Global Health 2020;10:1-3.
Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI). National Hospital Standards, V 2; 5 February, 2020.
Swerdlow DL, Finelli L. Preparation for possible sustained transmission of 2019 novel coronavirus: Lessons from previous epidemics. JAMA 2020;323:1129-30.
Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, et al
. The incubation period of coronavirus disease 2019 (COVID-19) from publicly reported confirmed cases: Estimation and application. Ann Intern Med 2020. doi: 10.7326/M20-0504. [Epub ahead of print].
Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. N
Engl J Med 2020. doi: 10.1056/NEJMp2003539. [Epub ahead of print].
Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al
. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 2020;395:912-20.
Chopra V, Toner E, Waldhorn R, Washer L. How should U.S. hospitals prepare for coronavirus disease 2019 (COVID-19)? Ann Intern Med 2020. doi: 10.7326/M20-0907. [Epub ahead of print].
Fang Y, Zhang H, Xie J, Lin M, Ying L, Pang P, et al
. Sensitivity of chest CT for COVID-19: Comparison to RT-PCR. Radiology 2020;19:200432. doi: 10.1148/radiol.2020200432. [Epub ahead of print].
Rolfes MA, Foppa IM, Garg S, Flannery B, Brammer L, Singleton JA, et al
. Annual estimates of the burden of seasonal influenza in the United States: A tool for strengthening influenza surveillance and preparedness. Influenza Other Respir Viruses 2018;12:132-7.
Klompas M. Coronavirus disease 2019 (COVID-19): Protecting hospitals from the invisible. Ann Intern Med 2020. doi: 10.7326/M20-0751. [Epub ahead of print].
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