Mapping COVID-19 related research from Saudi Arabia, a scoping review
=====================================================================

* Ibrahim Almaghlouth
* Tahera Islam
* Nurah Alamro
* Abdulrahman Alsultan
* Assim Alfadda
* Saleh Al-muhsen
* Abeer Almasry
* Majid A. Almadi
* Ahmad Hersi
* Ahmed BaHammam

## Between reality and dreams

## Abstract

**Objectives:** To map research production by Saudi-affiliated investigators in order to identify areas of strength and weakness.

**Method:** We followed the Arksey and O’Malley (2005) framework. Medline and Cochrane databases were searched with a focus on identifying articles related to COVID-19 and Saudi Arabia following the PRISMA protocol. The study was conducted at King Saud University, Riyadh, Saudi Arabia between March and May 2020.

**Results:** A total of 53 articles were ultimately included. Most of the research production from Saudi Arabia was opinion and narrative reviews related to the clinicopathological features of COVID-19 as well as control and prevention of virus spread.

**Conclusion:** The results of this scoping review identify a relative deficiency in original research, which requires further investigation.

*   scoping review
*   COVID-19
*   knowledge gap
*   research production
*   Saudi Arabia

The first case of the COVID-19 virus was reported by Chinese authorities in Wuhan on December 31, 2019. As it continue to spread, defying borders of countries and continents, the World Health Organization (WHO) declared a pandemic on March 11, 2020.1,2 As of May 5, 2020, 3,600,1063 people have contracted COVID-19, with 251,898 deaths, and the disease has been transmitted to 212 countries and territories worldwide. After just a month, the total number of patients had reached 30,251 (May 5, 2020) and 200 deaths.3,4

COVID-19 is a non-segmented betacoronavirus comprise of positive-sense single-stranded ribonucleic acid surrounded by a phospholipid bilayer viral envelope.5-7 The exact zoonotic host remains to be identified, although bats might be involved.8,9 The case history of the first several cases in Wuhan linked them to the local live animal and seafood market.10 The person-to-person transmission of the virus mainly occurs via droplet, close contact of healthy persons to infected individuals (examples, talking, sneezing, coughing), and indirect contact with contaminated objects (examples, stethoscope, thermometer) or surfaces.11,12 COVID-19 is a highly contagious disease with a relatively high reproductive number (R0) (examples the average number of new infections caused by an infectious person in a totally uninfected population) of 2-3.5.10,13,14 The fast-spreading nature of the disease threatens to inundate health care systems worldwide. The disease spectrum of COVID-19 varies from asymptomatic carriers to life-threatening conditions, including myocarditis and acute respiratory distress syndrome (ARDS).5,15 The fast-spreading nature of the disease threatens to inundate health care systems worldwide.

The COVID-19 pandemic has created a complex humanitarian emergency; the overwhelmingly high cost of the response is taking a toll on the economy and health facilities of even the developed countries.16 This leaves academic institutions with a major responsibility to investigate the disease from a holistic prospective, including asymmetric severity distribution, mortality, and spread among different geographical distribution, while avoiding duplicating research topics. Furthermore, national research institutes should focus on the most pressing issues related to COVID-19 on the national level. Hence, we aim in this scoping review to map research publications pertaining to COVID-19 research in Saudi Arabian institutions in order to guide research policies and priorities in the kingdom.

## Methods

We formulated our scoping review using the scoping review methodological framework proposed by Arksey and O’Malley17 and also following the recent scoping review publication by Tricco et al.18 We mapped the literature by following 5 key phases: i) identifying the research question; ii) identifying literature relevant to COVID-19 in Saudi Arabia; iii) selecting only those studies; iv) charting the data from the articles; and v) collating, summarizing, and reporting results. We did not consult any stakeholders. The study was conducted at the College of Medicine and Research Center, King Saud University, Riyadh, Saudi Arabia, from March to May 2020.

### Research questions

This scoping review was guided by the following questions: “What type of research was carried out in Saudi Arabian institutions on COVID-19? What aspects of the disease and its impact were investigated?”

### Data sources and search strategy

A comprehensive electronic database search was performed using PubMed, Ovid-Medline (1946-present), EBM Reviews, and Cochrane databases by an author and another independent reviewer individually. No language, date, or type of article restrictions were applied. Gray literature was not included. Search criteria were developed to capture articles that addressed the literature relevant to research regarding COVID-19 from Saudi Arabian institutions. Search terms used were COVID-19 and Saudi Arabia. Two reviewers independently reviewed extracted articles. Conflicts were resolved by agreement, and in case of dispute a third reviewer was responsible for the decision.

### Citation management

Duplicate citations were initially removed in Ovid for citations from Medline, the Editorial Board Member (EMB) reviews, and Cochrane databases.

All studies related to COVID-19 that were conducted in the institutions of Saudi Arabia, both local and in collaboration with scientists from other countries, authored by a Saudi researcher or a non-Saudi researcher representing a Saudi institution were eligible for inclusion. Both published and accepted articles in press that were already published online were also included.

### Title and abstract relevance screening

The titles and abstracts of the identified articles were first examined by one author and cross-checked by another author for relevance and inclusion criteria. The reason for omitting each of the excluded papers was recorded.

For selected papers, data were abstracted and charted in Microsoft Excel 2010 using the following categorization: title, first author, Saudi author (if the first author is not Saudi and another coauthor is Saudi), name of the Saudi Arabian institution involved in the study, year and month of the study (in case of published studies), articles in press (for published online articles), national or collaborative international, name of the countries in case of multinational studies, type of study (narrative, review/opinion, letter to editor/correspondence, comment/opinion/editorial, short communication, systematic review, guidelines and systematic review, observational including case reports, case series, cohort, cross-sectional, experimental, survey, modeling/epidemiological, and basic science), aim and objectives of the study, and keywords.

## Results

### Literature search

The initial search in different databases yielded 175 citations, of which 88 were duplicate and deleted. After rescreening, 34 articles did not meet the eligibility criteria; 27 papers mention Saudi Arabia in their abstract or text only as reference, but the researches were conducted in other countries and 7 papers were related to other coronaviruses and had mentioned COVID-19 in their abstract or text. Ultimately, 53 papers met the inclusion criteria. The study selection process is presented in full detail as a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram in **Figure 1**.

![Figure 1](http://smj.org.sa/https://smj.org.sa/content/smj/41/8/791/F1.medium.gif)

[Figure 1](http://smj.org.sa/content/41/8/791/F1)

Figure 1 
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 flow diagram

### Characteristics of sources of evidence

Among the included 53 papers, authors of 43 articles were Saudi nationals; in 10 articles (19%), Saudi nationals were first authors. Ten articles out of the 53 were authored by non-Saudi nationals affiliated with Saudi institutions. Most of the papers were coauthored by investigators under the affiliation of Johns Hopkins Aramco Healthcare, Dhahran (20 articles; 38%) and King Saud Medical City, Alfaisal University, Riyadh (16 articles; 30%). **Table 1** presents the study characteristics of the included studies.

View this table:
[Table 1](http://smj.org.sa/content/41/8/791/T1)

Table 1 
General characteristics of studies meeting eligibility criteria.

All the participating hospitals are listed in **Table 2**. All the papers were either published or accepted in 2020. Most of the papers (n=33; 62%) were accepted and published online ahead of print. The majority of the studies (38; 72%) were conducted in collaboration with scientists from other countries. The names of the countries are listed in **Table 3**.

View this table:
[Table 2](http://smj.org.sa/content/41/8/791/T2)

Table 2 
Participating institutions of the included studies.

View this table:
[Table 3](http://smj.org.sa/content/41/8/791/T3)

Table 3 
Countries in collaboration with Saudi Arabia for included studies.

### Topics and themes of identified studies

A total of 15 studies (28%) focused on control and prevention of COVID-19, investigating the importance of preventing mass gatherings, including Hajj and Umrah. Three of the 15 control/prevention articles outlined measures to be taken during various surgeries, including dental surgery. The clinicopathological features of COVID-19 (**Figure 2**) were described by 15 studies (28%). Six of the clinicopathological studies included discussion on the management of the infection. Nine papers (17%) focused on the virology and genomics. One paper investigated the mechanism of action of various drugs on the viral genome.19 Surgeons from the city of Al Madinah Al Munawarah, Saudi Arabia were involved in a huge multinational survey of 47 hand surgeons working in 34 countries, including the United States, China, and Canada, that focused on the different measures adopted to combat the pandemic.20 The effect of different drugs on humans were examined in only one clinical trial. Four different treatment options were administered in a multinational randomized trial: antibiotics, antiviral therapy for influenza, host immunomodulation with extended macrolide therapy, and alternative corticosteroid regimens, representing 240 treatment regimens.21

![Figure 2](http://smj.org.sa/https://smj.org.sa/content/smj/41/8/791/F2.medium.gif)

[Figure 2](http://smj.org.sa/content/41/8/791/F2)

Figure 2 
Identified topics and purpose of disease.

### Types of studies

Approximately one third of the papers are comment/opinion/editorial (n=15; 28%), one fourth are review articles (n=13; 25%), and one fifth letters to the editor/correspondence (n=11; 21%). **Figure 3** depicts the types of articles included in this review. A similar trend was noted in the publications where the first authors were Saudi nationals. Three out of 10 (30%) were in the category of comment/opinion/editorial and 2 (20%) were review articles. The remainder were categorized as basic science, modeling, and short communications.

![Figure 3](http://smj.org.sa/https://smj.org.sa/content/smj/41/8/791/F3.medium.gif)

[Figure 3](http://smj.org.sa/content/41/8/791/F3)

Figure 3 
Identified types of publications.

### Research priorities

To address the gap between the research priorities set by the WHO blueprint and the papers published by scientists affiliated with Saudi institutions, we categorized the papers according to the blueprint, looking at the themes and aims of the studies (**Table 4**). The table demonstrates the paucity of experimental research with clinical outcomes and vaccine-related research. It also highlights the lack of research on animals and environmental sources of virus origin as well as the human-animal interface.

View this table:
[Table 4](http://smj.org.sa/content/41/8/791/T4)

Table 4 
Research themes of the included articles according to the WHO research priorities for COVID-19.

## Discussion

This scoping review of research publication related to COVID-19 in Saudi Arabia identified 53 articles (**Table 5**). Most of the included studies focused on control and prevention and on the clinicopathological aspects of the disease. The articles focused on the importance of and ways to prevent community transmission, which included plans for preventing community gatherings such as Hajj and Umrah along with the Tokyo Olympics.30 Furthermore, issues related to the importance and prevention of cross infection to healthcare workers or different surgical and medical departments were reviewed. A significant number of studies focused on viral genomics and its implication on drug discovery including the potential use of existing drugs to target the virus.19

View this table:
[Table 5](http://smj.org.sa/content/41/8/791/T5)

Table 5 
The types of included studies.

Almost all of the articles were narrative, focusing on reported views and experiences. Only 2 were experimental; one of the 2 is a large multicentral, multinational clinical trial, investigating treatment modalities of community-acquired pneumonia and COVID19. The study was initially launched in European countries and later expanded to Saudi Arabia.

The findings of this scoping review highlight the collaborative nature of most of the research conducted by Saudi scholars in relation to COVID-19. However, the limited number of Saudi investigator-initiated studies, especially with respect to experimental research, is concerning. These findings highlight the gaps in COVID-19 related research from Saudi research institutes. First, the number of experimental studies focused on new treatment options were very low. Second, the economic impact on specific health resources in Saudi Arabia was not investigated. Moreover, epidemiological studies focused on disease transmission or modeling of important outcomes such as health resources utilization were lacking. Furthermore, the current published research seems to be discordant from the WHO research and development blueprint for epidemic research that was established in 2015 and updated in 2017 by international experts.72 The blueprint was developed to ensure research preparedness during outbreak crises with a special focus on vaccine development, diagnostic testing, and therapeutic testing.74 While it is possible that some of the national research projects are still ongoing and were not captured by the time we prepared this article, clearly, the current publications do not reflect strong national research preparedness to adequately address epidemics and pandemics.

This scoping review is useful in the context of fund allocation from the government through various institutions to support health care and COVID-19-related research on a national and international level. Interestingly, if we examine previous efforts from the Saudi Ministry of Health in the era of the MERS-Cov epidemic, we can find a road map that addressed similar issues related to emerging infection research, particularly in the field of vaccine development.73 The international workshop hosted by the Saudi government called for a paradigm shift establish clear goals of public health interest that guide epidemic research. The government, represented by the Ministry of Health, and academic institutions, in collaboration with international stakeholders, including the WHO, should work together to achieve this goal.75 Unfortunately, most of the published research during this pandemic seems to stray from the previously addressed road map and instead focuses on opinions and narrative reviews rather than original research. This calls for careful and in-depth analysis to identify the factors contributing to the current state of research. The research gap related to COVID-19 identified by the WHO that needs to be addressed by the global community are: i) Understand the natural history of infection, identify animal host, infection and transmission of infection including asymptomatic infection and susceptible population. ii) Determine the most effective standard of care approach using data from China and other countries. iii) Research on adjunctive and supportive therapies. iv) Research on rapid point of care diagnostics. v) Clinical trials for development of vaccine and investigating therapeutics. This can be utilized for planning future research steps.

This scoping review also identifies that Saudi Arabia scholars’ research is mainly focused on the pathogenesis of the COVID-19 infection and opinions related to viral control and prevention. This is important, since the priority of research at the level of funding agencies and even national strategy should take this into account in order to improve the knowledge gap in understudied and important fields such as epidemiological studies, diagnostic testing, immune response, genetic predisposition to sever phenotypes and experimental treatment interventions.

### Study limitation

We did not search the gray literature or the EMBASE. Also this study did not capture unpublished ongoing research projects, particularly in areas of molecular and basic science, at the time of this manuscript preparation.

Finally, the aim of this scoping review was to map our COVID-19–related research on a national level in order to identify areas of strength and weakness. The results of our knowledge mapping should be followed by coordinated efforts from all stakeholders in our national health research, including the Ministry of Health, Ministry of Higher Education, academic and research institutes, National Institutes of Health, and the Center of Chronic Disease Prevention in order to identify a national strategy that invests in building capacities inspired by Saudi Vision 2030 and in alignment with the WHO epidemic research and development blueprint. In particular, we call for clear national strategy for health research that takes inconsideration emerging epidemics along with other public health priorities. We urge all national research institutes to identify research infrastructure capacity in order to maximize the utility of these infrastructures and help overcome their shortcomings. In addition, we suggest establishing national capacity for regular laboratory research materials through the investment in national companies for laboratory materials. Furthermore, we strongly encourage the investment in public health schools especially in leading national universities which are entailed to handle public health crises while provide guidance to the government in the most scientific and evidence-based approach.

In conclusion, this scoping review was a first step by the authors toward contributing to the development of a national COVID-19 pandemic research agenda for decision-makers concerned with the role of national health research in priority setting and resource allocation. Many decision-makers are seeking research support and guidance in moving forward during this critical time.

Ultimately, the intention of the national research activities should be to maximize the impact and usefulness of national public health interventions and policies. The decision-makers are facing the constraints of national COVID-19 pandemic research to inform priority setting and resource allocation decisions. The next step is to produce a national research framework for COVID-19 with specific research projects to address critical gaps identified through this scoping review. This can be achieved through collaboration between decision-makers and researchers with interests in this field.

Statistics

Excerpts from the Uniform Requirements for Manuscripts Submitted to Biomedical Journals updated November 2003. Available from [www.icmje.org](http://www.icmje.org)

Describe statistical methods with enough detail to enable a knowledgeable reader with access to the original data to verify the reported results. When possible, quantify findings and present them with appropriate indicators of measurement error or uncertainty (such as confidence intervals). Avoid relying solely on statistical hypothesis testing, such as the use of P values, which fails to convey important information about effect size. References for the design of the study and statistical methods should be to standard works when possible (with pages stated). Define statistical terms, abbreviations, and most symbols. Specify the computer software used.

## Acknowledgment

*The authors would also like to thank SCRIBENDI ([www.scribendi.com](http://www.scribendi.com)) for English language editing.*

## Footnotes

*   **Disclosure.** Authors have no conflict of interests, and the work was not supported or funded by any drug company.

*   Received May 12, 2020.
*   Accepted June 10, 2020.


*   Copyright: © Saudi Medical Journal

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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