Trends in COVID-19

Discussion

More than half of the cases were males, and two-third aged 30-60 years. This goes with a study in Victoria, Australia¹⁷ regarding the age group of cases, although the vulnerable age group for death was ≥60 years, but it disagreed with a study in India where male constituted 65.4%, with age group 18-35 years formed 37.5% of the cases.¹⁸ The results of meta-analysis in 8 countries showed that the highest frequency of cases (in Germany, Chile, Portugal, South Korea, New Zealand, Turkey, Canada, and USA) was in the age group 20-39 years; while in Italy, Netherlands, and UK the highest frequency was among the age group >80 years.¹⁹ The differences in the access of COVID-19 testing could be the main reason, rather than in the actual number of cases, as testing the elderly was a priority. They were labeled as a high risk group, due to the severe complications they might face, taking in consideration the limited capacities in testing at the beginning of the pandemic. However, younger age groups began to receive a parallel consideration as testing capacities improved especially with increasing numbers of asymptomatic patients in most populations that may facilitate the transmission of the infection.^19,20

Two-third of the total deaths were males, half of whom age more than 60 years. Certain groups especially those age groups above 65 years or those with previous medical illnesses are more affected by COVID-19 complications and can result in more fatalities. Physiological effect due to aging process, such as waning of the immune system, dysfunction, and degeneration of body tissues can be the leading cause for deterioration and death.²¹ Coronavirus infection is now labeled as “the third leading cause of death for children and adults (697.5 deaths/million)”, that comes only after heart problems (1287.7 deaths/million) and cancer (1219.8 deaths/million).²²

Gender could play a part in vulnerability to coronavirus disease, however, this is still unclear. Several reports have indicated that men have a higher number of infection and case fatality rates than women. Reasons behind that might include variability in gender norms and habits, or differences in social roles in each society.²³ Islam et al²⁴ attributed that to several factors, such as occupational and lifestyle that may increase the likelihood of exposure among men or differences in underlying comorbidities between both genders.

The disease trend in the current study showed 2 peak; a moderate one (August-October 2020) following “Eid al Fitr” celebration, and a higher one (March-July 2021), while Saudi Arabia reported a single peak (June-July 2020). In Egypt, there the highest peak was in June 2020 with 2 moderate peaks in January 2021 and in June 2021. Iran experienced 2 moderate peaks in November 2020 and in April 2021, and a highest peak in August 2021.²⁵ Although large gatherings of people like religious ceremonies with massive overcrowding can participate in the disease trend fluctuation, small and informal social gatherings are thought to be an important source of transmission; birthdays, wedding, and funeral occasions can empirically quantify the impending role of small social gatherings in COVID-19 spread.²⁶

Case fatality rate seems to be relatively low in the current study compared to other countries, a study that included 20 European countries (severely affected with COVID-19), in addition to USA and Canada, concluded that the country-specific CFR showed a broad spectrum, ranging from 0.6 (Iceland) to 18.1% (France).²⁷ However, CFR in the current study was higher among males, which was consistent with most of the countries in Hoffmann and Wolf’s study.²⁷ Many heterogeneous reasons related to country-specific differences in cases and deaths have been evaluated, including genetic, socioeconomic, and environmental factors.²⁸

Coronavirus disease-19 cases distribution, deaths, and CFR by months during the period of the study showed that the highest number of deaths was in July 2020, and the maximum number of cases was in July 2021, whilst the CFR reached its peak at the beginning of the pandemic. These results were in line with WHO COVID-19 weekly global report, in which the elevated trend in the last 2 months (Jun-July 2021) was largely attributed to increase number of cases in the Western Pacific region (14.0% increase) and the Americas (8.0% increase), while at the country level, the peak numbers of new cases in the same period were reported by USA, Iran, and India.²⁹

The highest global death rate reported by WHO was in January 2021, while the highest global CFR was in April 2020.³⁰ Hasan et al³¹ in a meta-analytic study concluded that the weekly worldwide coronavirus CFR got a top at 7.2% during the 17th epidemiological week (April 22-28, 2020). The topmost 5 countries with coronavirus CFR were Yemen (28.9%), Italy (13.2%), UK (12.4%), Belgium (11.6%), and France (11%). Case fatality rate is a key measure of disease burden that is crucial for effective pandemic monitoring and control.^17,32 However, many reasons restrict obtaining an accurate estimate of CFR and Mortality rate by COVID-19.³³

The decline in CFR in this study was consistent with other studies in USA (New York), where the death rate among inpatients declined 18-20.0% in a 3-4 months period, from 25.6% in March to 7.6% in June 2020.³⁴ In another study in England, the death rate decreased among patients that were admitted in May related to those admitted in March 2020 (from 11.2% to 9.0%).³⁵ The relative drop in CFR could be due to some reasons, such as: increased public awareness, widespread testing that detects even asymptomatic or mild cases, precision of severely ill patients’ management, favorable outcomes for infection of younger people, and experience gained by health professionals.³¹

The morbidity and mortality statistics by governorates demonstrated that the highest incidence rates were in Wasit, Duhok, and Baghdad, whilst Sulaimaniyah recorded the highest mortality and case fatality rates. Despite the geographical variability between Iraqi governorates, it is generally expected that increased population density rises the susceptibility of some regions to get infection due to the high occurrence of social and economic interactions. Population density is certainly a crucial hint in studying virus spread, however, limited access to medical services due to a shortage of health personnel, hospitals beds (especially intensive care units) and intensive care beds, testing intensity and access to testing, in addition to low income level in more closely inhabited areas could be possible factors.²¹

The main challenges faced by the Iraqi health system during this pandemic as stated by decision makers in the Ministry of Health were shortage of medical personnel as a result of migration of doctors due to unfavorable security condition, also the limping health system and services represented by shortage of medicines and insufficient oxygen supply. In a study in Nepal, the most challenging aspects were the availability of testing kits, medical supplies, and personal protective equipment.³⁶ In a study in France, the main challenges were increase health workers’ awareness regarding management of suspected and confirmed cases, preparedness by education, and training that have been regularly organized for frontline health workers.³⁷

Moreover, the burden on the healthcare system was also attributed to the rapidly increasing number of cases. Governments have to take several measures to improve the capacity of the health system in order to tackle the prevailing healthcare crises, some healthcare professionals advise that the government should actively work on the security of the health workers. Lockdowns must be focused on places where clusters of cases are detected.³⁸

Many obstacles emerged during the process of the pandemic control, especially the sudden flare up in the number of cases beyond hospitals’ capacity (due to poor adherence of people to health instructions), in addition to the delay in closing the borders with the neighboring countries, and the slow and weak implementation of vaccination campaigns. The main reasons for loss of people’s role and cooperation during the pandemic were economic problems in making a living especially among those with daily work, which contributed to a negative outcome, in addition to panic that is fed by rumors from the social media especially with respect to vaccination. People generally rely on social media to gain information on the virus.^39,40

The interviewed decision makers made some suggestions to overcome the obstacles such as: establish modern hospitals in accordance with international health standards, intensify community sensitization, and engagement to encourage COVID-19 vaccine demand and uptake. Organizational, and institutional efforts and coordination approaches are compulsory for management of any global health crisis.⁴⁰

Important suggestions to overcome psychological problems that affect people or health personnel were also raised, such as psychological education of health workers, in addition to periodic home visits of psychiatrists to the patients to provide psychological/social support.

The findings of this study form a baseline information that would be helpful for quality improvement and governmental work for improving medical services.