Characteristics and outcomes of COVID-19 home monitoring in Saudi Arabia during the second and third waves

Introduction

As severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) spread around the world, patient care was shifted to outpatient care and home monitoring. This paper describes the characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) treated at home during the second and third waves in Saudi Arabia.

Materials and methods

Descriptive evaluation of the characteristics and outcome of COVID-19-positive cases enrolled in the home monitoring programme.

Results

This study included 14,970 SARS-CoV-2-positive patients (52.6% male). The mean age was 30.8 [standard deviation (SD) 19.9] years. Among the confirmed cases, 14,234 had documented vaccination status; of these, 3943 (27.7%) had not received any doses of COVID-19 vaccine, 1452 (10.2%) had received one dose, 4882 (34.3%) had received two doses, and 3957 (27.8%) had received three doses. The mean number of days in the home monitoring programme was 8.3 (SD 3.5) days. The mean interval from the last vaccine dose until SARS-CoV-2 infection was 116.6 (SD 75.5) days in 7975 patients. The presence of comorbidities was as follows: chronic kidney disease, 340 (2.3%); hypertension, 2569 (17.2%); chronic pulmonary disease, 2539 (17%); smoking, 1711 (11.4%) of 9269 with documented smoking histroy; coronary artery disease, 854 (5.7%); and diabetes mellitus, 1531 (10.3%). The hospitalization rate was 1.8%, and the case fatality rate was 5% of admitted patients, accounting for 0.11% of all cases. The mean age of patients who died was 76.6 (SD 17.7) years, which was higher compared with the mean age of those who survived [30.8 (SD 19.9) years] (P<0.001).

Conclusion

Utilization of a home monitoring programme was effective and safe for patients with COVID-19 who were either asymptomatic or had mild symptoms.

Accreditation of primary health care centres in the KSA: Lessons from developed and developing countries

Background/Objectives

In 2013, the KSA made Central Board for Accreditation of Healthcare Institutions (CBAHI) accreditation mandatory for all healthcare facilities, including primary health care centres (PHCs) and set a target to have 502 PHCs accredited by 2020. However, there is a real gap in knowledge and research on the impact of CBAHI accreditation on PHCs. This absence of research has been linked to the lack of understanding of the accreditation programme. Therefore, it was recommended by scholars that the KSA could learn from the experience of other countries to improve policy implementation and avoid future complications.

Methods

This study aimed to explore lessons that KSA can draw from developed and developing countries that have implemented accreditation programmes for PHCs. We performed a literature review using a systematic approach to identify articles related to the accreditation of PHCs. The identified articles were examined by applying evaluation criteria in respect of prospective policy transfer.

Results

The research results yielded 22 publications from different countries. There were variations among the countries in the specific information acquired. However, Denmark had the highest number of articles providing detailed information. Regarding their aims, most studies shared the same goal of improving quality and patient safety. Generally, there was limited discussion of policy failure compared with policy success. In addition, most of the countries were in the process of implementing local accreditation. Almost all of the countries that had implemented external programmes were developing countries. In terms of application criteria, most cases made recommendations for the programme or for PHCs.

Conclusion

Analysis indicated that because of the differences in information between countries and settings, there is no ideal country-based experience from which the KSA can transfer lessons. Lessons from outside the KSA would need careful consideration when adopting them in the local context of the Kingdom.

Phenology and production of Hassaoui grapevines as affected by climate anomalies in Al Ahsa region

Climate change is a dramatic crisis that has left severe impacts on viticulture. Phenological events over 41 years and annual climatic anomalies’ data over these years in Al Ahsa region were procured. Annual temperature and wind speed anomalies had the strongest influence on all phenological events of the varieties White and Red Hassaoui, starting from the beginning of budburst until harvest. Moreover, the average yield of both varieties decreased significantly by 319.4 and 317 kg ha⁻¹ respectively between 1997 and 2019 in comparison with the interval of years 1979–1996. Earlier phenological events were positively correlated with annual temperature anomaly and negatively correlated with annual wind speed anomaly. The latter shortened the dates of occurrence of beginning and full veraison. Yield decreased with higher annual temperature, wind speed and total cloud cover anomalies, and lower annual total precipitation anomaly. Higher annual temperature and wind speed anomalies were correlated with a shorter period between beginning of budburst to beginning of veraison (P3). Shorter periods between beginning and full veraison (P6) and beginning of veraison and harvest (P7) of Red Hassaoui were positively correlated with annual precipitable water anomaly. Results suggest a high level of adaptation of both tested varieties to changing climate conditions in Al Ahsa, though irrigating vines after harvest on a weekly basis would help overcoming the minimal reduction in yield which was caused by the shortage in precipitation.

Variations in length of stay of inpatients with COVID-19: A nationwide test of the new model of care under vision 2030 in Saudi Arabia

Objective

The coronavirus disease 2019 (COVID-19) has impacted the Kingdom of Saudi Arabia (KSA) as it has other nations. However, length of stay (LOS), as a healthcare quality indicator, has not been examined across the healthcare regions in the KSA. Therefore, this study aimed to examine factors associated with LOS to better understand the Saudi Health System's performance in response to the COVID-19 pandemic in the newly suggested five Saudi regional business units (BUs).

Methods

A retrospective study was conducted using Ministry of Health (MOH) data on hospital LOS during the period from March to mid-July 2020. Participants were adult inpatients (18 years or older) with confirmed COVID-19 (n = 1743 patients). The 13 regions of the KSA were united into the defined five regional BUs during the reorganization of the health system. Covariates included demographics such as age and sex, comorbidities, and complications of COVID-19. A multiple linear regression with stepwise forward selection was used to model LOS for other explanatory variables associated with LOS, including demographic, comorbidities, and complications.

Results

The mean LOS was 11.85 days which differed significantly across the BUs, ranging from 9.3 days to 13.3 days (p value < 0.001). BUs differed significantly in LOS for transferred patients but not for patients in the intensive care unit (ICU) or those who died in-hospital. The multiple regression analysis revealed that the LOS for inpatients admitted in the Eastern and Southern BUs was significantly shorter than for those in the Central BU. (p value < 0.001). Admission to the ICU was associated with lengthier stays (p value < 0.0001). Factors significantly associated with shorter stays (compared to the reference), were being Saudi, death during admission, and patients referred to another hospital (p value < 0.05).

Conclusion

The LOS for patients with COVID-19 differed across the proposed regional healthcare BUs, suggesting regional differences in quality of care under the reorganization of the national health system. Since patient and disease characteristics did not explain these findings, differences in staffing and other resources need to be examined to develop interventions.

Demographic, clinical, and outcomes of confirmed cases of Middle East Respiratory Syndrome coronavirus (MERS-CoV) in Najran, Kingdom of Saudi Arabia (KSA); A retrospective record based study

Introduction

MERS is caused by a viral infection, which was first identified in KSA, 2012. MERS-CoV infection consequences with either hospitalization or death.

Methods

All positive MERS-CoV cases that diagnosed in and reported to a referral hospital in Najran, KSA from March/2014 to December/2018 were revised retrospectively. We identified patients from infection control department and medical records. Demographic, clinical, and outcome data were collected.

Results

Of the 54 positive MERS-CoV cases, 3 cases were excluded because no available data. Therefore, the final number of the included cases in the study was 51 cases (94.4). Most of the patients were Saudi 36 (70.6%), and majority of cases were reported in the winter 18 (35.3) season. Fever 47 (92.2%), cough 44 (86.3%), and shortness of breath 37 (72.5%) were reported as most common symptoms. Most patients had diabetes mellitus and hypertension. Overall mortality rate was 37.3%, and interestingly the mortality rate dropped sharply over 5 years. In logistic regression analysis, Season and Chronic Kidney disease patients were the only two variables statistically significantly associated with death. The odds of death the patients infected by MERS-CoV during Autumn and Winter season were 4.09 times higher than those patients who infected during Spring and Summer season (OR = 4.09, CI 1.18-14.15, P < 0.026). Compared with MERS-CoV patients who had Non-Chronic kidney diseases, the odds of death the MERS-CoV patients who had chronic kidney diseases were 18.08 times higher (OR = 18.08, CI -2.01-162.99, P < 0.01).

Conclusion

The case fatality rate of MERS-CoV infection was high. Further studies with large sample sizes are needed to explore the reasons behind the decrease in the mortality rate over the time period.

Assessment of personal protective equipment use and occupational exposures in small industries in Jeddah: Health implications for workers

Small-scale industries account for a large proportion of jobs and play a vital role in most countries' economic growth and prosperity. Due to the very low use of personal protective equipment (PPEs), employees are exposed to numerous physical, chemical, and accidental hazards in small-scale industries. PPEs are very effective in minimizing occupational injuries, accidents, and other hazards which otherwise result in substantial manpower and financial losses. The study objective was to assess the availability and use of PPEs as well as self-reported occupational exposures among workers in surveyed small industries in Jeddah. The study involved 102 workers from 28 small-scale industries (vehicle repair, welding, and paint). A survey was conducted to gather data of socio-demographic characteristics, self-reported occupational exposures, and frequency of PPEs used by workers. The occupational exposures (never exposed, sometimes exposed and always exposed) were reported in percentages including; noise exposure (19.6, 73.5 and 6.9%); dust/smoke exposure (9.8, 69.6 and 20.6%); vapors/fumes exposure (11.8, 60.8 and 27.5%); and direct sunlight (43.1, 56.9 and 0%), respectively. The reported use of different PPEs in descending order was; knee joints mats (50%), welding shields (50%), safety glasses (33.3%), gloves (27.5%), face masks (26.5%), safety shoes (10.8%) and earplugs/ muffs (8.8%). On the basis of this study findings, hand hygiene and general OSH awareness like interventions can be developed which will help in minimizing workplace exposures among small-scale industry workers.

Vitamin D in the Middle East and North Africa

PURPOSE

The Middle East and North Africa (MENA) region registers some of the lowest serum 25‑hydroxyvitamin D [25(OH)D] concentrations, worldwide. We describe the prevalence and the risk factors for hypovitaminosis D, completed and ongoing clinical trials, and available guidelines for vitamin D supplementation in this region.

METHODS

This review is an update of previous reviews published by our group in 2013 for observational studies, and in 2015 for randomized controlled trials (RCTs) from the region. We conducted a comprehensive search in Medline, PubMed, and Embase, and the Cochrane Library, using MeSH terms and keywords relevant to vitamin D, vitamin D deficiency, and the MENA region, for the period 2012-2017 for observational studies, and 2015-2017 for RCTs. We included large cross-sectional studies with at least 100 subjects/study, and RCTs with at least 50 participants per arm.

RESULTS

We identified 41 observational studies. The prevalence of hypovitaminosis D, defined as a 25‑hydroxyvitamin D [25(OH)D] level below the desirable level of 20 ng/ml, ranged between 12-96% in children and adolescents, and 54-90% in pregnant women. In adults, it ranged between 44 and 96%, and the mean 25(OH)D varied between 11 and 20 ng/ml. In general, significant predictors of low 25(OH)D levels were female gender, increasing age and body mass index, veiling, winter season, use of sun screens, lower socioeconomic status, and higher latitude.We retrieved 14 RCTs comparing supplementation to control or placebo, published during the period 2015-2017: 2 in children, 8 in adults, and 4 in pregnant women. In children and adolescents, a vitamin D dose of 1000-2000 IU/d was needed to maintain serum 25(OH)D level at target. In adults and pregnant women, the increment in 25(OH)D level was inversely proportional to the dose, ranging between 0.9 and 3 ng/ml per 100 IU/d for doses ≤2000 IU/d, and between 0.1 and 0.6 ng/ml per 100 IU/d for doses ≥3000 IU/d. While the effect of vitamin D supplementation on glycemic indices is still controversial in adults, vitamin D supplementation may be protective against gestational diabetes mellitus in pregnant women. In the only identified study in the elderly, there was no significant difference between 600 IU/day and 3750 IU/day doses on bone mineral density. We did not identify any fracture studies.The available vitamin D guidelines in the region are based on expert opinion, with recommended doses between 400 and 2000 IU/d, depending on the age category, and country.

CONCLUSION

Hypovitaminosis D is prevalent in the MENA region, and doses of 1000-2000 IU/d may be necessary to reach a desirable 25(OH)D level of 20 ng/ml. Studies assessing the effect of such doses of vitamin D on major outcomes, and confirming their long term safety, are needed.

Stone formation in the Middle Eastern Gulf States: A review

Objectives

To review the possible causes of the high incidence of urolithiasis in the oil-rich Gulf States.

Methods

Data were extracted from published reports on the incidence of urolithiasis, affluence and diet in the Gulf States, various Western countries and China.

Results

There are strong relationships: (a) between the life-expectancy of stones in men and the Gross National Income (GNI) per capita of these countries; and (b) between the daily consumption of animal protein and GNI per capita. Together these data suggest that the occurrence of stones is proportional to the intake of animal protein, although they also indicate that there are additional factors that further increase the risk of urolithiasis in the populations of the Gulf. The consumption of oxalate in the Gulf is three times higher and that of calcium a half of what it is in Western countries. Thus, the average oxalate/calcium ratio in the intestines of the Gulf populations is five to six times higher than that in Western populations, leading to enteric hyperoxaluria and an increased risk of calcium-oxalate stone formation. The risk is further accentuated by the lower urine volumes, due to the hot, dry climate of the region, and lower excretions of citrate, from the highly acidic urine resulting from the high intake of animal protein. There is a high incidence of uric acid-containing stones from the acidic urine and the hyperuricosuria caused by the high intake of purine.

Conclusions

The high incidence of urolithiasis in the Gulf is due to an adverse combination of dietary and environmental factors.

The development of robotic surgery in the Middle East

Objectives

We provide an overview of the development of robotic surgery in the Middle East since its first introduction in April 2003 in the Kingdom of Saudi Arabia (KSA).

Methods

We searched MEDLINE using 20 keywords/phrases and identified 44 reports, of which only 15 were relevant. Five of these articles were duplicated when using two different keywords. Therefore, no more than 10 articles were found that were relevant to the scope of this review.

Results

After completing the MEDLINE search to identify articles related to robotic surgery in the Middle East, we noted that all of the nine case series (Level of evidence 3a) reported took place in the KSA, with no other reported series from other Middle-Eastern countries. To the best of our knowledge, there are no operating robotic surgery systems (da Vinci, Intuitive Surgical, CA, USA) in the Middle East other than in the KSA, Qatar and Egypt. The number of robotic surgery cases and newly adapted robotic procedures is increasing. Two major institutions in the KSA have expanded to robotic-assisted pyeloplasty in all of their cases since January 2005.

Conclusion

There are 10 da Vinci robots in the KSA, with over 35 trained surgeons, yet very few index cases. The cancer incidence rate, lack of practitioners’ referrals, and demographic age distribution are all factors that contribute significantly to the few index cases reported. By consolidating the robotic surgery procedures in high-volume speciality centres, hospitals can increase their case loads by promoting the multidisciplinary use of the robotic system. Even though growth is relatively slow, we believe that robotic surgery is gaining momentum, and its benefits and innovation will soon be grasped in other countries in the Middle East.