key: cord-0727592-q4c0dmf5 authors: Hussein, Nawfal R.; Naqid, Ibrahim A.; Saleem, Zana Sidiq M.; Almizori, Lokman A.; Musa, Dildar H.; Ibrahim, Nashwan title: A sharp increase in the number of COVID-19 cases and case fatality rates after lifting the lockdown in Kurdistan region of Iraq date: 2020-07-24 journal: Ann Med Surg (Lond) DOI: 10.1016/j.amsu.2020.07.030 sha: a0b63c0e21a0685ca284f63ac42291d9ab8753ed doc_id: 727592 cord_uid: q4c0dmf5 With the appearance of first cases of Coronavirus disease (COVID-19), strict control measures were implemented in the Kurdistan Region of Iraq to combat the infection. These measures included the closure of schools and universities, the closure of borders and airports, cancellation of public and religious gatherings, and mandatory quarantine for persons returning from traveling abroad. Such measures have played a major role in the control of COVID-19 spread. However, due to social and economic pressures, the government relaxed the lockdown. After relaxing the measures, a sharp increase in the number of patients was noticed. Besides, there was a significant increase in the number of symptomatic patients and the case fatality rate was doubled. In addition, the outbreak and outbreak response led to the loss of trust and a breakdown in relations between the society and local authority. To minimize the consequences for population health, local authority should have a plan that balances between health imperatives and socioeconomic imperatives. Finally, to be successful in controlling the infection, the government must rebuild public trust in the handling of COVID-19 outbreak and compensate people for lost earnings. The following information is required for submission. Please note that failure to respond to these questions/statements will mean your submission will be returned. If you have nothing to declare in any of these categories then this should be stated. All authors must disclose any financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work. Examples of potential conflicts of interest include employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding. There is no conflict of interest Please state any sources of funding for your research All sources of funding should be declared as an acknowledgement at the end of the text. Authors should declare the role of study sponsors, if any, in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication. If the study sponsors had no such involvement, the authors should so state. Research studies involving patients require ethical approval. Please state whether approval has been given, name the relevant ethics committee and the state the reference number for their judgement. The study was approved by the Scientific and Ethics Committee, College of Medicine, University of Zakho, Kurdistan region, Iraq. Studies on patients or volunteers require ethics committee approval and fully informed written consent which should be documented in the paper. Authors must obtain written and signed consent to publish a case report from the patient (or, where applicable, the patient's guardian or next of kin) prior to submission. We ask Authors to confirm as part of the submission process that such consent has been obtained, and the manuscript must include a statement to this effect in a consent section at the end of the manuscript, as follows: "Written informed consent was obtained from the patient for publication of this case report and accompanying images. 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Please specify the contribution of each author to the paper, e.g. study concept or design, data collection, data analysis or interpretation, writing the paper, others, who have contributed in other ways should be listed as contributors. We confirm that the manuscript has been contributed, reviewed and approved by all authors. We further confirm that the order of authors listed in the manuscript has been approved by all of us. In accordance with the Declaration of Helsinki 2013, all research involving human participants has to be registered in a publicly accessible database. Please enter the name of the registry and the unique identifying number (UIN) of your study. You can register any type of research at http://www.researchregistry.com to obtain your UIN if you have not already registered. This is mandatory for human studies only. Trials and certain observational research can also be registered elsewhere such as: ClinicalTrials.gov or ISRCTN or numerous other registries. Name of the registry: 2. Unique Identifying number or registration ID: 3. Hyperlink to your specific registration (must be publicly accessible and will be checked): The Guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish The first case of COVID-19 was diagnosed in Iraq on the 22 nd of February 2020. With the appearance of first cases in the country, Kurdistan Regional Government, the northern Region of Iraq, took strict measures to control the infection. These measures included cancellation of gathering and religious rituals, closing schools and education institutes and closing airports and boarders [3] . Then, stateimposed community-wide containment was declared [3, 4] . Region imposed strict regulations that all PCR-positive patients must be admitted to COVID centers regardless the presence of symptoms [5] . The considerable impact of economy and mounting pressure on the government increased the likelihood of losing control and closed the decision-making process prematurely before exploring reasonable alternatives. The lockdown was lifted and the measures were eased on the 22nd of May 2020. Easing the lockdown did not include any plan to protect high-risk groups including elderly, people with disabilities and people with underlying health conditions. Additionally, lifting the lockdown made a false sense of security and people started to gather again. In some cities, after cessation of cases for few days, victory against the virus was celebrated. After relaxing the measures, a sharp increase in the number of patients was noticed (Table 1) ( Figure 1 ). Besides, there was a significant increase in the number of symptomatic patients after easing the lockdown and the case fatality rate was doubled (Table 1) . A Novel Coronavirus from Patients with Pneumonia in China WHO. Rolling updates on coronavirus disease The Impact of Breaching Lockdown on the Spread of COVID-19 in Kurdistan Region The Impact of COVID-19 Pandemic on the Elimination of Viral Hepatitis in Duhok City, Kurdistan Region of Iraq Latest Information about Coronavirus (COVID-19) Combating COVID-19 is a national program therefore all data are published in Ministry of Health media and updated regularly. The study was approved by the Scientific and Ethics Committee, College of Medicine, University of Zakho, Kurdistan region, Iraq. No funding or support. The authors have declared that no competing interest exists We confirm that the manuscript has been contributed, reviewed and approved by all authors. We further confirm that the order of authors listed in the manuscript has been approved by all of us. Not commissioned, externally peer reviewed.