key: cord-0827768-v1xemivd
authors: Komies, S.; Aldhahir, A. M.; Almehmadi, M.; Alghamdi, S. M.; Alqarni, A.; Oyelade, T.; Alqahtani, J. S.
title: COVID-19 Outcomes in Saudi Arabia and the UK: A Tale of Two Kingdoms
date: 2020-04-29
journal: nan
DOI: 10.1101/2020.04.25.20079640
sha: 88e53a2c8246e9cb554a43e3951d6bd0d5b44add
doc_id: 827768
cord_uid: v1xemivd

Background: While the number of COVID-19 cases and deaths around the world is starting to peak, it is essential to point out how different countries manage the outbreak and how different measures and experience resulted in different outcomes. This study aimed to compare the effect of the measures taken by Saudi Arabia and the United Kingdom (UK) governments on the outcome of the COVID-19 pandemic as predicted by a mathematical model. Method: Data on the numbers of cases, deaths and government measures were collected from Saudi Ministry of Health and Public Health England. A prediction of the trend of cases, deaths and days to peak was then modelled using the mathematical technique, Exponential Logistic Growth and Susceptible Infectious Recovered (SIR) model. The measures taken by the governments and the predicted outcomes were compared to assess effectiveness. Result: We found over three months that 22 fast and extreme measures had been taken in Saudi Arabia compared to eight slow and late measures in the UK. This resulted in a decline in numbers of current infected cases per day and mortality in Saudi Arabia compared to the UK. Based on the SIR model, the predicted number of COVID-19 cases in Saudi as of 31st of March was 2064, while the predicted number of cases was 63012 in the UK. In addition, the pandemic is predicted to peak earlier on the 27th of March in Saudi Arabia compared to the 2nd of May 2020 in the UK. The end of transition phases for Saudi and UK according to the model, were predicted to be on 18th of April and 24th of May, respectively. These numbers relate to early and decisive measures adopted by the Saudi government. Conclusion: We show that early extreme measures, informed by science and guided by experience, helped reduce the spread and related deaths from COVID-19 in Saudi. Actions were taken by Saudi Arabia under the national slogan (We are all responsible) resulted in the observed reduced number of current and predicted cases and deaths compared to the UK approach (keep calm and carry on).

SARS-CoV-2 is one species in a family of many coronaviruses that can cause a range of diseases in humans, ranging from the common cold to severe acute respiratory syndrome (1).

One of the first pneumonia viruses of COVID-19 was identified in Wuhan city, the capital of Hubei Province in China on 17 th of Nov 2019 (2) . The first four cases reported were linked to Huanan Seafood Wholesale Market (3) . Since then, the disease has spread from Wuhan to other parts of China and worldwide. On the 30 th of January 2020, the World Health Organization (WHO) declared the 2019 coronavirus (Covid-19) as a public health emergency of international concern (4), and on the 11 th of March 2020, announced that COVID-19 is a global pandemic (4) . As of the 24 th of April 2020, a total of 2,801,065 laboratory-confirmed cases had been documented globally with a total of 195,218 deaths (5, 6).

Covid-19 is highly communicable, and the average infected persons spread the disease to two or three others resulting in an exponential rate of increase (7) . COVID-19 is indeed a massive threat to humanity, and governments across the globe realize that early and decisive actions are more effective in curtailing the disease. However, for most countries, this was not the case. In some countries, early and effective measures have been applied to contain the virus while others delayed or even overlook implementing any decisions. An example of effective early precautionary measures is that taken by the Chinese government which implemented unprecedented non-pharmaceutical interventions to curb the virus including stopping travel from and to Wuhan, the origin of the epidemic as well as 15 other cities in the Hubei province (8, 9) . In addition to case isolation, schools and universities were closed, flights and trains were suspended, and roads were closed (8, 9) .

Non-pharmaceutical interventions were the first measures that countries across the world implemented. These measures include individual case isolations, the closure of schools and universities, banning of mass gatherings and public events, and most recently, wide-scale social distancing including local and national lockdowns (9) . Way before COVID-19 spread to the middle eastern countries; Saudi Arabia implemented measures to prevent the disease from spreading to the country. On the 1 st of February, Saudi Arabia stopped flights from and to China before any infected confirmed cases in the kingdom. This was followed by several measures embodied by Saudi's national slogan "We are all responsible", including but not limited to flights suspension, school closures, case isolation and quarantine for travellers who came back to the country for 14 days in hotels until the decision was made to lockdown the whole country . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted April 29, 2020. . https://doi.org/10.1101/2020.04. 25.20079640 doi: medRxiv preprint and full travel suspension (6, (10) (11) (12) (13) . Indeed, the transmission of COVID-19 in Saudi Arabia to date has been low, which reflects the value of applying early precautionary measures.

The United Kingdom government's response to Covid-19 includes several stages of escalation.

The first policy was simple "Keep Calm and Carry On" campaign with mass gathering still allowed without restrictions or distancing. This was clearly stated when the government held its first official press conference on the 12 th of March 2020, no recommendations or instructions were announced to stop mass gathering even though the cases of COVID-19 have risen to over 6,000 and mortality above 100 (14, 15) . The government's lack of action continued despite the prime minister's admission that "many more families will lose loved ones before their time".

On 16 th of March, the tone of voice during a second press conference on the same day was different as the prime minister asked the public to avoid pubs, clubs, theatre and other social events as well as non-essential travels (16, 17). He also asked people to work from home were possible, and anyone with persistent cough or fever to self-isolate for seven days (18) . Although the government encouraged social distancing, there was no clear directive about mass gatherings. The main decision was only made when a group of researchers at the Imperial College London published a model that predicted that the National Health Service (NHS) may be overwhelmed if no action was taken. This was then immediately followed by a nationwide lockdown, including the closure of schools and universities (19) .

Mathematical models have always been used to understand and predict how diseases spread in populations. These models are tools for designing and evaluating the effectiveness of control strategies (20) . The mathematical models used in this paper is based on an Exponential Logistic Growth and Susceptible Infectious Recovered (SIR) model, which is a standard compartmental model in epidemiology (21) (22) (23) (24) (25) . Previously, this model was used to make daily predictions and to estimate the approximate final size of the coronavirus epidemic (22, 26, 27) . The model is based on the previous data from the population of interest. Thus, our prediction is based on the data of reported infected and death cases for each country (26, 28, 29) . Indeed, the purpose of this study was to analysis the preventative measures implemented by Saudi Arabia and the UK and how these measures affect the reported and predicted cases of COVID-19.

. CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted April 29, 2020. . https://doi.org/10.1101/2020.04. 25.20079640 doi: medRxiv preprint

We reported the trend of COVID-19 (new cases and deaths only) as well as the measures that had been taken by the governments. Data for Saudi Arabia and the UK were sourced from the Ministry of Health Saudi Arabia and Public health of England, respectively (6, 30) . Academic data used are available online at the Johns Hopkins University Coronavirus Resource Centre and other sources (1, 12, 30-32).

In terms of data comparison between the two countries, we compare the number of infected and death cases of COVID19 per day for each country. The process of implementing nonpharmaceutical measures and responses actions varies between the two countries. The measures were documented since the beginning of each decision or recommendation by the governments of the UK and KSA.

The expected trends for the two countries are predicted using an algorithm to extrapolate the number of infections and death cases per country (33) . The prediction model we used is based on a non-linear coupled differential equation called Susceptible Infectious Recovered (SIR) model, which is a common compartmental model in epidemiology (26, 28) . The model is datadriven, thus, the predictions were based on the variation in the data (26, 28, 29) . The method is not suitable if the epidemic is still in the early stage. Also, results are not significant if the regression statistic does not meet minimum criteria, say " if R 2 > 0.8, p-value < 0.05" (26, 28, 29) . The algorithm is available online on the MathWorks website and runs on MATLAB program software (29) . It was created by Milan Batista to track the spread of Coronavirus (COVID-19) (26, 28) . The algorithm models fit data to a logistic model in order to approximate the total number of cases, basic reproduction rate, death rates and expected time scale for the epidemic (26, 28, 29) .

The prediction model we used produces a figure that shows several phases of the epidemic ( Fig. 1) . For convenience, the evaluation of the epidemic was divided into five regions with four distinct colours and red divider in the middle. Each colour represents different phases of the epidemic.

 White block represents phase one, which follows an exponential growth pattern (slow growth or lag phase): < − 2/  First orange block represents phase two which describes a fast growth (growth phase or acceleration phase): − 2/ < < . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 29, 2020. . https://doi.org/10.1101/2020.04. 25.20079640 doi: medRxiv preprint  Second orange block represents phase three, which is fast to the steady-state growth (negative growth phase or deceleration phase):

< < + 2/  Yellow block represents the phase four, which is the steady-state transition to steadystate phase (slow growth or transition phase): − 2/ < <  The green block represents phase five, which is the end phase (plateau stage): > 2

The phases are not standard but arbitrarily chosen for convenience (26, 28, 34) . Compared to Saudi Arabia, the UK implemented eight measures over the same time. Over three months, the total numbers of confirmed cases in KSA and UK were 1,720 versus 29,461, respectively. A series of declines in the new confirmed cases in Saudi Arabia after 21 days from the date of the first case is shown in Figure 2 . In contrast, the number of new cases in the UK was still rising, with no further measures announced by the UK government. The UK takes . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 29, 2020. . https://doi.org/10.1101/2020.04. 25.20079640 doi: medRxiv preprint longer time than KSA to reach the peak of confirmed new cases of COVID-19, as shown in to KSA. In total, KSA announced 16 measures to be taken in order to control the deaths due to COVID-19. In total, the UK announced only four measures to be taken in order to control the deaths due to COVID-19. There was limited data to test the relationship between the number of measures and the number of deaths in both countries.

. CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 29, 2020. . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 29, 2020. . https://doi.org/10.1101/2020.04. 25.20079640 doi: medRxiv preprint . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 29, 2020. . https://doi.org/10.1101/2020.04. 25.20079640 doi: medRxiv preprint

The model was tested on the 1 st of April 2020, which is the 62 nd day of the epidemic. The predicted numbers of COVID-19 cases and death in the United Kingdom is presented in Figure   5 . At that time, we run the model, and the number of cases and deaths were 2,9461 and 2,350 respectively. The first case of COVID-19 in the UK was reported in late January 2020 after which the number of new cases surged dramatically. Accordingly, it took the UK two months to reach the peak number of cases per day (n=4400), with the number of daily deaths taking a relatively shorter time to jump from hundreds to thousands. Based on the logistic model, the estimated total number of coronaviruses cases in the UK would be around 63,012. Also, the peak of the epidemic was expected on the 2 nd of April 2020 and estimated end of transition phase on the 24 th of May 2020 (the region between yellow and green). 

The table below presents all the precautionary measures and recommendation versus date for the UK (14, 16, 30) . is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 29, 2020. . https://doi.org/10.1101/2020.04. 25.20079640 doi: medRxiv preprint

For the first time, we compare how the Covid-19 outbreak was tackled in Saudi Arabia and the UK. This included current infected cases, death cases, predicted outbreak and government's response in both countries. We found over three months that 22 quick and decisive measures were taken in Saudi Arabia compared to eight slow and lacklustre measures in the UK. This resulted in a decline in numbers of infected cases per day, mortality, and predicted new cases with their associated deaths in Saudi Arabia compared to the UK. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 29, 2020. . https://doi.org/10.1101/2020.04. 25.20079640 doi: medRxiv preprint suspended and flights to and from 13 nations including the European Union suspended for all residents and citizens. The land ports between Saudi and Jordan was closed. From the 13 th to 21 st of March, mass gatherings in the form of weddings, sporting events, workplaces, mosque prayers (including on the Prophet's mosque), and public transport were suspended. These were followed up on the 23 rd of March by a combination of six measures including curfews and regional isolation. All in all, Saudi followed and exceeded the WHO recommendations (6, 12, 13) . As of 24 th of April, currently confirmed cases in Saudi Arabia stands at 15,102 with 127 deaths, which indicates less transmission and consequently less mortality.

On the 31 st of January 2020, the UK government reported its first cases when two Chinese nationals from the same family test positive for the SARS-CoV-2. Early at this stage, the UK government initially adopted the WHO recommendation of contact tracing and isolation of people with proven exposure. However, this was abandoned, and mass gathering was still going on, including sporting events until the 20 th of March when the UK government officially announced a national lockdown (36) . By this time, the total number of infection had already gone above 6,000 with 48 COVID-19-related deaths (37). The delayed actions by the UK government against a background of a population with a higher proportion of older and highrisk people makes the UK susceptible to higher infection and death from COVID-19 (38, 39) .

This difference in approach may explain the difference in the total number of actual and predicted cases and death presented in this study. This may also explain the difference in the predicted days for the infection to peak according to the logistic model (Saudi = 17 days, 220 cases; UK = 2 months, 4400 cases). As of 24 th of April, currently confirmed cases in the UK were 143,464 with 19,506 deaths, which shows high transmission and death rate compared to Saudi (32). However, the high death rate reported in the UK may also be linked to limited access to respiratory support as part of COVID-19 management, the severity of the respiratory disease, and critical care capacity in each hospital or region (40) (41) (42) (43) .

Taken together, this shows a lack of preparedness by the UK government in preventing the spread and burden of COVID-19, and this is evident by the total number of infected cases and deaths compared to Saudi. "Keep Calm and Carry On" was the public face of the UK government's response to Covid-19 outbreak (44) . Nonetheless, this claim was based on the behavioural sciences viewpoint that "fatigue" with stringent COVID-19 control measures would be developed if they were activated too early (44) . Still decisions of this magnitude should have been made based on scientific evidence especially as the UK has the fourth-lowest . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 29, 2020. . https://doi.org/10.1101/2020.04. 25.20079640 doi: medRxiv preprint number of hospital beds per 1000 population among the G20 nations (45). The combined actions by the Saudi Arabia's government showed a high level of preparedness coupled with sound advice guided by science. These decisions were based and informed by extensive experience in the control of previous pandemic (MERS) (46, 47) . The aim was to reduce both the economic and human cost by taking early decisive and definitive actions understanding fully that early sacrifices will reduce the burden to the national health infrastructures and pressure on healthcare workers.

It is worth mentioning that the logistic model has some drawback, especially when approaching the final stage of the epidemic. More specifically, when the real number of cases is slightly larger than the number predicted by our model or it exceeded the predicted end-stage systematically. Another drawback is that the phase of the epidemic is not described by the SIR model; thus the model cannot be extrapolated unless the same arbitrary format is used (26, 28, 34) . Generally, the prediction model for new cases for both Saudi Arabia and the UK was not robust enough as it only explained 25% in Saudi Arabia, and 21% in the UK. Both models were generated for 31 days from the beginning to 1 st of April 2020. The model did not account for confounders such as age and gender fractions, governmental measures, and cities locked down. However, it assumes a uniform mixing of the population, where recovery is equally likely among the infected population (48) . The pattern of recovery and mortality rates in Saudi Arabia as well as in UK were not estimated due to incomplete data. Importantly, comparing infected cases in Saudi Arabia to the UK demonstrated a dramatic increase in UK. Similarly, the number of deaths in Saudi Arabia are less than the number of deaths in the UK. That may be due to the UK's higher population and population density compared to Saudi. However, the death per 1000 individual in Saudi is still significantly lower when controlled for population size (UK = 4.6x10 -4 ; Saudi = 3.5x10 -2 ). Thus, this difference might be related to the different governmental approaches taken at the time.

These findings contribute in several ways to our understanding of COVID-19 response in both kingdoms and provide a groundwork for future research. To our knowledge, this work is the first to compare the effects of two countries' measures on the outcome of a global pandemic with a specific focus on how decisive and early actions helped reduce the number of cases and deaths recorded. Although the results of this study were based on previously reported data from both countries, when applied to current data, the model still showed positive results favouring early measures as was taken by Saudi Arabia. Because this model relies on early reported cases, . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted April 29, 2020. . https://doi.org/10.1101/2020.04. 25.20079640 doi: medRxiv preprint it might serve as a resource for decision making regarding future pandemics. Also, as telemedicine have been effective in the delivery of care to individuals in their home (49, 50) , future studies should investigate the effectiveness of using telemedicine for Covid-19 patients in both countries and how this affects the pandemic outcomes.

We show that early decisive measures informed by science and guided by experience can help reduce the spread and related death from infectious diseases. Actions were taken by Saudi under the national slogan "We are all responsible" resulted in the observed reduced number of cases and deaths compared to the UK approach "keep calm and carry on". This strategy adopted by the Saudi authorities may serve as a blueprint for the management of potential future pandemics. . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted April 29, 2020. . https://doi.org/10.1101/2020.04. 25.20079640 doi: medRxiv preprint 

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