key: cord-0914093-xgmvzxc3 authors: Daw, M. A.; El-Bouzedi, A. H.; Ahmed, M. O.; Alejenef, A. A. title: The epidemiological characteristics of COVID-19 in Libya during the ongoing-armed conflict. date: 2020-09-18 journal: nan DOI: 10.1101/2020.09.17.20196352 sha: 299c8841635aa177bb604bcada264743fa0825da doc_id: 914093 cord_uid: xgmvzxc3 Abstract Introduction: COVID-19 can have even more dire consequences in countries with ongoing armed conflict. Libya, the second largest African country, has been involved in a major conflict since 2011. This study analyzed the epidemiological situation of the COVID-19 pandemic in Libya, examined the impact of the armed conflict in Libya on the spread of the pandemic, and proposes strategies for dealing with the pandemic during this conflict. Methods: We collected the available information on all COVID-19 cases in the different regions of Libya, covering the period from March 25 to May 25, 2020. The cumulative number of cases and the daily new cases are presented in a way to illustrate the patterns and trends of COVID-19 and the effect of the ongoing armed conflict was assessed regionally. Results: A total of 698 cases of COVID-19 were reported in Libya during a period of three months. The number of cases varied from one region to another and was affected by the fighting. The largest number of cases was reported in the southern part of the country, which has been severely affected by the conflict in comparison to the eastern and western parts of the country. Conclusion: This study describes the epidemiological pattern of COVID-19 in Libya and how it has been affected by the ongoing armed conflict. This conflict seems to have hindered access to populations and thereby masked the true dimensions of the pandemic. Hence, efforts should be combined to combat these consequences. The COVID-19 pandemic has had major impacts on all aspects of life worldwide. No country can be considered safe, whether rich or poor. COVID-19 is a global concern not only as a huge health problem, but also socially, economically, politically and even ethically [1-3]. COVID-19 has caused huge numbers of deaths even in advanced, economically strong, politically stable countries with the best healthcare services [4, 5] . impact may go even beyond the borders of these countries [12, 13] . reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, The copyright holder has placed this version posted September 18, 2020. . https://doi.org/10.1101/2020.09. 17.20196352 doi: medRxiv preprint Many studies have been published on all aspects of COVID-19, but not enough attention has been paid to its epidemiology in conflict zones [14, 15] , such as Libya, Sudan and Somalia. This study aimed to examine the status and patterns of COVID-19 in Libya during war time and the effect of the fighting on its emergence and spread. The study also seeks to highlight potential strategies to minimize the impact of this pandemic on Libyans during the conflict. Data such as the geographic locations and population densities in the counties and regions are shown in supplement-1 [16] . Laboratory confirmation of COVID-19 in Libya is being done by the National Center for Disease Control. Nasopharyngeal and oropharyngeal swab samples are collected following standard safety procedures. RNA is extracted using QIAamp™ viral RNA mini kit from Qiagen™ according to the manufacturer's instructions, as previously published [17] . Analysis is done by the real-time reverse transcriptase-polymerase chain reaction (RT-PCR) for all suspected cases following the protocol established by the WHO [18] . Biosafety cabinets are used and the work is done according to laboratory biosafety guidelines. reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, The copyright holder has placed this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.17.20196352 doi: medRxiv preprint The geographic distribution of COVID-19 and the mapping of the armed conflict during the pandemic were determined as described [10, 19, 20] . As the armed combat can affect the prevalence of COVID-19 in the surrounding communities, the prevalence of COVID-19 in each city was recorded along with the distance to the fighting on the front lines. Distant cities were defined as those over 100 km away from the fighting area and adjacent cities as those within 100 km. A map of the regional distribution of COVID-19 from March 25 to June 25 in Libya was made, and the number of confirmed COVID-19 cases was color coded on the map. Microsoft Excel and SPSS version 12.0 were used for data entry and analysis. The continuous variables included the daily cumulative number of cases, the daily number of newly confirmed cases, the number of deaths, and the numbers of severe and recovered cases [21] . The data were summarized as means ± standard deviation or medians, and the percentage of patients in each group was calculated. The available data were plotted to show the daily number of cumulative cases for each region and province. The geographical distribution of COVID- 19 Given that the southern region has the smallest population, COVID-19 prevalence was highest in the south (292, 41.8 % of all cases). There were 235 cases (33.7%) in the western region, which is the most populous, and 171 cases (24.5%) in the eastern region. reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, The copyright holder has placed this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.17.20196352 doi: medRxiv preprint Figure 1 shows the cumulative numbers of COVID-19 cases in the country from 25 March to 25 June, 2020. Figure 1A shows the total number of cases in the three regions of Libya. The total number of cases continued to increase with time in all parts of the country. Figure Nevertheless, despite the numerous challenges that the Libyan population has had to face since the armed conflict started in 2011, including deaths, injuries and internal displacement of populations, the response to the epidemic and the resilience of the healthcare system has been reasonable [22, 23] . However, the situation remains precarious and a COVID-19 outbreak in this country would overload an already fragile healthcare system and poor baseline health status. Libya was the last country in the MENA region to report the first case of corona virus. However, preliminary epidemiological analysis carried out by Daw indicated COVID-19 might have arrived in Libya as early as January-February 2020, which has not been reported by the Libyan health authorities [24, 25] . reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, The copyright holder has placed this version posted September 18, 2020. . https://doi.org/10.1101/2020.09. 17.20196352 doi: medRxiv preprint This study investigated the geographic distribution of COVID-19 in Libya and the effect of the ongoing armed conflict. The number of cases varied greatly from one region to another and the pattern was significantly influenced by the armed conflict. It is worth noting that Sebha in the southern region was the worst-hit city and had the highest number of infected cases. The increase in confirmed cases at any location will inevitably lead to increases in adjacent regions, a positive spillover effect. This was first seen after first cases were reported in Tripoli and Musrata in the western region, which were followed by spread to Zawia, Surman, Zletan and Alkomas. Likewise, in the eastern region the disease spread from Benghazi to Jalo, Ajdabia, Derna and Tubrak, and in the south from Sebha to Murzak, Obari, Wadishati and Ghat. This parallels, to a much smaller extent, the pandemic spread from Wuhan to the neighboring provinces and then all over China, and the Italian scenario, where the pandemic started in northern Italy, which at one time accounted for as much as 71.5% of the cases and 81.8% of the deaths, and then spread over the rest of Italy [26, 27] . Comparison of the epidemiologic situations in different parts of Libya indicates that the ongoing armed conflict has affected the geographic spread of COVID-19 in two ways. On the one hand, it hindered access to populations and thus masked the actual status of the pandemic, particularly in cities such as Tarhona, Tawerga and Sert. On the other hand, it aggregated the spread of the pandemic to distant cities such as Sebha. Hence, the cross-national variation in the cumulative number of COVID-19 cases due the armed conflict is evident. Intervention strategies should be planned with that in mind [28, 29] . Controlling the emergence of infectious diseases in conflict situations is challenging because the fighting creates situations that facilitate the emergence of infectious diseases and enhance their transmission. These may include but are not limited to inadequate surveillance and response reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, The copyright holder has placed this version posted September 18, 2020. reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, The copyright holder has placed this version posted September 18, 2020. -National and regional cooperation should be combined to combat particularly within countries affected by conflicts reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, The copyright holder has placed this version posted September 18, 2020. reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, The copyright holder has placed this version posted September 18, 2020. reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, The copyright holder has placed this version posted September 18, 2020. this preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, The copyright holder has placed this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.17.20196352 doi: medRxiv preprint reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. 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