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      Corona virus infection in Syria, Libya and Yemen; an alarming devastating threat

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      Travel Medicine and Infectious Disease
      Elsevier Ltd.

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          Abstract

          Dear Editor Since its emergence, the novel coronavirus (2019-nCoV) infection has been quickly spreading through all over the world [1]. However, no study has yet determined the impact of this infection on countries with armed conflicts such as Syria, Libya and Yemen. Here in we would like to highlight the burdens of corona virus on these countries and how it could be contained. Armed conflicts have resulted a high rates of Mortality, injuries and population displacement. The highest rate of mortality was reported in the Syrian conflict (7; 1000) followed by Libya (5; 1000) and yamen (3; 1000). Such conflicts were complicated by the destruction of health care system, lack of food and unstable daily life [2]. This was resulted in emergence of highly infectious diseases such as hemorrhagic fever, cholera and Tuberculosis [3]. The emergence of the new COVID-19 has resulted in a large number of deaths in European countries like Italy, Spain and France which considered to have heath care services with good quality an probably the best standards. Regarding the infectious period, transmissibility, clinical severity, and extent of community spread the European public health measures are not able to fully contain the outbreak of COVID-19.Thus they are facing this pandemic hardly and appealing for international help [4]. Hence then the spread of this contagious infection in Syria, Libya and Yemen will have a catastrophic impact not only on the citizens of these countries but all over the world. Corona virus have been confirmed in all countries surrounding Syria and full alert has been utilized in Jordan, Iraq and Lebanon, similarly those countries surrounding Libya, (Egypt, Algeria and Tunisia)as well as those surrounding Yemen (Oman and Saudi Arabia and even the African Horn countries and Madagascar) [5]. Therefore, concerns have been raised on the actual status of the spread of the corona virus infection in these countries and how they can be considered safe. These conflict countries are particularly prone to infectious disease such as corona virus and indeed difficult to trace and even hard to control. As many people were injured and thousands have been hold in prisons, refugees and immigrants camps without sanitation and food. Despite that WHO and whole world was united to fight against this pandemic, these countries were left alone with corona virus and no help was offered. Hence then global alert should be mounted to help these countries and specific plans have to be implemented. These may include but not limited to Emergency supply to the basic needs such as gloves masks and disinfectants which lacking in these countries. Building Emergency Hospitals for infected patients occupied with ventilation equipment and ICU services. In addition to specific quarantine places for suspected cases. Screening tests, particularly detection of corona via swabs or blood quick tests which to be obligatory implemented. Declaration of competing interest The author has no conflict of interest to disclosure. Funding No source of funding Declaration of competing interest No competing of interest.

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          Most cited references5

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          The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health — The latest 2019 novel coronavirus outbreak in Wuhan, China

          The city of Wuhan in China is the focus of global attention due to an outbreak of a febrile respiratory illness due to a coronavirus 2019-nCoV. In December 2019, there was an outbreak of pneumonia of unknown cause in Wuhan, Hubei province in China, with an epidemiological link to the Huanan Seafood Wholesale Market where there was also sale of live animals. Notification of the WHO on 31 Dec 2019 by the Chinese Health Authorities has prompted health authorities in Hong Kong, Macau, and Taiwan to step up border surveillance, and generated concern and fears that it could mark the emergence of a novel and serious threat to public health (WHO, 2020a, Parr, 2020). The Chinese health authorities have taken prompt public health measures including intensive surveillance, epidemiological investigations, and closure of the market on 1 Jan 2020. SARS-CoV, MERS-CoV, avian influenza, influenza and other common respiratory viruses were ruled out. The Chinese scientists were able to isolate a 2019-nCoV from a patient within a short time on 7 Jan 2020 and perform genome sequencing of the 2019-nCoV. The genetic sequence of the 2019-nCoV has become available to the WHO on 12 Jan 2020 and this has facilitated the laboratories in different countries to produce specific diagnostic PCR tests for detecting the novel infection (WHO, 2020b). The 2019-nCoV is a β CoV of group 2B with at least 70% similarity in genetic sequence to SARS-CoV and has been named 2019-nCoV by the WHO. SARS is a zoonosis caused by SARS-CoV, which first emerged in China in 2002 before spreading to 29 countries/regions in 2003 through a travel-related global outbreak with 8,098 cases with a case fatality rate of 9.6%. Nosocomial transmission of SARS-CoV was common while the primary reservoir was putatively bats, although unproven as the actual source and the intermediary source was civet cats in the wet markets in Guangdong (Hui and Zumla, 2019). MERS is a novel lethal zoonotic disease of humans endemic to the Middle East, caused by MERS-CoV. Humans are thought to acquire MERS-CoV infection though contact with camels or camel products with a case fatality rate close to 35% while nosocomial transmission is also a hallmark (Azhar et al., 2019). The recent outbreak of clusters of viral pneumonia due to a 2019-nCoV in the Wuhan market poses significant threats to international health and may be related to sale of bush meat derived from wild or captive sources at the seafood market. As of 10 Jan 2020, 41 patients have been diagnosed to have infection by the 2019-nCoV animals. The onset of illness of the 41 cases ranges from 8 December 2019 to 2 January 2020. Symptoms include fever (>90% cases), malaise, dry cough (80%), shortness of breath (20%) and respiratory distress (15%). The vital signs were stable in most of the cases while leucopenia and lymphopenia were common. Among the 41 cases, six patients have been discharged, seven patients are in critical care and one died, while the remaining patients are in stable condition. The fatal case involved a 61 year-old man with an abdominal tumour and cirrhosis who was admitted to a hospital due to respiratory failure and severe pneumonia. The diagnoses included severe pneumonia, acute respiratory distress syndrome, septic shock and multi-organ failure. The 2019-nCoV infection in Wuhan appears clinically milder than SARS or MERS overall in terms of severity, case fatality rate and transmissibility, which increases the risk of cases remaining undetected. There is currently no clear evidence of human to human transmission. At present, 739 close contacts including 419 healthcare workers are being quarantined and monitored for any development of symptoms (WHO, 2020b, Center for Health Protection and HKSAR, 2020). No new cases have been detected in Wuhan since 3 January 2020. However the first case outside China was reported on 13th January 2020 in a Chinese tourist in Thailand with no epidemiological linkage to the Huanan Seafood Wholesale Market. The Chinese Health Authorities have carried out very appropriate and prompt response measures including active case finding, and retrospective investigations of the current cluster of patients which have been completed; The Huanan Seafood Wholesale Market has been temporarily closed to carry out investigation, environmental sanitation and disinfection; Public risk communication activities have been carried out to improve public awareness and adoption of self-protection measures. Technical guidance on novel coronavirus has been developed and will continue to be updated as additional information becomes available. However, many questions about the new coronavirus remain. While it appears to be transmitted to humans via animals, the specific animals and other reservoirs need to be identified, the transmission route, the incubation period and characteristics of the susceptible population and survival rates. At present, there is however very limited clinical information of the 2019-nCoV infection and data are missing in regard to the age range, animal source of the virus, incubation period, epidemic curve, viral kinetics, transmission route, pathogenesis, autopsy findings and any treatment response to antivirals among the severe cases. Once there is any clue to the source of animals being responsible for this outbreak, global public health authorities should examine the trading route and source of movement of animals or products taken from the wild or captive conditions from other parts to Wuhan and consider appropriate trading restrictions or other control measures to limit. The rapid identification and containment of a novel coronavirus virus in a short period of time is a re-assuring and a commendable achievement by China’s public health authorities and reflects the increasing global capacity to detect, identify, define and contain new outbreaks. The latest analysis show that the Wuhan CoV cluster with the SARS CoV.10 (Novel coronavirus - China (01): (HU) WHO, phylogenetic tree Archive Number: 20200112.6885385). This outbreak brings back memories of the novel coronavirus outbreak in China, the severe acute respiratory syndrome (SARS) in China in 2003, caused by a novel SARS-CoV-coronavirus (World Health Organization, 2019a). SARS-CoV rapidly spread from southern China in 2003 and infected more than 3000 people, killing 774 by 2004, and then disappeared – never to be seen again. However, The Middle East Respiratory Syndrome (MERS) Coronavirus (MERS-CoV) (World Health Organization, 2019b), a lethal zoonotic pathogen that was first identified in humans in the Kingdom of Saudi Arabia (KSA) in 2012 continues to emerge and re-emerge through intermittent sporadic cases, community clusters and nosocomial outbreaks. Between 2012 and December 2019, a total of 2465 laboratory-confirmed cases of MERS-CoV infection, including 850 deaths (34.4% mortality) were reported from 27 countries to WHO, the majority of which were reported by KSA (2073 cases, 772 deaths. Whilst several important aspects of MERS-CoV epidemiology, virology, mode of transmission, pathogenesis, diagnosis, clinical features, have been defined, there remain many unanswered questions, including source, transmission and epidemic potential. The Wuhan outbreak is a stark reminder of the continuing threat of zoonotic diseases to global health security. More significant and better targeted investments are required for a more concerted and collaborative global effort, learning from experiences from all geographical regions, through a ‘ONE-HUMAN-ENIVRONMENTAL-ANIMAL-HEALTH’ global consortium to reduce the global threat of zoonotic diseases (Zumla et al., 2016). Sharing experience and learning from all geographical regions and across disciplines will be key to sustaining and further developing the progress being made. Author declarations All authors have a specialist interest in emerging and re-emerging pathogens. FN, RK, OD, GI, TDMc, CD and AZ are members of the Pan-African Network on Emerging and Re-emerging Infections (PANDORA-ID-NET) funded by the European and Developing Countries Clinical Trials Partnership the EU Horizon 2020 Framework Programme for Research and Innovation. AZ is a National Institutes of Health Research senior investigator. All authors declare no conflicts of interest.
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            Trends and patterns of deaths, injuries and intentional disabilities within the Libyan armed conflict: 2012-2017

            Background The consequences of armed conflicts impose considerable burdens on the economy and health care services, particularly in countries that are not equipped to deal with them, such as in the Middle-East, and North African countries. Little is known about the burden of mortality and injury resulting from the Libyan armed conflict. This study aimed to determine the trends and patterns of mortality, injury and disabilities directly associated with the Libyan armed conflict and analyze the geographic variation within the country during 2012–2107. Methods Data on conflict-related deaths, injuries, and disabilities were obtained from the national registry offices. The information included date, place, and demographic information. A questionnaire was also used to obtain information from the affected individuals and their families. National and regional trends of mortality, injury and disabilities were calculated. Spatial analysis was performed using geographic data available on all documented cases to analyze clustering of mortality and injury. Results A total of 16,126 deaths and 42,633 injuries were recorded with complete information during the Libyan conflict from 2012 till 2017. The overall mortality rate was 2.7/1000 population and injury rate was 7.1/1000. The overall male-to-female ratio of mortality and injury was 4.4:1; 42.3% were single and aged 20–30 years old, and 26.4% were aged 31–40 years. Moreover, injuries resulted in death in 20.1% of cases and disability in 33.5% of the cases. Most of the disabilities were caused by blasts, while gun shots resulted in more deaths. The overall mortality and injury rates were highest during 2015–2017. These rates were highest in the eastern region. Injuries were most concentrated in Benghazi and Derna in the east, followed by Sert and Musrata in the central region. Conclusions Conflict-related mortality, injury and disability has inflicted a heavy burden on the Libyan society that may persist for a long time. The rates of these casualties varied in time and place. National, well-planned efforts are needed to address this serious situation and its consequences.
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              Libyan healthcare system during the armed conflict: Challenges and restoration

              African relevance • Outlines the obstacles that an African healthcare system, particularly in Northern Africa, faces during a conflict period. • Outlines major strategies that an Africa healthcare system could implement. • Strategies herein can improve the quality of an African healthcare system. Background Armed conflicts have serious direct and indirect negative impacts on the affected nations. The direct effects of armed conflicts are seen in deaths, injuries, harm to people, and destruction of properties and infrastructures. The indirect effects result from, among others, reduced access to food, hygiene, health services, and clean water, and from the lifting of the thin veil of civilisation [1]. Furthermore, armed conflicts cause population displacement, breakdown of health and social services, and heightened risk of disease transmission [2]. Having gone through the 2011 war, Libya is still suffering its consequences. The conflict has been complicated and its consequences aggravated by internal fighting and fragmented regional instability. In addition to the killing, injury and population displacement, new challenges to Libyan society have arisen, such as human trafficking and economic crises combined with high rates of unemployment and corruption. Libya should now be in the process of reshaping itself in a positive way by facing the heavy challenges in all aspects of life, and those multiple challenges should be faced by all sectors. The Libyan healthcare system in particular has to deal with great challenges under unusual circumstances. In 2010, Libya’s human development index was ranked the highest in Africa and outperformed both Brazil and Saudi Arabia as shown in Fig. 1. There was “free healthcare [and] free public education,” but after the former socialist regime was toppled with the help of NATO air forces, the country has remained in a spiral of violence [3], [4]. Fig. 1 Libyan human development index: trends 2005–2010. Herein, we highlight the major obstacles that the Libyan healthcare system is facing and outline the strategies needed to overcome the challenges. Burden of the conflict Despite the lack of accurate epidemiological estimates of the burdens of the Libyan armed conflict, a few studies have shown that great damage has been inflicted on Libyan society, mirrored in the large numbers of deaths and injuries and in population displacements [5], [6]. A recent report on health in times of uncertainty in the Eastern Mediterranean region over the last decade has shown that Egypt, Libya, Syria and Yemen had a steady increase in life expectancy of about 0.25 years per year between 1990 and 2010. However, Egypt, Tunisia and Yemen have lost about 0.25 years of life expectancy after the uprisings that began in 2010. When comparing the observed life expectancy to the expected life expectancy if no crises had occurred, we found a large decrease in life expectancy in Libya of more than nine years for males and six years for females [7]. A surveillance study conducted between February 2011 and February 2012 showed that 21,490 (0.5%) persons were killed, 19,700 (0.47%) were injured, and 435,000 (10.3%) have been displaced. The calculated national mortality rate was 5.1 per 1000 per year (95% CI 4.1–7.4), but the rate varied significantly by region. This rate increased further as the armed conflicts escalated in 2014. Fig. 2, Fig. 3 show the distribution of direct deaths, injuries and population displacements during the Libyan conflict in 2011 by age and sex. Both soldiers and civilians died as a direct consequence of the conflict. However, the highest mortality was among men aged 15–59 years, indicating that almost all the fighters were men. Injuries and population displacements are two major concomitant complications of the Libyan armed conflict with which the country’s health service has to struggle with during the coming years. Fig. 2 Estimated gender distribution of deaths, injuries and displacements during the Libyan armed conflict. Fig. 3 Age distribution of deaths, injuries and internal displacement since the start of the Libyan armed conflict in 2011. War-associated injuries impose a heavy burden on a healthcare system. Hospital capacities become overloaded and the urgency of injured combatants and civilian casualties may displace “regular” patients. Furthermore, there is an urgent need for huge amounts of essential supplies (e.g. consumables, blood, blood products and pharmaceuticals), which are already in shortage. On top of all this, clinical workers suffer additional heavy emotional stress from working under unsafe conditions to deal with difficult battle-associated injuries. These problems pile additional burdens on health management and hospital environments [8]. In the long run, many if not most of these injuries will end up as permanent handicaps requiring special services that the healthcare system has to provide. As the Libyan healthcare information system has broken down, there is great uncertainty about the magnitude of mortality and disability. Massive population displacements during the Libyan conflict generated large numbers of internal refugees scattered in camps in the safer cities. This is expected to increase poverty, at least in the short term. Most of the displaced citizens have lost their jobs and income and have had to leave behind their assets and savings. Studies carried out on selected displaced communities in Iraq, Somalia and Southern Sudan indicate that microbial diseases and malnutrition have become endemic, usually due to inadequate water supplies and food delivery logistics [9]. The ongoing Libyan armed conflicts have added a disproportionate burden of morbidity and mortality from infectious diseases. A sudden surge in cases of tuberculosis, diarrhoeal diseases and parasitic infections have frequently been reported at healthcare facilities [10]. The incidences of mental health syndromes such as stress, anxiety and posttraumatic stress have also increased [11]. Transportation, communication and patient information systems within the Libyan healthcare system have been badly disrupted, particularly in primary and emergency services. There has also been direct damage to the buildings and infrastructures. This damage could diminish the ability to accurately measure the effects on the populations affected by the armed conflict, which leads to great uncertainty about the magnitude of mortality and disability [12]. The challenges to the Libyan healthcare system are evident and their nature and magnitude dictate the need for reassessment of the whole system. To deal with the heavy burdens, the Libyan healthcare system has to be re-configured; both immediate and long-term strategies are needed. Planning and future prospects The future of the Libyan healthcare system depends on the country’s ability to manage, remedy and resolve the consequences of the conflict. The system can be rebuilt with relative ease if the wealth of the country is put in good hands guided by appropriate strategies [13], [14]. Immediate interventions based on clear planning policies and followed up by periodic evaluations are urgent needs. Fig. 4 illustrates the requirements and the stages through which the Libyan healthcare system should pass in order to provide a healthy life for the Libyan population. Post-conflict assessment and rehabilitation can be divided into three phases. The first is an emergency phase that is associated with an initial response to the conflict period and aimed at immediate health needs. The second is a transitional phase that is associated with the post-conflict period and aimed at coordination and restoration needs. A final development phase consists of upgrading and long-term planning. These three phases should be totally integrated and must not be segregated from each other. The achievement of these goals is heavily dependent on the country’s security status, both internal and external. Libya’s strategic location and its wealth put it at risk of interference by various local and international forces, and all remedial efforts should be driven by national goodwill, held together by the strong social ties of Libyan society, and guided by a firm, new, modern, independent political leadership. Fig. 4 Strategies and framework needed for the restoration and development of the Libyan healthcare system. Conflicts of interest The author declares no conflict of interest. The views expressed in opinion pieces do not necessarily reflect the views of the African Journal of Emergency Medicine or the African Federation for Emergency Medicine and are solely the opinion of the authors.
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                Author and article information

                Contributors
                Journal
                Travel Med Infect Dis
                Travel Med Infect Dis
                Travel Medicine and Infectious Disease
                Elsevier Ltd.
                1477-8939
                1873-0442
                2 April 2020
                2 April 2020
                : 101652
                Affiliations
                [1]Department of Medical Microbiology & Immunology, Faculty of Medicine, University of Tripoli, Tripoli, Libya
                Article
                S1477-8939(20)30120-4 101652
                10.1016/j.tmaid.2020.101652
                7129830
                32247929
                a271931d-42d1-4ec9-9c84-363652e0e0e5
                © 2020 Elsevier Ltd. All rights reserved.

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                History
                : 23 March 2020
                : 27 March 2020
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                Infectious disease & Microbiology
                Infectious disease & Microbiology

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