Out of Adversity comes Innovation, How is Saudi Arabia Achieving a Low Case Fatality Rate during the Coronavirus Pandemic?

Achieving a Low Case Fatality Rate the Abstract In the Coronavirus pandemic, desperate times called for desperate measures and this is how Saudi Arabia maintained a low case fatality rate. Early public awareness programs and border closure led to a reduction in the rate of infection especially in those at high risk of mortality from the disease. At a clinical level, adoption of virtual clinics for routine outpatient care allowed the country to focus its efforts on the provision of COVID-19 care in specially adapted isolation centers. On a psychological level, the health care providers were well looked after which led to the provision of effective patient care.

As of the 7th of May 2020, we are now only 130 days on since this disease was first reported, and the WHO is estimating the current worldwide CFR to be over 3% [3]. The average case fatality rate has therefore doubled in the interim. One has to bear in mind that the case fatality rate is actually much higher in certain countries such as China (5.5%); where the pandemic has started, USA (6%), Italy (13.9%) and the United Kingdom (14.7%) to name but a few (these figures are calculated from the John Hopkins University of Medicine Coronavirus Resource Center website [2]. The CFR figures vary depending on the number of people affected, the point at which the country is in at the trajectory of its outbreak and the rate of accessibility to testing. Interestingly however, Saudi Arabia is amongst the countries with the lowest fatality rate of 0.64% despite performing over 433 thousand tests (239 deaths out of 37'136 confirmed COVID cases). The question that begs itself here is, how did Saudi Arabia manage to achieve this low CFR?
On the 11th of March 2020 and as the number of COVID-19 cases outside China had increased significantly involving 114 countries and over 4'000 deaths, the WHO declared the COVID-19 a pandemic. At that time, Saudi Arabia had already stopped pilgrimage to the holy sites by the 5th of March, schools by the 9th of March and international boarders were subsequently closed by the 15th of March 2020 [5]. As such, Saudi Arabia was amongst the first countries that locked their borders banning international and local travel. Immediate paid holiday and self-isolation was offered to those coming from outside the kingdom. They were also thoughtful about the social distancing and curfew (also known as lockdown) rules where it was announced at a short notice. This was presumably planned to avoid some of the pitfalls other countries found themselves in when they announced lockdown dates in advance. Some of the pitfalls included panic buying and long queues at doctor's surgeries which may potentially have increased the risk of exposure to the COVID-19 virus. The curfew rules were also being monitored continuously as the pandemic unfolded and were relaxed when the number of new reported cases decreased to allow people to have near normality in between.
The Muslims within Saudi Arabia are currently observing the Holy month of Ramadan and the Eid celebrations that follow. It is the cultural norm that during these months, family and friends would gather and people would visit the Holy cities of Mecca and Madina.
However, any form of travel was banned by the authorities including gatherings for prayers in the holy cities or within mosques. To further demonstrate the seriousness of these measures, penalties of over two and a half thousand dollars were introduced to people driving without a valid permit during curfew hours.
The Saudi MOH put huge emphasis on early prevention and public awareness campaigns. Educational mobile alerts were being sent about the subtle symptoms of COVID-19 and the simple measures to prevent transmission. All the mobile networks changed their logo to "stay home" and instead of a dialing tone, one would get a brief message to encourage people to stay at home and to remain safe.
Although outpatients and routine face-to-face clinics were suspended, elderly patients and those with chronic conditions were offered virtual clinics to maintain their continuity of care. "Your medication to your door" is an initiative to deliver prescriptions to patients at their homes. The patient would fill a medication request through the mobile application and the medication would arrive by In MNGHA, the patient safety department were continuously monitoring the wellbeing of staff through anonymous surveys.

The Mental Health team, under the auspices of the Chief Executive
Officer, launched a "be well" online support network program for healthcare professionals. This was nicely married up with free online webinars on how to stay well during the pandemic. A variety of webinars were offered to allow practitioners to continue their continuous professional development and more importantly, to discuss issues such as managing stress and how to use the current pandemic as an opportunity to better oneself. The health sciences library produced a link that provides a guide to recent medical literature published about COVID19.

Copy@ Anhar Hamza
As a healthcare provider, I was honored when the director of our protocol department attended in person to inform us that one of our patient-escort colleagues developed COVID-19 and that testing is offered to those who were in close contact and any concerned member of staff. Clinics were temporarily suspended until the entire staff test results were known. Another measure was put in place whereby staff were divided into two teams that do not physically meet at all. The two teams work on a Rota basis to ensure that if any member became infected, there was always a backup team to look after the patients.
A newly built simulation center was dedicated to screening frontline staff. It was chosen because of its proximity to the main site hospital and easy access to staff. It is well set up to accommodate symptomatic and asymptomatic staff in two separate areas. They

Conclusion
By putting societies and economies on hold, Saudi Arabia has curtailed the ability of the virus to continue to affect more lives. One of the lessons that we have learnt thus far is that the faster all cases are found, tested and isolated, the harder we make it for COVID-19 virus to spread. Implementing the above measures meant that Saudi Arabia managed to a certain extent to meet the WHO's goal of controlling the pandemic by slowing down the transmission and reducing mortality associated with COVID-19.
All the prevention measures have translated into fewer intensive care admissions and consequently fewer fatalities. The simple anticipatory measures mentioned above meant that the health system was prepared to accommodate the severe cases and offer an efficient yet sustainable quality of care.
It is undoubtedly difficult balancing all the costly prevention and health provision measures against individual countries' economy. The sooner we end this pandemic, the sooner we can return to normal safe life, which will revive the economy. As such, by applying some of the measures mentioned above, the manpower and resources can be appropriately redirected towards the current pandemic. Reducing the infection rate and saving lives should be every country's top priority. Furthermore, looking after the healthcare provider is of paramount importance to ensuring safe and effective provision of healthcare.

Conflict of Interest
None reported.

Funding/Support
The author received no financial support for the research,