Infection Spread, Recovery, and Fatality from Coronavirus in Different Provinces of Saudi Arabia

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Article Infection Spread, Recovery, and Fatality from Coronavirus in Different Provinces of Saudi Arabia

Mohammed Muberek Alharbi 1, Syed Imam Rabbani 1 , Syed Mohammed Basheeruddin Asdaq 2,* , Abdulhakeem S. Alamri 3,4 , Walaa F. Alsanie 3,4, Majid Alhomrani 3,4, Yahya Mohzari 5, Ahmed Alrashed 6, Reem Faisal Bamogaddam 7, Saleh Ahmad Alajlan 6, Mansour A. Alharbi 5, Norah N. Aldhawyan 5 and Saeed A. Najmi 8

1 Department of Pharmacology and Toxicology, College of Pharmacy, Qassim University, Buraydah 51452, Saudi Arabia; [email protected] (M.M.A.); [email protected] (S.I.R.) 2 Department of Pharmacy Practice, College of Pharmacy, AlMaarefa University, Dariyah, Riyadh 13713, Saudi Arabia 3 Department of Clinical Laboratory Sciences, The Faculty of Applied Medical Sciences, Taif University, Taif 21974, Saudi Arabia; [email protected] (A.S.A.); [email protected] (W.F.A.); [email protected] (M.A.) 4 Centre of Biomedical Sciences Research (CBSR), Deanship of Scientific Research, Taif University, Taif 21974, Saudi Arabia 5 Clinical Pharmacy Department, King Saud Medical City, Riyadh 12746, Saudi Arabia; [email protected] (Y.M.); [email protected] (M.A.A.); [email protected] (N.N.A.) 6 Pharmaceutical Services Administration, Inpatient Department, Main Hospital, KFMC, Riyadh 11525, Saudi Arabia; [email protected] (A.A.); [email protected] (S.A.A.) Citation: Alharbi, M.M.; 7 Pharmaceutical Services Department, Clinical Pharmacy, King Saud Medical City, Rabbani, S.I.; Asdaq, S.M.B.; Riyadh 12746, Saudi Arabia; [email protected] Alamri, A.S.; Alsanie, W.F.; 8 Pharmaceutical Care Services, Samtah General Services, Ministry of Health, Jazan 86735, Saudi Arabia; Alhomrani, M.; Mohzari, Y.; [email protected] Alrashed, A.; Bamogaddam, R.F.; * Correspondence: [email protected]; Tel.: +966-1-403555-3399 Alajlan, S.A.; et al. Infection Spread, Recovery, and Fatality from Abstract: The World Health Organization (WHO) announced COVID-19, a novel coronavirus out- Coronavirus in Different Provinces of break, as a pandemic in 2020. In the month of February 2020, the disease began to spread through Saudi Arabia. Healthcare 2021, 9, 931. the Middle East. The first case of COVID-19 in the Kingdom of Saudi Arabia was identified in https://doi.org/10.3390/ March 2020, and it is now one of the region’s most affected countries. Analyzing the disease’s healthcare9080931 propagation pattern may aid in the development of pandemic-fighting strategies. This study aims to analyze the trend of COVID-19’s spread, its recovery, and mortality in the Kingdom of Saudi Arabia Academic Editor: Christopher (KSA). Two to three major cities from the 13 provinces of the country were chosen, and the rate of R. Cogle infection recovery was recorded from the first month until the number of confirmed cases showed a

Received: 9 May 2021 decline. The data published on the official Ministry of Health website were recorded on an Excel Accepted: 20 July 2021 sheet, graphically represented as figures to indicate the pattern of spread. According to the study’s Published: 24 July 2021 findings, COVID-19 positive cases were discovered in the majority of provinces as early as March 2020. The province of Makkah had the largest number of COVID-19 positive cases (30.7%), followed Publisher’s Note: MDPI stays neutral by Riyadh (23%). The province of Al Jowf had the lowest number of COVID-19 cases (0.3%). Tabuk with regard to jurisdictional claims in province had the highest rate of recovery (97.8%), followed by the Northern Border Province (96.7%). published maps and institutional affil- Makkah province had the highest mortality rate (2.6%), followed by Al Jawf province (2.4%). The iations. peak case–fatality ratio was recorded in August and September. The highest number of tests to detect the COVID-19 was performed in the month of July, and the highest percentage of positive cases was detected in June (19.55%). All the provinces from the month of September 2020 showed a progressive decline in the number of confirmed COVID-19 cases. According to this study, COVID-19 infection Copyright: © 2021 by the authors. was found in the majority of Saudi Arabian provinces in March 2020, with a peak in June–July 2020. Licensee MDPI, Basel, Switzerland. Considering the climatic and demographic characteristics of the region, specific modalities need to This article is an open access article be adopted in collaboration with international guidelines to defeat the COVID-19 pandemic. distributed under the terms and conditions of the Creative Commons Keywords: COVID-19; pattern of spread; recovery; mortality; provinces; Saudi Arabia Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

Healthcare 2021, 9, 931. https://doi.org/10.3390/healthcare9080931 https://www.mdpi.com/journal/healthcare Healthcare 2021, 9, 931 2 of 12

1. Introduction COVID-19 is a highly infectious illness caused by a serious acute coronavirus respiratory syndrome [1]. The outbreak of COVID-19 disease 2019 started in Wuhan province in China; the epidemic is more widespread than initially estimated, with cases now confirmed throughout the world [2]. Many initial cases of COVID-19 were related to the Huanan Seafood wholesale market, implying that SARS-CoV-2 was transferred from animals to humans [3]. As the outbreak progressed, human to human became the main mode of transmission. The incubation period for SARS-CoV-2 is within 14 days after exposure, but most cases show symptoms within 4 to 5 days of exposure [4]. COVID-19 can cause illnesses ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV-2) [5]. According to the WHO, as of 1 May 2020, there have been more than 5 million confirmed cases of COVID-19 around the world. The latest data indicate that the number has crossed 50 million confirmed cases of COVID-19. The daily report of confirmed cases can be accessed at the link http://Covid19.cdc.gov.sa (accessed on 13 July 2021). The current methods of diagnosis of COVID-19 include detection of the virus or viral components by genomic techniques using either polymerase chain reaction (PCR)-based methods or deep sequencing [6–8]. According to the literature, all individuals are at risk of acquiring COVID-19 [9]. Male patients and those with other chronic comorbid conditions such as respiratory and cardiovascular diseases are more likely to die as a result of SARS-CoV-2 [10–12]. All pandemics follow a certain pattern of population distribution. Understanding this could enable policymakers to assess the path of infection, which could aid in the creation of pandemic-control strategies. Saudi Arabia is mostly comprised of deserts with some forests, grasslands, and mountains. Less than 7% of the land is suitable for cultivation. The population of the country is mostly located in the eastern and western coastal areas and rarely in deserts. The country has 13 provinces, and the population is mainly pocketed in cities and small towns [13,14]. Since the pattern of infectious disease is influenced by several factors, such as urbanization, socio-economic, infrastructure, and educational qualifications, this study focused on the spread, recovery, and mortality from the ‘first wave’ of COVID-19 in major cities of different provinces of Saudi Arabia.

2. Materials and Methods 2.1. Study Area A retrospective analysis of the spread of COVID-19 in different provinces of the Kingdom of Saudi Arabia was performed. The country consists of vast deserts, and the population is remotely distributed into separate regions, called provinces. There are 13 provinces, Riyadh, Makkah, Eastern, Al Madinah, Al Qassim, Hail, Northern border, Asir, Al Baha, Jazan, Al Jawf, Najran, and Tabuk, which include several cities, towns, and villages. In this study, two to three major cities in each province were selected to evaluate the pattern of spread, recovery, and mortality rate [15].

2.2. Collection and Recording of Data: The official data published by the Ministry of Health (MoH), Saudi Arabia, was used to record the number of cases daily (both symptomatic and asymptomatic) starting from March (https://Covid19.cdc.gov.sa/daily-updates/ accessed on 13 July 2021). The data about the number of cases reported in the selected two-three major cities were recorded in an Excel file. The recording was performed from the month when the first case was reported in this region until October 2020. This period was considered to be the ‘first wave’ of COVID-19 in the country. From October 2020, the region witnessed a significant decline in the number of COVID-19 cases. Healthcare 2021, 9, 931 3 of 12

2.3. Analysis of Data The data collected from day one were entered into an Excel spreadsheet. The values were expressed separately for each province to demonstrate the trend of the pandemic spread in different months. The following parameters were analyzed to study the infection spread, recovery, and fatality from COVID-19.

2.3.1. Pattern of Spread of COVID-19 in Different Provinces The data was collected from the first day when a confirmed COVID-19 positive case was officially detected in the country. The confirmed numbers of cases reported by the Ministry of Health were recorded for every province per month.

2.3.2. Percentage of Conﬁrmed Cases Detected This parameter determines the total number of COVID-19 tests conducted in a month and the percentage of conﬁrmed cases detected.

2.3.3. Infection Rate in Population of Different Provinces The infection rate was calculated for each month using Formula [16]: Number of conﬁrmed cases × 100/Total number of cases.

2.3.4. Rate of Recovery from COVID-19 in Different Provinces The daily reported cases of recovery from different provinces were used to calculate the rate of recovery.

2.3.5. Mortality Rate from COVID-19 in Different Provinces The ofﬁcial number of deaths reported from different provinces was used to record the mortality rate.

2.3.6. Case-Fatality Rate (CFR) in Different Provinces The CFR was calculated by using a formula used by Onder et al., 2020 [17]. CFR= (Total number of deaths × 100)/Total number of cases.

2.3.7. Total Pattern of Spread of COVID-19 in Different Provinces The total number of tests conducted, conﬁrmed cases detected, recoveries, and deaths reported from different provinces was summarized for every month to determine the pattern of the spread of COVID-19 in Saudi Arabia.

2.4. Representation of Data The data were represented graphically in the form of ﬁgures to indicate the number of cases reported in different months as well as the infection rate, percentage of conﬁrmed cases detected, recovery rate, mortality rate, and case-mortality ratio in Saudi Arabia.

2.5. Statistics The data on the confirmed COVID-19 cases and the number of recoveries and deaths were recorded for each province. A descriptive analysis was performed on the collected data. Each month’s values were separated. The GraphPad Prism 8.0 computer software package was used to summarize the data and plot the graphs. The X-axis in the figure indicates the months, while the Y-axis represents the number of confirmed cases/infection rate/number of recovery/confirmed deaths.

3. Results 3.1. Pattern of Spread of COVID-19 in Different Provinces of Saudi Arabia Figure1 depicts the pattern of COVID-19 distribution in various provinces. Riyadh province recorded cases beginning in March 2020. The peak increase in cases was detected in June 2020, and from then on, the number of conﬁrmed cases started to decline. The Healthcare 2021, 9, x 4 of 13

3. Results Healthcare 2021, 9, 931 4 of 12 3.1. Pattern of Spread of COVID-19 in Different Provinces of Saudi Arabia Figure 1 depicts the pattern of COVID-19 distribution in various provinces. Riyadh province recorded cases beginning in March 2020. The peak increase in cases was detected totalin June percentage 2020, and of from COVID-19 then on, detectedthe number in thisof confirmed province cases was 23%.started The to decline. pattern ofThe spread total of COVID-19percentage in of Makkah COVID-19 province detected was in active this province in March was 2020, 23%. increasing The pattern in April of andspread May of and reachingCOVID-19 a peakin Makkah in June, province then showing was active a slow in March decline 2020, (30.7% increasing of total in cases). April Similarly,and May in theand Eastern reaching province, a peak in theJune, first then case showing was detected a slow decline in March (30.7% 2020 of andtotal thecases). number Similarly, peaked ininJune the Eastern and then province, declined. the first The case spread was of de COVID-19tected in March started 2020 in and the the month number of March peaked 2020 andin June peaked and inthen May declined. and then The showed spread of a slowCOVID-19 decrease started in the in the number month of of confirmed March 2020 cases (18.6%and peaked of total in cases).May and then showed a slow decrease in the number of confirmed cases (18.6%The of Al total Madinah cases). province detected the first case in March 2020 and the rate of infection peakedThe in Al May Madinah (9.9% province of total cases).detected In the Al first Qassim case in province, March 2020 the and month the rate of Marchof infec- 2020 reportedtion peaked the in first May case, (9.9% and of infection total cases). increased In Al Qassim in April, province, May, and the Junemonth and of reachedMarch 2020 a peak inreported July (2.8% the offirst total case, cases). and infection In Hail province,increased in the April, spread May, of COVID-19and June and started reached in thea peak month ofin AprilJuly (2.8% and of reached total cases). a peak In inHail July, province then decreased, the spread slowly of COVID-19 (2.3% ofstarted total in infection). the month The northernof April and border reached province a peak recorded in July, the then first decreased case in March slowly 2020, (2.3% and of thetotal infection infection). increased, The reachingnorthern itsborder peak province in July (0.7% recorded of the the total firs infection).t case in March Asir province 2020, and reported the infection the first incase increased, March reaching 2020 and its then peak peaked in July in (0.7% July of (4.9% the total of total infection). confirmed Asir cases). province reported the first Incase Al in Baha March province, 2020 and the then pattern peaked of spread in July of(4.9% COVID-19 of total wasconfirmed found cases). in March 2020, the casesIn peaked Al Baha in province, July, and the pattern following of spread months of showedCOVID-19 a gradual was found decline in March in the 2020, rate of infectionthe cases (0.6%peaked of in total July, infection). and the following The Jazan months province showed data indicateda gradual thatdecline the in first the positive rate caseof infection was detected (0.6% of in total March infection). 2020, which The Jazan spread province fast to data reach indicated a peak that in August, the first and posi- then thetive spread case was declined detected slowly in March (2.3% 2020, of total which infection). spread Thefast Alto reach Jawf provincea peak in recordedAugust, and its first COVID-19then the spread case in declined the month slowly of April, (2.3% whichof total later infection). spread, The reaching Al Jawf its province peak in Julyrecorded (0.3% of its first COVID-19 case in the month of April, which later spread, reaching its peak in July the total infection detected). Positive COVID-19 cases in Najran province were detected in (0.3% of the total infection detected). Positive COVID-19 cases in Najran province were March 2020, and the infection was found to have a peak in July (2.1% of infection). Tabuk detected in March 2020, and the infection was found to have a peak in July (2.1% of infec- province recorded a COVID-19 active case in March 2020. The infection spread to other tion). Tabuk province recorded a COVID-19 active case in March 2020. The infection parts of the region, peaking in July (1.6% of the total infection). spread to other parts of the region, peaking in July (1.6% of the total infection).

March April May June July August September October 30000 26,284 25000 23,249

20000 18,462

15000

10000 4,766 4,382 5000 1,703 1,333 1,160 169 267 631 124 620 0 Number of confirmed cases confirmed of Number

FigureFigure 1.1. PatternPattern of spread of of COVID-19 COVID-19 in in different different provinces provinces of ofSaudi Saudi Arabia. Arabia.

3.2. Percentage of Confirmed COVID-19 Cases Detected The first case of COVID-19 was discovered in March, and the percentage of confirmed COVID-19 cases calculated from the total number of tests in this month was 9.63%. This rate increased faster and reached its peak in June (19.55%). The rate then began to fall, and extensive testing was conducted, yielding the lowest detected percentage of confirmed cases (3.86%) (Figure2).

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3.2. Percentage of Confirmed COVID-19 Cases Detected The first case of COVID-19 was discovered in March, and the percentage of confirmed COVID-19 cases calculated from the total number of tests in this month was 9.63%. Healthcare 2021, 9, 931 5 of 12 This rate increased faster and reached its peak in June (19.55%). The rate then began to fall, and extensive testing was conducted, yielding the lowest detected percentage of confirmed cases (3.86%) (Figure 2).

Figure 2. Percentage of conﬁrmed cases detected in each month. Figure 2. Percentage of confirmed cases detected in each month. 3.3. Infection Rate in Population of Different Provinces of Saudi Arabia 3.3. Infection Rate in Population of Different Provinces of Saudi Arabia The rate of infection in Saudi Arabia indicated that all the provinces recorded COVID- 19 casesThe rate in the of monthinfection of in March Saudi except Arabia Hail indicated and Jawf. that Riyadhall the provinces province hadrecorded the highest COVID-19 cases in the month of March except Hail and Jawf. Riyadh province had the infection rate (0.008% of the population) in this month, followed by Makkah province highest infection rate (0.008% of the population) in this month, followed by Makkah prov- (0.007%), Eastern province (0.006%), and Al-Qassim (0.0004%). The infection rate gradually ince (0.007%), Eastern province (0.006%), and Al-Qassim (0.0004%). The infection rate increased and reached peaks in the month of May (Al Madinah—0.344%), June (Riyadh— gradually increased and reached peaks in the month of May (Al Madinah—0.344%), June (Riyadh—0.404%,0.404%, Makkah—0.348%, Makkah—0.348%, Eastern—0.485%), Eastern—0.485%), July July (Al-Qassim—0.227%, (Al-Qassim—0.227%, Hail—0.368%,Hail— 0.368%,Northern Northern borders—0.186%, borders—0.186%, Asir—0.274%, Asir—0.274%, Jawf—0.111%, Jawf—0.111%, Najran—0.472% Najran—0.472% and and Tabuk— Tabuk—0.172%),0.172%), August August (Jazan—0.165%), (Jazan—0.165%), and Septemberand September (Al (Al Baha—0.098%). Baha—0.098%). Since Since these these months, months,the COVID-19 the COVID-19 infection infection rate hasrate graduallyhas gradually decreased decreased in in all all provinces provinces of the the coun- country. Al Healthcare 2021, 9, x try.Madinah Al Madinah province province had had the the highest highest infection infection rate rate (0.15%) (0.15%) in October, followed followed6 byof by13 Hail

Hail(0.05%), (0.05%), Najran Najran (0.03%), (0.03%), and and Jawf Jawf (0.0007%) (0.0007%) (Figure (Figure3 3).).

October September August July June May April March 1.6

1.4

1.2

0.8 0.348 0.6 0.404 0.485 0.472 0.368 0.4 0.344 0.274 0.227 0.098 0.165 0.172 0.2 0.189 0.111 0 Infection rate in population (Percentage) population in rate Infection

Figure 3. Infection rate in population of different provinces of Saudi Arabia. Figure 3. Infection rate in population of different provinces of Saudi Arabia. 3.4.3.4. RateRate of Recovery from from COVID-19 COVID-19 in inDifferent Different Provinces Provinces of Saudi of Saudi Arabia Arabia AccordingAccording to thethe availableavailable data, the rate of recoveryrecovery in RiyadhRiyadh province increased grad- uallygradually beginning beginning in March in March 2020 2020 and and peaked peaked in in June June (95.6%(95.6% recovery). In In Makkah Makkah prov- province, ince, the rate of recovery started to increase in March 2020 and peaked in May (96.4% recovery). The eastern province showed recovery from COVID-19 from March 2020, and the peak rate was observed in June (95.9% recovery). In Al Madinah province, the peak rate of recovery was found in May, though the province showed this in the month of March 2020 (96.7% recovery). Al Qassim province showed a recovery from March 2020, and the peak rate was found in July and then slowly declined (95.8% recovery). In Hail province, the peak rate of recovery from COVID-19 was found in July (94.2% recovery). Similarly, the peak rate of recovery was found to be in the month of July in the Northern border (96.7% recovery) and Asir (96.3% recovery) provinces. In Al Baha province, the peak rate of recovery was found in the month of September (95.4% recovery), while in Jazan, it was in August (96.6% recovery). Al Jawf (95.5% recovery) and Najran (96.3% recovery) provinces showed a peak rate of recovery in the month of July. The maximum recovery from the COVID-19 vaccine in Tabuk province was found in both the July and August months, and the total recovery was found to be 97.8% (Figure 4).

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the rate of recovery started to increase in March 2020 and peaked in May (96.4% recovery). The eastern province showed recovery from COVID-19 from March 2020, and the peak rate was observed in June (95.9% recovery). In Al Madinah province, the peak rate of recovery was found in May, though the province showed this in the month of March 2020 (96.7% recovery). Al Qassim province showed a recovery from March 2020, and the peak rate was found in July and then slowly declined (95.8% recovery). In Hail province, the peak rate of recovery from COVID-19 was found in July (94.2% recovery). Similarly, the peak rate of recovery was found to be in the month of July in the Northern border (96.7% recovery) and Asir (96.3% recovery) provinces. In Al Baha province, the peak rate of recovery was found in the month of September (95.4% recovery), while in Jazan, it was in August (96.6% recovery). Al Jawf (95.5% recovery) and Najran (96.3% recovery) provinces showed a peak rate of recovery in the month of July. The maximum recovery from the COVID-19 vaccine Healthcare 2021, 9, x in Tabuk province was found in both the July and August months, and the total7 of recovery 13 was found to be 97.8% (Figure4).

March April May June July August September October

25000 22,702 21,089 20000 18,782

15000

10000 8,600 7,200

5000 2,689 1,787 1,668 1,680 980 278 288 189

Number of recovered cases Number 0

FigureFigure 4.4. Rate of recovery recovery from from COVID-19 COVID-19 in indifferent different provinces provinces of Saudi of Saudi Arabia. Arabia.

3.5.3.5. MortalityMortality Rate Rate from from COVID-19 COVID-19 in inDifferent Different Provinces Provinces of Saudi of Saudi Arabia Arabia TheThe data for for the the mortality mortality rate rate from from COVID-19 COVID-19 infection infection are summarized are summarized in Figure in Figure 5. 5. RiyadhRiyadh provinceprovince reported reported mortality mortality in inthe the mo monthnth of March of March 2020, 2020, and this and peaked this peaked in July in July (total(total mortalitymortality rate rate of of 1.9%). 1.9%). Makkah Makkah province province followed followed a similar a similar pattern, pattern, with mortality with mortality beginningbeginning in March but but peaking peaking in in June June (mortality (mortality rate rate 2.6%). 2.6%). The Themortality mortality in the inEastern the Eastern provinceprovince waswas found in in April April and and reported reported its itspeak peak death death rate ratein August in August (mortality (mortality rate of rate of 1.9%). Al Madinah province reported the first mortality in March, and the peak rate was 1.9%). Al Madinah province reported the first mortality in March, and the peak rate was found in June (1.6% of mortality). The first death from COVID-19 was reported in April found in June (1.6% of mortality). The first death from COVID-19 was reported in April in the Al Qassim province, and the highest mortality rate was found in August (mortality inrate the of Al 1.8%). Qassim province, and the highest mortality rate was found in August (mortality rate ofHail 1.8%). province reported the first mortality in June, and the peak rate was found in AugustHail (mortality province rate reported 1.5%). theThe firstfirst mortalitydeath in the in Northern June, and border the peak province rate waswas foundre- in Augustported in (mortality May and rate became 1.5%). the The highest first in death August in the (total Northern mortality border rate of province 2.4%). The was Asir reported inprovince May and reported became the the first highest mortality in August in April, (total but mortalityin May, no rate deaths of 2.4%). due to The COVID-19 Asir province reportedwere found. the However, first mortality in the in month April, of but Septem in May,ber, the no deathshighest duerate toof COVID-19mortality was were rec- found. However,orded (1.4 intotal the mortality). month of In September, Al Baha provin the highestce, the first rate death of mortality due to COVID-19 was recorded was rec- (1.4 total mortality).orded in June, In Al and Baha the province,peak rate thewas first found death in September due to COVID-19 (total mortality was recorded rate of in2.3%), June, and thewhile peak in Jazan, rate was the foundfirst death in September was reported (total in April mortality and the rate peak of 2.3%), was found while in inSeptember Jazan, the first death(total wasmortality reported of 2.1%). in April Al Jawf and (2.5% the peak mortality) was found and Najran in September (1.1% mortality) (total mortality provinces of 2.1%). Alreported Jawf (2.5% the first mortality) death due and to Najran COVID-19 (1.1% in mortality) June, but provincesthe peak mortality reported was the firstfound death in due toJuly COVID-19 and October, in June, respectively. but the peakTabuk mortality province wasrecorded found the in first July mortality and October, in April respectively. but none in May, and the maximum deaths were reported in July (total mortality rate 1.8%).

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Healthcare 2021, 9, x Tabuk province recorded the ﬁrst mortality in April but none in May, and the maximum8 of 13 Healthcare 2021, 9, x 8 of 13 deaths were reported in July (total mortality rate 1.8%).

MarchMarch AprilApril MayMay JuneJune JulyJuly AugustAugust SeptemberSeptember OctoberOctober 600600 558558

500500 464464

400400

300300

200200 144144 104104 62 100100 4747 62 Number of deaths Number 39 Number of deaths Number 39 31 31 31 3129 29 22 22 8 8 9 9 0 0

FigureFigureFigure 5. 5. 5.MortalityMortality Mortality rate raterate from fromfrom COVID-19 COVID-19COVID-19 in indifferent different provinces provinces of Saudiof Saudi Arabia. Arabia. 3.6. Case-Fatality Ratio in Different Provinces of Saudi Arabia 3.6.3.6. Case-Fatality Case-Fatality Ratio Ratio in inDifferent Different Provinces Provinces of Saudiof Saudi Arabia Arabia TheTheThe case–fatality case–fatalitycase–fatality rate raterate suggests suggestssuggests that thatthat in inth e theth monthe month of March,of March, March, among among among the the thethree three three provinces provinces provinces thatthatthat recorded recorded recorded the the the deaths deathsdeaths (Riyadh—0.17%, (Riyadh—0.17%,(Riyadh—0.17%, Makkah—0.58%, Makkah—0.58%,Makkah—0.58%, and and and Al AlMadinah—0.89%), Al Madinah—0.89%), Madinah—0.89%), the the the highesthighesthighest number number number was waswas found foundfound in in inAl AlAl Madinah Madinah prov province.province.ince. The The peak peak peak case–fatality case–fatality case–fatality rates rates rates observed observed observed forforfor different different different provinces provincesprovinces were werewere in in inJune JuneJune (Northern (Northern borders borders – 6.50%), – – 6.50%), 6.50%), August August August (Eastern—4.97%, (Eastern—4.97%, (Eastern—4.97%, AlAlAl Madinah—6.65% Madinah—6.65% Madinah—6.65% and andand Jawf—7.96%), Jawf—7.96%),Jawf—7.96%), September SeptemberSeptember (Riyadh—8.59%, (Riyadh—8.59%, Makkah—8.35%, Makkah—8.35%, Makkah—8.35%, Al Al Al Qassim—9.12,Qassim—9.12,Qassim—9.12, Asir—8.78%, Asir—8.78%, Asir—8.78%, Jazan—2.88%, Jazan—2.88%, Jazan—2.88%, Najran—2.09% Najran—2.09% Najran—2.09% and and and Tabuk—5.0%), Tabuk—5.0%), Tabuk—5.0%), and and and Octo- October Octo- (Hail—5.89% and Al Baha—4.70%) (Figure6). berber (Hail—5.89% (Hail—5.89% and and Al Al Baha—4.70%) Baha—4.70%) (Figure (Figure 6). 6).

FigureFigure 6. 6. Case–fatalityCase–fatality rate rate in indifferent different provinces provinces of ofSaudi Saudi Arabia. Arabia. Figure 6. Case–fatality rate in different provinces of Saudi Arabia. 3.7. Total Pattern of Spread in All the Provinces 3.7. Total Pattern of Spread in All the Provinces Figure 7 depicts the overall pattern of COVID-19 distributed in Saudi Arabia’s various provinces.Figure 7 Thedepicts number the overall of positive pattern cases of startedCOVID-19 to grow distributed in March in 2020Saudi and Arabia’s steadily various provinces. The number of positive cases started to grow in March 2020 and steadily

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3.7. Total Pattern of Spread in All the Provinces increasedFigure until7 depicts hitting the a overallpeak in patternJune 2020, of COVID-19after which distributed the number in of Saudi positive Arabia’s cases began various provinces.to decrease. The In July number 2020, ofthe positive rate of recove casesry started was found to grow to be in at Marchits peak, 2020 andand mortality steadily increasedwas found until to be hitting at its peak a peak in inJune June 2020. 2020, Sim afterilarly, which the total the numbernumber of of tests positive performed cases began to detect COVID-19 peaked in July and then declined as the number of confirmed cases de- to decrease. In July 2020, the rate of recovery was found to be at its peak, and mortality was creased. found to be at its peak in June 2020. Similarly, the total number of tests performed to detect COVID-19 peaked in July and then declined as the number of conﬁrmed cases decreased.

Tests conducted Cases Recovery Deaths

October 206245 430

September 282151 710

August 410231 840

July 562150 1065

June 425261 1110

May 314390 348

April 158610 154 15407 March 10

0 100000 200000 300000 400000 500000 600000 700000 800000 Total numbers

FigureFigure 7. 7.Total Total pattern pattern ofof COVID-19COVID-19 spread in in different different provinces provinces of of Saudi. Saudi.

4.4. Discussion Discussion TheThe presentpresent study analyzed analyzed the the pattern pattern of ofCO COVID-19VID-19 spread spread in different in different provinces provinces of ofSaudi Saudi Arabia. Arabia. There There are are thirteen thirteen provinces provinces co comprisedmprised of ofseveral several cities cities and and small small towns towns spreadspread acrossacross a vast vast desert desert region. region. The The data data from from two to two three to major three cities major from cities each from prov- each provinceince were were recorded recorded from fromthe official the official website website of the Saudi of the Ministry Saudi Ministry of Health of on Health an Excel on an Excelsheet, sheet, which which was then was analyzed then analyzed graphically graphically and represented and represented in Figures in Figures1–5. 1–5. TheThe pattern pattern ofof spreadspread of the infection infection in in most most of of the the provinces provinces in inSaudi Saudi Arabia Arabia indi- indi- catedcated that that the the disease disease was was detected detected in in the the month month of of March March and and the the peak peak rate rate of of infection infection was foundwas found in the in months the months of June of andJune July. and RT-PCRJuly. RT-PCR swab swab testing testing is performed is performed in Saudi in Saudi Arabia sinceArabia this since test this is reported test is reported to be accurate to be a andccurate efficient, and efficient, and it detectsand it detects COVID-19 COVID-19 infection eveninfection before even the before person the becomes person becomes infectious infectious (https://www.moh.gov.sa (https://www.moh.gov.sa,, accessed accessed 12 June 12 June 2021). The total number of tests performed for both symptomatic and asympto- 2021). The total number of tests performed for both symptomatic and asymptomatic people matic people is represented in Figure 7. The testing of suspected individuals started at the is represented in Figure7. The testing of suspected individuals started at the beginning beginning of 2020, but the first confirmed COVID-19 case was detected in March. The rate of 2020, but the first confirmed COVID-19 case was detected in March. The rate of testing of testing increased dramatically as the number of confirmed cases increased, reaching a increased dramatically as the number of confirmed cases increased, reaching a peak in July. peak in July. The highest percentage of confirmed COVID-19 cases in comparison to the The highest percentage of confirmed COVID-19 cases in comparison to the total number of total number of tests was observed in June (19.55%) (Figure 2). As the number of con- tests was observed in June (19.55%) (Figure2). As the number of confirmed cases continues firmed cases continues to rise, healthcare authorities increased the testing rate in accord- toance rise, with healthcare international authorities guidelines increased (6). The the rate testing of infection rate in accordance then showed with a progressive international guidelinesdecline. However, (6). The in rate a few of infectionprovinces, then such showed as Al Baha a progressive and Jazaan,decline. the peak However,level of the in a fewspread provinces, of infection such was as Al observed Baha and in Jazaan,the months the peakof September level of theand spreadAugust, of respectively infection was observed(Figures 1–3). in the months of September and August, respectively (Figures1–3). COVID-19COVID-19 isis aa membermember of the the coronavirus coronavirus family, family, which which is isfound found throughout throughout the the worldworld in in various various species.species. Some of the the members members of of this this virus virus have have been been found found to be to bespecific specific toto particular particular species species of of animals animals and and have havenot not beenbeen shownshown toto causecause infectioninfection inin otherother species.spe- COVID-19cies. COVID-19 was foundwas found to be to common be common in bats in bats and and has beenhas been known known to beto presentbe present in themin forthem years. for Unlessyears. Unless there isthere a rare is a case rare of case mutation, of mutation, these virusesthese viruses do not do normally not normally change hosts [18]. The virus was suspected to have an intermediate host before being shown to infect humans. Although the first reported case of novel coronavirus was from the Wuhan

Healthcare 2021, 9, 931 9 of 12

province of China, traces of coronavirus genetic material were found in human samples at a much earlier date [19]. The World Health Organization gave several amendments to describe the pattern of spread of the infection after declaring it a ‘pandemic’. The latest information from the world’s premier health organization is that the coronavirus infection is airborne and spreads by the inhalation of infected droplets coming through coughing, sneezing, speech, and exhaled air [1]. The observations from this study indicated that COVID-19 infection was more prevalent in urbanized regions. The detection and spread of COVID-19 were also found to be early and fast in the major cities of the country (Figures1–7). The pattern of spread of COVID-19 infection indicated that all the provinces of Saudi Arabia except the Northern border and Al Jawf recorded COVID-19 in the month of March (Figure S1). The thickly populated provinces, such as Al Riyadh (0.404% of population), Makkah (0.348% of population), and the East (0.485% of population), recorded their peak in the month of June, except for Al Madinah province, where the highest numbers (0.344% of population) were recorded in May. The moderate to low population regions, such as Al Qasim (0.227%), Hail (0.368%), Aseer (0.274%), Najran (0.472%), the Northern border (0.186%), and Tabuk (0.172%), observed peak cases in the month of July, while Jazan (0.165%) and Al Baha (0.098%) provinces recorded peaks in August and September, respectively. Further, all the provinces showed a decline in the number of COVID-19 cases from the month of October (Figures1–3). The infection rate in different provinces suggested that the thickly populated provinces such as Riyadh, Makkah, and Eastern peaked in the month of June. Moderately populated provinces such as Al Qassim, Hail, Asir, Najran, and Tabuk peaked in July. Al Baha, a less populous but more popular province, peaked in September (Figure3). According to a study conducted in this region, men (71.7%) are reported to be more affected by COVID-19 infection compared to women (28.3%). The infection rate in the population was found to be highest in the 30–39 year age group (29.3%), followed by the 20–29 year age group (20.9%), 40–49 year age group (18.4%), 50–59 year age group (11.1%), 10–19 year age group (7.0%), 0–9 year age group (6.2%), 60–69 year age group (4.7%), 70–79 year age group (1.7%), and the lthe80 year age group (0.7%). The reason for this was reported to be the lack of strict precautionary measures followed by the younger generation of the population [20]. Earlier studies indicated that the average age of the Saudi population is 31.8 years. The mean age of the people infected with COVID-19 is 36 years, and deaths have been found to be in patients above 65 years old [21,22]. A study conducted in five major cities in Saudi Arabia indicated that the number of COVID-19 cases increased when the temperature, humidity, and wind speed decreased. Such a type of climate in this region can be seen in the peak winter (December–January) and peak summer (June–August) seasons [13]. In comparison to other Gulf countries (Figure S2), Saudi Arabia has shown an upward trend in infection, while other countries have shown a flattening of the curve since June despite the fact that all countries recorded an infection in March (https://www.moh.gov.sa, accessed on 12 June 2021). Several factors have been linked to this, including a dense human population, crowded areas, frequent human interactions, natural encroachment, inequalities between different classes of society toward the pandemic, and the population’s unhealthy lifestyle, which has resulted in cities becoming the epicenter of the pandemic [23]. The data also showed that the provinces with the highest rate of infection also had the highest rate of recovery, either in the same month or the month after (Figures1–7). The rate of recovery in the kingdom has now reached close to 97%. Several factors have been attributed to the recovery from the COVID-19 infection. The first and most important factor is the extent of the viral load carried by the susceptible individual. The compulsion to use a facemask, frequent hand sanitization, and maintaining social distancing have all been effectively implemented by the government authorities (https://www.moh.gov.sa, accessed on 12 June 2021). Healthcare 2021, 9, 931 10 of 12

These measures have also been advocated by the WHO as preventive strategies to contain the spread of infections in the population. Previous research has shown that if the virus load is limited, people may become ill, but the immune response effectively fights off the infection [24]. Together, the awareness of health providers created through various media in the public has significantly contributed to seeking medical interventions whenever there are symptoms. During the COVID-19 pandemic, the whole world worked as a single unit, where medical knowledge was freely exchanged between nations, including the Arabian peninsula countries. The cooperation of the healthcare organizations of different countries to share information for the treatment of COVID-19, such as the specific use of corticosteroids, anticoagulants, and antiviral agents and the duration between vaccine doses, has also helped in effectively treating the specific complications of the infection. Additionally, WHO regularly updates all the new approaches to the treatment and management of COVID-19 on its official website [25]. The case–fatality ratio (CFR) indicated that different provinces of the country peaked in different months. Most of the provinces showed a peak CFR in the month of September (Figure6). In Saudi Arabia, September is the month when the peak of summer ends, and it is associated with dust storms. This could have complicated the existing respiratory ailments in the patients, leading to higher CFRs (13, 20, 21). Additionally, the current study found that the mortality rate in the Kingdom is around 1–2% (Figures5 and6), which is considered to be within the average found in countries that effectively deal with the infection, such as Switzerland, South Korea, and New Zealand. COVID-19 mortality is determined by a number of factors. The most important thing is the comorbid conditions of the patient. The prevalence of existing respiratory and cardiovascular diseases is reported to be the important determinant of the occurrence of complications of COVID-19 infection [26]. According to the WHO, the pandemic situation is still prevalent in major parts of the globe. It is essential for all healthcare members to work unitedly to defeat COVID- 19. The precautionary and preventive measures being implemented by the government agencies in the Kingdom of Saudi Arabia include a blanket ban on international travel, especially to the countries severely affected by COVID-19. People coming from permitted countries are required to undergo quarantine and compulsory PCR tests before being allowed free movement in the country. Precautionary measures are strictly implemented in public places such as prayer halls, malls, hospitals, universities, and marketplaces. Online classes for school-going children have been made compulsory. Prior permission is mandatory for private functions where people gather. Wearing masks and maintaining social distancing are strictly followed in all public places. Mass immunization of the general public including children of age 12 to 18 years is performed free of cost and is taking place in all provinces at a war-footing level. Further, separate medical facilities are provided for COVID-19 patients as well as those who might have come into contact with a patient (https://www.moh.gov.sa, accessed on 13 July 2021). Due to the above-mentioned measures, currently, the rate of COVID-19 infection is showing a progressive decline in different provinces of Saudi Arabia. This is one of the remarkable accomplishments at a time when infection rates are rising in many other countries. According to official data, about 70% of the adult population is covered with the first dose of the COVID vaccine, and the second dose is underway in all the regions of the country. The proactive measures taken by the government agencies in the Kingdom of Saudi Arabia are attributed to the effective control of infection and must be continued until the end of the pandemic. The health status of the public, including the infected and immunized, is being recorded in a common platform, and restriction of entry is being planned for non-immunized individuals in public places. As per the WHO, there is a need to defeat the pandemic. It has suggested the immunization of every individual in the world and urged every country to cooperate in its mission. It has suggested elaborate research and a necessity to find effective therapies, including vaccines, to prevent future occurrences of pandemics [25]. Additionally, the government authorities regularly update and follow international guidelines for the effective control of pandemic situations such as COVID-19 Healthcare 2021, 9, 931 11 of 12

(https://www.moh.gov.sa. Accessed on 13 July 2021). In addition, the country supports local and international research for the development of new medical interventions to treat global health issues including coronavirus infections [14,21].

5. Conclusions According to this report, the pattern of COVID-19 spread in most provinces began in March and peaked in June and July. The death rate was estimated to be around 1–2%. Despite the fact that the COVID-19 infection is declining, it is still present in all provinces. To ﬁght the COVID-19 pandemic, precautionary steps and successful treatment methods, such as vaccination, are considered the most suitable strategies.

Supplementary Materials: The following are available online at https://www.mdpi.com/article/ 10.3390/healthcare9080931/s1: Figure S1: Geographical distribution of provinces of Saudi Arabia, Figure S2: Number of COVID-19 infection in gulf countries. Author Contributions: Conceptualization, M.M.A.; data curation, Y.M. and S.A.A.; funding acqui- sition, A.A. and A.S.A.; methodology, R.F.B. and W.F.A.; resources, S.A.A. and M.A.; supervision, S.I.R.; validation, M.A.A.; writing—original draft, M.M.A.; writing—review and editing, S.M.B.A.; visualization, R.F.B., N.N.A., and S.A.N. All authors have read and agreed to the published version of the manuscript. Funding: Walaa F. Alsanie would like to acknowledge Taif university for support No. TRUSP (2020/53). Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. Data Availability Statement: Data are contained within the article. Acknowledgments: The authors gratefully acknowledge the support and encouragement extended by Qassim University, represented by the Deanship of Scientific Research in completing this research. The authors are also thankful to AlMaarefa University, Riyadh, for providing support to perform this research. Conflicts of Interest: The authors declare no conflict of interest.

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