The use of neutrophil-to-lymphocyte ratio (NLR) as a marker for COVID-19 infection in Saudi Arabia: A case-control retrospective multicenter study

Objectives:To assess the neutrophil-to-lymphocyte ratio (NLR) diagnostic and prognostic value in the context of Coronavirus disease-2019 (COVID-19) infection in Saudi Arabia.Methods:A case-control study in which 701 confirmed COVID-19 patients (of which 41 were intensive care unit [ICU]-admitted) and 250 control subjects were enrolled. The study was conducted retrospectively in October on patients admitted to 3 separate hospitals in Saudi Arabia namely: King Abdullah Bin Abdulaziz University Hospital (Riyadh), Ohud Hospital (Madinah), and Nojood Medical Center (Madinah) between May and September 2020. Neutrophil-to-lymphocyte ratio was calculated based on absolute neutrophil and lymphocyte count. Institutional ethical approval was obtained prior to the study.Results:Patients (median age 35 years), of which 54.8% were females, were younger than the control cohort (median age 48 years). Patients had significantly higher NLR compared to the control group. Intensive care unit admitted patients had significantly higher platelet, WBC and neutrophil counts. The ICU patients’ NLR was almost twice as of the non-intensive patients. The NLR value of 5.5 was found to be of high specificity (96.4%) and positive predictive value (91.4%) in diagnosing COVID-19. Furthermore, it had a very good sensitivity (86.4%) in predicting severe forms of disease, such as, ICU admission.Conclusion:Neutrophil-to-lymphocyte ratio is an important tool in determining the COVID-19 clinical status. This study further confirms the prognostic value of NLR in detecting severe infection, and those patients with high NLR should be closely monitored and managed.     

Outcomes of tracheostomy in COVID-19 patients in National Guard Health Affairs,Riyadh, Saudi Arabia

Objectives:To evaluate coronavirus disease 2019 (COVID-19) patient tracheostomy outcomes.Methods:All COVID-19 patients at the National Guard Hospital, Riyadh, Saudi Arabia, were retrospectively recruited. Those who had tracheostomies between April and December 2020 were included.Results:The population was 45 patients, of which 30 (66.7%) were males, 15 (33.3%) were females and the mean age was 66.76±12.74 years. The tracheostomy indications were anticipated prolonged weaning in 40 (88.9%) and failed extubation in 5 (11.1%) of the patients. The mean intubation to tracheostomy duration was 20.62±7.21 days. Mortalities were high, with most attributed to COVID-19. Mortality and a pre-tracheostomy C-reactive protein (CRP) uptrend were significantly related (p=0.039). Mortality and intubation to tracheostomy duration were not significantly related. The mean post-tracheostomy time to death was 10.64±6.9 days. Among the survivors, 20 (44.4%) males and 11 (24.4%) females were weaned off mechanical ventilation; 9 (20%) remained on ventilation during the study. The mean ventilation weaning time was 27.92±20 days.Conclusion:The high mortality rate was attributed to COVID-19. Mortality and a pre-tracheostomy CRP uptrend were significantly related; uptrend patients experienced far more mortalities than downtrend patients. Unlike previous findings, mortality and intubation to tracheostomy duration were not significantly related.     

Evaluation of COVID-19 myths in Saudi Arabia

Objectives:To examine the awareness level of COVID-19 and to highlight the frequency of myths and misconceptions among Saudi Arabia’s population.Methods:We conducted a cross-sectional study from June 13 to 20, 2020 by distributing a 16-item online Google forms questionnaire among adults (18-65 years old) living in Saudi Arabia. We utilized the convenience sampling. Data analysis was performed using Chi-square and multiple regression analysis on Jamovi.Results:A total of 1436 responses were analyzed with 43.5% males and 56.5% females. Most respondents (89.1%) thought that only the elderly above 60 years old are considered at high risk of contracting COVID-19. Most respondents (86.5%) agreed that people with other health conditions could be more affected by COVID-19. Approximately 97.2% agreed that wearing a mask and avoiding touching eyes, nose, and mouth with unwashed hands was the leading preventive action. Most participants (99.4%) chose fever as an associated symptom. Respondents from the healthcare sector presented statistically higher scores than those in non-healthcare sectors (p<0.001). Higher education and higher salary were important predictors of better COVID-19 knowledge.Conclusion:Public health officials need to increase awareness measures on COVID-19 to limit myths and misconceptions and reduce psychological distress associated with it.     

How has the COVID-19 pandemic affect the rejection rates and repeat reasoning of digital radiography?

Objectives:To compare the digital radiology rejection rates and reasoning pre-COVID-19 (PC) and during COVID-19 (DC) from September 2019 to August 2020.Methods:This record-base retrospective study where data were extracted from the radiography equipment (Carestream Health, Rochester, New York, USA) at the Department of Radiology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia over 12 months. The data were equally divided into PC and DC.Results:The DC rejection rate decreased from PC by 2.6% with a significant p=0.00001. During COVID-19 there were 15,376 images of different body parts, versus 23,861 images during PC. Position errors were the main reasons for rejection for both PC (39.8%) and DC (42.7%), followed by technique errors (PC: 19.2%) (DC: 17.2%).Conclusion:Different sectors in hospitals were affected by COVID-19, including diagnostic radiology, in the positive direction. Thus, the DC rejection rate was markedly reduced compared with PC. This may be due to radiology technicians becoming more cautious in dealing with patients.     

COVID-19 in children ranging from asymptomatic to a multi-system inflammatory disease: A single-center study

Objectives:To identify clinical and laboratory characteristics of the Saudi children with confirmed COVID-19.Methods:Eighty-eight children (0-14 years) with COVID-19 who were admitted to Prince Sultan Military Medical City (PSMMC), Riyadh, Saudi Arabia from April to June 2020 were recruited.Results:Mean age was 5.74 ± 4.7 years with 41 (49.4%) males and 42 (50.6%) females. The length of hospital stay (LOS) ranged from 1 to 17 days. The main source of infection was infected family members. Mean values of C-reactive protein (CRP), serum ferritin, and lactate dehydrogenase (LDH) were noticeably above normal. Degree of severity and length of stay was significantly correlated with lymphopenia (r= -0.36; p=0.001), whereas it was positively correlated with absolute neutrophil count and with high inflammatory markers, such as CRP, LDH, and others.Conclusions:Identifying the clinical and laboratory characteristics of the Saudi children with confirmed COVID-19 will improve understanding of this disease’s presentation and will help put rapid and proper management strategies into place to face this pandemic. A high index of suspicion is needed for cases presenting with multi-system inflammatory disease, which represented 5.7% of the included study population.     

Prevalence of COVID-19 antibodies among operating room and critical care staff at a tertiary teaching hospital: A cross-sectional study

Objectives:To identify the prevalence of COVID-19 antibodies among operating room and critical care staff.Methods:In this cross-sectional study, we recruited 319 Healthcare workers employed in the operation theater and intensive care unit of King Abdulaziz University Hospital (KAUH), a tertiary teaching hospital in Jeddah, Saudi Arabia between August 9, 2020 and November 2, 2020. All participants completed a 20-item questionnaire on demographic data and COVID-19 risk factors and provided blood samples. Antibody testing was performed using an in-house enzyme immunoassay and microneutralization test.Results:Of the 319 participants, 39 had detectable COVID-19 antibodies. Five of them had never experienced any symptoms suggestive of COVID-19, and only 19 were previously diagnosed with COVID-19. The odds of developing COVID-19 or having corresponding antibodies increased if participants experienced COVID-19 symptoms (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.2-7.5) or reported contact with an infected family member (OR, 5.3; 95% CI, 2.5-11.2). Disease acquisition was not associated with employment in the ICU and involvement in the intubation of or close contact with COVID-19 patients. Of the 19 previously diagnosed participants, 6 did not possess any detectable COVID-19 antibodies.Conclusions:Healthcare workers may have undiagnosed COVID-19, and those previously infected may not have long-lasting immunity. Therefore, hospitals must continue to uphold strict infection control during the COVID-19 pandemic.     

Clinical characteristics and outcomes of children with COVID-19 in Saudi Arabia

Objectives:To determine the demographic and clinical characteristics, underlying comorbidities, and outcomes of children with coronavirus disease 2019 (COVID-19) infection.Methods:In this retrospective study, we reported 62 pediatric patients (age <14 years) with confirmed COVID-19 between March 2 and July 1, 2020, at King Abdulaziz University Hospital, Jeddah, Saudi Arabia.Results:Comorbid conditions, including cardiac, neurological, respiratory, and malignant disorders, were reported in 9 patients (14.5%). The most prominent presenting complaints were fever (80.6%) and cough (48.4%). Most of our patients (80.6%) had mild disease, 11.3% had moderate disease, and 8.1% exhibited severe and critical illness. Twenty-one patients (33.9%) were hospitalized, with 4 patients (6.5%) admitted to the pediatric intensive care unit, and 3 (4.8%) patients died.Conclusion:All pediatric age groups are susceptible to COVID-19, with no gender difference. COVID-19 infection may result in critical illness and even mortality in subsets of pediatric patients.     

Clinical characteristics and in-hospital mortality of COVID-19 adult patients in Saudi Arabia

Objectives:To provide a detailed study of demographic, baseline comorbidities, clinical features, and outcome for Coronavirus disease 2019 (COVID-19) patients.Methods:A record-based case-series study conducted from March 23 to June 15, 2020 in King Saud Medical City, Riyadh, Saudi Arabia. Demographic data, clinical presentation, laboratory investigations, complications, and in-hospital outcome of COVID-19 patients collected with analysis of the clinical characteristics for survivors and deceased.Results:A total of 768 patients were included. The mean age was 46.36±13.7 years and 76.7% were men. Approximately 96.3% reported more than one comorbidity; diabetes mellitus was the most frequent (46.4%). Fever (84.5%), cough (82.3%), and shortness of breath (79.8%) were the main presenting symptoms. During the follow-up, pneumonia reported in 68.6%, acute respiratory distress syndrome in 32.7%, septic shock in 20.7%, respiratory failure in 20.3%, and acute kidney injury in 19.3%. Approximately 45.8% of enrolled patients required intensive care unit admission. Lung disease (odd ratio [OR]=3.862 with 95% confident interval [CI] (2.455-6.074), obesity (OR=3.732, CI=2.511-5.546), smoking (OR=2.991, CI=2.072-4.317), chronic kidney disease (OR=2.296. CI=1.497-3.521), and diabetes mellitus (OR=2.291, CI=1.714-3.063) are predictors of ICU admission. Fatality ratio was 89/2084 (4.27%). Men were more prevalent in dead group.Conclusion:Coronavirus disease 2019 places a huge burden on healthcare facilities, particularly in patients with comorbidity. Coronavirus disease 2019 patients who are obese and smokers with history of diabetes mellitus have a high risk of death.     

Clinical and epidemiological characteristics of COVID-19 mortality in Saudi Arabia

Objectives:To analyze the clinical and epidemiological characteristics for 224 of in-hospital coronavirus disease 2019 (COVID-19) mortality cases. This study’s clinical implications provide insight into the significant death indicators among COVID-19 patients and the outbreak burden on the healthcare system in the Kingdom of Saudi Arabia (KSA).Methods:A multi-center retrospective cross-sectional study conducted among all COVID-19 mortality cases admitted to 15 Armed Forces hospitals across KSA, from March to July 2020. Demographic data, clinical presentations, laboratory investigations, and complications of COVID-19 mortality cases were collected and analyzed.Results:The mean age was 69.66±14.68 years, and 142 (63.4%) of the cases were male. Overall, 30% of the COVID-19 mortalities occurred in the first 24 hours of hospital admission, while 50% occurred on day 10. The most prevalent comorbidities were diabetes mellitus (DM, 73.7%), followed by hypertension (HTN, 69.6%). Logistic regression for risk factors in all mortality cases revealed that direct mortality cases from COVID-19 were more likely to develop acute respiratory distress syndrome (odds ratio [OR]: 1.75, confidence intervel [CI: 0.89-3.43]; p=0.102) and acute kidney injury (OR: 1.01, CI: [0.54-1.90]; p=0.960).Conclusion:Aging, male gender and the high prevalence of the underlying diseases such as, DM and HTN were a significant death indicators among COVID-19 mortality cases in KSA. Increases in serum ferritin, procalcitonin, C-reactive protein (CRP), and D-dimer levels can be used as indicators of disease progression.     

新型冠状病毒肺炎疫情期间非疫区发热门诊应对措施分析

目的 分析新型冠状病毒肺炎（COVID-19）疫情期间医院发热门诊各项措施调整后的诊疗数据,为非疫区COVID-19的防控工作积累经验。方法 收集整理非COVID-19疫区海军军医大学（第二军医大学）长海医院发热门诊2019年12月21日至2020年2月22日和2019年1月1日至2019年3月5日相关诊疗数据,并将其分为4组：A组（2020年COVID-19疫情期间）为2020年1月22日至2020年2月22日,B组（2020年COVID-19疫情前）为2019年12月21日至2020年1月21日,C组（2019年与A组同期）为2019年2月2日至2019年3月5日,D组（2019年与B组同期）为2019年1月1日至2019年2月1日。对收集的2020年及2019年发热门诊数据进行同比和环比分析。结果 2020年春节前后发热门诊诊疗总体情况与2019年同期相当。同比结果显示,2020年COVID-19疫情期间发热门诊每日就诊患者减少[（114.3±62.9）例vs（171.7±37.0）例],每位医师单次接诊时间延长[（11.7±1.8）min vs（6.5±1.3）min],但患者平均候诊时间减少[（7.5±0.6）min vs（22.8±1.5）min],差异均有统计学意义（P均<0.05）。环比结果显示,2020年COVID-19疫情期间每日就诊患者减少[（114.3±62.9）例vs（216.3±41.8）例],每位医师单次接诊时间延长[（11.7±1.8）min vs（5.6±0.8）min],患者平均候诊时间减少[（7.5±0.6）min vs（23.3±3.2）min],差异均有统计学意义（P均<0.05）。2020年COVID-19疫情期间发热门诊CT检查比例明显多于2019年同期[7.9%（292/3 658）vs 3.7%（206/5 493）],虽因加强防护措施延长了检查时间[（12.5±3.8）min vs（10.0±3.2）min],但患者获取CT检查报告时间明显减少[（10.6±2.5）min vs（58.4±9.6）min],差异均有统计学意义（P<0.05,P<0.01）。结论 COVID-19疫情期间非疫区发热门诊调整相关的流程和配置、配备专门CT机等举措可减少每位医务工作者每日接诊时间,提高诊疗效率,减少交叉感染。     

Transperineal versus transrectal multi-parametric magnetic resonance imaging fusion targeted prostate biopsy

Objectives:To compare transperineal biopsies (TPBx) with transrectal ultrasound-guided biopsy (TRUSBx) in order to provide evidence, making clinicians able to select the appropriate biopsy approach under different conditions.Methods:A comparative prospective study, conducted in King Khalid University Hospital (KKUH) and King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Kingdom of Saudi Arabia, between March 2019 and February 2020. All patients with raised prostate-specific antigen or atypical digital rectal examination findings were subjected to multi-parametric magnetic resonance imaging (MRI). Those with positive findings were referred to targeted fusion- guided biopsy either TPBx or TRUSBx, randomly. Complication rate, cancer detection rate, and procedure time were recorded.Results:Transperineal biopsies and TRUSBx had an equivalent complication rate. However, both case detection rate and clinically significant cancer detection rate were significantly higher in TPBx versus TRUSBx (45.1% versus 29.1%, p=0.003; and 71.8% versus 43.7%, p=0.002; respectively). Transperineal biopsies was a longer procedure than TRUSBx (41.2±0.7 min versus 13±2.3 min, p=0.0001).Conclusion:No difference in complication rate was detected between the 2 procedures; however, TPBx was more effective for cancer detection in general and clinically significant cancer detection in particular.     

Role of the Coronavirus Disease 2019 (COVID-19) pandemic in the upgrading of personal hygiene. A cross-sectional study in Saudi Arabia

Objectives:To assess the role of the Coronavirus Disease 2019 (COVID-19) pandemic in improving personal hygiene in Saudi Arabia.Methods:We administered a questionnaire distributed online between 19 and 28 May 2020 to determine alterations in personal hygiene practices during this pandemic compared to the pre-pandemic phase.Results:We included 211 respondents from the Kingdom of Saudi Arabia (KSA) in this study. Improvement at different levels was detected in all examined personal hygiene items compared to the pre-pandemic stage. The percentages of respondents who always washed their hands after coming back home (34.1%), used soap to wash their hands (58.8%), used a hand sanitizer outside (5.2%), wore a face masks while outside (1.4%) and washed their hands before preparing and/or eating food (74.9%) was increased before the pandemic to 89.6%, 90%, 63.5%, 59.2% and 89.1% during the pandemic, respectively. The percentage of respondents who never shake hands with people they know increased from 0% before the pandemic to 62.6% during the pandemic. The mean duration of washing hands with soap significantly increased from 13.31 seconds before the pandemic to 28.01 seconds during the pandemic (p<0.0001).Conclusion:The COVID-19 pandemic resulted in a noticeable improvement in the personal hygiene habits in Saudi Arabia mainly those related to COVID-19 prevention.     

Prevalence and determinants of distress among oncology patients at a tertiary care medical city in Riyadh,Saudi Arabia

Objectives:To estimate the prevalence of distress in patients with cancer in Saudi Arabia and to identify common psychosocial stressors in these patients. We also looked for associations between distress and psychological, sociodemographic, and medical factors.Methods:This cross-sectional study was performed in the oncology outpatient clinic at King Saud University Medical City, Riyadh, Saudi Arabia, from January 2018 to December 2019. It included 280 patients with breast cancer, colorectal cancer, or lymphoma. Sociodemographic information was collected using questionnaire, along with information on medical history and any psychiatric history. Distress was assessed using the Distress Thermometer and Problem List. Satisfaction with social support was rated using the visual analog scale. All patients were screened for depression using the Patient Health Questionnaire 9-item depression scale and anxiety using the Generalized Anxiety Disorder 7-item scale.Results:The prevalence of distress in our study population was found to be 46%. Distress was associated with several practical, family, emotional, and physical stressors in the problem list. Logistic regression identified predictors of distress to be anxiety (odds ratio [OR] 8.7, confidence interval [CI] 1.98-38.24, p=0.002) and receiving radiotherapy (OR 3.6, CI 1.33-9.99, p=0.009), while Saudi nationality (OR 0.22, CI 0.05-0.95, p=0.037) and stage I cancer (OR 0.18, CI 0.05-1.40, p=0.002) were associated with low distress.Conclusion:Approximately half of cancer patients were found to have distress. Anxiety, advanced cancer stage, and radiotherapy were independently associated with distress.     

Health care worker burnout during the COVID-19 pandemic: A cross-sectional survey study in Saudi Arabia

Objectives:To estimate the prevalence of burnout among health care workers (HCWs) who are working in Saudi Arabia during the Coronavirus disease 2019 (COVID-19) pandemic, and explore individual and work-related factors associated with burnout in this population.Methods:In this cross-sectional study conducted between June to August of 2020, we invited HCWs through social channels to complete a questionnaire. The questionnaire inquired about demographics, factors related to burnout, and used the Copenhagen Burnout Inventory scale to indicate burnout. A total of 646 HCWs participated.Results:The mean (SD) age of participants was 34.1 (9.5) years. Sixty-one percent were female. The prevalence of burnout among HCWs was 75%. Significant factors associated with burnout were age, job title, years of experience, increased working hours during the pandemic, average hours of sleep per day, exposure to patients with COVID-19, number of times tested for COVID-19, and perception of being pushed to deal with COVID-19 patients.Conclusion:Health care workers as frontline workers, face great challenges during this pandemic, because of the nature of their work. Efforts should be made to promote psychological resilience for HCWs during pandemics. This study points out the factors that should be invested in and the factors that may not be influential.     

Impact of COVID 19 on red flag discussions for haematological malignancies within the Belfast trust

Introduction:During the COVID-19 pandemic, there have been suggestions that there will be a reduction in cancer diagnoses, causing a detrimental effect on patients¹. We therefore conducted an analysis to assess if there has been a reduction in new haematological malignancy diagnoses within the Belfast Health and Social Care Trust (BHSCT).Methods:We observed a significant decline in diagnostic tests used in the diagnosis of haematological malignancies. We therefore decided to analyse the impact of COVID-19 on the volume of tests performed to see if this impacted the number of new cases of haematological malignancies diagnosed. To ascertain the number of new diagnoses referred to Clinical Haematology we decided to analyse the number of new diagnoses discussed at the local Multidisciplinary Team Meetings (MDM) between March and June 2020 and compare this with the same period in 2019. In line with NICE guidelines² there has been no change to the referral pathway for patients with new haematological malignancy.Results:Results show that there is no significant difference between the number of new malignant haematological diagnoses discussed during March to June 2020 and the same period in 2019. This confirms that the number of new diagnoses remains the same within the two time periods.Conclusion:This analysis highlights that despite a reduction in primary and secondary care diagnostic blood tests, there is no difference in the number of new cases of haematological malignancies discussed at Haematology MDM throughout the first surge of the COVID-19 pandemic locally.     

Challenges in diabetic foot treatment during pandemic of COVID-19

Objectives:To avoid hospital spread of Coronavirus-2019 (COVID-19) and to analyze out of hospital outcomes after amputation.Methods:Prospective analysis of data obtained from 60 diabetic patients in 2020 was performed at Cantonal Hospital Zenica, Zenica, Bosnia and Herzegovina. Personal protection equipment included double surgical mask, glasses, disposable surgical coats, and surgical masks for patients. Swabs were used to take samples from wounds. We randomly divided patients in 2 groups of 30 patients each. In pre-operative treatment, we used local anesthesia lidocaine hydrochloride 2% (Belupo, Koprivnica, Croatia) in group A and systemic analgesia intravenous tramadol chloride 100 mg intravenous (Krka, Novo Mesto, Slovenia) in group B. Wounds were surgically treated each day and heal spontaneously. Periodical control exams were performed.Results:Wound healing did not present any statistically significant differences between groups (group A: 69±21.97 and B: 61±22.13 days, t=−1.22; p=0.11). No statistically significant differences (p<0.05) between groups A and B in wound healing regarding to gender or cigarette use was noted.Conclusion:No significant differences in amputation treatment between the 2 comparative groups were noted. No confirmed COVID-19 infections in medical staff who performed surgical interventions or in treated patients were detected.     

Risk factors for hospital admission among COVID-19 patients with diabetes: A study from Saudi Arabia

Objectives:To elucidate the risk factors for hospital admission among COVID-19 patients with type 2 diabetes mellitus (T2DM).Methods:This retrospective study was conducted at the Prince Sultan Military Medical City, Riyadh, Saudi Arabia between May 2020 and July 2020. Out of 7,260 COVID-19 patients, 920 were identified as T2DM. After the exclusion process, 806 patients with T2DM were included in this analysis. Patients’ data were extracted from electronic medical records. A logistic regression model was performed to estimate the risk factors of hospital admission.Results:Of the total of 806 COVID-19 patients with T2DM, 48% were admitted in the hospital, 52% were placed under home isolation. Older age between 70-79 years (OR [odd ratio] 2.56; p=0.017), ≥80 years (OR 6.48; p=0.001) were significantly more likely to be hospitalized compared to <40 years. Similarly, patients with higher HbA1c level of ≥9% compared to <7%; (OR 1.58; p=0.047); patients with comorbidities such as, hypertension (OR 1.43; p=0.048), cardiovascular disease (OR 1.56; p=0.033), cerebrovascular disease (OR 2.38; p=0.016), chronic pulmonary disease (OR 1.51; p=0.018), malignancy (OR 2.45; p=0.025), chronic kidney disease (CKD) IIIa, IIIb, IV (OR 2.37; p=0.008), CKD V (OR 5.07; p=0.007) were significantly more likely to be hospitalized. Likewise, insulin-treated (OR 1.46; p=0.03) were more likely to require hospital admission compared to non-insulin treated patients.Conclusion:Among COVID-19 patients with diabetes, higher age, high HbA1c level, and presence of other comorbidities were found to be significant risk factors for the hospital admission.     

Effects of the Coronavirus disease 2019 pandemic on routine pediatric immunization coverage rates at the main University Hospital in Saudi Arabia

Objectives:To investigate whether the coronavirus disease-2019 pandemic has had any effects on pediatric vaccination rates at the main university hospital in Saudi Arabia.Methods:A retrospective study conducted at King Saud University Medical City, Riyadh, Saudi Arabia using electronic health records. The vaccination statuses of all children who were scheduled for vaccinations at birth and at 2, 4, 6, 9, and 12 months during March, April and May between 2017 and 2020 were included in the study with total sample of 15,870 children, and comparisons between the cohorts were performed.Results:All vaccination visits during April and May 2020 were below the lower extremes except for the birth vaccinations. In March, April, and May 2020 there were respective drops in vaccination visits of 49.93%, 71.90% and 68.48% compared with the mean numbers of vaccination visits during the same months from 2017 to 2019. In comparisons of mean numbers of visits from March 2017 to May 2019 and March to May in 2020, the respective reductions in visits for birth and 2, 4, 6, 9 and 12-month vaccinations were 16.5%, 80.5%, 74.7%, 72.9%, 80.0% and 74.1%.Conclusions:The huge impact of the coronavirus disease-2019 pandemic on childhood vaccinations will require urgent vaccination recovery plans with innovative approaches and future action plans to maintain vaccination coverage during any subsequent pandemics.     

The battle against Coronavirus disease 2019 (COVID-19) in the Kingdom of Saudi Arabia: Public health perspective

Coronavirus disease 2019 (COVID-19) which was initially reported in the Chinese city of Wuhan has now spread unprecedented all over the world, including the Kingdom of Saudi Arabia (KSA). The World Health Organization declared this outbreak as a public health emergency of international concern during late January 2020 while the announcement of this viral infectious condition was made as COVID-19 disease during February 2020. As of late May 2020, the global death rate due to COVID-19 was 357,714 and 441 in KSA alone. This review provides an overview of COVID-19 and the public health measures adopted by KSA in the context of COVID-19.