Current COVID-19 situation in Palestine

¹Prices Basma Teaching Hospital, Amman, Jordan, ²Al Hussein Hospital, Al Salt, Jordan, ³An-Najah National University Nablus-Palestine, Nablus, Palestine Territory, ⁴University of Baghdad, College of Medicine, Baghdad, Iraq, ⁵Medical Research Center, Kateb University, Kabul, Afghanistan, ⁶Kabul University of Medical, Kabul, Afghanistan, ⁷Punjab Medical College, Faisalabad, Pakistan

^&Corresponding author
Hashim Talib Hashim, University of Baghdad, College of Medicine, Baghdad, Iraq

Commentary    

The emergence of severe acute respiratory syndrome coronavirus 2 in Wuhan, China, in December 2019, has caused a large global outbreak and a pandemic of acute respiratory disease, which is a major public health issue [1]. On 11 February 2020, the International Committee on Taxonomy of Viruses named the novel coronavirus "SARS-CoV-2", and the WHO named the disease "COVID-19". On 30 January 2020, the WHO declared COVID-19 as the sixth public health emergency of international concern. In April, the United States recorded the highest number of cases than other countries that reached 311,656 confirmed cases with a death rate of 2.71% and recovery rate of 4.75% on 5^th April [1]. On 5 March 2020, seven cases of Coronavirus disease 2019 (COVID-19) were confirmed in the State of Palestine, the cases had first been detected at a hotel in the Bethlehem area, where a group of Greek tourists had visited the hotel in late February, with two later diagnosed with the virus [2]. On 7 March 2020, there were 22 cases of infections that increased to 44 cases by 18^th of Marchand it has been on the rise since then. The first two cases in Gaza were confirmed on the 21^st of March by the Palestinian sources. The United Nations humanitarian coordinator for the occupied Palestinian Territories announced one million dollars of urgent joint financial support from multiple United Nations Organizations to provide health aid and technical support to Palestine to help it confront the outbreak [2]. In Palestine, at the end of June, the reported cases were increased very sharply by about six times; as more than 3,095 cases were reported.

The Palestinian authorities continued to ramp up the testing and on August 13, 2020 a significant increase was observed. By then, the cases had surpassed 20,000 in the Palestinian territory. The Palestinian authority further eased restrictions, in accordance with strict health measures, WHO delivered a new PCR machine to Gaza to enable rapid testing for COVID-19 [3], 24, 2021, the total cases had gone up to 177,768, of whom 1,999 died and 163,795 had recovered [4]. As of February 2021, 66 vaccine candidates are in clinical research, including 17 in Phase I trials, 23 in Phase I-II trials, 6 in Phase II trials, and 20 in Phase III trials. Trials for four other candidates were terminated. In Phase III trials, several COVID-19 vaccines demonstrate efficacy as high as 95% in preventing symptomatic COVID-19 infections. As of February 2021, eleven vaccines are authorized by at least one national regulatory authority for public use: two RNA vaccines (the Pfizer-BioNTech vaccine and the Moderna vaccine), four conventional inactivated vaccines (BBIBP-CorV, Covaxin, CoronaVac and CoviVac), four viral vector vaccines (Sputnik V, the Oxford-AstraZeneca vaccine, Convidicea, and the Johnson & Johnson vaccine), and one peptide vaccine (EpiVacCorona) [4].

Efforts: Palestine has outperformed many other countries in responding to COVID-19 especially at the beginning of the outbreak as the government acted quickly and imposed strict preventative lockdown measures. President Mahmoud Abbas declared a state of emergency the same day that the first cases was identified (in Bethlehem) on 5 March 2020. President Abbas mandated Prime Minister Dr. Mohammed Shtayyeh to take all measures to implement the State of Emergency. With authority from President Abbas, Prime Minister Shtayyeh established an Emergency Command Centre in the Prime Minister´s Office (PMO), supported by inter-ministerial and multilateral emergency committees and regional committees. The GoP approach of COVID-19 focuses on preparation, containment and communication [5]. Individuals suspected to have COVID-19 are home quarantined until symptoms develop or they have a positive test: all in-coming travellers are placed in government quarantine for two weeks. Individuals with positive samples or symptoms are cared for in government hospitals. There are contact and trace units in each governorate. All cases were under medical observation at designated health facilities and contact tracing was initiated for all cases. The East Jerusalem Hospital Network has also announced preparations for Jerusalem hospitals to deal with cases of COVID-19 that require clinical care. In the Gaza Strip, the local health authorities have expanded the laboratory monitoring process to include hundreds of samples for quarantine inmates and contacts of patients with COVID-19 in quarantine centres since the beginning of March 2020. In this period, more than 1760 people were in one of 25 designated quarantine facilities including at Rafah crossing quarantine centre or at health facilities, schools, or hotels designated as quarantine facilities [6].

The quarantine period was 2-3 weeks (21 days). Those coming from crossings at Rafah or Erez have been quarantined since March 15. Home quarantine ended 26 March for those who entered Gaza 14 days prior. On 5 March, the Palestinian government announced a complete ban on entry of foreign tourists. On 16 March, Kuwait has contributed $5.5 million to help the Palestinians overcome coronavirus. By 22 March, all schools, universities and public parks have been closed for 30 days (from 5 March - 5 April) and the following guidelines have been putin place: Palestinian labourers who travel to Israel for work are asked not to move between State of Palestine and Israel: this means that they should return to their homes (and remain in home quarantine for two weeks) or remain in Israel until the situation changes; closure of all borders and government quarantine (14 days) and testing for all incoming travellers (from Ben Gurion airport). No movement between West Bank governorates; no movement within all urban areas (except for exceptional circumstances), with all citizens requested to remain with their homes and closure of all stores, public institutions and government offices, except for essential providers; all citizens are asked to stay at home, except for essential activities and emergencies; the Government of Palestine continues to implement social distancing regulations and mandatory mask-wearing in business establishments, public transportation, and government facilities due to COVID-19. On 27 April, Restaurants in the Gaza Strip were allowed to reopen [6]. The vaccination efforts in Palestine have been the center of unequal distribution as the area continues to struggle with procuring vaccine doses. In the last week of March, 37,440 doses of Pfizer vaccine 24 000 doses of the AstraZeneca vaccine arrived in Palestine as part of the COVAX programme. The COVAX shipment enabled Palestine to start the vaccination campaigns but the state is still far away from vaccinating a good chunk of population to produce herd immunity in effort to curb the spread of the virus.

Challenges: as a nation already suffering from a decades-long military and economic occupation, we recognize that the State of Palestine is already handicapped to contain the COVID-19 outbreak. Palestine does not have the necessary sovereignty (control over borders, etc) and national resources (medical, financial, etc) to cope with a significant outbreak, particularly when the population has many high-risk characteristics (crowded cities and refugee camps, poverty, food insecurity, non-communicable diseases, etc). In the context of COVID-19, this means that there is difficulty in the ability to cover the full salaries of health workers in the months leading State of Palestine State of emergency: COVID-19 response plan - needs for donor support 6 to a significant reduction in GoP´s ability to manage the pandemic. Additionally, there is insufficient funds to cover the scheduled government transfers to the most vulnerable population, with greater numbers of Palestinians expected to need government support due to the economic impact of COVID-19. Widespread incidence of the virus will be catastrophic in a population that is overcrowded, undersupplied, and in high poverty and food insecurity. The ongoing closure of the Southern Governorates means that the GoP cannot freely mobilize its national health resources to respond to any outbreak [7]. 0n 7 April, The Palestinian Ministry of Health had reported that only 250 medical ventilators are available throughout all Palestinian hospitals and that two-thirds of these machines are already in use [7]. The National COVID-19 Response Plan specifies a requirement of $120 million over 90 days. On 27 March 2020, the humanitarian clusters released an updated inter-agency multi-sectoral COVID-19 response plan in support of this totalling $34 million over 90 days and forming a part of the global UN appeal launched on 25 March 2020. The United Nations Relief and Works Agency for Palestine Refugees in the Near East resumed the distribution of food aid in the Gaza Strip on 31 March. Food baskets are delivered directly to beneficiaries´ homes as a precautionary measure by UNRWA, to prevent gatherings as part of its steps to reduce and prevent the spread of the coronavirus [8].

But even when a safe and effective COVID-19 vaccine or treatment is eventually developed, further challenges will emerge with regards to the manufacturing and distribution process of it. There are many challenges and difficulties related to the COVID-19 vaccine in Palestine. Because of the political situation and wars in Palestine, the health care system is facing extreme staff shortages. The health system in Palestine is underfunded and neglected. The unique requirements of the upcoming immunization drive pose another layer to the distribution challenge. Another challenge is that most vaccines require two shots, including Pfizers, which needs two shots injected three weeks apart. Because of the current situation in Palestine, where people are harder to contact or may live a long way from vaccination centers, some people do not come back for a second shot. The stability of a country also plays an important role in whether people can access vaccines. In the global race to secure access to vaccines, there are fears that poor countries and countries suffering from wars may miss out. Global competition or vaccine nationalism may prevent a COVID-19 vaccine reaching those most in need. Ineffective allocation of any vaccine could mean that vulnerable people in certain countries receive the vaccine after lower risk individuals in other countries, leading to preventable deaths [9]. In Palestine, people still value the family and place emphasis on people´s strong social relationships. The people are closely related to each other and adhere to certain customs that contribute to the spread of the virus, such as greeting by hand, hugs, kissing and large gatherings. Besides, there are many places where people gather in abundance, such as funerals, weddings, and large family gatherings at certain times, such as the month of Ramadan. Many people denied the existence of the virus and did not believe in its existence until the numbers began to increase dramatically and the number of deaths increased and the people close to them became infected with the virus.

As of April 23, a total of 480 Palestinians (including East Jerusalem) have been confirmed to have COVID-19. Approximately 80% of people detected positive are below the age of 50, the vast majority of whom are asymptomatic. Although the apparent spread of the virus by this period was limited compared to other countries, this may reflect the limited testing capacity, with slightly over 26,000 samples were tested only [10]. By July the highest cases were in Hebron Governorate (4620 cases), with about 70% of the total reported cases, with these confirmed cases Palestine ranked 87 among 215 countries that have coronavirus; with the highest outbreak rate in the world too; compared to population number. Within only 2 weeks the Palestine rank changed from 97 to 87. The high outbreak of the disease in this region (Hebron Governorate), as 90% of infections have been caused by people meeting up with their families or attending wedding parties or funerals and failing to follow health recommendations and maintain social distancing. The lockdown has affected society on many levels. Many workers have been left jobless since everything is closed; only essential businesses like supermarkets and pharmacies are open. Job losses will be a result of both slowdown in economic activities and disappearance of certain occupations as the Work-from-Home (WFH) business model is adopted. So, they were violating the lockdown in order to search for a job and money.

Conclusion     

Although authorities in the West Bank and Gaza Strip are following a restrict management approach to control COVID-19, their plans are still non consolidated. Yet, further coordinated efforts such as testing, tracing, public engagement, socioeconomic support packages are required for more efficient COVID-19 preparedness and response in Palestine. A more concise and unified response plan with a long-term vision including a robust exit strategy is essential for effectively combating the pandemic in Palestine. The response plan should include strategic directions; increased financial investments and efforts in strengthening the public health system´s governance, capacity, and health research and surveillance. Although life has returned to normal, the people became more educated about the dangers of the disease and they became committed to the preventive protocols. Despite challenges, Palestinians have managed to maintain a basic level of healthcare that can be built upon with the support of the international community.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All the authors have read and agreed to the final manuscript.

References