Background:

COVID-19 is a disease caused by a virus named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and was discovered in December 2019 in Wuhan, China (1). After a few months, it was spread throughout most countries of the world and considered pandemic by WHO in March 2020. COVID-19 is characterized clinically by respiratory symptoms ranging from a mild respiratory infection (including fever, cough, and fatigue) to pneumonia, acute respiratory distress syndrome (ARDS), shock, and death. Although the lungs are the most affected parts of the patient’s body, other parts may also be affected by the inflammatory and immunological processes.

It is a very contagious disease and like other respiratory viruses, coronaviruses spread quickly through droplets that the patients generate when they sneeze, cough, speak, or even breath (2). People of any age might get infected by SARS-CoV-2. Most people with COVID-19 have mild symptoms or sometimes no symptoms, but some people become severely ill (2). Older people (more than 65), and people with pre-existing conditions (such as heart diseases, hypertension, diabetes, and respiratory conditions) appear to be more susceptible to becoming severely ill with the virus and suffer worse consequences (3). The severe disease means that the person with COVID-19 may be hospitalized, need intensive care, require a ventilator to help them breathe, or die (4). This is due to people living with NCDs being at increased risk of becoming severely ill with the virus as well as the disruption of health services is particularly problematic for those living with NCDs who need regular care.

In addition to symptomatic management, several therapeutic options are now available for the treatment of individuals with COVID-19 (5), and numerous randomized controlled trials (RCTs) are underway. However, uncertainties remain about the efficacy of existing treatments for COVID-19 – against emerging SARS-CoV-2 variants. Since treatment is not available in most countries, especially the low-income ones, all the developed and approved vaccines are highly effective at preventing severe diseases, hospitalizations, and deaths (6), however, cases of infection are expected among fully vaccinated people, but limitations in global access to vaccines mean that many populations remain vulnerable. Even in vaccinated individuals, uncertainties remain about the duration of protection and efficacy of current vaccines (7), the preventive measures are still valid and important to protect yourself and slow the spread of SARS-CoV-2; 1) keep the social distance at least 1 meter away from others, even if they don’t have symptoms because they might be asymptomatic infected, 2) wear a mask especially when social distancing is not achievable, 3) avoid crowded or poorly ventilated places, 4) clean surfaces regularly and avoid touching surfaces in public settings, 5) frequently clean your hands with soap and water, or an alcohol-based hand rub, 6) apply respiratory etiquette and cover your coughs and sneezes with a bent elbow or tissue, throwing used tissues into a closed bin right away. Then wash your hands or use an alcohol-based hand rub.

By March 4. 2022 there have been 440,807,756 confirmed cases of COVID-19, including 5,978,096 deaths, reported to WHO. As of 26 February 2022, a total of 10,585,766,316 vaccine doses have been administered (8).

In Syria where the conflict during the last eleven years has created one of the most severe and complicated humanitarian crises in the world today by ongoing hostilities which have killed hundreds of thousands of people, triggered one of the worst displacement crises of our time, and led to the multisectoral collapse. Millions have left their homes and become internally displaced people inside Syria or refugees outside Syria. In Northwest Syria which is under the opposition groups’ control and depends on crossing border modality from Turkey to get humanitarian assistance including health, there are about 4.4 million living there and almost 3.5 million are people in need (9). The first case of COVID-19 in Northwest Syria was detected on July 9. 2020 (10). Northwest Syria has witnessed three waves of COVID-19 from Jul 2020 to Dec 2021. The third wave started in Aug 2021 and was the most severe wave of COVID-19 that hit Syria. In northwest Syria, the number of confirmed cases of COVID-19 almost doubled in Oct 2021 (11), reaching nearly 83,000 compared to about 41,000 cases recorded by the end of August 2021. The positivity rate of the tests reached 61% in Oct 2021. Worth mentioning that the vaccination activities against SARS-CoV-2 started in May 2021, when the first vaccination campaign was kicked off in Northwest Syria (12). The target was vaccinating the health care workers who are on the front line dealing with suspected or confirmed COVID-19 cases in the health settings in addition to the high-risk population groups who were associated with chronic morbidities then extended to all individuals above 18 years old. By March 2. 2022, 98,213 confirmed cases of COVID-19 including 2,395 deaths. A total of 527,843 vaccine doses were administered with about 15.96% of the targeted population (more than 18 years old) being vaccinated (13).

The study aimed to determine the impact of age, non – communicable diseases as co-morbidities, and vaccination status on the severity of the clinical situation and mortality rate of COVID-19 patients.  

Discussion:

During the last three waves of COVID-19 in Northwest Syria, there were 88,421 COVID-19 positive cases by end of Oct 2021 and 1,362 deaths. The severity of the clinical status of the COVID-19 cases was increased by 1) age going up, 295 (58%) out of 508 severe cases were for people 60+ years old, and 2) if the patients had at least one NCD 39 (7.7%). While it was less among people who got at least one dose of COVID-19 vaccines, only 4 (0.8%) cases had severe symptoms.

The majority of the deaths 951 (70%) were from the age group of people who were 60+ years old. Out of the deaths, there were 120 (9%) cases had at least one NCD. The COVID-19 mortality rate among patients with NCD demonstrated that death was 5 times more among people with at least one NCD (7.1%) compared to people without NCD (1.4%). And 1,351 (99%) cases didn’t get vaccinated.

All cases included in the EWARN report were for patients with positive results of SARS-CoV-2 only, which means in other words that the report doesn’t include all the classified COVID-19 death cases (16), according to the WHO definition of the COVID-19 death case. Moreover, in the last wave of COVID-19 which reached the peak in mid of Sep 2021 with nearly 1500 daily cases, the occupancy rate of the COVID-19 dedicated hospitals reached 100% and exceeded 90% in the COVID-19 Community Treatment Centers CCTCs (17), in addition to the severe shortages in the oxygen in the NGO supported health settings (18), which overwhelmed the capacity of the already-stretched health settings (19), and obliged people to seek medical care in the privet sector which is already not well equipped due to the conflict challenges. In addition to a lack of well-qualified health staff due to the crisis who might already be negatively affected by the COVID-19 pandemic (20,21). This means that not all COVID-19 cases or deaths were registered or even followed by the EWARN teams on the ground and the situation might be worse than reported. As per the above discussion, we can conclude that the severity of the disease increased with age, in the presence of a non – communicable disease, and if the patient was not vaccinated. The study findings added more evidence that by increasing vaccination coverage, more fatalities can be avoided, particularly among the elderly and those with non-communicable disorders. 

The authors declare no conflict of interest.

Funding: none

Table 2: The prevalence of severe clinical status and mortality rate among COVID-19 cases by age group:

Table 3: The COVID-19 mortality rate per NCD

Table 4: Mortality rate among vaccinated (at least one dose) and not vaccinated patients of COVID-19

Table 5: Mortality rate of the COVID-19 patients who were 60+ years old and those who have at least one NCD regarding the vaccination status.