Letter

The Impact of Breaching Lockdown on the Spread of COVID-19 in Kurdistan Region, Iraq

Dear Editor,

Social distancing is important to decrease the interactions between people in the society. As a set of measures, social distancing is taken to reduce infections transmitted by droplets. To achieve its aim, social distancing should include the cancellation of funerals and weddings, the closure of schools and universities, and the cancellation of mass gatherings (1). In a study conducted in China during the epidemic outbreak of coronavirus disease 2019 (COVID-19), the death rate was about 10% in the epicenter of the epidemic whereas the death rate was 1% in other areas. It was concluded that the high death rate was due to the breakdown of the healthcare system owing to the large number of patients. It was then recommended that social distancing may help in preventing the breakdown of healthcare system (2). In another study in China, it was concluded that social distancing can reduce the number of infections by 98% and the number of deaths by 99% (3). The first case of COVID-19 in Kurdistan region was diagnosed in beginning of March 2020, and from that time 324 confirmed cases have been recorded onwards. The region is divided into four cities: Duhok (15 COVID-19 cases), Erbil (168 cases), Sulaimani (120 cases), and Halabja (21 cases). The age range of COVID-19 patients was from 10 months to 70 years old. Amongst the 324 patients, 52% were female, 80% were asymptomatic and diagnosed while in the quarantine, and 0.9% passed away (4). The regional government in Kurdistan, northern Iraq imposed strict measures to stop the spread of the infection. These measures included the closure of educational institutions, workplaces, roads, and the cancellation of public gatherings including Friday prayers, church gatherings, funerals, and weddings. Besides, measures included mandatory quarantine of uninfected subjects with a history of travel or exposure to SARS-CoV-2. However, imposing these rules was challenging in the area. On March 23, 31 cases of COVID-19 were diagnosed in Erbil city which was the highest number of patients discovered in one day. Careful examination and tracing revealed that those patients had attended unpermitted funerals. Healthcare authority in the city launched a tracing operation to quarantine and test all the people attended the funeral. This resulted in the diagnosis of 98 funeral-related patients in the city. This also represented 129/168 (76.78%) of the patients diagnosed in Erbil. In another incidence in Sulaimani city, 15/120 (12.5%) patients were diagnosed after attending unpermitted funeral in the city. Totally, these patients comprised 44.4% of the patients diagnosed in the region. It appeared that breaching the lockdown and social distancing increased the number of patients sharply in the region and particularly in Erbil city. Therefore, it seems imposing social distancing must be accompanied with health education programs to educate the people about the consequences of cancellation of gatherings and importance of lockdown in preventing the transmission of the virus.

To conclude, the strict social distancing measures helped in limiting the spread of infection. However, breaching the lockdown increased the number of patients sharply. Health education is required alongside in order to increase the awareness of the people and ensure better commitment.

Conflict of Interests

We wish to confirm that there are no known conflicts of interest associated with this publication.

Acknowledgments

We would like to thank all the doctors and medical staff working in COVID-19 hospital for their continuous support during the study. As a part of COVID-19 national program, all the COVID-19 data are published in the Ministry of Health and The Directorate of Health media and the data are updated continuously.

Ethical Statement

The study was approved by the Scientific and Ethics Committee, College of Medicine, University of Zakho, Zakho, Iraq.

Authors’ Contribution

We confirm that the manuscript has been contributed, reviewed and approved by all named authors. We further confirm that the order of authors listed in the manuscript has been approved by all of us.

References

1. Wilder-Smith A, Freedman DO. Isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019-nCoV) outbreak. J Travel Med 2020; 27(2). doi: 10.1093/jtm/taaa020 [Crossref]
2. Mizumoto K, Chowell G. Estimating risk for death from 2019 novel coronavirus disease, China, January-February 2020. Emerg Infect Dis 2020; 26(6). doi: 10.3201/eid2606.200233 [Crossref]
3. Zhang Y, Jiang B, Yuan J, Tao Y. The impact of social distancing and epicenter lockdown on the COVID-19 epidemic in mainland China: a data-driven SEIQR model study. medRxiv. 2020. 10.1101/2020.03.04.20031187
4. MoH. Latest Information about Coronavirus (COVID-19). MoH; 2020 [updated 2020; cited 2020 10/4/2020]. Available from: https://gov.krd/coronavirus-en/.