This study conducted trend analyses with longitudinal COVID-19 data for the MENA region from 2020 through 2023. Data on COVID-19 transmission and death were sourced from Our World in Data (OWID) [55]. OWID compiles data on COVID-19 cases and mortality from multiple sources, including individual websites, statistical reports, and press releases. The MENA region was defined by the World Bank’s economic and geographical metrics [9], and the data comprised an unbalanced panel of 20 countries and territories from September 4, 2020, to May 12, 2023. Because several countries around the world switched from daily to weekly reports at various points in 2023, we used a cubic spline to interpolate daily new cases and deaths when any country had 4 consecutive periods of non-zero new cases interspersed by 6 days of zero new cases. A cubic spline is a statistical function used to assess the “smoothness” of data points and estimate missing or unclear data on a line given surrounding trends.

To identify the appearance and duration of variants of concern, we used data on sequenced SARS-CoV-2 variants from the Global Initiative on Sharing All Influenza Data (GISAID), which is an effective and trusted online resource for sharing genetic, clinical, and epidemiological COVID-19 data [56-60]. We used Nextclade nomenclature [61] to collect clade designations from sequences and Pangolin nomenclature for lineage designations of SARS-CoV-2 [62,63]. Nextclade nomenclature is an open-source tool for viral genome analysis, mutation identification, clade assignment, and phylogenetic mapping. Pangolin nomenclature is an open-source tool (Phylogenetic Assignment of Named Global Outbreak Lineages) used to track the transmission and spread of SARS-CoV-2 and its lineages. Metadata for the study period were collected on June 22, 2023. To avoid low frequency or potentially erroneous samples, the data set was further filtered to exclude months with fewer than 100 available samples, variant groups with fewer than 5 samples in a month, and variant groups representing less than 0.5% of the total samples in a month. The final data set consisted of 184,386 total samples available on GISAID [56-59].

This study provides updates of traditional surveillance data and dynamic panel estimates from the original study by Post et al [8,52,53,64-66]. The “speed” of spread of the pandemic is the rate of new COVID-19 cases per 100,000 population. Novel metrics go beyond speed to add acceleration, jerk, and 1- and 7-day persistence measures. Acceleration is the difference in speed from one week or day to the next. Acceleration identifies whether the number of new cases is increasing (positive acceleration), decreasing (negative acceleration), or at a stable inflection point (zero). “Jerk” is the change in acceleration from one time interval to the next, and its name is adopted from physics nomenclature. A positive jerk can indicate explosive growth in the spread of a disease. Finally, 1- and 7-day persistence measures capture the impact of the 1- and 7-day lag of speed on current speed. These measures capture the echo-forward effect of COVID-19 cases on future cases either 1 or 7 days later. They are derived from coefficient estimates on lagged transmission rates in an Arellano-Bond dynamic panel data model [67]. The model follows the general form of:

y_it = ρy_it-1 + βX_it + α_i + u_it (1)

where the dependent variable is the rate of COVID-19 transmissions, the independent variables include weekend and recent week indicators, α_i denotes country fixed effects, and u_it is the idiosyncratic error term. Please see the initial study for more details [8].

We further analyzed the potential “statistical end” to the pandemic with a 1-sided t test for whether the mean of speed of spread, defined as the rate of new COVID-19 cases per 100,000 population in a given time period, was equal to or greater than the outbreak threshold of 10. We ran the test on a rolling 6-month window over weekly speed for the region, and we plotted the P values from the test over time. All statistical analyses were conducted with the plm package (version 2.6-2) in R (version 4.2.1) [64,65].

This study followed the guidelines of the World Medical Association’s Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects [68,69]. This research relied on publicly available data with no private, identifiable information. Thus, institutional review board review was unsolicited.

The principal finding to the stated objective of this study is that the MENA region meets the 3 criteria for moving from a pandemic to an endemic. First, the transmission rates before and after the WHO declaration of the end of the COVID-19 public health emergency of international concern on May 5, 2023, were well below the threshold of an outbreak. Second, the transmission and death rates approached 0 and remained extremely small and stable. Finally, the pandemic in MENA is no longer propagating forward. Our findings therefore signal that COVID-19 has changed from a pandemic to an endemic in MENA. Nonetheless, COVID-19 had profound effects on the region’s economy, political, and public health institutions since the pandemic began in spring 2020.

The MENA region saw several waves of infection over the course of the pandemic, with significant spikes driven by new SARS-CoV-2 variants and the rollback of COVID-19 restrictions. The region saw significant disparities in how effectively countries were able to enforce quarantine rules and contain the virus. During an initial wave in 2020, MENA countries with the economic, social, and political resources to institute quarantines were quick to respond to the pandemic and had substantially lower infection and fatality rates compared with countries in Europe and North America. This response allowed them to reopen their economies quickly. MENA governments similarly responded to later waves by reinstituting quarantine rules in focused areas. For example, Saudi Arabia, Kuwait, and Qatar each saw the number of COVID-19 cases drastically increase in May 2020 after restrictions were eased for Ramadan. These governments quickly reinforced strict lockdowns to control the spread of the virus [74].

Other MENA countries, which were already struggling with economic and sociopolitical instability, faced heightened crises as COVID-19 strained their already fragile societies. In Syria, which has grappled with internal conflict since 2011, COVID-19 created a health care catastrophe as the country’s already strained health care system was pushed to the breaking point. According to the WHO, only 50% of hospitals in Syria were fully functioning, and 25% were partially functioning at the start of the pandemic due to shortages of staff and medical equipment from years of war [75]. Refugee camps, which lacked proper medical staff and equipment, created grounds for the virus to spread quickly [76]. Yemen, which has dealt with a long and protracted civil conflict, faced its own crisis in the pandemic. Trade restrictions due to COVID-19 led to more than 50% of Yemen’s population facing food insecurity and hunger [77-79].

In economic impacts, the MENA region saw a 3.5% decline in gross domestic product (GDP) in 2020 driven by COVID-19 containment measures. However, as vaccines became more prevalent and countries began easing COVID restrictions, economies rebounded, with GDP growth of 4.5% in 2021 [80]. Some countries, such as Saudi Arabia, Kuwait, and the United Arab Emirates, also faced a secondary economic shock from a sharp decline in oil prices in 2020 [81].

Many countries in the region approved large fiscal packages to support struggling economic sectors. These packages typically included direct cash support for affected workers, tax relief for individuals and corporations, investment in strained health care systems, and economic investment in specific sectors. Saudi Arabia announced a SR 70 billion (US $18.6 billion; 2.7% of GDP) private support package, which suspended government tax payments and provided additional liquidity to the private sector. Kuwait allocated KD 500 million (US $1.6 billion; 1.5% of GDP) toward economic stimulus, which included the provision of full unemployment benefits for Kuwaiti nationals [81]. Many MENA countries began the pandemic with underfunded health care systems and had to drastically increase their health care expenditure and invest in personal protective equipment, ventilators, and other medical supplies. Egypt allocated £5 billion (US $103 million) toward the purchase of necessary medical supplies and funds for additional medical staff [81]. Overall, these health and social welfare packages required MENA countries to borrow substantial amounts of money, leading to increases in government debt [82].

Given prior experience with the Middle East respiratory syndrome (MERS), many countries in the region were quickly able to enact containment strategies. The backbone of these strategies consisted of masking, border closures, contact tracing, social distancing, quarantines, and lockdowns. However, there were significant disparities in how effective these measures were implemented given the large differences in economic resources, health care infrastructure, and the political stability between countries. The United Arab Emirates was one of the first countries to issue a COVID-19 alert before the WHO declared COVID-19 a public health emergency. Saudi Arabia, a deeply religious country, barred Muslims from conducting prayers inside mosques. Pilgrimages to holy sites such as Mecca and Medina were banned for foreigners [83]. Additionally, the United Arab Emirates and Saudi Arabia levied fines against any individuals or businesses that failed to adhere to mask mandate policies [84]. Saudi Arabia also built makeshift hospitals to increase their health care capacity and accommodate surges in COVID-19 cases [85]. Israel’s Ministry of Health implemented a containment strategy focused on early travel restrictions to countries reporting COVID-19 cases, and 14-day self-quarantine measures were imposed on anyone arriving from abroad [86]. More extensive lockdown measures were ultimately implemented, including the closure of schools, universities, and all nonessential businesses [87]. Another cornerstone of Israel’s containment strategy was the use of its extensive health care resources to test and quarantine patients at scale [88]. Israel also utilized mobile apps and spatial data collected from mobile phones to effectively perform contact tracing [88,89].

Some countries in the region lacked the health care resources to effectively fight the spread of the virus. At the start of the pandemic, Morocco had a hospital bed capacity of 1.1 beds for 1000 people, among the lowest in MENA [90]. Morocco therefore adopted an early, strict containment strategy to prevent straining their limited health care system. Policies included suspension of public events, suspension of international travel, and restrictions on intercity travel [18,21,25,90,91]. Additionally, the government created a “COVID-19 Fund,” which provided funding to increase hospital beds and intensive care unit capacity, purchase personal protective equipment, and increase testing capabilities [92]. Morocco experienced one of the lowest fatality rates in the region during the initial wave of infections [92].

Yemen faced difficulties implementing a comprehensive containment strategy given the violent civil conflict facing the country. Health infrastructure lacked the capability to properly test patients and track the virus [93]. In parts of the country controlled by the Houthi faction, almost no COVID-19 restrictions were implemented [81,94].

As the pandemic continued, countries eventually relaxed their restrictions to stimulate the economy and only reinstated lockdowns when COVID-19 cases began to spike [22,95]. MENA countries focused on achieving herd immunity through widespread vaccination campaigns. The Pfizer-BioNTech vaccine was the first vaccine approved in Saudi Arabia in mid-December 2020, with millions of vaccine doses being administered throughout the pandemic [96]. In July 2021, Saudia Arabia was also one of the world’s first countries to implement a large-scale vaccine mandate to combat a new surge in cases from the COVID-19 Delta variant. This mandate required proof of vaccination to enter public and private institutions, including schools, shops, malls, public transportation, and more [97]. The United Arab Emirates also mandated vaccinations for all people attending live events such as sports events and art exhibitions. Attendees also had to provide a negative polymerase chain reaction (PCR) test within 48 hours of the event [98]. Egypt announced that COVID-19 vaccinations were mandatory for people over the age of 18 years. The country banned all nonvaccinated people from entering public, governmental, and educational buildings to further incentivize vaccination [99]. In June 2021, Egypt also signed an agreement with Chinese vaccine manufacturer SinoVac to locally produce the company’s inactivated vaccine, CoronaVac [100,101].

There were large disparities in access to vaccines, with richer nations such as the United Arab Emirates and Saudi Arabia able to vaccinate their population much faster than less-resourced countries. For example, by early December 2021, the United Arab Emirates had one of the world’s highest vaccination rates at 90% of the population, while Yemen had just reached a rate of 1% [23,82].

One unique issue facing countries in the MENA region was the need for halal-certified vaccines. Many countries in the region have significant Muslim populations [102]. Islamic law requires that Muslims avoid using vaccines manufactured with certain types of ingredients (such as pork products) [102]. To avoid potential vaccine hesitancy, religious leaders in several MENA countries, including the United Arab Emirates and Egypt, declared vaccines halal and encouraged citizens to get vaccinated to prevent further spread of the virus [103].

Limitations of our data analysis and resulting manuscript include the following. COVID-19 data had become less frequently reported around the world by the time the WHO declared an end to the COVID-19 Emergency of International Concern [104]. Additionally, more people began to use at-home tests as the pandemic evolved [105]. Because the enhanced surveillance metrics of speed, acceleration, jerk, and 7-day persistence are based on rates, not total counts, statistical bias caused by countries dropping in or out of the sample is mitigated, but to the extent that a nonincluded country is unrepresentative of the region in disease burden, the omission of a country or territory can still influence historical data comparisons. Viral specimen tests for variants of concern in GISAID are also dependent on testing and sequencing capacity, which varied by country across the region.

Overall, the COVID-19 pandemic had far-reaching effects on MENA, impacting health care systems, economies, and social well-being. Although the region fared better in disease burden than several others, many countries in the region continue to face challenges due to limited economic and health care resources [48,106-108]. Although COVID-19 continues to circulate in MENA, the rate of transmission remained well below the threshold of an outbreak for over 1 year ahead of the WHO declaration.

The concern about potential resurgences of the SARS-CoV-2 virus is valid [20,109-111]. As long as COVID-19 continues to spread and mutate, the possibility of new variants emerging remains. Variants could potentially be more transmissible, resistant to vaccines, or cause more severe illness. For example, 4 months after the WHO declared the end to the public health emergency, Omicron has further mutated into Omicron EG.5, incorrectly referred to as Eris and sensationalized in the media [112]. There is no evidence that this subclade results in more severe disease or death [113]. This underscores the importance, however, of continued vigilance, vaccination efforts, and global cooperation to control the spread of the virus [19,24,26,27,51,114-116].

Our findings underscore the importance of the following efforts on a country and regional basis: government investment in epidemiological surveillance and preparedness for future pandemics and public health emergencies; identification of barriers to access of key public health resources including care (including acute and preventative care [ie, vaccines]), education, and material goods and financial support; additional crisis management preparations in the social and economic spheres given their intersectionality with public health; regular assessment of social attitudes toward health crises, including both ongoing and potential future emergencies.