Discussion
The pandemic was a challenge in the MENA region as some of which are weak, fragile and conflict-affected countries, however, the situation is not same in all the Gulf countries. In conflict-affected areas, where health systems are already fragile and medical resources are scarce. The common challenges faced in the EMR countries specially Lebanon, Syria and Yemen were strained healthcare system due to various social and economical issues12,13. In Syria, the WHO estimates that 70% of health care workers have left the country as migrants or refugees14. Lebanon had initially managed to contain the first COVID-19, but following the explosion in the port of Beirut destroyed medical centres and the health situation has gotten largely out of control15,16. Moreover, the lack of testing capacity has resulted in months of under-reporting, in particular in Syria and Yemen17,18. At the same time, the region suffers from a drop in demand at the regional and at global levels, while most supply chains are disrupted. International organisations have also mobilised to help the most fragile countries in the region in strengthening their capacity to respond to the crisis19. UAE’s role in swift diagnosis of COVID-19 and further strengthening its healthcare system specially to increase the diagnostic capacity helped to tackle the pandemic successfully. Furthermore, the UAE’s support to other countries in EMR in identifying circulating strains was significant.
Genomics is a key tool that provides critical data to advise public health responses, which has been illustrated throughout the COVID-19 pandemic20. Novel variants have emerged and become dominant on no fewer than five occasions during the pandemic, with each variant having differences in sensitivity to vaccination, transmission frequency, and molecular detection21. Multiple demonstrations have occurred throughout the pandemic, including the loss of sensitivity of PCR testing due to S-gene mutation (SGTF) when the delta variant emerged22,23 and the rapid expansion of cases when the Omicron variant became dominant in 2021/202224,25. In each case, the wide availability of sequencing data was a key that allowed public health responses to be tailored to each situation.
The limited capacity of health systems and the lack of bioinformatics expertise and trained laboratory personal to perform the sequencing were the major constrained faced by most of the countries around the world26. Logistics and capacity to rapidly commence sequencing, added to lack of expertise, are the primary challenges with these countries. This was further worse in the EMR countries due to the economical and logistical issues posed great challenge in implementing genomics survellience27-29. In these situations, a hub-and-spoke model can be adopted to ensure that some data is obtained for these countries to allow for global awareness of the situation being faced. In the case of the EMR, three hubs have been established by WHO-EMRO, selected for their geographical location, capacity and expertise in laboratory procedures (Figure 1). Under this hub-and-spoke model, samples are collected in different location throughout EMR, and then sent to the three central hubs for the final processing of genomic sequencing and subsequent retrieval of the results to the country where the samples are received from for the subsequent necessary action. However, there were potential time gap in moving samples from conflict affected countries to the sequencing hubs, which delayed the sample receipt, processing and the report sharing. The success of this sequencing hubs is depending on the scientific infrastructure and from sample acquisition through reporting the results, meets or exceeds the high-quality standards of the international community. Moreover, this genomic hub-spoke model, need to have a schematic system to collect, receive, store the samples and timely delivery of the results. Also, adding a global unique identifier and a common data element to ensure that the relevant data is collected enable data to be used across multiples studies30.
The hub and spoke model was successfully adopted in several developed and developing country to provide support to the far reached areas of the country and provide necessary expertise in times of need interms of medical, surgical support and vaccine distribution during COVID-1931-33. Genomic testing in the NHS England is being provided through a national testing network, a hub-and-spoke model consolidating and enhancing the existing laboratory provision to create a world class genomic testing resource for the NHS and underpin the NHS Genomic Medicine Service. The national genomic testing service is delivered through a network of seven Genomic Laboratory Hubs (GLHs), each responsible for coordinating services for a particular part of the country 34.
RLID-AD in UAE is one of these hubs, with a wide array of diagnostic and molecular capacity available on multiple platforms. During the COVID-19 pandemic, provision of genomic and diagnostic support to emergency countries was a key aspect of the regional public health response, and UAE, as a hub directly supported Yemen, Syria and Lebanon with sequencing capacity while efforts were made to operationalize genomics directly in-country. The primary challenge faced was logistical, taking around 3-6 months to move the samples into the country, with transport challenges at the country end and import issues faced in bringing samples into the country. These delays in the critical information required by the counties directly impact the quality of the data that can be provided to support public health, and WHO/EMRO is working with both member states and hubs to facilitate a more streamlined transfer of samples in future.