Factors Contributing to the Containment of the COVID-19 in Kurdistan Region of Iraq

A highly contagious coronavirus disease 2019 (COVID-19) is caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which was first identified in Wuhan, China in December 2019 (1). The virus primarily affects the respiratory system of human beings and results in the symptoms of headache, fever, dry cough, sore throat, shortness of breath and fatigue with abnormal chest computed tomography (CT) scan. In some cases, nasal sputum discharge and diarrhea have been also reported (2-4). Up to the 26th of April 2020, more than three million laboratory confirmed cases of COVID-19 have been recorded worldwide with more than 220,000 confirmed deaths (5). In the Kurdistan region of Iraq, the first case of laboratory confirmed COVID-19 was recorded in March 1st, 2020 in Sulaymaniyah province (6-8). Figure 1 shows the number of mortality and morbidity cases in the four different cities of Kurdistan region of Iraq; By May 2nd, 2020, the number of COVID-19 cases rose to 387 people, with 5 deaths, and 330 recovered patients in Kurdistan region (9). Considering the geographical location of the Kurdistan region of Iraq to the highly infected COVID-19 neighboring countries of Iran and Turkey (figure 2) and also the reproduction number (R0) of the disease, it was expected that the disease will spread faster and would infect a greater number of people in the region (10). In Iran and Turkey, the mortality to the morbidity number were 6091/95646 and 3258/122392 respectively up to May 2nd, 2020 (11). In addition, COVID-19 is highly contagious and having the reproduction number (R0) of 3.28, meaning every single infected person will infect about 3.28 others, on average (10). Although the Kurdistan regional government may have played an important role in controlling the spread of the disease by applying early travel restriction, shutting down airports, schools and other public places and imposing a curfew to enforce social distancing. It is also expected that low rate of morbidity and mortality in the region could relate to the immunity of the resident of the region against the disease. Particularly, the majority (>75%) of the confirmed COVID-19 cases in Kurdistan region of Iraq were asymptomatic (8). In addition, all the five recorded deaths had underlying health conditions, and only two of them were hospitalized COVID-19 patient, the rest were confirmed to have died of COVID-19 base on post-mortem examination of the corpses. There are three hypotheses that proposed to explain low morbidity and mortality rate of the COVID-19 in the Kurdistan region of Iraq: first, the local strain of the SARS-CoV2 may be different, second, the Bacillus Calmette–Guérin (BCG) vaccination may have contributed in the immunity of the people (8). Lastly, the residents of the region may have already passed through herd immunity of COVID-19 before or during the outbreak.