Using a stochastic continuous-time Markov chain model to examine alternative timing and duration of the COVID-19 lockdown in Kuwait: what can be done now?

BACKGROUND: Kuwait had its first COVID-19 in late February, and until October 6, 2020 it recorded 108,268 cases and 632 deaths. Despite implementing one of the strictest control measures-including a three-week complete lockdown, there was no sign of a declining epidemic curve. The objective of the current analyses is to determine, hypothetically, the optimal timing and duration of a full lockdown in Kuwait that would result in controlling new infections and lead to a substantial reduction in case hospitalizations. METHODS: The analysis was conducted using a stochastic Continuous-Time Markov Chain (CTMC), eight state model that depicts the disease transmission and spread of SARS-CoV 2. Transmission of infection occurs between individuals through social contacts at home, in schools, at work, and during other communal activities. RESULTS: The model shows that a lockdown 10 days before the epidemic peak for 90 days is optimal but a more realistic duration of 45 days can achieve about a 45% reduction in both new infections and case hospitalizations. CONCLUSIONS: In the view of the forthcoming waves of the COVID19 pandemic anticipated in Kuwait using a correctly-timed and sufficiently long lockdown represents a workable management strategy that encompasses the most stringent form of social distancing with the ability to significantly reduce transmissions and hospitalizations.

Effectiveness of BNT162b2 and ChAdOx1 Vaccines against Symptomatic COVID-19 among Healthcare Workers in Kuwait: A Retrospective Cohort Study.

BACKGROUND: Estimating vaccine effectiveness (VE) against severe, acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among healthcare workers (HCWs) is necessary to demonstrate protection from the disease. Between 24 December 2020 and 15 June 2021, we determined the factors associated with vaccine coverage and estimated VE against SARS-CoV-2 infection in HCWs at a secondary hospital in Kuwait. METHODS: We extracted sociodemographic, occupational, SARS-CoV-2 infection, and vaccination data for eligible HCWs from the hospital records. Vaccine coverage percentages were cross-tabulated with the HCW factors. Cox regression was used to estimate hazard ratios in vaccinated versus unvaccinated. RESULTS: 3246 HCWs were included in the analysis, of which 82.1% received at least one vaccine dose (50.4% only one dose of ChAdOx1, 3.3% only one dose of BNT162b2, and 28.3% two doses of BNT162b2). However, 17.9% of HCWs were unvaccinated. A significantly lower vaccination coverage was reported amongst female HCWs, younger age group (20-30 years), and administrative/executive staff. The adjusted VE of fully vaccinated HCWs was 94.5% (95% CI = 89.4-97.2%), while it was 75.4% (95% CI = 67.2-81.6%) and 91.4% (95% CI = 65.1-97.9%) in partially vaccinated for ChAdOx1 and BNT162b2, respectively. CONCLUSIONS: BNT162b2 and ChAdOx1 vaccines prevented most symptomatic infections in HCWs across age groups, nationalities, and occupations.

Epidemiological characteristics of COVID-19 cases among Indians residing in Kuwait.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has rapidly spread to most countries around the world. Disproportionate spread of COVID-19 among the Indian community in Kuwait prompted heightened surveillance in this community. AIMS: To study the epidemiological characteristics of COVID-19 patients and their contacts among the Indian community in Kuwait. METHODS: Data collection was done as a part of contact tracing efforts undertaken by the Kuwaiti Ministry of Health. RESULTS: We analysed contact-tracing data for the initial 1348 laboratory-confirmed Indian patients and 6357 contacts (5681 close and 676 casual). The mean (standard deviation) age of the patients was 39.43 (10.5) years and 76.5% of the cases were asymptomatic or had only mild symptoms. Asymptomatic patients were significantly older [40.05 (10.42) years] than patients with severe symptoms [37.54 (10.54) years] (P = 0.024). About 70% of the patients were living in shared accommodation. Most of the close contacts were living in the same household, as compared with casual contacts, who were primarily workplace contacts (P < 0.001). Among the different occupations, healthcare workers had the highest proportion of cases (18.4%). Among the 216 pairs of cases with a clear relationship between the index and secondary cases, the mean serial interval was estimated to be 3.89 (3.69) days, with a median of 3 and interquartile range of 1-5 days. CONCLUSION: An early increase in the number of COVID-19 cases among the Indian community could be primarily attributed to crowded living conditions and the high proportion of healthcare workers in this community.

Analysis of intervention effectiveness using early outbreak transmission dynamics to guide future pandemic management and decision-making in Kuwait.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a World Health Organization designated pandemic that can result in severe symptoms and death that disproportionately affects older patients or those with comorbidities. Kuwait reported its first imported cases of COVID-19 on February 24, 2020. Analysis of data from the first three months of community transmission of the COVID-19 outbreak in Kuwait can provide important guidance for decision-making when dealing with future SARS-CoV-2 epidemic wave management. The analysis of intervention scenarios can help to evaluate the possible impacts of various outbreak control measures going forward which aim to reduce the effective reproduction number during the initial outbreak wave. Herein we use a modified susceptible-exposed-asymptomatic-infectious-removed (SEAIR) transmission model to estimate the outbreak dynamics of SARS-CoV-2 transmission in Kuwait. We fit case data from the first 96 days in the model to estimate the effective reproduction number and used Google mobility data to refine community contact matrices. The SEAIR modelled scenarios allow for the analysis of various interventions to determine their effectiveness. The model can help inform future pandemic wave management, not only in Kuwait but for other countries as well.

Antenatal depressive symptoms and adverse perinatal outcomes.

BACKGROUND: The association of antenatal depression with adverse pregnancy, birth, and postnatal outcomes has been an item of scientific interest over the last decades. However, the evidence that exists is controversial or limited. We previously found that one in five women in Kuwait experience antenatal depressive symptoms. Therefore, the aim of this study was to examine whether antenatal depressive symptoms are associated with preterm birth (PTB), small for gestational age (SGA), or large for gestational age (LGA) babies in this population. METHODS: This was a secondary analysis based on data collected in the Transgenerational Assessment of Children's Environmental Risk (TRACER) Study that was conducted in Kuwait. Logistic regression analysis was used to examine whether antenatal depressive symptoms assessed using the Edinburgh Depression Scale (EDS) were associated with preterm birth, small for gestational age, and large for gestational age babies. RESULTS: A total of 1694 women had complete information about the outcomes of interest. Women with depressive symptoms in pregnancy had increased, albeit non-significant, odds of having PTB (OR = 1.41; 95%CI: 0.81, 2.45), SGA babies (OR = 1.26; 0.80, 1.98), or LGA babies (OR = 1.27; 0.90, 1.79). Antenatal depressive symptoms had similar increased odds for the three outcomes even after adjusting for several covariates though none of these reached statistical significance. CONCLUSIONS: In the present study, the depressive symptoms in pregnancy did not predict adverse birth outcomes, such as PTB, SGA, and LGA, which adds to the currently non-conclusive literature. However, further research is needed to examine these associations, as the available evidence is quite limited.

Extreme temperatures and mortality in Kuwait: Who is vulnerable?

BACKGROUND: Previous climate change temperature-related health studies have been performed mostly in western countries with relatively cooler temperatures than the Gulf region. Regions that are inherently hot, like Kuwait, are witnessing soaring temperatures unlike ever before. Meanwhile, Kuwait and other Gulf countries are unique in their demographic profiles due to the large number of non-national migrant workers. OBJECTIVE: To examine the associations of hot and cold temperature extremes on the risk of mortality across gender, age groups and nationality in Kuwait. METHODS: We investigated daily variations of all-cause non-accidental and cardiovascular mortality death counts and ambient temperatures from 2010 to 2016 in a time-series design using a negative binomial distribution. The temperature lag was modeled with distributed lag non-linear models. RESULTS: A total of 33,472 all-cause non-accidental deaths happened during the study period. For the extreme hot temperatures and over the entire lag period, comparing the 99th percentile of temperature to the minimum mortality temperature, the risk of dying among males was 2.08 (95% CI: 1.23-3.52). Among non-Kuwaitis, males and working age group (15-64 year) had relative risks of death from extreme hot temperatures of 2.90 (1.42-5.93), and 2.59 (1.20-5.59), respectively. For extreme cold temperatures and over the entire lag period, comparing the 1st percentile of temperature to the minimum mortality temperature, the relative risk of death among Kuwaitis was 2.03 (1.05-3.93). Elderly Kuwaitis (65+ year) exposed to extreme cold temperatures had a relative risk of 2.75 (1.16-6.52). CONCLUSIONS: Certain subpopulations in Kuwait are vulnerable to extreme temperatures with doubling to tripling risk of mortality. Nationality is an important effect modifier in temperature-related mortality studies in Kuwait and possibly the Gulf region. To the best of our knowledge, we are the first study to examine specific subpopulation vulnerabilities to temperature in this region. Our findings could carry a potential for broader insight into similar hyper-arid and hot regions.

The effects of temperature on short-term mortality risk in Kuwait: A time-series analysis.

BACKGROUND: In light of climate change, health risks are expected to be exacerbated by extreme temperatures. Many studies showed that high and low ambient temperatures are associated with increased short-term mortality risk, but little is known about these risks in Kuwait and the Gulf Region. OBJECTIVE: To examine the dose-response relationship between 24-h average ambient temperatures and daily mortality risk in Kuwait. METHODS: We gathered mortality and meteorological data from 2010 to 2016 in Kuwait. We did a time-series analysis using a negative binomial distribution, and studied the lag effects of temperature with distributed lag non-linear models. RESULTS: A total of 33,574 all-cause non-accidental deaths were analyzed. The relationship was shown to be non-linear. Overall relative risks of death comparing the 1st percentile (10.9 °C) and the 99th percentile (42.7 °C) to the optimum temperature were 1.67 (1.02-2.73), and 1.65 (1.09-2.48), respectively. Cold effects persisted for 9 days, while the effects of hot temperatures were the highest at lag 0 and only persisted for a week. Adjusting for PM10 and ozone did not change the temperature-mortality estimates. CONCLUSION: Our findings show evidence that there is a statistically significant positive association between temperature extremes and mortality in Kuwait. The evidence has significant implications in assessing climate vulnerability and provides insight into environmental challenges in an inherently hot and arid region.

Postnatal depressive symptoms in women with and without antenatal depressive symptoms: results from a prospective cohort study.

Evidence exists that the risk factors for depression in the antenatal and postnatal period may differ, but only a handful of studies looked at depression longitudinally. The aims of this study were (1) to estimate the prevalence of postnatal depressive symptoms in Kuwait where data about postnatal depression are scarce and identify its determinants and (2) to compare these risk factors between women who had experienced antenatal depressive symptoms and those that did not. Data collected in the TRansgenerational Assessment of Children's Environmental Risk (TRACER) Study in Kuwait were used in this analysis. The sample was restricted to the 1348 women who answered the Edinburgh Postnatal Depression Scale (EPDS) both antenatally and postnatally. The prevalence of postnatal depressive symptoms, defined by an EPDS score ≥ 10, was 11.7%. Overall, antenatal depressive symptoms were the strongest determinant of postnatal depressive symptoms. Multivariable logistic regression analysis showed that in women with depressive symptoms in pregnancy, having a lower household income was the most significant risk factor for postnatal depressive symptoms. Among women without antenatal depressive symptoms, those who had lower income, were Kuwaitis, experienced other problems in pregnancy such as perceived stress, PTSD symptoms and social isolation, and those who delivered a boy had higher odds of postnatal depressive symptoms. Antenatal depressive symptoms and other psychosocial characteristics can predict postnatal depressive symptoms. Therefore, maternal mental health issues should be detected during the antenatal period and support should be provided in order to lower the risk of postnatal depression and its sequelae.

Depressive symptoms and comorbid problems in pregnancy - results from a population based study.

OBJECTIVE: To estimate the prevalence of antenatal depressive symptoms, identify relevant risk factors, and assess comorbid mental health problems, among pregnant women enrolled in a population based study. METHODS: This was a secondary analysis of data collected from 1916 pregnant women who participated in the TRansgenerational Assessment of Children's Environmental Risk (TRACER) study in Kuwait, and had answered the Baseline Questionnaire and completed the Edinburgh Depression Scale (EDS). Logistic regression models were used to examine the association of depressive symptoms with baseline socio-demographic characteristics and psychosocial indicators. RESULTS: The prevalence of antenatal depressive symptoms, using a cut-off of EDS score ≥ 10, was 20.1%. Depressive symptoms were reported more by women of lower family income and had self-reported history of depression prior to pregnancy, with women in the third trimester having higher odds of antenatal depressive symptoms compared to those in the second trimester. Pregnancy-related anxiety, higher perceived stress levels, and post-traumatic stress disorder symptoms were comorbid with the presence of depressive symptoms. CONCLUSION: The findings showed that one in five pregnant women in Kuwait experiences antenatal depressive symptoms and that these symptoms are comorbid with other mental health problems. Screening for antenatal depression and providing support to pregnant women should be considered.

Birth Outcomes in a Prospective Pregnancy-Birth Cohort Study of Environmental Risk Factors in Kuwait: The TRACER Study.

BACKGROUND: Rapid development and westernisation in Kuwait and other Gulf states have been accompanied by rising rates of obesity, diabetes, asthma, and other chronic conditions. Prenatal experiences and exposures may be important targets for intervention. We undertook a prospective pregnancy-birth cohort study in Kuwait, the TRansgenerational Assessment of Children's Environmental Risk (TRACER) Study, to examine prenatal risk factors for early childhood obesity. This article describes the methodology and results of follow-up through birth. METHODS: Women were recruited at antenatal clinical visits. Interviewers administered questionnaires during the pregnancy and collected and banked biological samples. Children are being followed up with quarterly maternal interviews, annual anthropometric measurements, and periodic collection of biosamples. Frequencies of birth outcomes (i.e. stillbirth, preterm birth, small and large for gestational age, and macrosomia) were calculated as a function of maternal characteristics and behaviours. RESULTS: Two thousand four hundred seventy-eight women were enrolled, and 2254 women were followed to delivery. Overall, frequencies of stillbirth (0.6%), preterm birth (9.3%), and small for gestational age (7.4%) were comparable to other developed countries, but not strongly associated with maternal characteristics or behaviours. Macrosomia (6.1%) and large for gestational age (23.0%) were higher than expected and positively associated with pre-pregnancy maternal overweight/obesity. CONCLUSIONS: A large birth cohort has been established in Kuwait. The collected risk factors and banked biosamples will allow examination of the effects of prenatal exposures on the development of chronic disease in children. Initial results suggest that maternal overweight/obesity before pregnancy should be targeted to prevent macrosomia and its associated sequelae of childhood overweight/obesity.