Lessons learnt from the first wave of COVID-19 in Damascus, Syria: a multicentre retrospective cohort study

Abstract

Objectives: The decade-long Syrian war led to fragile health infrastructures lacking in personal and physical resources. The public health of the Syrian population was, therefore, vulnerable to the COVID-19 pandemic, which devastated even well-resourced healthcare systems. Nevertheless, the officially reported incidence and fatality rates were significantly lower than the forecasted numbers.

Design: A retrospective cohort study.

Setting: The four main responding hospitals in Damascus, which received most of the cases during the first pandemic wave in Syria (i.e., June-August 2020).

Participants: One thousand one hundred eighty-four patients who were managed as inpatient COVID-19 cases.

Primary and secondary outcome measures: The records of hospitalised patients were screened for clinical history, vital signs, diagnosis modality, major interventions and status at discharge.

Results: The diagnostic and therapeutic preparedness for COVID-19 was significantly heterogeneous among the different centres and depleted rapidly after the arrival of the first wave. Only 32% of the patients were diagnosed based on positive reverse transcription-PCR tests. Five hundred twenty-six patients had an indication for intensive care unit admission, but only 82% of them received it. Two hundred fifty-seven patients needed mechanical ventilation, but ventilators were not available to 14% of them, all of whom died. Overall mortality during hospitalisation reached 46% and no significant difference was found in fatality between those who received and did not receive these care options.

Conclusions: The Syrian healthcare system expressed minor resilience in facing the COVID-19 pandemic, as its assets vanished swiftly with a limited number of cases. This forced physicians to reserve resources (e.g., ventilators) for the most severe cases, which led to poor outcomes of in-hospital management and limited the admission capacity for milder cases. The overwhelmed system additionally suffered from constrained coordination, suboptimal allocation of the accessible resources and a severe inability to informatively report on the catastrophic pandemic course in Syria.

Keywords: COVID-19; international health services; organisational development; public health.

Figure 1

Diagnosis modalities flow chart. The flow of the chart does not reflect a chronological order but logistic availability of the diagnostic investigations. Green cells represent patients diagnosed or treated as diagnosed with COVID-19 infection. Red cells depict mortality during hospitalisation in each group after excluding patients discharged on their own request or transferred to other hospitals (n=1065). CP, clinical presentation; CXR, chest radiograph; RAT, rapid antigen test; RT-PCR, reverse transcription-PCR.

Figure 2

Management and mortality flow chart. Red cells depict mortality during hospitalisation in each group after excluding patients discharged on their own request or transferred to other hospitals (n=1065). ICU, intensive care unit; MV, mechanical ventilation; NIV, non-invasive ventilation.