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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 4  |  Page : 333-340

Role of basic healthcare structures in strengthening the COVID-19 response strategy: Improving quality of care project in oujda-angad prefecture in Eastern Morocco


1 LAPABE Laboratory, Department of Biology, Faculty of Sciences, University Mohamed Ier, Oujda, Morocco
2 Higher Institute of Health Nursing and Technical Professions Oujda (Annex Nador), Ministry of Health Morocco, Morocco

Date of Submission23-Dec-2021
Date of Decision06-Jul-2022
Date of Acceptance24-Jul-2022
Date of Web Publication12-Oct-2022

Correspondence Address:
Saliha Mharchi
LAPABE Laboratory, Department of Biology, Faculty of Sciences, University Mohamed Ier, Oujda
Morocco
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsm.jnsm_162_21

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  Abstract 


Introduction: In June 2020, the Oujda-Angad prefecture recorded the highest number of positive cases at the regional level. In this context, our objective is to improve the quality of care for COVID-19 patients through the implementation of an effective response strategy. Material and Methods: This monocentric, retrospective study was carried out in two health care facilities: A Regional Hospital Center AL FARABI, and a first-level health center (Health Centers), in order to record the number of patients treated by each facility. In addition, we report in parallel the different decisions issued by the persons in charge during this same period since the registration of the first case COVID-19 March 2020 until January 2021 in the prefecture of Oujda-Angad, capital of the eastern region of Morocco. Results: The response strategy installed was based on a set of decisions, of which the involvement of the first-line health centers was the main action. Since their involvement, these centers have responded by performing from November to May 2020 (9457 tests) for suspected cases, of which 4760 (50%) were detected positive. 3956 of them were managed at home (83%), and 682 (14.32%) were referred to regional hospital facilities. The case fatality rate recorded in hospitals was 2.56% (122 cases). Conclusion: Different strategies have been put in place at the level of the prefecture of Oujda-Angad in its response plan, based on international experiences (containment and mitigation strategy) and local decisions (involvement of frontline facilities in the care of COVID-19 patients). The epidemiological situation has been stabilized, and the number of cases has decreased because of these actions.

Keywords: COVID-19, eastern region, health system, morocco, primary health care facilities, response strategy


How to cite this article:
Mharchi S, El Mostafa B, Maamri A. Role of basic healthcare structures in strengthening the COVID-19 response strategy: Improving quality of care project in oujda-angad prefecture in Eastern Morocco. J Nat Sci Med 2022;5:333-40

How to cite this URL:
Mharchi S, El Mostafa B, Maamri A. Role of basic healthcare structures in strengthening the COVID-19 response strategy: Improving quality of care project in oujda-angad prefecture in Eastern Morocco. J Nat Sci Med [serial online] 2022 [cited 2022 Nov 30];5:333-40. Available from: https://www.jnsmonline.org/text.asp?2022/5/4/333/358409




  Introduction Top


Since its emergence, coronavirus (COVID-19) disease has been a global health problem with serious health, security, economic, and social implications.[1] The causative agent is SARS-CoV-2, a strain with high contagious potential that emerged in Wuhan, China, in December 2019.[2] The seriousness of this crisis lies in the speed and scale of its spread and the mutations of the virus. With this in mind, the public authorities have reorganized and adapted their modes of governance and operations through the change of management tools and the implementation of a new design to deal with the negative impact of this pandemic.[3]

According to WHO data, (2020) 78% of countries have a preparedness and response plan in place. However, only 66% of countries have a clinical referral system in place to manage patients with COVID-19.[4]

On a global scale, a range of emergency measures have been put in place to limit the spread of the pandemic, including containment, border closures, and cessation of commercial, industrial, tourist, cultural, and sporting activities.[5]

In this sense, five strategies have been identified at the global level, oscillating among the excursion strategy, the elimination strategy, the suppression strategy, and no basic strategy [Figure 1].[6]
Figure 1: Number of positive cases recorded between January and March 2020

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The choice of strategy is not necessarily a fixed decision. Sweden, for example, initially appeared to pursue a version of mitigation with the intention of achieving herd immunity and then switched to a suppression strategy.[6]

In China, Taiwan, and France, the response plan was based mainly on the application of elimination and containment measures with the closure of the whole country. Institutional measures were accompanied by sanctions and certifications to limit individual mobilization.[6],[7] On the other hand, Sweden and Australia have preferred a mitigation strategy based on the encouragement and leadership of people, without resorting to recommendations to close schools, workplaces, and public transport.[7] Other countries, such as South Korea, have advocated the elimination strategy through active testing to stop the chains of transmission.[8] The implementation and success of these strategies were secondary to two contextual factors: The institutional measures put in place and the cultural orientations of the people.[7]

In Morocco, since the announcement of the pandemic COVID-19 in March 2020, and trying to protect an already fragile health system, drastic measures of hygiene and collective and individual safety were adopted on a large scale, including opting for general containment and the mandatory wearing of masks.[9]

However, the lifting of the containment on June 11, 2020, after the Feast of the Sacrifice (the latter of the two official holidays which are celebrated within Islam) caused an epidemic fallout with a considerable increase in the number of positive cases to herald the entry into a second wave more ferocious than the previous one.[10] As of October 23, 2020, the state Moroccan government reported a total of 190426 cases, 15717 cures, and 3205 deaths, corresponding to a case fatality rate of 1.7%.[11]

The eastern region, specifically its capital, the prefecture of Oujda-Angad, recorded the largest proportion of cases (53.25%) and a case fatality rate of 2.32%, higher than the national average.[11] Faced with this particularly difficult situation, those in charge of the health system at the regional levels were obliged to develop a response strategy and issue decisions and recommendations in order to control the situation and limit contamination in the city of Oujda. COVID-19 patient management quality improvement project was carried out to determine whether the decisions made as part of a response strategy were effective and contributed to the management of the pandemic risk in the prefecture of Oujda-Angad. To this end, we described the situation and the evolution of the number of positive cases, cited with chronology all the decisions issued, and finally quantified the role of the health centers involved in this management process and evaluated their impact on the control of the situation [Figure 1]: Strategic choices for responding to COVID-19 and other pandemics.[6]


  Materials and Methods Top


This monocentric, retrospective study was carried out in two health care facilities: The Regional Hospital Center (RHC) AL FARABI and the six primary health care establishments (PHCE) designated as COVID-19 centers, in order to record the number of patients treated by each facility. We also report in parallel the different decisions issued by the persons in charge during this same period since the registration of the first case COVID-19 on March 1, 2020 until January 31, 2021 (11 months) in the prefecture of Oujda-Angad, capital of the eastern region of Morocco. The authors of the present study collected data from notified patient registers. The researchers are health professionals who have gone through this experience, and every action or decision has been faithfully recorded. The data collected was calculated as a frequency or percentage.

The study describes the situation of COVID-19 a priori and a posteriori, i.e., before the involvement of the PHCEs (8 months) and after (3 months) while analyzing the evolution of cases in each period. Our analysis seeks to assess the impact of these decisions on the stability and flattening of the positive case curve.

Ethical considerations

Our research work does not involve direct interviews with human beings. However, case statistics and incidence rates have been collected from databases. For this reason, no institutional request to the ethics committee institutional review board was made (not sought/obtained). On the other hand, the ethical rules were respected during the data collection: Request for authorization to access the data from the Regional Director of Health (Minister's Representative to the Eastern Region), respect for anonymity, nondisclosure of file secrets, and retention of data by the author.


  Results Top


A/Organizational scheme and response strategy for the Eastern Region of Morocco during the 1st and 2nd waves of the pandemic [Scheme 1] and [Scheme 2].



The first wave of the pandemic (March-April-May 2020)

At the beginning of the outbreak of COVID-19, RHC-Al Farabi was the only facility that received infected patients. Our data analysis focuses on the evolution of hospitalizations during this first wave, exactly between the months of March and June 2020.

Due to the wide application of rigorous measures during these 3 months (March-April-May 2020) [Scheme 1], the epidemiological situation in the prefecture of Oujda-Angad was well controlled and the number of hospitalizations recorded decreased with respect to (0,53, 13 cases). At the end of May, the prefecture of Oujda-Angad was declared free of all COVID-19 cases [Figure 1].

During the same period, the rate of admission to intensive care increased from 2% in April to 15% in March, and the case fatality rate increased from 8% to 38% [Figure 2]. During this period, the RHC set up only one part of its structure (Pole A) to receive infected patients while ensuring continuity of care in the rest of the establishment. To this end, the care circuits were well identified, and medical and nursing staff were redeployed to ensure that COVID-19 activities were carried out, divided between screening (carrying out tests) and care of hospitalized patients. Those in charge at the national and local levels ensured that COVID-19 services were supported throughout the crisis (circulars and care protocols), trained professionals online, and provided the structure with the necessary personal protection, hospitalization, and diagnostic equipment.
Figure 2: Evolution of the case fatality rate and admission to intensive care between March and May 2020

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Second wave of the pandemic (June-July-August- September)

A rise in hospitalizations was recorded from the month of June 2020, the first lifting of confinement that allowed movements within the country and between cities after the Feast of the Sacrifice, in addition to noncompliance with hygiene measures and distancing between individuals.

The number of hospitalizations increased six-fold from July to September, from 73 cases to 442 [Figure 3]. This considerable increase heralds the beginning of a second wave that is more ferocious than the first. Similarly, the rate of admission to intensive care doubled between June and September, rising from 7% to 12%, which justifies the decrease in the case fatality rate from 8% in June to 5% in September [Figure 4]. In October, following the increase in the number of hospitalizations (510 patients), the health authorities were obliged to adapt the entire hospital to take charge of only the COVID-19 patients and to create an additional number of intensive care and hospitalization beds. In spite of this decision, the number of beds was insufficient in relation to the important flow of patients, and the capacity of both the intensive care unit (84 cases) and the inpatient beds was quickly reached [Figure 5]. This situation had a negative impact on the management of patients who did not receive adequate care according to their state of aggravation, which had a clear impact on the case-fatality rate, which reached 10% in October compared to 6% in June 2020 [Figure 6].
Figure 3: Positive cases and admissions to intensive care between June and September 2021

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Figure 4: Positive cases and lethality rate between June and September 2020

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Figure 5: Number of patients in intensive care compared to hospitalizations between October 2020 and January 2021

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Figure 6: Lethality rate between October 2020 and January 2021

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Despite all of the recommendations to increase the number of staff, beds, and equipment, the situation has not improved as of November 2020. As a result, the situation is more fateful, with 425 hospitalizations and 129 deaths (30% lethality rate) recorded in November 2020.

Faced with this tragedy, health officials considered reorganizing the local system of patient care in order to reduce tension and burden on the hospital and avoid as many deaths as possible. To that end, a countermeasure involving the mobilization of primary health care facilities (PHCFs) employee stock purchase plan to assist hospital structures in overcoming this wave has been implemented.

B/purpose and role of primary health care facilities

On November 26, 2020, the energy savings performance contracts responded to the new mission delegated to them to manage suspected cases. This reorganization of the care circuit (mandatory passage through the centers) would allow health professionals in hospitals to focus on the most critical cases, to limit the patients' flow, to free up beds, to perform early detection of suspected cases before complications arise, and to keep track of benign cases at home.

In addition to these missions, the role of educating and informing the population on good hygiene practices to limit transmission is also. For this reason, the new reorganization of the care circuit for COVID-19 patients provides that all suspicious cases must go through the said centers, and no access is available for hospitalization unless through a referral form established by the primary care physician [Scheme 3].



In this regard, six of the 34 health centers in the prefecture of Oujda-Angad have been designated COVID-19 centers, which are Al FATH, MAKCESS, SAADA, JORF LAKHDAR, RIAD, and NAJD. Besides, these centers are distributed geographically in an equitable manner to meet the needs of the entire population of the prefecture of Oujda-Angad by ensuring accessibility nearby. Consequently, the populations under the responsibility of these centers have been transferred to proximal structures to ensure that their needs for care, vaccination, consultation, promotion, and rehabilitation are not neglected; this was the initial role of the front-line centers. Then a set of measures were put in place and decisions were taken.

  • A reorganization within these centers was envisaged to identify the circuits, and to set up reception areas and transfer modalities
  • Equipping the facilities with screening and management equipment, protection and disinfection materials
  • Ensuring the availability of the necessary COVID-19 treatment for patients
  • Coordination by the emergency medical assistance service between the two levels, ambulatory and hospital
  • Training of professionals on the protocols of care and technical sheets
  • Implementation of procedures for the management of waste from care activities with infectious risks
  • Establishment of an on-call list to ensure continuity of care and services
  • Motivation of health professionals through bonuses.


January 29: Start of the COVID-19 vaccination campaign as a health measure: The frontline teams (health professionals and law enforcement) were the first to benefit from this preventive measure [Figure 3]. From February onwards, the curve gradually flattened out thanks to the response strategy implemented and the commitment of professionals to deal with this epidemic. The hospital resumed its normal activities, and only three COVID-19 health centers were kept open [Scheme 3].

C/impact of primary health care facilities mobilization

From November 2020 to May 2021, 9457 tests were performed, and more than 50% of them were screened positive. (4760) The majority (80%) of positive cases were managed and treated at home according to the national management protocol with daily telephone follow-up by a scientific committee [Table 1].
Table 1: Total number of cases taken from November to June 2021

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The most tests were carried out between November 2020 and January 2021 (3 455 tests). Since February 2021, the number of positive cases decreased significantly, with monthly totals never exceeding 500. Simultaneously, the case fatality rate curve increased between the months of October 10% and November 30%, but after the integration of frontline centers, this curve began to fall from the month of January 26%. It should be noted that the 33% case fatality rate recorded in December is only the accumulation of cases hospitalized upstream [Figure 7].
Figure 7: Evolution to the lethality rate between August 2020 and February 2021

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  Discussion Top


To the best of our knowledge, this study is the first of its kind in the eastern region and in Morocco as well. It describes the strategy pursued throughout the pandemic to combat SARS-CoV-2 and the critical role of PHCFsin this response. This data will serve as a reference for other countries and will help develop effective pandemic strategies. The COVID-19 pandemic was a time of innovation for scientists seeking to understand and rapidly develop an effective vaccine, but it was also an experience for managers and officials struggling to put in place plans and response strategies to eliminate transmission. The Department of Health was the first agency to be affected by this ordeal, and the World Health Organization's survey confirmed that these disruptions were more marked in low-income countries.[12] To this end, different strategies to combat the disease and its spread have been put in place by governments. In general, five public health response strategies are identified [Figure 1]:

  • Exclusion strategy: Includes maximum vigilance actions to eliminate the disease, i.e., Pacific Islands of Iceland
  • Elimination strategy: Based on actions that exclude the disease and eliminate transmission; containment, active surveillance of cases, preparation of health care facilities, control of gatherings, and education of populations
  • Suppression strategy: Aims at implementing progressive and targeted vigilance actions to reduce the number of cases, as in most European countries and in the North of America
  • Mitigation strategy: Includes actions that aim to flatten the peak, avoid overloading health services and protect the vulnerable, e.g., Sweden
  • No strategy: A largely uncontrolled pandemic example to low income countries.[6],[13]


These strategies were effective for some high-income countries (Singapore and Australia),[14],[15] but other countries would need to adopt stricter laws to implement these actions (Iran and Italy).[16],[17] The typical approach in high-income countries (such as North America and Europe) has been a “suppression strategy,” to flatten the epidemic curve sometimes after the initial use of a “mitigation strategy”[6] [Figure 1].

Morocco, as an African country with a health system already weakened by inadequacies and dysfunctions, was put to the test in the face of a health crisis of pandemic nature. However, our country, through its early response strategy, has so far avoided a health disaster. Several recommendations and guidelines have been put in place by the government. Since March 2020, a strategy of elimination has been applied throughout the country: Strict confinement with education of the population via audio-visual communication. In addition, a reorganization of the hospital structures of isolation to increase the capacity of the resuscitation services and the endowment of these services in medicine, materials, and devices is necessary during this crisis. These response actions had a positive impact on the control and transmission of the COVID-19 virus and were more effective in the clinical management of infected patients.[13] However, the response differs from one country to another and within the same country each region may adopt its own plan according to its context and predispositions (California and New York, USA).[13]

In our case, the prefecture of Oujda-Angad, which ranks first at the level of the Eastern region with a population of 0.58 million inhabitants, has experienced an exponential increase in infected cases from June 2020. To this end, actions were implemented, whose objective was to ensure effective coordination and good risk management. Initially, the first wave (April 2020) was discreet, given the reduced number of hospitalizations that did not exceed 50 patients, thanks to the strict containment measures that were adopted by the country very early (early March 2020).

Containment was the only option applied over the world, including North African countries.[6],[18] The effectiveness of this option seems to have a relationship with the earliness of its application, as was demonstrated in the comparative analysis carried out on the evolution of cases between Morocco, Algeria, and Tunisia.[18] While the second wave (June 2020) was more challenging in terms of deaths and infected cases. The surge of hospitalized cases is related to noncompliance with physical and social distancing measures and hygiene rules. This behavior was well noted in Cameroon, which experienced an outbreak following the failure to comply with physical distancing measures and the mandatory use of masks.[19] Similarly, New Zealand experienced the population control failure after 3 months with no cases in the community, but the outbreak was brought under control and elimination status was restored after extensive testing, contact tracing, data analysis, and risk assessment.[6] In this regard, during September 2020, hospitals were overwhelmed with increased hospitalized cases, prompting national and local health officials to take urgent countermeasures as part of a mitigation strategy.

Decision 1

convert the entire hospital to a COVID-19 service by adding inpatient and resuscitation beds. Italy has taken this action, converting sports fields into isolation zones and constructing additional isolation beds.[5]

Decision 2

Mobilization of PHC in the management of infected cases, thereby concretizing ASTANA's vision of primary health care's pivotal role in the health-care system.[20] Since the beginning of the epidemic, many countries have included primary care facilities in their response: Canada,[21] Belgium,[22] and France.[23]

This reorganization of the care circuit towards the PHCFs showed these results in the decrease of hospitalizations on one hand (a decrease of 68% between November and December 2020), and the number of complicated cases in intensive care on the other hand (a 45% regression between November and December 2020). In addition, it reduced the flow of patients to the regional hospital and gave time to the medical staff to take care of the hospitalized patients and provide them with the necessary care, the effects of which were clear in the decrease of cases in intensive care between November and December 2020. On the other hand, active screening of all suspected cases in the PHC, home follow-up of positive cases (80% of total positive cases), and timely referral of complicated cases have all contributed to the outbreak's abolition in the prefecture of Oujda-Angad.

In spite of knowing that 45% of the patients had chronic pathology, a risk factor that can negatively affect the vital prognosis in the event of delayed diagnosis, 80% of the infected cases were declared cured without complications. Moreover, according to the literature, the number of tests performed reflects the screening capacity of a country, which depends on the sensitivity of the case definition and the case or mass screening strategy.[8] Thus, this action is central during an epidemic, the more we test; the more we have the chance to detect even asymptomatic cases and to break the chain of transmission.[8]

In Morocco, 2 877 502 tests have been performed since October 11, 2020, which corresponds to 0.08 test per inhabitant or 871 541 tests per one million inhabitants.[24] The positivity rate in the prefecture of Oujda-Angad was 50%, exceeding the critical threshold of 5% and the alert threshold of 10%.[24] This increasing trend may suggest a stronger progression of the virus than assumed by the reported case numbers. Thus, the prefecture of Oujda-Angad' strategy has allowed them to flatten the curve of positive cases and overcome the wave by following different advantageous decisions and recommendations, mainly based on suppression and elimination. On the other hand, the analysis of Baker. et al.(2020) demonstrated the opposite by arguing that countries that follow an elimination strategy (notably China, Taiwan, Australia, and New Zealand) have lower mortality rates than countries in Europe and North America that are pursuing a mitigation and suppression strategy.[6] Regardless of the strategy adopted by countries, the key is the outcome in terms of virus elimination, case reduction, and mortality. This experience identified the importance of PHC in the health care system, the need to improve hospital infrastructure, and the importance of public participation in the implementation of the measures taken.


  Conclusion Top


The COVID-19 pandemic exacerbated the flaws in the healthcare system, but it also highlighted the critical role of PHC in this time of crisis. The reorganization of the care circuit towards these facilities allowed for a reduction in hospitalizations, a decrease in case fatality rates, and allowed healthcare professionals to focus on important and organizationally critical patients. At the preventive level, its role in early detection of suspected cases through testing has reduced prognostic delays, optimized case management in the home, allowed for continuous surveillance and timely referral of complicated cases, and enabled extensive participation in the vaccination campaign. These actions enabled the improvement of governance, the assurance of quality care, the limitation of suspected cases, hence, the stabilization of the situation. This experience will serve as a response model for other provinces or countries, and the lessons learned can be used at any time during a similar crisis. Well-functioning health systems are a source of health security, stability, and prosperity.

Interest and limitation of the study

Our work presents certain strong points that reside essentially in the originality of the subject and the scarcity of studies conducted in the Maghreb countries, particularly in Morocco, on health response strategies. However, this study has certain limitations. Indeed, the analytical and descriptive aspects of the study could be reflected in the content, which becomes more exhaustive. Our vision of explaining and detailing the events emanates from our conviction that the reader should be as close as possible to the reality experienced and draw lessons from it. The monocentric aspect of this study does not allow the generalization of the results, but will serve as a model of Benchmark for the decision makers of health services.

Acknowledgement

We would like to thank the Regional Director of Health for the Eastern Region for facilitating access to the data and statistics related to our article. Our thanks also go to all the health professionals of the two health structures, the cornerstone of our system, who have preserved no effort to be successful in the implementation of the response strategy despite all the organizational constraints.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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