key: cord-270956-qpe5u43q authors: amouzou, agbessi; kante, almamy; macicame, ivalda; antonio, adriano; gudo, eduardo; duce, pedro; black, robert e title: national sample vital registration system: a sustainable platform for covid-19 and other infectious diseases surveillance in low and middle-income countries date: 2020-09-24 journal: journal of global health doi: 10.7189/jogh.10.020368 sha: doc_id: 270956 cord_uid: qpe5u43q nan t he covid-19 pandemic raises the critical need for effective national surveillance systems, capable of detecting the onset of outbreaks rapidly but also sustainable platforms for mortality and cause of death (cod) surveillance that allow rapid data collection to address questions during and after epidemics or crises. these pre-, during, and post-outbreak functions are necessary for effective responses. they are particularly needed in resource-constrained countries where health systems are limited. low-and middle-income countries (lmic) struggle to establish exhaustive surveillance platforms at community level for national response in real time. systems such as integrated disease surveillance and response are mostly limited to health facilities. beside, they do not generate standard mortality and cod indicators over time. many organizations, including the world health organization, react to the covid-19 by developing tools to support countries with rapid mortality surveillance strategies. however, a significant challenge is the crucial lack of comparable historical data allowing an assessment of excess mortality due to the covid-19 [1, 2] . well-designed sample vital registration systems (svrs) offer rapid, and sustainable platforms for achieving the need for real-time data and the ability to nest data collection to respond to rising questions [3] . registration system: a sustainable platform for covid-19 and other infectious diseases surveillance in low and middle-income countries sample vital registration systems (svrs) provide strong and sustainable platforms for continuous monitoring of mortality, causes of death, diseases and population health at national and subnational levels that low-and middle-income countries can reliably and quickly develop and implement to monitor outbreaks and pandemics such as cov-id-19. an svrs uses a national random sample of communities to continuously track population and demographic events to measure multiple indicators including mortality and cod. it constitutes a second alternative to exhaustive monitoring of the entire country population, as in civil registration and vital statistics (crvs) systems. an svrs fulfills the features needed in a multi-surveillance system. first, with most deaths occurring at the community level, it is an ideal platform for generating recent nationally representative mortality and causes-specific mortality rates. it allows an understanding of the seasonal patterns of deaths over time, thus permitting the measurement of any excess mortality due to temporary crises, as well as changes in cod patterns by socio-demographic characteristics. second, the system is often structured and staffed from communities to national levels, with long-term staff, making it ready for addition of data collection modules. third, the system is ready for drawing subsample for specific purposes, including surveillance of diseases. the clusters will be well-established platforms for determining important epidemic transmission patterns, needed for adequate response. the rapid growth in digital solutions offers a real-time data collection system solution, allowing rapid data access and analysis. svrs complements and reinforces other existing systems such as crvs, routine health information systems, and household survey programs, and can serve to assess the accuracy, completeness and quality of these systems. an svrs can be developed and operationalized within a short period. however, to date, few lmics are implementing it, as most continue to rely exclusively on household surveys. india initiated an svrs in the 1970s and now covers 7597 clusters with over 7 million population. it produces reliable national and state representative mortality and cod statistics [4] . the bangladesh srvs system was initiated in the 1980s in 103 communities and progressively increased to 2012 communities, covering about 700 000 people [5] . china's svrs integrated since 2013 two separate parallel systems and collects data from 601 clusters and about 324 million people [6] . in africa, mozambique launched an svrs in 2017 with 700 clusters, about 900 000 people, producing mortality and cod indicators [7] the government of mozambique is implementing the svrs with technical assistance from the johns hopkins university [8] . using innovative digital tools, the system is set up for real-time data production, analysis, and release. the government is mobilizing the system to support its response to the covid-19 pandemic, starting from the epicenter province in northern mozambique. svrs systems have not received needed attention because the international community has hitherto focused on promoting household surveys. the emergence of outbreaks, such as the ebola epidemic and the covid-19 pandemic, which call for more permanent monitoring systems, provides further impetus for investment in sustainable and multi-purpose national srvs. svrs complements and reinforces other existing systems, including civil registration and vital statistics (crvs), health information systems, and household surveys. photo: from comsa project showing interview of a mother with a baby. data are collected directly on a phone (from the authors' own collection, used with permission). author contribution: aa wrote initial draft, aa, im, aa, eg, pd, reb reviewed and edited the draft. all authors reviewed and approved the manuscript. the authors completed the icmje unified competing interest form (available upon request from the corresponding author). all authors are funded by the bmgf for the implementation of the comsa project in mozambique. revealing the toll of covid-19: a technical package for rapid mortality surveillance and epidemic response mortality surveillance during the covid-19 pandemic sample registration of vital events with verbal autopsy: a renewed commitment to measuring and monitoring vital statistics report of bangladesh sample vital statistics an integrated national mortality surveillance system for death registration and mortality surveillance comsa. available: www.comsamozambique.org correspondence to: agbessi amouzou, phd johns hopkins bloomberg school of public health institute for international programs department of international health 615 key: cord-326590-ocd9ojnc authors: boggio, andrea title: human rights and global health emergencies preparedness date: 2020-04-07 journal: journal of global health doi: 10.7189/jogh.10.010334 sha: doc_id: 326590 cord_uid: ocd9ojnc nan t he spread of infectious disease is always ranked high as a global threat. it features prominently among the list of urgent health challenges for the next decade, issued in early january 2020 by who [1] . the emergence of the 2019 novel coronavirus in the hubei province in china, is a reminder of global health vulnerabilities. since the 2002-03 sars outbreak, the global health community has engaged in substantial efforts to be prepared to handle outbreaks such as the ongoing covid-19 outbreak. a milestone achievement is the international health regulations, a binding instrument of international law that entered into force on 15 june 2007 intending to assist countries to work together to save lives and livelihoods endangered by the international spread of diseases. the regulations target the response to the international spread of disease as well as the core surveillance and response capacities of countries. additionally, they give certain powers to state parties (ie, closing ports, airports, and ground crossings) that governments cannot ordinarily exercise. yet, these powers must be exercised with caution, in accordance with their relevant national law and obligations under international law, including human rights law, and upon considering scientific principles, available scientific evidence of a risk to human health, and who' s guidance or advice [2] . as habibi and colleagues point out, the intention of the regulations is that "countries should not take needless measures that harm people or that disincentivise countries from reporting new risks to international public health authorities" [3] . yet, even when done correctly, in line with the scientific knowledge, and full respect of international human rights law, emergency handling and planning is not sufficient to manage the spread of infectious disease. to be effective, emergency handling and planning must be carried out in an environment in which new treatments -such as drugs and vaccines developed ad hoc to stop the outbreak -can be developed rapidly and delivered efficiently to all persons affected. this was not the case in the urban area of wuhan, which suffered from health care delivery problems at the time of the outbreak. in a matter of days, the local authorities conclude that the health care facilities were insufficient to handle the emergency and announced plans to build from scratch not one but two new hospitals. these construction projects were completed in just a few days and accommodate 2300 patients. similar problems are experienced by other nations as covid-19 spreads. this is extraordinary. but it should not be. strengthening the health care infrastructure should have been planned for a while. the failure to do so is a cautionary tale of insufficient efforts to protect global health. the global health community must thus push countries harder to keep strengthening their research capacity and basic health care infrastructure along with emergency handling and planning efforts. human rights play a key told in pushing countries hard. they are a powerful tool to act as they create legal obligations that go beyond the immediate and pressing needs of emergency preparedness and handling. international human rights law is critical as it transforms global health best practices in legal duties. the leading treaty in this area is the covenant on economic, social and cultural rights, which recognizes the right to health (art. 12) and the right to science (art. 15) [4] . while the right to health is often invoked in the global health arena -although only to a limited extent in the context of global health preparedness -the links between right to science and global health have received very little attention (with some exceptions in the area of drug-resistant tb policies) [5] . this provision imposes on state parties the duty to ensure that scientific knowledge is produced and translated into applications, such as drugs and vaccines, that are beneficial to rightsholders. for this, substantial public funds must be allocated on a regular basis to r&d. the covenant also includes the duty to ensure a sufficient degree of scientific literacy in the population so that, when vaccines become available, patients readily embrace new treatments. human rights advocacy in this area is about to become more effective due to the recent approval by the un committee on economic, social and cultural rights of a general comment on the relationship between science and economic, social and cultural rights [6] . when the official version of the general comment is published (likely in april 202), this instrument will provide a clear framework of state obligations under article 15 of the covenant. in fact, the draft that was made public makes the case. it stresses that governments have "a positive duty to actively promote the advancement of science" and must fund basic and applied research (para. 50). to this, it adopts the recommendation of the scientific advisory board of the united nations [7] that "all countries, including the poorest, to invest at least 1% of their gdp on research and urged the most advanced countries to spend at least 3% of their gdp on research and development" (para. 51). furthermore, it states that governments must approve "policies and regulations which foster scientific research, allocating appropriate resources in the budgets and, in general, creating an enabling and participatory environment for the conservation, development and diffusion of science and technology" (para. 50). the general comment on science and economic, social and cultural rights is an important addition to the human rights that are traditionally invoked in the global health arena. most importantly, it reinforces the power of human rights law to frame the global health discourse not only in terms of public health necessity to act but also in terms of a legal duty to act. the global health community should not forget that ensuring good science and the attainment of the highest level of health are human rights and an indispensable dimension of global health policy. only when cultivated and guaranteed as a human right, science provides the support needed to fight global health emergencies. photo: image by miroslava chrienova from pixabay. strengthening their research capacity and basic health care infrastructure must be incorporated in epidemic preparedness. human rights law provides the necessary legal support to hold countries accountable for these efforts. authorship contributions: ab is the sole author. the author has completed the icmje form (available upon request from the corresponding author), and declares no conflict of interest. world health organization. urgent health challenges for the next decade geneva: world health organization do not violate the international health regulations during the covid-19 outbreak funding for tuberculosis research-an urgent crisis of political will, human rights, and global solidarity scientific advisory board of the united nations secretary-general. the future of scientific advice to the united nations, a summary report to the secretary-general of the united nations from the scientific advisory board. unesco key: cord-296445-0spqe4r2 authors: supady, alexander title: consequences of the coronavirus pandemic for global health research and practice date: 2020-06-11 journal: journal of global health doi: 10.7189/jogh.10.010366 sha: doc_id: 296445 cord_uid: 0spqe4r2 nan the discussion primarily focuses on clinical treatments and public health responses in high-and middleincome countries. but, due to the pandemic spread of the virus, we must expect further spreading of the disease to countries with weak public health and health care systems, which may easily be overwhelmed by the occurrence of many patients within a short period. we must consider the potential impact of current travel and movement restrictions on global health interventions and research projects. by nature, global health practice and research heavily relies on international exchange and free international movement of persons and goods. travel restrictions, if upheld for a longer time, may interfere with project plans and interventions. vulnerable individuals and populations may suffer from interruptions in the provision of health services. ongoing projects and interventions may be paused, planned projects may be postponed -this can affect the lives and the well-being of many people. the risk management of the covid-19-pandemic in the context of global health research and practice not only needs to take into account microbiological and epidemiological knowledge and expertise on the characteristics and spread of sars-cov-2, but also social and economic impacts and challenges in different countries and settings. on the one hand, the resumption of temporarily interrupted projects may endanger people by unintended the coronavirus pandemic challenges ongoing and planned global health research and practice activities throughout the world; project planners and responsible persons must cautiously balance out the risks of interruption and resumption of the projects in the respective settings. transmission of the virus from researchers, aid workers and other project staff to people in vulnerable settings. nearly all populations within the focus of global health research or interventions must be considered at a particular risk. clinical data suggest that elderly and immunocompromised persons are at a very high risk of infections and poor outcomes when infected with sars-cov-2, the high contagiousness of the virus puts people in densely populated settings, such as refugee camps, at a particular risk [3] . on the other hand, disease control measures successfully implemented in high-income countries, may not be the preferred nor the adequate solution for all countries and settings. sustained lockdowns, first imposed on the city of wuhan in china and later announced in almost all countries seriously affected by the pandemic, may not be rational everywhere, considering practicability, proportionality and potential side-effects. proportional and context-adequate measures need to reflect the age-structure of the populations and further risk-factors for developing serious or fatal courses of covid-19. young people are at a lower risk for developing serious covid-19 than elderly, whereas non-communicable diseases such as hypertension, diabetes, pulmonary or heart disease, that are prevalent in many low-and middle-income countries, are known risk factors for unfavorable courses of covid-19 [4, 5] . therefore, information on the age-structures and diseases and risk-factors in different communities and societies need to be included critically in the decision-making and project-planning process. equally important, though, are the economic and social implications of the interventions. in many resource-constrained settings, people work as day-laborers or they live from subsistence economy; many live in densely populated urban settings. under these conditions, sustained lockdowns, movement and contact restrictions are not only impossible to upheld, but they will also have serious side-effects such as further impoverishment and hunger, which also endanger the health and survival of the people. project managers and people in charge must very cautiously discuss and evaluate the balance of risks of extended interruption and continuation before resuming the projects. this evaluation process may yield different results and consequences for different settings. photo: kutupalong rohingya refugee camp in bangladesh. densely populated refugee camps are highly vulnerable to the spread of coronavirus (from the author's own collection, used with permission). there will be no one-size-fits-all-solution -different local circumstances will require different approaches and security mechanisms. the current situation may be considered a chance for restructuring the global health system, establishing more resilient and sustainable structures. the more we learn about the spread and contagiousness of sars-cov-2 the better we can develop strategies to resume project work while providing safety to people at risk. the availability and the use of personal protective equipment (ppe) and the possibility to wash or sterilize hands regularly need to become routine in global health projects. the coronavirus pandemic may thus help to reconsider and redesign the basic structure and foundations of global health research and practice. recently, the contradiction between frequent international air travel of global health professionals and researchers and efforts of mitigation of climate change has been discussed [6] . this discussion may well be extended to questions of disease prevention in light of international spread of pathogens. further and more extensive strengthening of local capacities and empowerment of human resources in many low-and middle-income countries that are in the focus of global health activities will help to decrease the demand of deployment of foreign staff. long distance air travel for short meetings should be reduced. instead, long term exchanges of staff can strengthen institutional ties and help to guarantee consistency in the projects. technology may also play an increasing role in global health projects -video calls and conferences should be used more often in project planning and team exchange. therefore, strategic planning in international cooperation and global health should also keep an eye on the spread of digital technologies and the availability of broad-band internet connections -mobile or landline network based. the ongoing coronavirus pandemic puts particularly strains on the global health system. we may use this exceptional situation to reconsider and restructure the system for the better of global population health and well-being. clinical features of patients infected with 2019 novel coronavirus in wuhan coronavirus disease (covid-2019) situation reports 2020 available host susceptibility to severe covid-19 and establishment of a host risk score: findings of 487 cases outside wuhan clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study clinical course and risk factors for mortality of adult inpatients with cov-id-19 in wuhan, china: a retrospective cohort study air travel for global health: flying in the face of sustainable development? key: cord-284353-f7zkp9cf authors: sheikh, aziz; sheikh, asiyah; sheikh, zakariya; dhami, sangeeta title: reopening schools after the covid-19 lockdown date: 2020-06-27 journal: journal of global health doi: 10.7189/jogh.10.010376 sha: doc_id: 284353 cord_uid: f7zkp9cf nan w ith nationwide school closures currently operating in 191 countries, the united nations educational, scientific and cultural organization (unesco) has estimated that 1.6 billion (90.2%) students are currently out of primary, secondary and tertiary education (henceforth schools) as a result of the global covid-19 lockdown [1] . these restrictions have been introduced to help maintain physical distancing and have contributed to the stabilising incidence of sars-cov-2 infections and resulting covid-19 hospitalizations and deaths now being witnessed in many parts of the world. these measures have the potential however -particularly if prolonged -to result in major detrimental effects on the health and well-being of children and adolescents. in the absence of a robust evidence base on lockdown exit strategies, we consider the range of options being taken globally to reopen schools with a view to informing the formulation of national plans. it is now well recognized that children and young people can be asymptomatic carriers of sars-cov-2 or develop covid-19 [2] . although covid-19 tends to be less severe in children and adolescents, and thankfully relatively few students have died of the condition, a key policy concern has been that young people may be important community reservoirs for the transmission of the virus to household members. emerging evidence however suggests that children are not super-spreaders of the virus and in fact may not be significantly contributing to spreading the virus [3] [4] [5] . a recent (unpublished) systematic review concluded that children and young people under 20 are 56% less likely to contract sars-cov2 from infected individuals than adults this suggesting they may play a smaller part in transmission than originally thought [6] . it appears therefore that sars-cov-2 behaves differently in this respect from many other viral respiratory infections that are responsible for upper respiratory tract infection (urti) and influenza. a recent systematic review on school closures, which drew primarily on the evidence base from severe acute respiratory syndrome (sars), concluded that around 2-4% of covid-19 deaths could be prevented as a result of school closures [7] . whilst there are still many unanswered questions in relation to children and covid-19, there is emerging evidence that they are at lower risk of acquiring and transmitting the infection than adults and at markedly lower risk of developing severe disease. we present a synopsis of currently available options to enable children to return to school as safely as possible. although an important public health intervention in the context of epidemics/pandemics, school closures can have adverse effects on children and adolescents in multiple ways [8] . not only are they missing out on their education -with potential lifelong implications -children from deprived backgrounds are at increased risk of hunger from missing free school meals, domestic violence, and the poverty that ensues from parents being unable to work because of daytime caring responsibilities. these consequences are felt most by the most vulnerable members of society. the longer lockdowns continue, the greater the risks to the well-being of young people. what then are the options for reopening schools? the key consideration is how to enable the safe return of as many learners and staff as possible whilst maintaining physical distancing. table 1 summarises the approaches that are being employed internationally. we briefly consider these four broad approaches in turn. the first is to maintain school closures until a vaccine can be administered at sufficient levels to achieve herd immunity or a treatment is found. optimistic estimates suggest that it will be at least 12-18 months before a vaccine is developed and deployed [9] . given the substantial negative effects of school closures, it seems most unlikely that this will be a tenable strategy for most countries in the medium-to longer-term. a second approach is to reopen schools completely once the effective reproduction number (r t ) is well below 1. whilst this has the benefits of resuming normal schooling, it runs the risk of triggering further peaks in infection. the magnitude of this risk will become clearer as the epidemiology of sars-cov-2 transmission in young people becomes better understood. the approach being employed in denmark whereby children are being taught outdoors and maintaining 2m physical distancing through for example the rearrangement of desks, in an attempt to reduce droplet and contact transmission, could potentially be replicated in a number of other countries [10] . the third strategy is to partially reopen schools such that there are fewer students at school at any one point in time thereby enabling physical distancing. this has been the most popular school lockdown exit strategy employed thus far with students typically attending for part of the week or in shifts. finally, a hybrid approach whereby inperson classes are live-streamed to those who for example need to be shielded because of underlying chronic disease or have the capacity to study from home. this is however clearly dependent both on having high speed internet access and appropriate devices (personal computer, laptop or tablet) at home. the final three options all need to be accompanied by developing surveillance capability and the ability to rapidly test, trace and isolate suspected covid-19 cases and their contacts. these also requires capacity for regular deep cleaning of schools to minimise the risk of contact transmission. it is clear that there are no easy answers. whichever approach countries choose to take, it is crucial that there are carefully planned evaluations of the approaches employed to help develop a robust evidence base to guide decision making for this and future pandemics. united nations educational, scientific and cultural organization. covid-19 educational disruption and response covid-19 infection in children children are not covid-19 super-spreaders: time to go back to school no evidence children are covid-19 'super spreaders', says hiqa. ir times children are unlikely to be the main drivers of the covid-19 pandemic-a systematic review children appear half as likely to catch covid-19 as adults school closure and management practices during coronavirus outbreaks including covid-19: a rapid narrative systematic review united nations educational, scientific and cultural organization (unesco) the pandemic pipeline photos of danish children returning to school while staying six feet apart highlight the country's cautious approach to lifting its lockdown measures. business insider singapore authorship contributions: azs conceived this paper and commented critically on drafts of the manuscript. ass, zs & sd sourced the examples and jointly drafted the manuscript. all authors approved the final version of the manuscript. group. this work in no way represents the views of the scottish government. the authors have completed the icmje uniform conflict of interest form (available upon request from the corresponding author), and declare no further conflicts. key: cord-313904-745u0si8 authors: salimi, rasoul; gomar, reza; heshmati, bahram title: the covid-19 outbreak in iran date: 2020-06-11 journal: journal of global health doi: 10.7189/jogh.10.010365 sha: doc_id: 313904 cord_uid: 745u0si8 nan a ccording to the world health organization, as of april 21, 2020, 2 397 217 cases of coronavirus disease 2019 (covid-19), including 162 956 deaths, have been reported worldwide [1] . the outbreak began in iran after the detection of the first death associated with covid-19, on feb 19, 2020 in qom, a holy city in central iran. after a short period, covid-19 has widely spread in all other provinces in iran. as of april 21, 2020, of 330 137 tested patients, 80 868 people have been infected with covid-19. of them, 55 987 people have recovered, 3513 people are critically ill and 5031 people have died [2] . the formal announcement of the outbreak in iran has generated public panic and anxiety. the sudden explosion in the number of suspected cases of covid-19 in the first week in several provinces has overwhelmed some designated hospitals very quickly. medical personnel faced shortages of protective equipment, essential medications and care facilities. people rushed to the stores to purchase masks, gloves and disinfectants. this created a black market, which some hospitals had to rely on to provide the protective equipment. furthermore, fake news and misinformation have increased public anxiety. to respond to the outbreak, the headquarter for coronavirus combat and prevention has been established. the main measures, such as stopping mass gatherings, closure of educational institutes, national coordination with volunteers, civilian and military forces, national screening program, and social distancing led to shortage management to some extent. it had a potential to alleviate some of the public fear. although the measures that were implemented to control the outbreak, along with some half-measures, may have made it harder to control the disease. at the same time, they could affect the economy through long term and avoidable burden of covid-19. also, there was a question whether early stopping of the mass gatherings such as parliament election and restrict travel in qom could have acted to slow the spread of the disease through qom and into other cities. measures like the closure of schools, educational institutes, religious and sacred places (despite the opposition of some religious figures), and stopping mass gatherings -such as religious and sporting events -were the major pillar of the response to the outbreak. they caused reduction in the number of cov-id-19 super-spreading events in iran. authorities widely reminded the public of their role to control the outbreak. they strongly encouraged people to stay home and avoid social contact with family and friends. before the iranian new year festival, people were urged to strongly avoid familial gatherings and trips to celebrate the new year. most of the people followed these recommendations, but some ignored them. after the new year, on the 20th of march, 2020, some trips did occur and some people left the cities to visit their hometowns. although travelers were screened with thermal scanners at the points of entry and exit to those cities, this was not a guarantee that the possible importation of the disease to other cities and rural areas would be prevented. the national covid-19 screening program in iran is a successful measure of the response to the outbreak. significantly reduced the massive influx of cases to the hospitals and has decreased the potential infection exposures in hospitals by limiting unnecessary visits. also, it was so helpful in early detection of new cases and consequently early isolation and treatment. sired effect and lead to flattening the epidemic curve. however, is seems that new year holidays missed due to avoidable delays and the question remained -if stricter measures were launched before the new year, could they have been more effective in the control of the outbreak? as one of the main measures, the national screening program was implemented on march 17, 2020. it was set up to allow early detection, diagnosis, isolation, and treatment of the new cases, and to follow their contacts. the screening was performed by primary care providers or people themselves via website (https://salamat.gov.ir/) or a phone number (4030). screening was based on the questions about the symptoms of covid-19. suspected people were referred to special 16-hour medical centers and screened by the covid-19 response teams based on body temperature, spo2, respiratory rate, lung scanning (if available) and covid-19 diagnostic tests. subsequently, screened patients were isolated at home, at isolation centers or hospitalized in designated hospitals (figure 1) . this measure significantly reduced the massive influx of infectious cases to emergency departments and hospitals. but without widespread testing, the screening could not be so helpful in cutting down the transmission chain. the response to covid-19 outbreak in iran faces some challenges. two of the main challenges that suffered painfully during the outbreak were sanctions against iran and the circulating fake news and misinformation on social media networks. the us unilateral economic sanctions against iran and the further recent sanctionary measures [3] have restricted the import of essential goods. successful actions in stopping the outbreak required sufficient essential medicines and facilities. so, it was critical that sanctions and barriers to providing essential supplies to iran would be stopped, or to be postponed at least until in order to control the outbreak faster and efficiently in iran, social distancing must be more rigid, widespread testing must be performed to cutting down the transmission chain, and us unilateral economic sanctions must be restricted to import essential goods. the end of the covid-19 epidemic. on the other hand, fake news and misinformation imposed hardship on the health system. a fake news, "drinking alcohol has a protective role for covid-19" disseminated through multiple social media channels, caused more than 3000 cases of poisoning and more than 700 deaths associated with drinking fake alcohol to date [4] . effective communication will help eliminate fake news and promotion of appropriate behavior. so, authorities should pay more attention to social media networks. all interventions during the outbreak helped to flatten the curve of covid-19 cases in iran. with some half-measures, control of the outbreak will prolongate and new waves will be expected. some aspects of the response to the outbreak need more attention. first, the number of diagnostic tests is very low. therefore, the scope of the outbreak in iran cannot be traced. widespread testing must be performed to interrupt new transmission chains and keep clusters under control. second, early reduction of the restrictions by the government to avoid severe economic impact, along with the fact that the prolonged duration of staying home had put many people at risk of depression and anxiety, can both lead to increased risk of premature end to restrictions. this can cause further waves of infection with varying intensity and duration. third, the government has promised people financial support. some promises have been postponed. delay to receiving timely support might lead to more stress and anxiety and can prevent effective action. finally, medical facilities shortages, prolonged disease outbreak, and the further waves of infection can increase the mortality risk among health care workers, more reporting of physical and mental exhaustion, irritability, poor work performance, reluctance to work, and burnout. world health organization national committee on covid-19 epidemiology. daily situation reports on coronavirus disease 2019 (covid-19) in iran office of the spokesperson. sanctions on entities trading in or transporting iranian petrochemicals. us department of state key: cord-297823-0d3lsjjp authors: čivljak, rok; markotić, alemka; capak, krunoslav title: earthquake in the time of covid-19: the story from croatia (crovid-20) date: 2020-05-02 journal: journal of global health doi: 10.7189/jogh.10.010349 sha: doc_id: 297823 cord_uid: 0d3lsjjp nan o n the hundredth day since the who was notified of the first cases of "pneumonia with unknown cause" in china, the covid-19 pandemic, caused by sars-cov-2, has spread throughout the world to 195 countries with over 1.5 million cases and more than 85 000 deaths [1] . in early january, when we had just learned that a newly discovered disease was spreading in faraway china, only a few thought it would soon be coming to croatia. nevertheless, by february, when the epidemic was rapidly spreading in northern italy, it was already quite likely that it would not bypass croatia, and on 25 february 2020 the first case of covid-19 was registered in our country [2] . the government of the republic of croatia has established the national civil defense headquarters in order to raise the level of preparedness of all the competent authorities, protect the health of croatian citizens and coordinate all the services in the battle against sars-cov-2 in croatia. the deputy prime minister and minister of the interior was chosen to lead the headquarters, whose members are the director of the croatian institute of public health, the director of the croatian institute of emergency medicine, and the director of the dr fran mihaljević university hospital for infectious diseases (uhid), who is also the president of the croatian society for biosafety and biosecurity. after the daily meetings, the headquarters issues press releases. together with other public services, all the health care institutions were quickly mobilized in preparation for the battle against the covid-19 epidemic, with the uhid taking the leading role, from the establishment of quarantine to being declared the national hospital for covid-19. the minister of health issued the decision to proclaim the threat of a covid-19 epidemic as an administrative measure, which does not indicate the degree of the threat but permits the minister to mobilize all the resources in the health care system, redeploying id physicians, other health care workers (hcws) and equipment, in order to improve the administration of the health care system. unfortunately, what few had thought possible has come to pass. an infectious disease has transformed social and economic relations, as well as humanity as a whole, entering and altering every pore of society. colleges and schools have closed their doors, students are attending classes from home, via television and computers, the majority of the public sector employees are working from home, while some, regrettably, have lost their jobs. the churches have also closed their doors. at the end of the fourth week of the epidemic in croatia, a total of 206 cases had been confirmed, with 49 newly diagnosed on 21 march 2020. when we thought that nothing worse could happen, on 22 march 2020, the citizens of zagreb, the capital of croatia, home to a quarter of the total croatian population, were awakened at 6:24 am by an earthquake of 5.5 magnitude on the richter scale, followed in the next 24 hours by 57 aftershocks. due to extensive property damage, several hospitals had to be evacuated, including the uhid, where there were 86 patients at the moment, including 22 covid-19 patients, 15 of whom were in the icu. this additional misfortune has jeopardized the safety of us all, especially the most vulnerable members of our society: children, the elderly and the sick. a total of 27 persons were injured during the earthquake, of whom one, sadly a 15-year-old girl, died of her injuries. we as hcws were expected to remain clear-headed, gather all our strength, knowledge and skills, and provide our patients with the best of what was possible, and sometimes even the impossible. but we also remember the scene around our hospital buildings, where the old and young, staff and patients, corona-positive and negative, were scattered on the grass and the parking lot, shivering from the cold and fear. nevertheless, we survived that, too, and we will continue to survive, even when faced with greater challenges. we have demonstrated and proven that we cannot do without one another: physicians without nurses, patients without hcws, hcws without non-medical and support staff, parents without children, and children without parents. in addition to property damage, we were quite apprehensive that the earthquake would accelerate the spread of the covid-19 epidemic in croatia since the earthquake, which left many homeless and fearful of earthquakes to come, triggered migrations to other parts of the country. however, six weeks since the first covid-19 case and three weeks after the earthquake, only 1650 cases have been registered in we have learned that we cannot do without one another: physicians without nurses, patients without hcws, hcws without non-medical staff, parents without children, and children without parents. conscientious public compliance with social distancing and other preventive measures have successfully prevented the covid-19 epidemic from spreading in our country. croatia (figure 1) , with 25 deaths (cfr of 1.5%) [3], making croatia a country with one of the lowest rates of covid-19 infection in europe: 343 cases and 5 deaths per million inhabitants [4]. the subtitle of the previously cited article by čivljak et al. [2] , what's next?, warns of the looming danger from infectious diseases and the need for ongoing surveillance, because respiratory infections such as coronavirus diseases (sars, mers and covid-19) are major threats to humanity. nevertheless, no one expected that a second misfortune, the earthquake, would occur during this pandemic in our little country. all hcws, including physicians, nurses, technicians, laboratory personnel, caregivers and other staff who come into contact with patients, are being directly or indirectly exposed to the infected and sick, which places them at risk. at the uhid, among 691 employees, only two have acquired sarc-cov-2 infection in the post-earthquake period: one nurse and one ancillary worker. on the national level, no increase in the incidence of covid-19 was experienced in the post-earthquake period, as shown in figure 1 . moreover, owing to the chronic shortage of medical personnel throughout the entire health care system, particularly now when the demands are increasing, we are being expected to make great sacrifices in order to provide the best possible care to all citizens. an additional burden is that 216 hcws in croatia have covid-19, while another 562 are in self-isolation at the moment. all of them are currently unable to perform their regular professional duties and the number may soon increase. the minister of health has stated that the health care system is not in jeopardy for now and the ministry is redeploying hcws in order to fill the most crucial positions. this third coronavirus epidemic underscores the need for the ongoing surveillance of infectious disease trends throughout the world. however, in combination with a natural disaster, such as earthquake, the risk for increasing the number of the infected, as well as outbreaks of other infectious diseases, is higher. as shown in the systematic review by suk et al., cascading effects of post-disaster outbreaks are possible after earthquakes, such as outbreaks of salmonella, chickenpox, or other infectious diseases in general [5] . by now, due to a well-organized public health system and coordinated outbreak response, croatia has overcome the current challenges, including extensive damage to hospitals, shortage of hospital personnel, and disruption of supply chains. we hope that everything done so far will provide the basis for stopping this epidemic in croatia and mitigating the damage done from the covid-19 epidemic and the recent earthquake. covid-19); situation report -80 the third coronavirus epidemic in the third millennium: what' s next? key: cord-288352-qt4ugr95 authors: ajari, esther ejiroghene; ojilong, daniel title: assessment of the preparedness of the ugandan health care system to tackle more covid-19 cases date: 2020-08-18 journal: journal of global health doi: 10.7189/jogh.10.020305 sha: doc_id: 288352 cord_uid: qt4ugr95 nan c oronaviruses are human and animal pathogens causing mainly respiratory infections but their potential to cause serious diseases, even pandemics, with the right conditions have been predicted by several studies [1] . for example, in a 2017 briefing to the united states (us) president, the us military predicted the possibility of such an outbreak [2] . the coronavirus disease 2019 (covid-19), a global pandemic caused by the novel sars-cov-2 virus, confirms the accuracy of such predictions. this disease which originated from wuhan, china gave the rest of the world some window of opportunity to prepare to tackle a possible widespread outbreak. the ugandan health care system, for example, had an 81-day pre-outbreak opportunity and still has a post-outbreak opportunity since it only has 413 confirmed covid-19 cases, a relatively low figure, as at may 30, 2020 [3] . did the system utilise the preoutbreak opportunity? is the system utilizing the post-outbreak opportunity? these are the questions this paper aims to address. uganda's doctor-patient and nurse-patient ratio is approximately 1:25 000 and 1:11 000 respectively [4] . this is way below the who recommended doctor-patient ratio of 1:1000. also, even though there is no official who recommended nurse-patient ratio, 1:11 000 is still inappropriate considering that most developed health care systems have a doctor:nurse ratio of 1:2-5. in addition, the latest report, on staffing levels in public health facilities in uganda, pegged the figure at 72% [5] . this is below the acceptable standard. also, the country's health sector allocation is 8.9% of the national budget (for the 2019/20 fiscal year), down from 9.2% (in the 2018/19 fiscal year) [6] . this budget is 6.1% lower than the acceptable health sector allocation according to the abuja declaration of 2001. in uganda, there are 2 national referral hospitals, 4 specialized government hospitals, 14 regional referral hospitals and hundreds of lower rung hospitals. of these, only one of the national referral hospitals, one of the specialized government hospitals and the 14 regional referral hospitals have been designated as covid-19 treatment sites by the ministry of health as at may 30, 2020. most of these facilities, especially the regional referral hospitals, are ill equipped to handle covid-19 cases. some experts project that 500 cases could completely overwhelm the health assessment of the preparedness of the ugandan health care system to tackle more covid-19 cases esther ejiroghene ajari 1,2,3 , daniel ojilong 4,5 the ugandan healthcare system might soon be overwhelmed by the increasing number of covid-19 cases. system [7] . also, there are some reports that the country's institutional quarantine system exposed quarantined individuals to further risk of infection [8] . the arguments, in support of these reports, are that these individuals mixed up and shared the same toilets and bathrooms, and some of them stayed in the quarantine facilities beyond the mandated 14-day quarantine period despite testing negative for the virus several times. this was, reportedly, due to non-compliance with quarantine guidelines, according to the ministry of health. many of these individuals tested positive for the virus later on. the uganda human rights commission also reports receiving several complaints of lack of access to food and drugs from some of these individuals. furthermore, some studies report that 5%-7% of patients sick with covid-19 requires intensive care unit (icu) admission [9] . but a 2018 study reported the availability of only 55 functional icu beds in 12 health care centers [10] . however, according to media reports, the recently refurbished and reopened mulago specialized hospital increases to 102 the total number of icu beds in the country. however, the hospital has no functional website for confirmation of this information, and the ministry of health has not confirmed this either. thus, the 2018 study is a more reliable data source. taking into account uganda's population size, of about 40 million people, this report shows that there are only 1.3 icu bed per million population, implying a very limited access to intensive health care in the country. moreover, 83% of these icu facilities are located in kampala city and 75% in private hospitals [10] . the uneven distribution of these facilities further impedes access to intensive health care. thus, it is logical to assert that uganda's health care sytem might truly be overwhelmed if the number of confirmed covid-19 cases increases. furthermore, there is paucity of studies documenting the total number of ventilators in uganda but it is likely that the number is either lower or the same with that of icu beds. despite the above limitations in the health system, uganda, so far, seems to have done comparatively better than its neighbors in keeping the number of confirmed cases down with no registered covid-19 related deaths as at may 30, 2020 [3] . in addition, 17% of confirmed cases have been cured and discharged as at this date [3] . however, for two reasons, this situation report might not represent the true epidemiological picture of the outbreak in uganda. first and foremost, as at may 30, 2020, only 96 825 covid-19 confirmation tests have been done so far in the country [3] . this implies that lesser than 0.25% of uganda's population has been tested for the virus. also, uganda has the world's youngest population (approximately 78% of ugandans are below 30 years of age), and several studies have indicated that the coronavirus infection in young people are mostly asymptomatic and with a low death incidence rate. therefore, since, most covid-19 cases in the country, has been among males, aged between 20-49 years, there is reason to suspect that the zero death incidence from the disease might not be due to the efficiency of the ugandan health care system. the best time for massive investment into the ugandan healthcare system was before the pandemic, the second best time is now. photo : graphic representation of cumulative covid-19 confirmed cases and recoveries in uganda plotted against the number of days after the index case confirmation. retrieved june 3rd, 2020 (source: https://covid19.gou.go.ug/). severe acute respiratory syndrome coronavirus as an agent of emerging and reemerging infection exclusive: the military knew years ago that a coronavirus was coming. the nation moh: covid-19 information portal cost of sacking 1,000 doctors. the observer ministry of finance p and ed. national budget framework paper fy 2019/20 -fy 2023/24 covid 19: health workers likelihood to get infected is high crisis looms at douglas villa quarantine centre. daily monitor clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study assessment of the current capacity of intensive care units in uganda; a descriptive study uganda did not completely neglect its window of opportunity for health care system strengthening, as necessitated by the pandemic. this is evident from the "no-death from covid-19" situation in the country. however, it could have done better in upgrading several health care system development metrics in preparedness for the outbreak. this is, therefore, a call to ugandan healthpolicy makers to heavily invest into the development of the country's health sector and implement innovative and efficient strategies for managing more cases of the disease as they arise.funding: the authors receive no funding for the development of this paper.authorship contributions: both authors contributed equally to the development of this paper. the authors completed the unified competing interest form (available upon request from the corresponding author), and declare no conflicts of interest. key: cord-343172-9o4p0q0q authors: huynh, toan luu duc title: the covid-19 containment in vietnam: what are we doing? date: 2020-04-15 journal: journal of global health doi: 10.7189/jogh.10.010338 sha: doc_id: 343172 cord_uid: 9o4p0q0q nan t his viewpoint provides an explanation from the public health policies of vietnamese government to contain the contagious disease with regard to covid-19 pandemic. a combination of an early lockdown, increase in "virality" of the health information, encouragement in health declaration, regulation for wearing mask in the public, and country' s unity have been the effective ways to cope with this deadly virus in vietnam, a developing country, which became the first country to halt the sars spread successfully in 2003. obviously, many people will ask the question of why we should care about vietnam in the fighting campaign against covid-19. before answering this question, i will stress that an outbreak of severe acute respiratory syndrome (sars), a fatal infectious disease, became a global emergency in 2003. at that time, vietnam became the first country to halt the sars spread successfully. thus, vietnam is of interest to the epidemic health policies as a case study of successful epidemic containment. the covid-19 pandemic was confirmed to have spread within vietnam on january 23, 2020. at the time of writing this article, there were no confirmed deaths in this country. from january 23, 2020 to february 13, 2020 (ie, 21 days), the country only recorded 16 confirmed cases. in the next 22 days, there were no new cases in vietnam. although the numbers of confirmed cases are now increasing daily, the rate of the increase remains below 15% since the first case was detected. the vietnamese government declared that covid-19 is initially under the control. in addition, the risk perception of covid-19 among vietnamese citizens is higher than the average [1] . this viewpoint will discuss potential reasons for these findings, which might be helpful for many countries to implement as the appropriate policies. especially, the director of world health organization, tedros adhanom, appreciated the timely policies and regulations which were implemented in vietnam. figure 1 summarizes the timely policies to cope with the spread of the covid-19 pandemic. when the first case was found in vietnam, the vietnamese government chose to close the border with china by canceling all filghts from wuhan. besides, the following actions were made based on the global situation, shown in figure 1 . in summary, the government had considered the covid-19 pandemic as a serious concern from the beginning. they primed the vietnamese citizens to become more cautious about the worst-case scenario of the major public health crisis. this is a clear lesson for many european countries, which overlook the covid-19 at the first stage. therefore, vietnam did well to use 'the golden time' to contain the spread of the novel coronavirus. while the recent study by la et al. [2] emphasized the role of official news from the newspaper, socioeconomic aspects, and academic research, this viewpoint will offer more insights about the "nudging behaviors", which are widely applied in behavioral and health economics to call people to do things right. instead of causing the mass panic, the vietnam authorities launched the covid-19 video going viral as a prevention message. the song, a collaboration between vietnam' s health ministry and musician, has been viewed more than thirty-two million times on youtube [3] . the song evokes healthy practices to wash the hands and not to touch the face regularly. after that, the song went "viral" and was broadcasted on american television and on many european channels. this was also a part of the national campaign to deliver health policy messages to people. instead of forcing the citizens with the compulsory regulation, the vietnam government did well to disseminate nudging-behavior policies, which can increase the "virality" of the information [4] . also, the vietnamese authorities continuously informed the citizens through many methods, such as mobile phone messages. according to the ministry of information and technology, about 6 billion messages have been sent to the vietnamese citizens to raise their awareness about the hand-washing, self-quarantine, self-checking health, etc. notably, on march 19, 2020, there were 1 040 000 downloads of the mobile application "ncovi", then 146.741 health declaration forms (paper-pencils), and 378 000 online declarations via vietnam health declaration application. it meant that the use of modern technology in the fight against the covid-19 in vietnam was well executed. moreover, this viewpoint will also briefly discuss the role of wearing medical masks in vietnam. the recent study of huynh [5] found that vietnamese people wear mask because of the high risk perception. on march 16, 2020, the vietnamese government requested that everyone should wear face masks when going into public spaces to protect themselves and others. it was not only an encouraging message, but also the regulation applied to every citizen. although world health organization recommended that only positively-confirmed patients should wear medical masks to mitigate covid-19 transmission, it seems that in several asian countries mask adoption seems to correlate with slowing down the pace of covid-19 transmission. china, south korea and vietnam are all good examples. finally, the campaign of fighting the covid-19 is not the sole duty of the vietnamese government. this is the first time since the unification after the vietnam war that the whole vietnamese community, including military, scholars, businessmen, and many different classes in our society, have participated in different types of contributions. there are many universities and student dormitories which are used as the quarantine areas. the soldiers are encouraged to become public servants to supervise those who come back from the epidemic areas in quarantine areas. the businessmen are raising the movement to donate photo: the compulsory quarantine area for vietnamese citizens who came back from overseas (from the author's own collection, used with permission). vietnam does not look at covid-19 as the challenge in violation of our citizens' freedom. what we are learning from the event is the importance of our country's unity. lands and provide financial incentives to fight against the covid-19 outbreaks. our last point means that vietnam does not look at covid-19 as the challenge in violation of our citizens' freedom. what we are learning from the event is the importance of our country' s unity. therefore, according to the international survey conducted by the 12 different institutions, including harvard, cambridge, iese, and warwick university, vietnam is ranked the second position that participants trust their country' s government to take care of its citizens [6] . although the covid-19 pandemic is a complex global challenge, the timely actions conducted by the vietnamese authorities are appreciated based on behavioral economics [7] . the world is accelerating to find a way to cope with the covid-19 outbreaks; therefore, there are enormous studies in different fields to contribute to the covid-19 containment, including the virology, public health, epidemic studies and others. at that time, these studies must trade-off thoroughness against speed, at least to some extent. therefore, although this view is based on a single country, our perspectives are intended to prioritize the effective policies which are done by a developing country, vietnam. the covid-19 risk perception: a survey on socioeconomics and media attention policy response, social media and science journalism for the sustainability of the public health system amid covid-19 outbreak: the vietnam lessons using gossips to spread information: theory and evidence from two randomized controlled trials the more i fear about covid-19, the more i wear medical masks: a survey on risk perception and medical masks uses measuring worldwide covid-19 attitudes and beliefs combining behavioral economics and infectious disease epidemiology to mitigate the covid-19 outbreak acknowledgement: i thank the anonymous referee, and rachael atherton for helpful comments and support.disclaimer: all authors contributed in their individual capacities and the views that are expressed in this commentary do not necessarily reflect the views of their respective organizations. authorship contributions: the single author fully contributes to this study. the author has completed the icmje unified competing interest form (available upon request from the corresponding author), and declares no conflicts of interest. key: cord-312029-xsojdbdk authors: sham, lauren; ciccone, ornella; patel, archana a title: the covid-19 pandemic and community health workers: an opportunity to maintain delivery of care and education for families of children with epilepsy in zambia date: 2020-10-02 journal: journal of global health doi: 10.7189/jogh.10.020329 sha: doc_id: 312029 cord_uid: xsojdbdk nan t he covid-19 pandemic has had a significant impact on the delivery of care for chronic neurological diseases globally. as requirements for physical distancing have led to restrictions on the availability of health care services, many countries have adapted methods of telemedicine to sustain care access for patients [1] , while making difficult decisions surrounding which aspects of direct clinical care can be deferred and the time span acceptable for delaying chronic medical care [2] . for people with epilepsy, issues such as determining criteria for what constitutes urgent management, managing the risk of increased seizures in the setting of illness, as well as ensuring a stable medication supply, have all been raised as critical concerns during this pandemic [3] . in resource limited settings, there is a paucity of neurologic care at baseline due to limited availability of specialists, diagnostics, and treatment options [4] . during infectious disease outbreaks, such issues become compounded as resources become even more constrained, and alternate care delivery through telemedicine is a limited option at the primary care level in the developing world. in africa, the vast majority of people are low-income and live in crowded homes where physical distancing is impossible, and transport to obtain essential medications may require use of crowded public transportation. in such situations, risk of disease transmission while accessing health care during a pandemic is of extremely high concern [5] . as a result, continued adherence to anti-seizure medications can become difficult for people with epilepsy, compounding the strain on the system by resulting in potential exacerbation of seizures [6] . however, the workforce in africa does provide a unique opportunity for care delivery through community health workers (chws). chws have been a longstanding method of mobilizing people from within a community with varying the covid-19 pandemic and community health workers: an opportunity to maintain delivery of care and education for families of children with epilepsy in zambia a community health worker (chw) program is effective to improve healthcare utilization and health education for pediatric epilepsy in resourcelimited regions. knowledge bases to deliver basic medical screening and education to those with limited access to clinical care, working through challenges due to differing belief systems, limited knowledge base, geographic barriers, and stigma. through this system, there has been proven success in improving health seeking behaviors in the community, particularly in conditions such as hiv and epilepsy [7] . in 2019, we launched a chw program for pediatric epilepsy in the linda township of zambia, a region approximately 16 km south of the capital city of lusaka. linda compound is a very low income community, comprising of a population of approximately 25 000 people living in fewer than 4000 households total, with only 2000 people holding formal employment. our program was created in partnership with neri/i4life clinic, which had an existing chw program for pediatric nutrition. the initial goals of our epilepsy chw program were to improve adherence to treatment for children with epilepsy and provide education to reduce associated stigma and improve overall inclusion in society. we combined a training program for local health providers on epilepsy clinical management with the chw program, and 10 chws were provided training on the basics of seizures, medication adherence, seizure safety in the home, and psychosocial issues, and were prepared for their role as a connection to the clinic for these families of children with epilepsy. the chws were then connected with 40 families, whom they visited twice monthly. they were 4 months into the program when the covid-19 pandemic led to restricted activities in zambia. in early march 2020, warnings of covid-19 on ongoing clinical care were emerging quickly across africa. during this time, a monitoring site visit of our chw program was in process. as zambia reported the first positive cases during that time and initial restrictions for covid-19 prevention were implemented by the government, it became clear that adaptation of all services would be required. while necessary for safety, our team struggled like many others in this time with the potential impact on care and risk to our patients' neurologic health. with this in mind, we re-evaluated how the existing infrastructure created from this program could be used in this time. neri clinic, like many rural health centers in the region, is a small building with crowded spaces where people wait in close proximity to see clinicians and collect their medications on a monthly basis. even if solely present for the purposes of medication collection, families would be at high risk for exposure. as adherence to medication is essential for seizure management, we wanted to ensure that families did not have gaps in coverage during this time period. we quickly realized that our chw program provided an excellent opportunity to deploy individual workers to households for medication distribution, mitigating the risk of families congregating in the clinic. personal protective equipment and hand sanitizer were provided for each chw to decrease their own exposure risk. in addition, an educational component surrounding covid-19 could be delivered to each household by the chws. while the zambian ministry of health had provided guidance on appropriate hygiene and social distancing measures, many of our clients are illiterate and have limited access to information. the chws were able to deliver up to date education on covid-19 and social distancing information to families in a reliable manner and in the local dialect with opportunity for discussion. adaptations to make this process safer included reducing visits from twice monthly to once monthly, and incorporating basic screening questions (with history obtained by chws, then reviewed by providers at the clinic) to determine if an urgent clinic visit was necessary, all in efforts to limit exposure but not compromise care for the child's epilepsy. antiseizure medication supply gaps, which have been exacerbated by resource shifting and increased purchasing restrictions, have been supplemented by the ngos supporting the program. this chw program has provided a unique opportunity to support the linda compound community in zambia during the covid-19 photo: photo provided by sally bell-cross of neri clinic/i4life clinic (used with permission). during an infectious disease pandemic such as covid-19, when healthcare access is further restricted, chw programs present a unique model for providing healthcare access for chronic medical conditions in regions where telehealth is not a feasible option. pandemic. it has been possible to implement a system in which access to essential medications could continue to be provided in a safer manner, and children who were in need of urgent clinician visits could be specifically identified, to reduce overall outpatient volumes and allow spacing of visits for physical distancing. additionally, we could continue to provide education and support to our families, in alignment with our original objectives for the program. during this time of crisis, we have seen the chws in our program continue to be motivated to help their community and continue to see the positive impact our program has on the participating families and the linda community as a whole. beyond our original goals, this program has provided a unique model of health care access for a chronic medical condition during times of infectious disease outbreaks requiring physical distancing, which is feasible to implement in a developing region where telehealth mechanisms are limited. the coronavirus disease 2019 crisis as catalyst for telemedicine for chronic neurological disorders invited commentary: is pediatric epilepsy surgery "elective"? considerations in the era of covid-19 keeping people with epilepsy safe during the co-vid-19 pandemic epilepsy: a public health imperative. geneva: world health organization limiting the spread of covid-19 in africa : one size mitigation strategies do not fit all countries adherence to treatment in patients with epilepsy: associations with seizure control and illness beliefs correspondence to: archana a. patel, md mph 300 longwood avenue fegan 9 department of neurology, division of epilepsy boston children's hospital boston the authors would like to thank the community health workers and coordinators at neri/i4life clinic in linda compound, zambia, with special thanks to prisca kalyelye, harriet chongo and sally bell-cross. we also would like to thank lisa and mitch brown for their generous donation to row foundation supporting this work. the authors completed the icmje unified competing interest form (available upon request from the corresponding author), and declare no conflicts of interest. key: cord-284128-3obc5k5u authors: ahmed, ali; dujaili, juman; sandhu, anisha kaur; hashmi, furqan khurshid title: concerns of hiv-positive migrant workers in covid-19 pandemic: a call for action date: 2020-09-08 journal: journal of global health doi: 10.7189/jogh.10.020342 sha: doc_id: 284128 cord_uid: 3obc5k5u nan t he unaids set a goal to eradicate the acquired immunodeficiency syndrome (aids) epidemic worldwide by 2030 [1] . the global coronavirus disease 2019 (covid-19) pandemic is deemed to pose a greater risk to patients with chronic diseases, including those that are affected by human immunodeficiency virus hiv/aids [2] . during this time, it is crucial to properly identify hiv/aids patients to ensure that they continue to receive timely and equitable access to health care and health support as they are increasingly vulnerable to covid-19 consequences [2] . covid-19 emerged in china at the end of 2019 spreading rapidly to infect over 213 countries and territories worldwide resulting in more than 11 500 000 confirmed cases and 500 000 deaths as of 6th july 2020 [3] . while it has been realized that patients with chronic conditions require additional health support to mitigate risk of covid-19, it is also important to recognise the vulnerability of chronically-ill migrant populations whose health issues are often neglected [2] . this is especially of concern in hiv/aids-infected migrant populations who avoid deportation and are considered illegal as immigration laws in various countries do not permit carriers of hiv infection to work or stay regardless of their legal status [4, 5] . reports have confirmed that russia, middle-east and south-east asian countries usually deport migrant workers who test positive for hiv [6] . reports have confirmed that until 2014, approximately 51 000 hiv-positive patients have been deported back to pakistan from the gulf countries [7] . in a bid to escape deportation, these hiv positive migrants are often forced to obtain antiretroviral therapy (art) illegally through exploitation of informal channels, friends or family to continue treating their condition [6, 8] . in other cases, these migrants are forced to buy expensively priced drugs (or in desperation, share the highly sought treatment with other migrants in order to afford it) [8] . additionally, access to health care has been challenging during the covid-19 pandemic with governments globally opting to curb the spread of the virus by introducing different national measures including lockdown or movement control, self-isolation and social distancing [2] . the lockdown and quarantine measures taken by most countries have been daunting for its hiv/aids-infected migrant population (legal or illegal) many of whom have been forced into unemployment and are unsure how to access appropriate health support, obtain essential medications or treatment [6] . not only do these migrants face difficulties in accessing public and health services they may have depended on previously, but they also may be living in inadequate accommodation where they are unable to observe safe and appropriate social distancing and hygiene protocols [5] . migrants living with hiv/aids often feel reluctant to inform their employers of their condition due to the social stigma associated with being a hiv/aids patient [4] . hence, they continue to work, exposing themselves and others to risk [4] . despite the increased risk of contracting covid-19, hiv-infected migrants in the uk tend not to be eligible for financial employment assistance though they may be in unstable employment. hence, they face increasing difficulties in earning or receiving sufficient funds to afford art medication [4, 9] . ensuring a migrants' good health is critical for the countries in which they originate from and move to [10] however, reports globally show that migrants are often subject to health inequalities due to lack of access to adequate health care as a result of neglect, exclusion, discrimination, unfavourable employment conditions causing ill health, inadequate living conditions, financial constraints or lack of appropriate legal status [10] . studies conducted in australia and europe respectively show that migrants are behind in fulfilling the unaids 90-90-90 target (a strategy where 90% of hiv patients should be aware of their hiv status, receive sustained antiretroviral therapy and achieve viral suppression by the year 2020) and more prone to being lost to follow-up art treatment when compared to non-migrant population [11, 12] . access to health care is also affected by a divide in the skill level of employment that migrants are hired for [10] . highly-skilled professional foreigners, often referred to as 'expatriates', tend to experience better health care access when compared to migrants working in low-skilled employment [10] . the pressures of social adjustment and poor health literacy also increase the migrant workers vulnerability to deteriorating health in times of a pandemic as they navigate through the difficulties of integrating into a foreign culture and language, while accepting the loss of their traditional values, beliefs and support systems [13] . overall, these factors further expose a highly-vulnerable migrant population suffering from hiv/aids to the threat of contracting the covid-19 virus [8] . hiv/aids patients are advised to observe precautions similar to general recommendations for cov-id-19 such as hand washing, cough and sneezing etiquettes, and social distancing [14] . they should also be assured with a 30-day supply of art treatment as well as adequate supply of appropriate medications to treat other acute or chronic illnesses or addictions [14] . while sufficient evidence is not available at present to link hiv/ aids patients undergoing art treatment to a higher susceptibility of covid-19 virus, nonetheless individuals with advanced-stage or poorly regulated hiv (low cd4 tlymphocytes count and high viral load) are at increased risk of infection, health complications and therefore, stand an increased chance of contracting covid-19 [14] . studies have shown that migrants seldom bring infections that pose a threat to the population of the host country [13] . in the past, outbreaks of hepatitis a, b, hiv and tuberculosis have occurred in non-endemic regions due to a lack of timely treatment provision to refugees [13] . a study conducted by mendelsohn et al. in malaysia compared the adherence of art between refugees and the host population. it has been noted that, if asylum seekers are included in primary care, the high levels of compliance achieved (equal to those in the domestic population) have decreased onward hiv transmission [15] . in short, most migrants (whether legal or illegal) lack adequate health entitlements and face health inequalities that prevent them from accessing health care in a safe, appropriate and fair manner [13] . some countries, such as thailand and spain have ensured equal access to health care for all legal and illegal who need to issue advisory to all the countries for timely access of antiretroviral therapy to hiv positive migrants regardless of their legal status. photo: from the authors' own collection, used with permission. migrants in accordance with the human rights framework [13] . the world health organization (who) should provide guidelines to all countries with hiv/aids infected migrants (whether legal or illegal) to adhere to so the migrant population continues to receive fair, assured and uninterrupted supply of art treatment during the covid-19 pandemic to maintain their immunity, health and decrease risk of co-vid-19 contraction. this will ensure another step is taken in a positive direction for the who to fulfil its slogan of "health for all". funding: we declare we received no direct or indirect funding from any institution or organization for this viewpoint. authorship contributions: aa conceived the idea, aks, fkh, and aa retrieved the data, did write up of viewpoint and finally jd reviewed and provided her inputs. all authors approved the final version of manuscript. competing interest: all authors completed the icmje form (available upon request from the corresponding author) and declare no conflict of interest. what is required to end the aids epidemic as a public health threat by 2030? the cost and impact of the fast-track approach redefining vulnerability in the era of covid-19 countries where covid-19 has spread migrants with hiv of concern in covid-19 era infectious diseases and migrant worker health in singapore: a receiving country's perspective i was waiting to die': in russia, hiv+ migrants fear death and deportation 51,000 migrants deported from gulf states due to hiv labour migrants in central asia deserve our attention migrants living with hiv during the coronavirus (covid-19) pandemic 2020 breaking down the barriers: understanding migrant workers' access to healthcare in malaysia gaps in the hiv diagnosis and care cascade for migrants in australia effect of legal status on the early treatment outcomes of migrants beginning combined antiretroviral therapy at an outpatient clinic in milan, italy healthcare is not universal if undocumented migrants are excluded is forced migration a barrier to treatment success? similar hiv treatment outcomes among refugees and a surrounding host community in kuala lumpur key: cord-296803-tde8k4kr authors: lundin, rebecca; armocida, benedetta; sdao, paola; pisanu, sigrid; mariani, ilaria; veltri, antonella; lazzerini, marzia title: gender-based violence during the covid-19 pandemic response in italy date: 2020-09-07 journal: journal of global health doi: 10.7189/jogh.10.020359 sha: doc_id: 296803 cord_uid: tde8k4kr nan g ender-based violence (gbv), with one out of three women worldwide experiencing violence in their lifetime, has been defined by the world health organization (who) as a "global public health problem of epidemic proportions" [1] . during the current covid-19 pandemic, the who and other international authorities have warned about the increased risk of gbv related to more time spent indoors, isolation from social and protective networks, and greater social and economic stress related to both the epidemic and response measures [2] [3] [4] . in fact, since the onset of the covid-19 outbreak, reports from many countries including france, germany, spain, the united kingdom, cyprus, argentina, singapore, canada, and the united states indicate that violence against women has increased [3] [4] [5] [6] . in italy, the most recent national data indicate that 31.5% of women between 16 and 70 years of age have experienced physical or sexual abuse at any point in their lives, with violence attributed to a current or former partner in 13.6% of cases [7] . after identification of the first covid-19 case in italy on 21 february 2020, social distancing measures were progressively enacted, culminating in a nation-wide lockdown which lasted about two months, from 11 march 2020 to 3 may 2020 [8] . as signatory of the council of europe convention on preventing and combatting violence against women and domestic violence -known as the istanbul convention -italy recognises gbv as a violation of human rights [9] . it is the obligation of the national government to fully address violence against women in all its forms and to take measures to prevent it, protect its victims and prosecute perpetrators. the state should also collect relevant disaggregated statistical data at regular intervals on cases of all forms of violence against women, and support research in the field in order to study its root causes and effects, incidence and conviction rates, as well as the efficacy of measures taken to implement this convention [9] . we report here data from the italian national women's network against violence, d.i.re. the network collects data annually from anti-violence centers which fulfill the istanbul convention minimum criteria for specialized service providers. during the covid-19 pandemic network members were asked to review the number of women contacting anti-violence centers during two time periods, corresponding to about one month each (between 2 march and 5 april 2020 and between 6 april and 3 may 2020). data from 58 centres during march 2020 and april 2020 were compared to monthly averages during the previous years (figure 1) . participating centres were located in 16 out of italy's 20 re-gender-based violence during the covid-19 pandemic response in italy rebecca lundin 1 , benedetta armocida 1 , paola sdao 2 , sigrid pisanu 2 , ilaria mariani 1 , antonella veltri 2 , marzia lazzerini 1 telephone contacts with antiviolence centres in italy increased during the covid-19 lock-down compared with the same period in previous years, with a notable increase among repeat callers. gions, with more centres in tuscany (n = 12), emilia romagna (n = 10), and lombardy (n = 10), regions with, respectively, the 5th, 3rd, and 1st highest numbers of covid-19 cases during the pandemic. in this sample, while the monthly average of women accessing anti-violence services was relatively stable during the years 2016, 2017, and 2018 (mean value: 1306 women, 95% ci 1255 to 1357), a sharp increase was observed during march and april 2020 (mean value: 2496 women, 95%ci 2442 to 2550, +191,1% p < 0.00001). interestingly, women with a history of previous contact with these anti-violence centres accounted for less than one third of cases during 2016, 2017, and 2018 (mean value: 27%, 95%ci 23% to 31%), but for over two-thirds of cases from march to april 2020 (mean value: 68%, 95%ci 64% to 72%, p < 0.00001). these findings are in keeping with data published by the italian national institute of statistics (istat), indicating a 59% increase in calls to a hotline for gbv victims between 1 march and 16 april 2020 compared to the same period in 2019, with the vast majority of calls (93.2%) made by women with a longterm history of gbv [10] . both the d.i.re. network and the national government rolled out advertising campaigns on social and traditional media early in the covid-19 pandemic, which may have increased awareness of their services. however, notably, both channels for the support of women at risk of or suffering gbv have consistently advertised their services in the past. the who and other un agencies have recommended concrete actions and strategies to address gbv in the context of covid-19 [3, 4, 11, 12] , and many countries have begun to take action to address the issue. canada and france have provided millions in extra funding for organizations providing support to gbv victims, while italy has released earmarked funds ahead of schedule [13] . china, spain, and the uk have created and widely distributed guidelines for assisting gbv victims during the covid-19 pandemic, and chile has developed e-learning courses and counseling materials to prevent gbv [13] . campaigns to identify and support gbv victims in pharmacies and shopping centres have been initiated in ar-further research and a coordinated, intersectoral, humanrights centred public health response are crucial to prevent gbv and support victims during the ongoing covid-19 response. photo: by ulrike mai, via https://pixabay.com/photos/woman-desperate-sad-tearscry-1006100/. gentina, france, and spain, and telephone hotlines and whatsapp services have been created or reinforced in argentina, portugal, spain, and france [13] . these activities, often accompanied by media campaigns, are a step in the right direction, however much work remains to be done to protect those at risk of gbv and support victims. specifically, further research is needed to identify the drivers of the observed increases in contact with anti-violence centers and to develop and test effective interventions to protect women at risk of gbv during the ongoing covid-19 response. there is also crucial need for a coordinated public health response to covid-19 based on an intersectoral, human-rights centered framework, and science-driven theory and methods. despite this, in italy the current phase 2 monitoring framework includes only 21 indicators, and none of these consider expected adverse effects of covid-19 containment measures such as violence against women and children, mental health problems, or reduced or delayed access to health services [14] . in the absence of a comprehensive monitoring framework, whether emerging data on violence against women will actually be considered to shape future policies in italy, or how, are still unanswered questions. greater cooperation is needed as well between law enforcement, health, and social services, among others, to improve surveillance of gbv and facilitate continuity and quality of care for victims [15, 16] . finally, sufficient resources must be provided for prevention and support services for gbv victims, and for data collection and research to inform effective policies. ethics approval: as this viewpoint reports observational, aggregate, anonymized data, no ethics approval was required. funding: authors did not receive funding for the preparation of this viewpoint. authorship contributions: rl conceived the paper in discussion with ba, ml, av, ps and sp. ps and sp cleaned and analyzed existing data, rl developed the graphic, and ml conducted additional analyses. im reviewed all analyses and the graphic. rl and ba drafted the initial manuscript and all authors reviewed/edited the manuscript for critical intellectual content and approved the final version of the manuscript. the mental health consequences of covid-19 and physical distancing: the need for prevention and early intervention world health organization. covid-19 and violence against women issue-brief-covid-19-and-ending-violence-against-women-andgirls-en.pdf?la=en&vs=5006 the gendered dimensions of covid-19 covid-19: a public health approach to manage domestic violence is needed raccolta degli atti recanti misure urgenti in materia di contenimento e gestione dell'emergenza epidemiologica da covid-19 convention on preventing and combating violence against women and domestic violence. istanbul, 11 violenza di genere al tempo del covid-19: le chiamate al numero verde 1522. allegato testo integrale e nota metodologica interim technical note protection from sexual exploitation and abuse (psea) during covid-19 response not just hotlines and mobile phones: gbv service provision during covid-19 medidas de contencion de la violencia de genero durante la pandemia de covid-19. gac sanit. 2020. online ahead of print emergenza covid-19: attività di monitoraggio del rischio sanitario e connesse al passaggio dalla fase 1 alla fase 2 di cui all'allegato 10 del dpcm26/4/2020 centering sexual and reproductive health and justice in the global covid-19 response il contributo dell'epidemiologia per orientare le attività di sanità pubblica ed assistenziali durante la fase 2 della epidemia covid-19 in italia the authors completed the unified competing interest form (available upon request from the corresponding author) and declare no conflicts of interest. key: cord-348743-fy7le3ar authors: bellizzi, saverio; pichierri, giuseppe; napodano, catello mario panu; picchi, sara; fiorletta, serena; panunzi, maria grazia; rubattu, edoardo; nivoli, alessandra; lorettu, liliana; amadori, antonella; padrini, susanna; ronzoni, anna rita title: access to modern methods of contraception in italy: will the covid-19 pandemic be aggravating the issue? date: 2020-07-27 journal: journal of global health doi: 10.7189/jogh.10.020320 sha: doc_id: 348743 cord_uid: fy7le3ar nan t he strain on health system imposed by the current covid-19 pandemic is undoubtedly impacting the sexual and reproductive health of women and girls of many countries in the world. reconfiguration of health systems to cope with the epidemic has led to the forced closure of health services deemed not essential as well as diversion of health care workers to fulfill other needs. in addition, physical distancing and travel bans are having adverse effects on access to and supply of contraceptive commodities. manufacturing of specific pharmaceutical components is, for instance, causing a shortage of condoms [1] . a mathematical model exercise done by the guttmacher institute has estimated a 10% proportional decline in the use of short-and long-acting reversible contraceptive methods in low-and middle-income countries (lmics) due to reduced access [2] . other pieces of very recent research have predicted much worse scenarios, with decline in sexual and reproductive health services up to 80% [3] . access to contraception is not just an lmics issue: the contraception atlas 2019 initiative, powered by the european parliament forum for sexual and reproductive rights (epf) in partnership with a group of experts in sexual and reproductive health and rights, showed that for many european countries, ensuring that people have choice over their reproductive lives is not a priority [4] . specifically, the atlas tracks government policies on access to contraceptive methods, family planning counselling and the provision of online information on contraception in 46 european states. in the 2019 european contraception atlas, italy ranked just 26th out of the total 46 countries. access to modern methods of contraception in italy: will the covid-19 pandemic be aggravating the issue? access to contraception is not just a low-and middleincome countries issue: in the 2019 european contraception atlas, italy ranked just 26th out of the total 46 countries for various reasons such as the very limited provision of free contraception as well as under-resourced and understaffed family planning centers. despite the disruption due to the current covid-19 pandemic, it is essential to ensure that women can have control over their bodies and their sexual and reproductive life, and protect the access to modern contraceptives and family planning services for both men and women. in order to analyze the bad performance of italy in terms of access to contraception, a national atlas has been promoted in order to understand also the impact of the regional differences. despite the fact that access to contraception is regulated at the national level, in italy the organization and implementation of contraceptive services are left to the regional governments. for this reason, only 4 regions out of 21 have introduced the provision of free contraception [5] . the 2019 italian contraception atlas indicates two main results which have to be considered when the effect of covid 19 on contraception is taken into account in terms of advocacy and emergency policies. the first is the huge differences among regions with the historical divide between north and south (with the only exception of puglia which is the first region that has introduced free contraception at regional level). such regional differences are multi-factorial and likely driven by cultural and social aspects. the second is a widespread tendency to fund programs which handle the access to the information of contraceptive methods more than those directed to their provision. this is as a result of the scarcity of public resources as well as the strict manner in which related budgets can be spent. information programs are preferentially funded as they are less expensive than providing actual contraceptive methods. the fragmentation of the policies has an impact on the equal opportunity to have free access to contraception in italy. there is evidence that a lack of general direction at national level generates gaps among territories which could be addressed with several initiatives, as the introduction of a sort of minimum level of assistance and the vocational training of medical professionals, thus facilitating integrated programmes on contraception and reproductive health, or by improving what has been already implemented as the web page on the portal of the ministry of health dedicated to contraception. despite the establishment of the counseling centers under the law n. 405 in 1975 [6] , with the aim of supporting "responsible parenthood" through providing information on contraception and by protecting the health of women and their children, institutionalized provision of appropriate information on contraception is still broadly lacking: 89% of boys and 84% of girls seek for information related to sexual and reproductive health in the internet [7] . on the other hand, 68% of boys and 76% of girls have never been in a counseling center [7] . in italy, family planning centers are often under-resourced and understaffed; as a consequence, individual counselling is rarely provided by interdisciplinary teams, which might affect the quality of the service depending on users' needs [8] . moreover, few centers are directly linked to hospitals or specialized services, so that women are not always referred to specialists when appropriate. importantly, family planning centers are not easily accessible outside the larger cities [8] . in the north-eastern regions plus lombardy and molise there is less than 1 family planning center per 10 000 women. this picture is worse even compared to southern regions (where the average is 1 to 2) as well as to other regions in the north and the center (where the average is 2 to 3) [8] . as far as the use of contraception is concerned, 26% of adolescents use withdrawal as preferred method of contraception while 11% relies on standard days and 10% do not use any contraceptive method [7] . this non-optimal situation is compounded by the largely stigmatizing vision on reproductive health, specifically around abortion and some modern methods of con-photo: a young italian couple engaging in discussion about contraception (from saverio bellizzi's collection, used with permission). traception like the pill. in fact in italy, despite the legalization of voluntary interruption of pregnancy under the law n. 194 in 1978 [9] , conscientious objection remains one of the main obstacles, with a percentage of 68.4% of gynecologists who avail themselves of this option [10] , preventing women in italy from accessing the human right to have control over their bodies and the legal right to terminate their pregnancies, often forcing them to seek treatment abroad. financial accessibility represents another key bottleneck: the intrauterine device (iud), a very effective contraceptive method with a long-term effect on avoiding or delaying pregnancy, could be as costly as 200 euros, which is well beyond the reach of all women and girls belonging to vulnerable social group who cannot afford this method. as for the pill, the italian pharmaceutical agency has classified in the "c" category, which makes it almost completely in charge of women and requires prescription. one of the main recommendations of the 2019 atlas report refers to the need for financially strengthening counseling centres, which should be much more widespread in the territory (1 every 20 000 inhabitants instead of the current 1 every 35 000). the counseling centres, perform key function in providing information, support and promotion of women's health. data collected during an iss (istituto superiore di sanita') survey carried between 2018-2019, showed that more than 75% of the counseling centres involved in the survey provide support and care related to sexuality, contraception, vip' s pathway, preconceptional health, family planning, birth pathway, sexually transmitted diseases, cancer screening, menopause and postmenopause [11] . furthemore, 25% of the overall counseling centres in italy offer free contraceptives [11] . sexual education in the schools is another crucial recommendation. despite the disruption due to the current covid-19 pandemic, it is essential to ensure that women can have control over their bodies and their sexual and reproductive life, and protect the access to modern contraceptives and family planning services for both men and women. in line with the call made by the un secretary general, access to contraception must be streamlined, even without prescription and free of charge. when regular health care services are disrupted, access to long-acting and emergency contraceptives becomes even more essential. how will covid-19 affect global access to contraceptives -and what can we do about it? devex estimates of the potential impact of the covid-19 pandemic on sexual and reproductive health in low-and middle-income countries. guttmacher institute methodology for calculating impact of covid-19 european parliamentary forum on population & development (epf). contraception atlas 2019 associazione italiana donne per lo sviluppo (aidos) legge 29 luglio 1975, n. 405. istituzione dei consultori familiar ministero della salute, istituto superiore di sanita'. principali risultati del progetto "studio nazionale fertilita women' s access to modern contraceptive choice -barometer legge 22 maggio 1978, n. 194. norme per la tutela sociale della maternità e sull'interruzione volontaria della gravidanza legge 194, la relazione annuale al parlamento con i dati consultori: indagine dell'istituto superiore di sanita', 1800 strutture censite no funding was received for this report.authorship contributions: all authors contributed to writing and conceptualizing the manuscript. the authors completed the icmje unified competing interest form (available upon request from the corresponding author), and declare no conflicts of interest. key: cord-336409-crkcxpw0 authors: ganasegeran, kurubaran; ch’ng, alan swee hock; looi, irene title: covid-19 in malaysia: crucial measures in critical times date: 2020-08-11 journal: journal of global health doi: 10.7189/jogh.10.020333 sha: doc_id: 336409 cord_uid: crkcxpw0 nan m alaysia contracted a high number of covid-19 positive cases among the southeast asian countries. albeit the global covid-19 pandemic trend is increasing, malaysia is seeing a decrease on the number of infections, with high recoveries and low mortality rates [1] . this viewpoint aims to discuss the targeted containment strategies executed by malaysia, which till date is showing positive responses in controlling the spread of covid-19. as of july 04, 2020, malaysia recorded 8658 covid-19 positive cases, with 121 deaths and 8461 recoveries, leaving with only 76 active cases [1] . the first wave of the outbreak (january 25, 2020 -february 16, 2020) reported 22 cases and constituted mostly of imported cases [2] . malaysia noted zero new cases until february 27, 2020, however, beyond this date marked the beginning of the second wave that observed an exponential rise of daily positive cases. as of april 10, 2020, malaysia recorded 4346 positive cases with 70 deaths, being one of the highest across the southeast asian countries [2] . figure 1 shows time trends of positive cov-id-19 cases overtime, since the first day when malaysia contracted a positive case up to july 04, 2020. the figure shows a declining trend with the implementation of the four phase (reviewed every two weeks apart in view of covid-19 incubation period of fourteen days) movement control order (mco) that was enacted since march 18, 2020. with declining trends, malaysia further enforced the conditional movement control order (cmco) and the recovery movement control order (rmco) that have seen cases declining to single digits per day. however, periodic peaks were observed during the cmco phase due to detection of positive cases among migrants in detention centers (figure 1 ) [1] . measures to contain the outbreak were formulated based on three principal strategies: (1) slowing introduction of global infections; (2) slowing infection of local outbreaks; and (3) executing community mitigation strategies. travel restrictions for citizens, suspension of immigration facilities to travelers from affected regions, isolation of confirmed cases and quarantine of exposed individuals were imposed to slow introduction of global infections [4, 5] . entry and exit points were monitored closely with thermal scans installed to screen potential infectees [5] . an exponential growth of covid-19 cases was triggered in the second wave (from february 27, 2020) due to a massive cluster gathering within the state of selangor [2] . the movement control order (mco) that promulgated restriction of movement and activities under the prevention and control of infectious diseases act 1988 and the police act 1967 was enforced on march 18, 2020 [6] . under mco, the following measures were implemented: (1) prohibition of mass movements, religious, sports, social and cultural activities; (2) closure of business premises except for daily necessities and needs services; (3) selfquarantine and health check measures for those who returned from abroad; (4) restrictions on tourists and visitors; (5) closure of schools, kindergartens and higher institutions of learning; and (6) closure of all government and private premises except for essential services like water, electricity, telecommunications, etc [6] . spatial hotspots (red zones) with high incidence of positive infections (≥40 cases) would trigger an enhanced movement control order (emco) (a full lockdown) [7] . such measures slowed local infections and enabled health care authorities to perform contact tracing, identify potential clusters for investigation and optimize health care resources for screening and treatment. violators of the mco regulations are subjected to penalties under the penal code, which is under a federal gazette; where violators may receive a penalty of up to myr 1000 (approximately us$ 230 at the time of writing) and/or up to six months imprisonment [1] . with legislative and non-pharmacological interventions being put into place, the success of compliance was highly correlated with community engagement and support. the implemented interventions were concurrently executed with community mitigation strategies. key community mitigation measures include: (1) obeying the cancellation or postponements of ad hoc or planned events, sports and religious activities; (2) high compliance on the practice of physical distancing measures and the usage of face mask; (3) reducing flight and public transportation services; (4) self-quarantine at home; (5) changes to crucial essential services like funerals to minimize crowd size and exposure to body fluids; and (6) avoidance of misinformation -verified and clear information regarding covid-19 needs to be delivered on-time and consistently to the public to avoid fake news, rumors and panic. conveying accurate and rapid information on covid-19 risk factors, transmissibility, clinical features and prevention strategies via social, print or electronic media would enhance community's understanding of the disease. consistent daily interaction between the government and the people to digest latest statistical updates and the do's and don'ts during mco via short messaging service (sms) reminders, daily press conference and social media posts had maintained transparency and compliance for successful execution of legislative measures [1] . the level of public commitment was appreciable when the malaysian government announced alternatives to the conventional bazaars during the fasting month with novel alternatives; such as to use food delivery services and e-services. this prevented massive gatherings that would increase the risk of infections. with declining trend of positive cases, malaysia executed a relaxed conditional movement control order (cmco) that aims to carefully re-open the country's major economy in phases [1] . malaysia adopted the carefully crafted standard operating procedures (sops) based on the avoidance of 3cs (crowded places, confined spaces, close conversation) and the practice of 3ws (wash hands, wear masks, warn against risks, symptoms, prevention and treatment) during the enforcement of the four main legislation acts through the mco, emco, cmco and rmco till date, which have seen success in flattening the epidemic curve [1] . contact tracing is more critical when individuals with high risk of transmission within detected clusters are difficult to track rapidly. other vulnerable groups such as migrants or homeless people with poor living conditions compounded with overcrowding have increased susceptibility towards the spread of potential local contagion [8] . the execution of institutional quarantining of people who have been in contact with confirmed or probable cases may be unrealistic at certain times as this overwhelms the system and may lead to more infections. self-quarantine may be a more realistic measure [9] . rigorous and routine screening efforts and disinfection process in public or overcrowded places is important to control the spread of the infection. as severe complications and high mortality rates is correlated with older people [1] , more focused and targeted interventions of infection control efforts and potential treatment modalities should be prioritized to the aged population. specific and more comprehensive guidelines on hygienic processes and infection control strategies should be directed to elderly care homes. while there are guidelines in place [10] , monitoring the compliance in these homes are crucial to prevent the spread of covid-19 among the elderly. lockdowns have unprecedented psychological repercussions to people [11] . to overcome stress, anxiety, depression or isolation, malaysia has introduced psychological services through the establishment of care lines and virtual counseling sessions [12] . misinformation cause panic, as such, it is crucial to provide verified information of the contagion through daily updates. we are in the midst of battling the transmission of a pathogen that disrespects national and international borders with many uncertainties. while being the most potent infection to the human population globally, the anticipated hazards and implications are expected to prolong for months to come until appropriate evidenced based treatment modalities and vaccines are discovered. pending answers to the many puzzles of covid-19 from the scientific and medical perspective, it is crucial to reckon the importance of executed public health measures in such critical times to disallow an uncontrolled spread and replication of the virus to the human living environment, which would ultimately be difficult to tackle. malaysia has taken a unique targeted approach in controlling the covid-19 outbreak. current situation of covid-19 pandemic in malaysia coronavirus disease (covid-19) pandemic covid-19 outbreak live updates coronavirus travel ban: malaysia stops visas for chinese travelers from affected areas. the star malaysia to announce additional measures to prevent spread of new china virus the prime minister's special message on covid-19-16 press release: enhanced movement control order refugee and migrant health in the covid-19 response covid-19 and community mitigation strategies in a pandemic guidelines for care homes for older people in the context of covid-19 the psychological impact of quarantine and how to reduce it: rapid review of the evidence correspondence to: dr kurubaran ganasegeran clinical research center seberang jaya hospital ministry of health malaysia penang malaysia medkuru@yahoo acknowledgements: this article is dedicated with utmost appreciation to the government of malaysia, the minthe authors completed the icmje unified competing interest form (available upon request from the corresponding author), and declare no conflicts of interest. key: cord-347535-tgou78o7 authors: goh, kah kheng; lu, mong-liang; jou, susyan title: zero confirmed cases: the ways we curb covid-19 in taiwanese prisons date: 2020-08-23 journal: journal of global health doi: 10.7189/jogh.10.020377 sha: doc_id: 347535 cord_uid: tgou78o7 nan t he problem of transmission of infectious diseases in prison has come into focus amid the covid-19 pandemic. even outwith the immediate covid-19 pandemic, it is well known that prisoners are at higher risk of infectious diseases than those in the wider community at other times [1] . it has been reported that most prisoners return to their communities with their illness occasionally untreated and sometimes worsened. these prisoners increase the public health burden by acting as reservoirs of infection [1] . it needs to be fully acknowledged that prison health is an issue of public health. prison covid-19 outbreaks have been reported and documented in china, india, iran, egypt, malaysia, usa, italy, uk, congo, nairobi, salvador, brazil, colombia -indeed, almost every country where people in the wider community have contracted covid-19 [2] . overcrowding and inadequate health services within the prison estate have fueled the prison as a highly infectious environment [3] . national level data for the majority of all countries worldwide indicate have prison occupancy levels exceeding their officially reported capacity [4] . accessibility to health service, testing capacity, the supply of personal protective equipment are budget-constrained and are not being prioritized for inmates zero confirmed cases: the ways we curb covid-19 in taiwanese prisons [5] . calls for decarcerating (early release for example) prisoners convicted of low-level crimes and misdemeanors during this pandemic has been encouraged by the un high commissioner for human rights [6] . as a solution to mitigate the harms of covid-19 outbreak in prison [7] , several countries including iran, france, italy, child, usa, and indonesia have taken action to reduce the prison population by releasing "low-risk" offenders. besides a general decarceration policy, prison-specific guidance for responding to covid-19 has also been introduced [8] . with its proximity to china, taiwan was expected to have the second-highest number of covid-19 cases [9] . there are approximately 60 000 inmates in taiwanese prisons, with 115% prison occupancy level and the cell spatial density is only 2.3 m 2 per person. most of the prisoners occupy a single large cell, with approximately 16 to 20 inmates per cell. since the outbreak of covid-19 until 6 june, zero cases have been reported in taiwanese prisons. the prisoners followed the same principles of the covid-19 testing as for those in the wider community, which was around 1274 tests per confirmed case, considered adequate testing in taiwan. due to concern about risk management in the community, no decarceration of prisoners has taken place in taiwan. however, the taiwanese government has adopted several proactive measures to minimize the possibility of a co-vid-19 health catastrophe developing in the prisons. measures have included the establishment of the joint planning and central command with central epidemic command center (cecc), the prevention, control, and risk management among the prisoners, the cooperation and involvement of prison staffs, and the environment sanitizing. a first crucial step was creation of a rapid response to covid-19 through the establishment of cecc as an operational command point to integrate resources of the administration, the academic, medical, and private sectors. cecc enables direct communication among central and local authorities, including the prison and correctional authorities in developing an overall response to the crisis. the guidelines for prevention and control of covid-19 was developed by cecc. the agency of corrections, ministry of justice was adopted and introduced its own guideline that applied to all prisons. at least one response hospital each in six special municipalities was designated to be response for isolation of the patients with emerging infectious diseases before this pandemic and the numbers of response and isolation hospitals were increased to 134 during covid-19 pandemic. the suspicious cases in the prisons were first reported to cecc and transferred to those response hospitals that assigned by cecc, for screening, testing, and further management. updated information and resources were thus provided daily to local prisons, including educational materials, screening and testing tools, and other equipment. the government made appropriate requisition for surgical masks, thermometers, and other resources which ensured the prisons were equipped with adequate resources. weekly, all the prisoners were equipped with two surgical masks by the authorities. prisoners were asked to wear the surgical masks whenever in contact with others. good personal hygiene habits were implemented by all prisoners, especially during mealtimes and use of toilet facilities. all the prisoners are required to check body temperature twice a day and whenever they left and re-entered the prison for court hearing, work release, or other conditions. for those who re-entered the prisons or after their daily routine classes, they were mandated to bathe and change their clothes before entering their own cells. unlike other countries, inmates in taiwanese prisons have a highly structured activities program, filled with intensive activities; thus, they had a relatively low chance of close individual contact. arguably, this acted as a form of social distancing, and this could also be a factor leading lower risk in the covid-19 outbreak. although no additional formal limitations were put on prisoner entry or re-re-entry from prison to minimize the risk of covid-19 outbreak in taiwanese prisons, several steps have been taken, including the establishment of the joint planning and central command with cecc, the prevention, control, and risk management among the prisoners, the cooperation and involvement of prison staffs, and the environment sanitizing. to the community, nevertheless, prisoners were encouraged to avoid unnecessary risk of infection. prisoners were encouraged to use the medical clinics in prisons and reduce the community hospital visits. at least 2 medical clinics were available daily in each prison, including specialist clinics that operated weekly or monthly depending on the demand. the robustness of taiwan's health care systems arguably enables the prison health system to maintain its continuing everyday function during this pandemic. following, the criteria announced by the cecc, those who displayed symptoms of fever, cough, other acute respiratory symptoms, an abnormal sense of smell or diarrhea and with history of travel, or close contact with anyone with those symptoms were tested for covid-19. to avoid transmission and spread within prisons, isolation areas were designated for suspicious cases. prisoners who had body temperature ≥37.5°c or with upper respiratory tract symptoms were being quarantined in the isolation areas for 14 days. new prisoner entrants were asked to stay at the isolation areas for 14 days before being allocated to a prison cell. authorities were asked to check these new entrants' travel and contact history by using their national health insurance card data accessed via the online "medicloud system". while seeking to maintain a level of isolation, taiwanese authorities also recognized the importance of human contact for prisoners during this pandemic. visits were not prohibited, except for volunteering and educational visits. all prison visitors were required to have body temperature checks, wear surgical masks, and report their travel history, occupational history, and contact history. those who failed to comply were allowed only telephone visits. all prison staff were trained on basic covid-19 disease knowledge, hand hygiene practice, and use of appropriate prevention protective equipment. they were asked to ensure self-health monitoring, including regularly checking body temperature and the wearing of a surgical mask. prison staffs who developed fever, cough, abnormal sense of smell, diarrhea or other acute respiratory symptoms and who had a past 14-day travel history or close contact with anyone with symptoms, were asked to report it to cecc and isolate at home for 14 days. local health agencies contacted those self-isolating at home to check their health twice a day. all prison staffs were required to be tested before returning to work. all visitors were asked to use 75% alcohol sanitizer for disinfection. environment sanitizing was done after every visit session. all the equipment, including clothing and coverlets used in isolation areas was disinfected before being removed from the cells. the covid-19 crisis has mobilized jurisdictions to release prisoners in many countries to minimize the risk of covid-19 outbreak in prison. early release of prisoners, particularly when the resources are scarce, may pose a threat to public safety. it is clear that there are no easy answers. taiwanese prisons are among the most overcrowded prisons in the world. yet, rather than a simple decarceration policy, the authorities in taiwan chose to fight the covid-19 pandemic proactively through evidently effective and well implemented strategies. there may be lessons for other countries in considering the detail of taiwan's success. funding: this article was supported by grants from department of psychiatry, taipei medical university-wan fang hospital (109-wf-eva-15) for article publication fee. the funder had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. the health of prisoners covid-19 action: news & resources. available prison cell spatial density and infectious and communicable diseases: a systematic review world prison brief online database prisons are "in no way equipped" to deal with covid-19 unaids and ohchr joint statement on covid-19 in prisons and other closed settings covid-19, prison crowding, and release policies prisons and custodial settings are part of a comprehensive response to covid-19 response to covid-19 in taiwan: big data analytics, new technology, and proactive testing authorship contributions: all authors contributed to the writing and conceptualization of the manuscript. all authors have seen and approved the final version of the manuscript submitted. the authors completed the icmje unified competing interest form (available upon request from the corresponding author), and declare no conflicts of interest. key: cord-306090-i8sriw08 authors: tan, zihui; khoo, deborah wen shi; zeng, ling antonia; tien, jong-chie claudia; lee, aaron kwang yang; ong, yee yian; teo, miqi mavis; abdullah, hairil rizal title: protecting health care workers in the front line: innovation in covid-19 pandemic date: 2020-05-15 journal: journal of global health doi: 10.7189/jogh.10.010357 sha: doc_id: 306090 cord_uid: i8sriw08 nan t he covid-19 pandemic has now infected almost 700 000 people, killing more than 30 000 people. although singapore was previously able to control the rapid rise in daily cases through tight quarantine, rapid contact tracing and strict social distancing measures, our health care institutions are now facing a second surge from imported cases. the protection of health care workers (hcws) is vital in continuing patient care in health care systems that are currently challenged by the pandemic, but also important in ensuring they do not spread the virus. in our country, there are no guidelines or unified practices as to the degree of hcw protection required for performing routine throat swabs. a unique feature of many testing venues in singapore is that they are outdoors with the average of 30°c tropical weather, rendering the prolonged use of conventional personal protective equipment (ppe) or full-body protection uncomfortable. the widespread incidence and expected protracted duration of the covid-19 pandemic has also prompted concerns for minimising the use of ppe especially for high-volume or brief procedures with a short duration of high-risk patient contact, such as throat swabbing. we offer this invention as a versatile component of a modular system that can be adapted to several situations and clinic setups. hcws no longer have to change their disposable face shield, cap and gown between patients. this has allowed us to conserve our current ppe supply. in time when testing may be carried out more extensively in community settings, we hope that this would ease logistic difficulties in streamlining the need to test a heavy caseload. it has been close to three months since the first covid-19 case was diagnosed in singapore [1]. the co-vid-19 pandemic has now infected almost 700 000 people, killing more than 30 000 people [2]. although singapore was previously able to control the rapid rise in daily cases through tight quarantine, rapid contact tracing and strict social distancing measures, our health care institutions are now facing a second surge from imported cases. given our country' s unique geographical location, and inherent lack of natural resources and raw materials, we are ultimately dependent on open trade borders to maintain our supply chain. as more countries start to implement travel and border restrictions and in various countries; a total lockdown, this will compromise our ability to maintain a comfortable supply of personal protective equipment. the protection of health care workers is vital in continuing patient care in health care systems that are currently challenged by the pandemic, but also important in ensuring they do not spread the virus. in hubei, china more than 3000 health care workers have been infected and in italy 20% of responding health care workers were infected [3,4]. our singapore public health institutions have had 8 cases of co-vid-19 infections among staff [5] . singapore also depends on an intensive testing programme with one of the highest rates of testing globally at 6800 tests per million people as of 25 march 2020 [6]. since january, our emergency department colleagues have been at the frontline battling the surge in attendance due to the pandemic. throat swabs of suspected patients from the community are taken in a designated fever area (figure 1) . up to 70 patients are seen daily in this area and the number will only increase. although full personal protective equipment (ppe) is provided, concerns regarding ppe wastage and the need for conservation have surfaced. this is due to the continuing rapid increase in the number of patients seen in the community. another important consideration is the proximity of the health care worker to the suspected patient especially when the patient sneezes, coughs or gags. whilst nasal swabs were initially taken, there has been a shortage of these. therefore, we have moved to throat swabs for testing. one study showed that throat swabs have a lower pick up rate as compared to nasal swabs [7] , hence the importance of proper swabbing technique to accurately diagnose cov-id-19. by providing better protection for the health care workers (hcw), we hope to reduce the incidence of false negatives and hence false assurance. together with a local bioengineering company, the biofactory pte ltd, we proposed a screen between the patient and the hcw that fits the following criteria: • protect hcw from droplet ± aerosol contamination, • clear barrier for visualization, • light source to visualize oropharynx, • good dexterity, ie able to use both hands for tongue depressor and swab, • easy to clean, meets local infection control standards, • mobile, • easy for storage, • dual functionality, ie, it can be inverted to contain the patient as well. the first prototype was subsequently tested and used in the emergency department (figure 2) . hcw expressed increased confidence for personal safety despite the high number of suspected patients seen daily. more importantly, hcws no longer have to change their disposable face shield, cap and gown between patients. this has allowed us to conserve our current ppe supply in view of the potential supply shortage if the pandemic continues for a prolonged period of time. innovation in health care is itself difficult, balancing the competing concerns for patient and operator safety, infection control, resource conservation and cost. the current pandemic has exacerbated these restrictions, but ironically made it all the more urgent that efficient and innovative solutions are sought out to address surging patient loads and high infectivity. reported examples of innovation in this pandemic range in scale from individuals repurposing scuba diving masks with 3d-printed "charlotte valves" [8] to vacuum cleaner and automotive manufacturers producing ventilators [9, 10] . testing suspected patients is a cornerstone of epidemiologic control of this outbreak. various devices have been described, from the south korean "phone booth" [11] to simple plastic shields shown in media from the uk and taiwan [12] the aim of these devices is both to contain infection as well as protect a hcw exposed to tens to hundreds of suspect cases. some of the features of these existing devices are seen in table 1 . in our country, there are no guidelines or unified practices as to the degree of hcw protection required for routine testing. a unique feature of many testing venues in singapore is that they are outdoors with the average of 30-degree-celsius tropical weather [13] , rendering the prolonged use of conventional ppe or full-body protection uncomfortable. the widespread incidence and expected protracted duration of the cov-id-19 pandemic has also prompted concerns for minimising the use of ppe especially for high-volume or brief procedures with a short duration of high-risk patient contact, such as throat swabbing. while single-use items have been the erstwhile gold standard of hcw protection and reduction of cross-contamination, we recognise that this is also reliant on supply chains and in many cases overseas manufacturer capacities (that are themselves subject to stresses of the pandemic in their own countries). we offer this invention as a versatile component of a modular system that can be adapted to several situations and clinic setups. in time when testing may be carried out more extensively in community settings, we hope that this would ease logistic difficulties in streamlining the need to test a heavy caseload. our innovation allows for a reversal of the traditional model where an infectious patient is in a negative pressure room, as this requires significant time and labour to disinfect the room between patients. by allowing the health care worker to be protected inside and the patients to pass through outside in an outdoor setting, it will allow for much shorter times between patients and thus be able to rapidly collect swabs for large numbers of patients if the outbreak worsens. difficulties encountered in the production of this device were exacerbated by the rapid evolution of management strategies for the pandemic. as a relatively "unknown enemy", the requirements of infection control policy and organisational directives were developing as practitioners on the ground sought to counter practical challenges such as the heat and fatigue from rapid and repeated donning and doffing of ppe. ready access to bioengineering expertise enabled the rapid production of a prototype. the use of technology to visualise and transmit ideas allowed for multiple practitioners to give their input remotely. video-conferencing platforms allowed for immediate remote previewing of a physical prototype, while mobile messaging facilitated rapid transfer of images and feedback to and from multiple parties and stakeholders. more importantly, tele-communication also reduced the need for physical meetings and also prevented spread of infection by allowing for physical distancing without hampering or slowing the innovation process. emergency grants would accelerate device production in view of the ongoing pandemic, similar to the additional publication of covid-19 related research in medical literature. an extraordinary time in evaluating the accuracy of different respiratory specimens in the laboratory diagnosis and monitoring the viral shedding of 2019-ncov infections james dyson designed a new ventilator in 10 days. he' s making 15,000 for the pandemic fight ford to build 50,000 ventilators in 100 days south korea dials up covid-19 testing with hospital "phone booths taiwanese doctor creates cheap protective device amid virus crisis -focus taiwan the authors would like to acknowledge the division of anaesthesiology and perioperative medicine, singapore general hospital. the views expressed in the submitted article are his or her own and not an official position of the institution or funder. human history calls for special measures to match the needs of a shifting and transforming battleground. as various industries turn their efforts to addressing the needs of health care, those on the ground should be equipped to contribute their first-hand expertise by all means possible. key: cord-279345-dgdujcy3 authors: sudhir, amita; mor, nachiket title: a primary care alternative to a hospital-based approach to covid-19 in india date: 2020-08-11 journal: journal of global health doi: 10.7189/jogh.10.020346 sha: doc_id: 279345 cord_uid: dgdujcy3 nan i ndia, like many low-and middle-income countries (lmics), lacks significant hospital and emergency transportation infrastructure. as the covid-19 pandemic spreads in india, large urban centres are already starting to become overwhelmed as they did in higher income countries. with only 0.7 hospital beds per 1000 population [1] , the system stands to be overloaded, in great part by patients who require no intervention or only require oxygen support and little other intervention, because the focus in treating covid-19 has been nearly entirely hospitalbased in india, just as elsewhere in the world. india, however, has the primary care infrastructure to offer a different solution, one that is based in the community, utilising the skills held by primary care providers, and the resources available to them. in india, as in the rest of the developing world, the number of hospital beds and ventilators per 1000 population is quite low as compared to high income countries (hics), where, despite the greater availability of beds, resources were quickly overwhelmed. a significant positive correlation between mortality and the rising number of cases causing health systems to be overwhelmed has been observed, and this is particularly concerning for lmics [2] . given this reality, every effort should be made to minimize the burden on hospitals, to allow them to focus on caring for patients who require critical care interventions such as non-invasive positive pressure ventilation, mechanical ventilation, and blood pressure support. most cases of covid-19 are mild and do not require hospital based care. in the first large study of the breakdown of covid-19 patients conducted by the chinese centers for disease control in wuhan, china, 81 percent had disease that was classified as mild. 14 percent had disease that was classified as severe, which was defined as hypoxia, dyspnea, or worsening lung infiltrates. there were no deaths in either the mild or severe groups. and only 5 percent were defined as critical, with respiratory failure, septic shock, or multiorgan dysfunction, with all deaths in this group [3] . the vast majority of covid patients, therefore, can be managed in an outpatient setting, and safely sent home with isolation instructions and return precautions after a diagnosis is made, or even pending a diagnosis. of the patients classified as severe, many can be managed with simple interventions such as nasal cannula oxygen to reverse hypoxia, and fluid resuscitation if needed. these interventions do not require a trained hospitalist or intensivist to administer, nor do they necessarily need to be administered in a traditional hospital setting. primary care providers with a knowledge of basic medicine can correct hypoxia and make a determination of when to escalate to higher levels of care when interventions are not working. of the available interventions to correct hypoxia, which is often the primary reason for hospital admission in covid-19 patients, the simplest is oxygen by nasal cannula. this can be administered at any facility with the ability to keep patients overnight or for multiple days, but other than oxygen concentrators or cylinders, nasal cannulas, and simple pulse oximeters, no specialized equipment or advanced moni-a primary care alternative to a hospital-based approach to covid-19 in india amita sudhir 1 , nachiket mor 2 oxygen therapy in primary care settings holds the key to an effective covid-19 response in india. toring is needed. concentrators have the advantage of not relying on a continuous supply chain and do not need to be frequently replaced; oxygen cylinders have the advantage of not needing a reliable power supply to operate [4] . the source of oxygen can be tailored to the constraints of the setting. many patients will respond to these interventions and can be kept at the initial treatment site until symptoms improve. if possible, arrangements could also be made for patients with appropriate home support and lower oxygen requirements to be discharged with oxygen delivery devices and strict return precautions. patients who are deemed too sick to go home or who lack the necessary care support could be kept at the facility. iv access could be established in case of deterioration and the need for fluid resuscitation. the assessment of these patients and a decision about whether they need to be transferred to a higher level of care can be made by primary care physicians even without subspecialty training, using easy to measure parameters: spo 2 , blood pressure, heart rate, and respiratory rate. the development of protocols and guidelines would aid these physicians in providing standardised care. other low cost and simple interventions such as steroids [5] , antibiotics for secondary pneumonia, bronchodilators, and prophylaxis against venous thromboembolism can also be administered in these facilities. awake proning is another simple but beneficial intervention that can be applied with minimal provider training, and does not require a higher level of care to execute [6] . remote expert assistance via telemedicine could be made available to these providers for cases in which the need for hospitalization or transfer to a higher level of care is unclear. we have created a simple oxygen protocol that can be modified or added to, allowing it to be used in a variety of different settings [7] . if clinic spaces are unavailable to establish a facility, any large space that allows for appropriate distancing between patients, has toilet facilities, and adequate ventilation, can be repurposed as an oxygen centre. staff would undergo a brief, basic training in implementing the protocol. india and most lmics have the resources to approach this problem using existing primary care providers and clinics. while hospital beds and emergency transportation infrastructure are scarce commodities in these countries, a strong community-based infrastructure exists, consisting of community organizations and local nonprofits. india, for example, has a large network of primary care and community health facilities: 25 000 primary health centers and 5300 community health centers owned by the government and a much larger number in the private and the non-profit sectors [8] . these organizations could be harnessed in the covid-19 effort as follows: identifying the most vulnerable and guiding families on how to keep them protected; teaching home-care guidelines, even for sick patients, to avoid hospitalization [9] ; mapping out a network of primary care providers, (public, private and non-profit); assigning each family a provider who would be responsible for testing and evaluation should anyone become sick, to avoid a trip to the hospital; providing resources to these primary care providers for managing all but the sickest of patients, including training and education on the basic management of covid patients. the availability of such physicians and nurses, including those with formal undergraduate or graduate qualifications in allopathic, ayurvedic, unani, and siddha medicine and surgery, and the availability of maternity homes and mini hospitals [8] are valuable potential assets in the fight against covid. the issues impacting coronavirus care in india are common to many developing countries and this framework for tackling it as a primary care problem could be applied to many other health care systems across the world. much of the published literature on covid in lmics focuses on prevention, and while this is of paramount importance, recent events show us that this is clearly not enough. the solution of using primary care facilities and providers is adaptable to either a public or private setting, depending on the resources available in any given country. the investment in infrastructure needed is not only relatively small (the cost of oxygen concentrators and provider training), but also represents an investment in items that will have continued utility post-covid (if we may look forward to such a time)widespread availability of oxygen, a life-saving and temporizing intervention, and training for providers in oxygen delivery, an important aspect of basic emergency care. a primary care focused covid-19 response has the potential to strengthen overall long-term health systems capacity in developing countries. photo: use of an oxygen concentrator in primary health care (basic healthcare services https://bhs.org.in). oxygen concentrators are portable, and once the need for using them for covid patients has passed, they can be repurposed to ambulances, clinics, and even home health settings for a host of other diseases causing hypoxia. if oxygen cylinders are used, maximizing that supply chain will continue to be of benefit for the treatment of respiratory illnesses for years to come. if the pandemic drags on for months to years, oxygen centers could also become screening points for other diseases likely to be neglected during the pandemic, such as tuberculosis, or foci for immunization campaigns for ongoing endemic or epidemic illnesses beyond covid. frenk and colleagues describe the need for a "diagonal" approach in building health systems. while the focus is on the "vertical" strategies needed to address the immediate crisis, their implementation also keeps in mind the needs of the overall "horizontal" health system [10] . the solution we outline meets exactly these two criteria and has the potential to help lmics respond at a sufficient scale to the current crisis but also to leave behind a considerably strengthened health care system. hospital beds (per 1000 people) managing covid-19 in low-and middle-income countries characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention respiratory support in covid-19 patients, with a focus on resource-limited settings effect of dexamethasone in hospitalized patients with covid-19 -preliminary report early self-proning in awake, non-intubated patients in the emergency department: a single ed' s experience during the covid-19 pandemic indicative protocol for a first level oxygen centre for patients with suspected or confirmed covid-19 covid-19 control in low-income settings and displaced populations: what can realistically be done? london school of hygiene and tropical medicine organization and provision the health systems agenda: prospects for the diagonal approach authorship contribution: nmr was an originator of the concept of treating covid-19 patients in a primary care setting based on the early data on the breakdown of needed treatments for covid-19 patients. as provided the medical expertise to back up this concept. both authors created an oxygen protocol that can be used in primary care settings and contributed equally to the writing of this paper. the authors completed the icmje unified competing interest form (available upon request from the corresponding author), and declare no conflicts of interest. key: cord-302271-js06pel9 authors: primorac, dragan; matišić, vid; molnar, vilim; bahtijarević, zoran; polašek, ozren title: pre-season football preparation in the era of covid-19: croatian football association model date: 2020-05-06 journal: journal of global health doi: 10.7189/jogh.10.010352 sha: doc_id: 302271 cord_uid: js06pel9 nan w ith over 3.3 million confirmed cases worldwide and over 230 000 confirmed deaths, the covid-19 pandemic is, without doubt, the most important event of the 21 st century so far. the covid-19 pandemic has upended all areas of life -and sports is no exception. unsurprisingly, this pandemic has also stopped the sporting calendar, with professional leagues everywhere suspending their activities to limit the spread of the virus. guidelines for covid-19 diagnosis change on a day-to-day basis, as we progress with primary studies and gain more. the guidelines encompass clinical criteria, epidemiological patient history, and molecular diagnostics. football coaches are keen on perspective and realize that the challenges they face now and in the months ahead hardly compare to the hardships the world confronts during a pandemic, but the return to pre-pandemic activities requires medical guidelines. croatian football federation, with its medical committee is launching a new model of pre-season systematic examination of football players with a particular emphasis on diagnosing covid-19. studies suggest that the proportion of asymptomatic cases ranges from 17.9% onboard the diamond princess cruise ship, up to 78% detected in newly reported chinese data [1, 2] . in our opinion, there is little doubt that covid-19 is far more widely distributed than some may believe, knowing the data implies that an asymptomatic person can spread the infection, particularly during the incubation period [3] [4] [5] . identifying the asymptomatic carriers of the disease has become crucial in preventing further spread of the epidemic. it is expected that majority of people who recover from covid-19 will not have long-term consequences. however, covid-19 is a multi-organ disease commonly affecting the lung, heart, kidney, digestive tract, and nervous system, with unclear situation regarding long-term consequences [6, 7] . survivors of the severe covid-19 disease were reported to have changes in their lungs, similar to those observed in sars, marked by the diminished pulmonary capacity [8] . important lessons on long term outcomes for patients who contracted covid-19 are still to be learned, but in order to adapt to the global situation, we believe it is paramount to draw parallels with the epidemics of sars (severe acute respiratory syndrome) and mers (middle east respiratory syndrome). a recent study showed that approximately 20% of covid-19 patients suffered from cardiac injuries [9] . studies of sars and mers reported high occurrence of hypertension, persistent tachycardia and myocarditis in convalescent patients. a study on 121 patients who were infected with sars showed that hypertension occurred in over half of all the patients, while 71.9% of them developed persistent tachycardia [10] . one the other hand, it has been shown that mers causes myocarditis, most likely by the direct viral infection; the same was implied for covid-19 [11] . acute kidney injury and proteinuria were also reported in covid-19 patients, suggesting direct cellular damage of the kidney tissue [7] . by comparison, covid-19 patients who were treated in the icu, particularly those who were mechanically ventilated, were reported to suffer from "post-intensive care syndrome", most likely because the lack of oxygen in blood [12] . all these reports suggest that covid-19 infection might be regarded as higher risk than it was initially believed. this is of paramount importance in football activities, knowing that career development requires a lot of time and effort invested into prevention of injury, disease, disability and even death [13] . the sport community finds itself facing uncharted territories in both the wake and the aftermath of this pandemic. therefore, we firmly believe that coordinated, well-communicated and transparent action is of utmost importance if we want the return to regular activities be safe for all stakeholders. although professional football players are generally a healthy population without chronic respiratory, cardiac, renal diseases, as well as other chronic conditions, we must take covid-19 seriously and act accordingly before returning to football pitches. underlying genetic factors must also be taken into account as they might be aggravated by covid-19 causing their clinical manifestation. together with croatian football federation, with its medical committee, is launching a new model of pre-season systematic examination of football players with a particular emphasis on diagnosing covid-19 before returning to training and competitive football. the list of medical examinations that players must undergo in order to be eligible to participate in uefa competitions, we hereby propose a model for screening professional football players returning to the field after the lift of the ban on all sport activities because of the covid-19 pandemic. besides pre-season physical examination (primarily 12-lead ecg, spirometry with bronchodilatation test, diffusing capacity of the lung for carbon monoxide (dlco) test and fractional exhaled nitric oxide (feno) test) and medical examination defined by the uefa medical regulations (for the next season), we are proposing that every football player from the croatian first national league must have negative consecutive two rt-qpcr covid-19 pharyngeal swabs over a 5-day interval. such tests are targeting two regions of the viral nucleocapsid gene (n1 and n2) or rna-dependent rna polymerase (rdrp) and envelope (e) genes [14] . this is of special interest due to the long virus incubation -median incubation period for covid-19 was estimated to approximately five days [15] . however, it has been noted that time from exposure to onset of infectiousness (latent period) may be shorter than the incubation period [5] . therefore, it is essential to do two subsequent tests during the proposed period. in addition to the detection of viral genetic material, we will target the immune response of the athlete being screened, looking specifically for antibodies (igm and igg) against the virus or viral antigens. those tests are less complex than molecular tests but since antibody responses to infection take days to weeks to be detectable, serologic tests will not be reliable among those with recent exposure to virus. however, antibodies detected by this test indicate that a person had an immune response to covid-19, implying the infection was subclinical if the person was asymptomatic. serologic tests could play an important role in establishing diagnosis, if the covid-19 patient with late complications of disease is examined since rt-qpcr could produce false-negative results, presumably because of the low viral load [14] . in addition to limiting the potential of viral spread with the start of regular sport activities, the results of this screening protocol will allow us to estimate how many football players have been infected nationally. the results will also provide information on the percentage of croatian football players who have not had covid-19 and are still at risk of being infected. we propose that football players need a gradual return to physical activities during four separate phases. the first phase includes training in a small group, while the second phase comprises training of the entire team. consequently, players will start with the national leagues' competition (phase three), while in phase four, the clubs will be joining international competitions. ideally, the club' s prior international competition should provide for all registered players, certificates issued by the accredited laboratories that the players are negative for covid-19. in addition to all these procedures mentioned above, special preventive recommendations will be given to the football players and other team members in addition to the above described screening program prior to the continuation of competitive matches. those include the following: 1) trainings must be performed outdoors. entry into club rooms and other closed spaces are prohibited. 2) no more than 5 players can participate in training sessions at the same time. the personal distance must be met at all times with at least 5 m separating the players. players must use own lanes for running and sprints, if this requirement can't be met, the same lane may be used by more players, but they must keep a distance between each other of at least 40 m when sprinting. headers are not allowed in training sessions due to close contact of the ball with orifices of the body. 3) the number of coaches in training sessions should be kept to a minimum. apart from the coaches only a physio or a team doctor may be present in the session. protective equipment is mandatory for the medical team when they are getting in close contact to a player. protective equipment includes face masks (n95, ffp2 or ffp3), protective gloves and face shields. 4) original, sealed plastic water bottles must be used and properly discarded after training. they may not be shared between players. 5) players and coaches must come to the training grounds alone, in their own cars, wearing appropriate clothes. changing and shower rooms will not be available for the athletes nor coaches. 6) after the training session both players and coaches must go to their homes using the same transport they came with. this should be done orderly whilst respecting the social distancing measures. we propose to implement these measures first in the croatian first league. they will also be recommended to lower leagues when they start with training and competitions and will be adhered to until a broader relaxation of preventive measures is advised by the local authorities. we presented our model to the leadership of fifa and uefa, with the goal of sharing our knowledge and ideas, as well as synchronising the actions of all the members during the covid-19 pandemic. we believe that adherence to the recommendations and testing of players will drastically reduce the risk of them being exposed to sars-cov-2 and other pathogens. in turn, it should allow a steady return to football we all know and love. estimating the asymptomatic proportion of coronavirus disease 2019 (covid-19) cases on board the diamond princess cruise ship covid-19: four fifths of cases are asymptomatic, china figures indicate delivery of infection from asymptomatic carriers of covid-19 in a familial cluster world health organization transmission of 2019-ncov infection from an asymptomatic contact in germany plasma metabolomic and lipidomic alterations associated with covid-19 renal histopathological analysis of 26 postmortem findings of patients with covid-19 in china long-term sequelae of sars: physical, neuropsychiatric, and quality-of-life assessment association of cardiac injury with mortality in hospitalized patients with covid-19 in wuhan, china. jama cardiol. 2020;e200950. online ahead of print cardiovascular complications of severe acute respiratory syndrome acute myocarditis associated with novel middle east respiratory syndrome coronavirus post-intensive care syndrome: an overview sudden cardiac death in football players: towards a new pre-participation algorithm diagnostic testing for severe acute respiratory syndrome-related coronavirus-2: a narrative review the incubation period of coronavirus disease 2019 (covid-19) from publicly reported confirmed cases: estimation and application key: cord-288983-a6s9di4g authors: su, sheng-fang; han, yueh-ying title: how taiwan, a non-who member, takes actions in response to covid-19 date: 2020-06-17 journal: journal of global health doi: 10.7189/jogh.10.010380 sha: doc_id: 288983 cord_uid: a6s9di4g nan o n 11 march 2020, the world health organization (who) declared that the coronavirus disease 2019 (co-vid-19) outbreak could be characterized as a pandemic [1] . meanwhile, covid-19 has spread rapidly from wuhan, china to numbers of countries in asia, the middle east, and europe. as of 12 march 2020, more than 100 counties, territories or areas had reported covid-19 cases with a total of 125 260 confirmed cases and 4613 deaths globally [1, 2] . while covid-19 is raging worldwide [4] , taiwan [5] -a non-who member, located 130 km from china with more than 400 000 of its 24 million citizens working there, and with almost three million chinese visitors in 2019, which was predicted to be one of the countries that was most affected by the virus, has defied the expectation to have only 429 confirmed cases (343 imported, 55 indigenous, 31 panshi how taiwan, a non-who member, takes actions in response to covid-19 fast combat support ship) and 6 deaths as of 28 april [3]. how taiwan emerged as self-reliant from the experiences of 2003 severe acute respiratory syndrome (sars) and 2009 h1n1 pandemic, has become a successful example during the covid-19 pandemic. this article describes the measures that taiwan took to prevent the spread of the novel coronavirus. on 31 december 2019, epidemic prevention physicians of the taiwan centers for disease control (cdc) were alerted by seven cases with suspected atypical pneumonia from wuhan, china of whom all had exposure history to the huanan seafood market of wuhan. immediately on that day (31 december, 2019) taiwan cdc sent an email to who international health regulations (ihr): "news resources today indicate that at least seven atypical pneumonia cases were reported in wuhan, china. their health authorities replied to the media that the cases were believed not sars; however, the samples are still under examination, and the cases have been isolated for treatment" [3]. in response to potential pneumonia outbreak in wuhan, taiwanese government immediately activated enhanced border control and quarantine measures based on the possibility of human-to-human transmission assumption on 31 december, 2019. the success of taiwan for anti-epidemic measures included: quick response and efficient management, central production and distribution of masks/medical supplies, quarantine/isolation regulations with tracking contacts technology, and coordination between government, medical workers, public health professionals, and the whole taiwanese society. in preparedness to potential influenza outbreak to formulate the first phase of prevention strategies [6] . in addition to the existing measure of onboard quarantine inspection, including fever screening of arriving passengers, suspected cases screening through history of travelling, occupation, contact and cluster (tocc) inquiring, and health assessments conducting, all health care facilities should reinforce reporting severe cases of pneumonia among people who arrive in taiwan from wuhan. all health care workers should strictly adhere to standard precautions for preventing nosocomial infection, wearing n95 respirators as required while performing invasive medical procedures such as intubation and tracheostomy [3,6]. to minimize the threat of the outbreak, on 20 january 2020, the taiwan cdc activated the central epidemic command center (cecc) for severe special infectious pneumonia that composed of government agencies and medical experts/specialists to take charge of the domestic epidemic prevention and control, and to coordinate resources from across ministries and private stakeholders [3, 6, 7] . since then, the cecc convened a daily press conference to update the latest epidemic, prevention measures and health guidelines. such efforts included reporting criteria of all pneumonia cases, testing and quarantine procedures, preparation of pharmaceutical and medical supplies, capacity ensuring of isolation wards, and public health education (mask wearing, temperature checking, hand washing, avoiding eyes, nose, and mouth touching, environmental disinfection, etc.). following identifying the first imported covid-19 case returning from wuhan on 21 january 2020, cecc raised travel notice level for wuhan, china to level 3 warning. the confirmed case was treated in a negative pressure ward at the hospital, the close contacts were traced and the quarantined individuals were electronically monitored. in light of the ongoing outbreak, cecc has introduced guidelines for high-risk individuals regarding 1) self-health management (reported cases who have tested negative and met criteria for being released from isolation, or people under "covid-19 community-based surveillance), 2) 14-day home quarantine (with travel history), and 3) 14-day home isolation (who had contact with confirmed cases), and provided quarantine sites with free meals and a us$30 compensation per day during the 14-day period. furthermore, on 11 february an electronic health declaration system was established for returning travelers, allowing updated health care services. starting from 19 march, home quarantine measures have been expanded to include arriving passengers from all countries. taiwan designated 134 response and isolation hospitals, as well as 52 regional hospitals or medical centers for treatment of confirmed cases, to establish the communicable disease control medical network (cdcmn) [3]. according to the communicable disease control act, the taiwan cdc classified covid-19 as a category 5 communicable disease on 15 january. people who meet the epidemiological criteria within 14 days: 1) history of traveling or living abroad, or contact with symptomatic (fever or other respiratory tract infection symptoms) individuals returning from abroad; 2) history of close contact with symptomatic suspected or confirmed case(s); 3) history of cluster related to confirmed cases are required to report to the cdc and placed for laboratory diagnosis. furthermore, starting april, patients with pneumonia are required to be reported and subjected to testing. a total of 161 medical facilities were designated for collecting specimens. the laboratory testing capacity in taiwan has reached 37 laboratories for 3900 cases per day. as of 9 may, 66 861 cases have been tested and 65 619 were excluded (as negative) with 440 laboratory-confirmed cases. people with three negative testing results were able to be released from isolation [3]. the community surveillance system has been implemented since 16 february for travelers to scan the qr code with a health declaration and home quarantine e-system (entry quarantine system). people in 14-day home isolation were contacted twice a day by local health agencies to follow their health status. in collaboration with telecom companies, taiwan launched an electronic security monitoring system to cellphone track people subjected to home quarantine/isolation [3, 8] . the responsible civil affair bureau worker could receive a notification via sms when the phone signal disappears, allowing the police to per-form the location check. violators could be fined or forcibly placed to the designated sites. taiwan central and local governments provided consultation and support services for the assistance of transport arrangements, medical care arrangements and household services. isolation hospitals, hotels and transportation arrangements for epidemic prevention were designated for home quarantined/isolated individuals. a special act for prevention, relief and revitalization measures for severe pneumonia with novel pathogens was adopted on 25 february to respond to the coming crisis [3]. to evacuate taiwanese in wuhan, cecc deployed a thorough onboard quarantine procedure. individuals with symptoms were sent to negative pressure isolation wards directly upon arrival. all other evacuees were sent to designated quarantine sites by designated transport vehicles and placed under 14-day period of quarantine with their luggage disinfected. all related staff and health care workers participated in the charter plane operation wore personal protective equipment. different from the stigmatization in the west, the less negative perception of wearing a face mask in taiwan (and eastern asia) has contributed to the "first line of defense" of covid-19 [9] . for taiwanese, it has become a cultural norm to wear a face mask due to various reasons, including: a courtesy to others when feeling sick, to keep face warm in winter, and as a protection from vehicle exhaust or air pollution. it is not implication for crime and security in the society. more importantly, from the sars outbreak in 2003, taiwanese government and citizens have learned how viral respiratory diseases can inflict and realized the impact of wearing a mask on reducing the risk of disease transmission, adopting mask wearing for covid-19 was implemented quickly. people in taiwan wear masks when taking mass transportation (metro, trains, buses and taxis), and going into the crowded public places. in addition, taiwanese acknowledge scientific-based evidence, respect experts' recommendations, and follow government' s policies at the preparedness phase of the pandemic. the whole community voluntarily partnering with the government to create a network of databases with transparent information is another key to the success of "testing, tracing and isolating" strategy for fighting covid-19 [8] . the taiwanese government has been collaborating with developers and citizens to develop strategies and solutions at the online town hall (https://info. vtaiwan.tw/), where people can participate in the dialogue and the process of policy making and therefore, inspire the trust. the consensus of sharing digital data temporarily and of understanding how it is used have kept the virus from spreading in the community. taiwan though excluded from membership in the who stands out in the covid-19 pandemic as an example of successful prevention and outbreak control [5] [6] [7] . as of 9 may, while covid-19 affected over 210 countries with a total of 3 937 813 confirmed cases and 274 898 deaths worldwide [2] , taiwanese society maintained routine daily life without long-term nationwide school closures or bushiness shutdown. taiwan's baseball league was the first professional game to open the 2020 season on 11 april. given its effective actions and managements, taiwan had the capability to donate up to 17 million masks to the us, europe, and diplomatic allies, and collaboratively work with the world [6, 7] . it is the time to rethink how the world is tightly connected. taiwan' s model of fighting covid-19 set an example of how to effectively prevent or better response to the next public health crisis. coronavirus disease 2019 (covid-19) situation report covid-19 dashboard by the center for systems science and engineering (csse) at johns hopkins university (jhu) covid-19-a timeline of the coronavirus outbreak as government fumbled their coronavirus response, these four got it right. here' s how how my country prevented a major outbreak of covid-19 taiwan health minister: covid-19 outbreak underscores importance of taiwan' s inclusion in who. ipoli-tics it' s taiwan. bloomberg opinion asia may have been right about coronavirus and face masks, and the rest of the world is coming around. cnn. available we thank dr chien-jen chen, dr huei-wen chen and mr. nathan peluso for their constructive suggestions, and the ministry of science and technology for the support. authorship contributions: all authors contributed to writing and conceptualizing the manuscript. the authors have completed the icmje unified competing interest form (available upon request from the corresponding author) and declare no conflicts of interest. key: cord-311601-w2jqmpww authors: muzemil, abdulazeez; fasanmi, olubunmi gabriel; fasina, folorunso oludayo title: african perspectives: modern complexities of emerging, re-emerging, and endemic zoonoses date: 2018-10-25 journal: journal of global health doi: 10.7189/johg.08.020310 sha: doc_id: 311601 cord_uid: w2jqmpww nan r ecent events have shown that public health, animal health and national economies have been threatened, globally, by the increased occurrence of emerging and re-emerging infectious diseases (ereids) [1] . specifically, land use change cum agricultural practices, surging human demographic, pathogen evolution (antimicrobial resistance), failure of public health systems, global travel and more global interconnectedness in spatial and temporal dimensions have driven these threats [2] . other aggravating factors include: ecological changes, incursion into previously uninhabited areas, changes in human behavior, environmental degradation, international trade, technology and industry, antimicrobial misuse, and deficiencies in public health infrastructure and decision-making [1] [2] [3] . major ereids − including zoonoses − have been reported in the last two decades including: bovine spongiform encephalopathy, hendra, nipah, severe acute respiratory syndrome (sars), highly pathogenic avian influenza (hpai) h5n1, h5n8 and h7n9 subtypes, west nile fever, pandemic h1n1 influenza, ebola virus disease (evd) and middle east respiratory syndrome coronavirus (mers-cov). many of these diseases have been documented in africa. in africa, 47 of the 54 countries (87%) have reported ereids to the who since 1997 ( table 1) . while several initiatives have been implemented globally to accelerate progress toward a safer world [4] , it is yet not clear whether african countries are ready and capable of handling the magnitude and threats associated with ereids [4] . here, we reviewed plausible reasons and drivers for the upsurge of ereids in africa and proffer some mitigating measures. human populations in african countries have rapidly increased in the last few decades (figure 1 ). population growth has occurred together with a substantial modification of human and pathogen behaviours [2, 4] . for example, hoosegood has identified that societal behaviours eg, union formation and cohabitation, re-marriage and partnering, union instability-widowhood, divorce and separation, fertility and fecundity, and fertility-related decisions significantly impact on and are impacted by hiv and aids in sub-saharan regions particularly, in southern africa [5] . second, urban growth has disrupted wildlife and pathogen ecology [1, 2] . as human-pathogen contacts increase, so does the probability for more outbreaks. pathogens affected include cowpox, lyme disease, nipah, hendra and ebola viruses as well as the group named eskape -which includes enterococci, s. aureus, k. pneumoniae, a. baumannii, p. aeruginosa and en-terobacteria-which explains between 45 and 77% of all african human mortalities [1, 3] . as human-pathogen contacts increase, so does the probability of more outbreaks. to prevent epidemics, it is needed to markedly improve public infrastructures, sanitation, and the health systems. for instance, the public and animal health surveillance systems must transform, so interventions occur within acceptable response times [1, 3, 4] . third, in the 20 th century, the average temperature has increased approximately 0.7°c in the african continent. climate change has predisposed africa to highly vulnerable situations, particularly around internationally shared water resources. consequently, new challenges have emerged, including: border-related conflicts, food security risk due to declines agricultural production, vectorand water-borne diseases, (especially in areas with inadequate health infrastructure), flooding and exacerbation of desertification by changes in rainfall and intensified land use [2] . predictions related to water resources include: (a) decreased rainfalls in portions of the sahel, (b) increased rainfalls in east central africa, (c) increased temperature ranging from 0.2°c to >0.5°c per decade, especially in the semi-arid margins of the sahara and central southern africa [6] . some studies have also suggested that major climate change will influence water resource use, natural resources management and biodiversity, human health, food security, resettlement and infrastructure re-allocation, and desertification [2, 6] . variance in climatic conditions will impact significantly on disease ecology and epidemiology with upsurge in human-animal disease conditions due decreased salinity of the soil which can increase the number of toxic bacteria and breeding sites for mosquitoes and rodents. these challenges can have consequences on international trade and commerce. since the liberalization of trade policies between countries over the past two decades, national economies have grown in leaps and bounds. while such policies have fast-tracked growth forecast for african countries, they also have augmented the risks of emergent and trans-boundary animal and human diseases especially associated with long flights, such zoonotic tuberculosis, influenza viruses, hiv/aids and cholera. because trans-border movements of livestock and/or some commercial practices may bring together disease vectors and humans, human and animal health should be addressed together [1] [2] [3] . fourthly, the rapid expansion in human populations (and consequently, the need to meet the food security needs) has warranted the intensification of animal and crop agriculture. these changes have converted previously fallow lands and forest into arable, agricultural and/or grazing lands. associated with these changes are increased (a) rodents populations, (b) dispersal and redistributions of wild ruminants populations and their ectoparasites, (c) wildlife-livestock-human interactions, and (d) occurrence of diseases like rift valley fever. bodies of evidence have suggested that the rate of future zoonotic diseases will be closely linked to the evolution of the agriculture-environment nexus [1, 2] . it is suggested that, as long as africa (or any other continent) does not address complex interactions -such as those that involve agriculture, the environment, economics, sociology, as well as zoonotic pathogens, disease outbreaks may follow human-driven disruptions, as those observed after major changes in land use, eg, those related with the construction of dams, mines, and intensive agriculture. the fact that pathogens have evolved and keep evolving should be emphasized. microbes such as mycobacterium tuberculosis, enterococcus faecium, enterobacter cloacae, klebsiella pneumoniae, s. aureus, acinetobacter baumanii and pseudomonas aeruginosa have developed multiple resistance mechanisms due to excessive and long-term use of antimicrobials, genetic transfers of resistance genes and selective pressures [2, 3] . endemic antimicrobial-resistant africa will need to prioritize rapid detection, prompt response to ereids, optimize the benefit of geospatial epidemiology in policy decisions and utilize interdisciplinary educational programs. ) . intense human-animal interactions, and consumption of non-certified pathogen-free animal products facilitate the spread of zoonoses pathogens come with heavy clinical and economic burdens, especially in the developing countries. recent review had indicated that endemic infections associated with antimicrobial resistance requires a particular attention because such diseases are linked with approximately 44 to 77% of all annual human deaths in africa [3] . it has been estimated that, by 2050, more lives will be lost due to antimicrobial resistance (amr) than cancer [3] . one major component of antimicrobial resistance is the overuse of antimicrobials in the production of livestock, which are then passed to humans [3] . because vaccines reduce the incidence of infectious diseases (and, therefore, antibiotic use), immunisations might reduce amr [1, 3, 7] . prevention and mitigations: given the numerous and serious issues here identified, african governments need to prioritize efforts aimed at rapid detection and prompt response to emerging or re-emerging pathogens. for example, the critical response time (crt or time available to implement effective epidemic control measures) should be considered in decision-making [1, 5] . that is so because for any intervention to be very effective (≈ 100%), it must be deployed under a realist timeframe; if it requires a longer period of time, it will necessarily be (i) less effective (if not ineffective), and (ii) more expensive [5] . crt may or may not include geo-referenced data. when it lacks geographical data, it becomes much shorter, making useless almost any intervention. thus, the real significance of crt is that it should be expanded (giving decision-makers more time to complete interventions) − which can only be achieved when high-resolution geo-referenced epidemiologic data are analyzed in time and space. thus, to achieve improved epidemic control measures, geographically explicit data should be collected from epidemics, analysed and lessons learnt made available for future interventions. only such (local or regional) data can support scientifically valid decision-making. yet, even recent epidemics have been addressed with ad hoc policies, such as the classic '3-km radius control rings' -which assume all epidemics (ie, all pathogens, all host species, and all local geographies) are identical [1] [2] [3] . failure to consider local bio-geo-epidemiological information has led to widespread dissemination of major epidemics, such as ebola in guinea, liberia, and sierra leone [8] . infectious diseases and zoonoses are extremely expensive to nations both clinically and economically, for example a recent valuation had estimated such costs to include: sars in asia and canada (us$ 30-50 billion), hpai h5n1 globally (us$ 30 billion), worldwide influenza h1n1 (us$ 45-55 billion), ebola in west africa (us$ 10 billion) and zika in latin america and the caribbean (us$ 7-18 billion) [9] , promptly delivered pre-emptive actions and control measures, as well as targeted interventions can significantly reduce burdens associated with these diseases. the creation of interdisciplinary educational programs aimed at local and regional decision-makers involved in disease diagnosis, dissemination, and control, is recommended. such programs could develop and integrate: (i) local data on antimicrobial resistance, (ii) high-resolution, local geo-referenced data, and (iii) site-specific control measures that can be implemented within biologically valid critical response times. one health contributions towards more effective and equitable approaches to health in low-and middle-income countries urbanization and disease emergence: dynamics at the wildlife-livestock-human interface clinical and economic impact of antibiotic resistance in developing countries: a systematic review and meta-analysis the world health report 2007 -a safer future: global public health security in the 21st century the demographic impact of hiv and aids across the family and household life-cycle: implications for efforts to strengthen families in sub-saharan africa working group ii). impacts, adaptation and vulnerability. the third assessment report of the intergovernmental panel on climate change working group ii the role of vaccines in preventing bacterial antimicrobial resistance ebola virus disease in west africa -the first 9 months of the epidemic and forward projections investing in one health: a concerted approach to address shared risks to humans, animals, and the environment acknowledgments: population data from the united nations was utilized in this work. authorship contributions: am initiated the study, contributed to the data and initial draft; ogf contributed to data filtering and analysis; fof reviewed the concept, analyzed data, wrote, edited and reviewed the manuscript and took overall direction of the work. the authors completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available upon request from the corresponding author), and declare no conflict of interest. key: cord-354339-tchu91av authors: shahzad, naeem; abid, irfan; mirza, wajahat javed; iqbal, muhammad mazhar title: rapid assessment of covid-19 suspected cases: a community based approach for developing countries like pakistan date: 2020-05-06 journal: journal of global health doi: 10.7189/jogh.10.010353 sha: doc_id: 354339 cord_uid: tchu91av nan t he coronavirus pandemic started in late december 2019, when an unexplained case of mass pneumonia occurred in wuhan, china raising concern of the responsible health department of the city. the chinese government notified the who of the epidemic situation in the first week of january 2020 and subsequently, the causative agent was identified as a new coronavirus (2019-ncov), followed by genetic sequence analysis and the development of a detection method [1] . in the second week of january, the new coronavirus pneumonia was included in the management of class b infectious diseases by the national health and health commission china on the approval of the state council. city went under lockdown and the chinese government made the highest-level commitment to mobilize every effort to stop the epidemic. understanding the epidemiological characteristics of corona virus (2019-ncov) transmission is critical to developing and implementing effective control strategies. this virus spread rapidly affecting 31 provinces (autonomous regions / municipalities) from 30 days after the first reported case, the epidemic reached its first peak on january 24-26, 2020, and an unusually high incidence of single-day event on february 12, 2020, and then gradually decreased till china was able to contain this virus to its track [2]. covid-19 has become one of the largest spreading diseases on the global front in the recent times after spanish flu in early 20 th century. current globalized environment and rapid modes of transportation have helped spreading this virus at an enormous rate, which is unprecedented. the non-availability of cure for the disease and rapid transfer rate has brought the world to a halt. there is also a deficiency of testing kits on the global front coupled with the capacity of available health facilities to test and treat the patients, especially in the under developed world. this required a scientific approach to shortlist the case requiring medical attention for testing and treatment. another important factor raising red flag for the spread is a period of 14 days inactivity of the virus, which may lead to a wrong diagnostic, resulting into spread of the disease. photo: nurse wearing locally produced low cost covid-19 kit and filling the score card from a suspected patient for initial screening and triage at the emergency control room (from the collection of dr naeem shahzad, used with permission). inclusion of epidemics and pandemics amongst biological hazards by the sendai framework for disaster risk reduction (unisdr, 2015) and other related frameworks and conventions, the corona virus outbreak has exposed the loop holes which many countries are struggling to respond and manage, as their health care systems have been overwhelmed by exponential increase in cases with every passing day. it is worth mentioning that notwithstanding all odds, countries like china, south korea and singapore have effectively controlled the spread of this pandemic while us is managing huge number of patients with considerable fatalities. by observing the response of the us and most european countries to covid-19, it is apparent that the developing countries and countries with poor economic infrastructure will not be able to cope up with this health emergency. it is contingent that countries with low gdps are already over burdened due to number of factors including overwhelmed health care systems and different underlying co-morbidities. therefore, it is imperative to infer that risks posed by covid-19 in countries with poor economies will be entirely different as compared to us, china and europe. the average household in low-income countries is on higher side as compared to middle and high-income countries thereby highlighting the vulnerabilities of these countries to rapid spread of covid-19 [3] . for this reason depending on the existing health care systems in countries with low gdps will be unrealistic to contain and stop the covid-19 transmission. different strategies for suppression of the covid-19 are being practiced globally ranging from lockdown of cities to isolation of cases, in order to prevent the number of cases having severe illness requiring icu [4] . different countries are resorting to massive lock down and social distancing to manage and contain the covid-19. this is more critical in the case of developing countries like pakistan to avoid stretching of its already weak health care facilities by resorting to excessive testing, contact tracing, isolation and quarantine of the suspected cases to circumvent health care system overload [5] . aggressive testing of the individuals becomes tiring and cumbersome in the absence of covid-19 testing kits. therefore, this study has made an effort to design a rapid assessment score card using bottom up approach starting from community level which will help the low-income and developing countries to ascertain the suspected covid-19 cases at community level. this will be quite beneficial for rapid triage especially for the countries like pakistan where the suspected cases of covid-19 are likely to be under-detected due to low testing capabilities [6] . based on different research findings [7] [8] [9] [10] [11] [12] , a score card has been developed encompassing maximum possible/ probable causes of covid-19 suspicion among the community. to develop an effective tool for patient screening without overburdening the health care infrastructure while still not compromising the control over the spread of the disease and preventive measures, an effective score card has been developed covering numerous effective parameters for rapid assessment of the probable coivd-19 cases, as shown in figure 1 . for this purpose the trends and effects of spread rate, age factor, previous health history, travel history, isolation period, appearance of the symptoms and contact with the suspected or confirmed patients has been taken into consideration. this score card has been designed for low income countries with no or limited testing capabilities of covid-19 tests. it is perceived that countries like pakistan, could resort to this score card at community level to triage the suspected patients and may adopt testing of only basing on the discussed factors, the over burdening of the health system can be controlled with a systematic filtering and triage of the suspect cases using the proposed score card, where the parameters discussed have been given due weight to assess the total score of the suspect to filter him/her for a probable test case or otherwise. those patients who have higher scores (ie, ˃100). this will help lessen the burden of already limited laboratory testing facilities available in the country. the method will also be helpful for low-income countries like afghanistan, bangladesh, chad etc., which are vulnerable to exponential outbreak of this virus due to their in-capacity to detect covid-19 patients and availability of the testing kits is badly hampering and overburdening the who efforts to fight this pandemic. the score card has been tested on a small community of risalpur cantonment (34.06048 latitude, 71.99276 longitude) which is an enclosed community consisting of a population of around 30 000. the demographic distribution of this community cannot be shared due to security issues as it is housed in a cantonment. this score card was tested for its effectiveness after the area was under complete lock down since march 23, 2020 and limited entrance and exit was allowed to this community. an emergency control room has been developed in the community to deal with the covid-19 situation. this room is manned 24/7 and any person entering risalpur cantonment was sent here in order to screen the individual for covid-19 suspicion. besides, any individual complaining or expecting probable symptoms of covid-19 was first screened at this centre and was then further referred to the hospital if required. until april 3, 2020, 1166 persons were screened at the control room. these results show that 21 persons were suspected and their scores suggested that they were required to be tested on priority, while 14 others were immediately hospitalized. since the burden of patients was not much at the health facility available in the area, which is class 'c' hospital, so tests of all the suspected patients ie, 35 were sent to islamabad and peshawar and all tested negative. however, these patients were isolated and quarantined for 14 days. it can be easily inferred that instead of testing all the 1166 individuals who reported to the control room for suspicion of covid-19, only 35 persons required covid-19 tests which accounts for 3% only. low-income countries with limited health facilities may resort to this technique to reduce the burden on their testing facilities. it is pertinent to mention that this is not an ide covid-19: extending or relaxing distancing control measures using observational data to quantify bias of traveller-derived covid-19 prevalence estimates in wuhan, china time course of lung changes on chest ct during recovery from 2019 novel coronavirus (covid-19) pneumonia clinical characteristics and intrauterine vertical transmission potential of covid-19 infection in nine pregnant women: a retrospective review of medical records coronavirus disease 2019 (covid-19): situation report covid-19 and the cardiovascular system severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and corona virus disease-2019 (covid-19): the epidemic and the challenges pathological findings of covid-19 associated with acute respiratory distress syndrome covid-19): a perspective from china korea' s response to covid-19: early lessons in tackling the pandemic the authors hereby acknowledge the risalpur cantonment authorities for sharing the data regarding persons reporting the control room. no funding was available for this study.authorship contributions: ns was involved in data gathering and preparing of initial draft. ia was involved in preparing part of the paper and reviewing and improving the initial draft. wjm was involved in developing the score card and assisting in data gathering. mmi reviewed the final draft. the authors completed the icmje competing interests form (available upon request from the corresponding author) and declare no conflict of interests. al way of tracing the covid-19 suspected patients but can be an alternative to no testing at all due to minimal or low testing capacities.besides findings highlighted above, following deductions have been made for the observed statistics.1. for a country where the disease has been imported after february 20, 2020, the rate of spread has been lower while still being on the exponential scale, as the preventive model of isolation and lockdown of the society was already inferred basing on the initial devastation of the disease.2. poor health facilities result in better immunity of the people to fight against the illness but the same also results in a less average age due to a fatigued life, there by having significantly less people with age over 70 years in the under developed world.3. previous health history is associated to age, health infrastructure, trends in the society, and to some extent geographical location. this also contributes significantly to the potential proneness for disease adaptability and seriousness.4. nevertheless, travel history is also a significant parameter. although most of the countries have started to exercise the travel ban internationally, but the ghost phenomenon of the disease for a period of 14 days and local mobility within the country or affected region can still affect the patient count dramatically (both for confirmed and non-confirmed cases).5. an already exiting mechanism evolved over the experience of last few weeks to deal with the spread, prevention, and cure of this disease has shown the efficacy of the isolation period and appearance of the symptoms of the disease. this is helpful in eliminating the disease and its spread in a locality or a region. the two successful strategies to contain and control corona virus have been adopted by china and korea [13, 14] . for countries like pakistan, korea' s strategy to trace, test and treat is difficult to adopt due to limited testing capabilities. similarly, owing to the poor economic conditions of the country, complete lock down will lead to economic crisis especially for small businesses and daily wagers. in addition to enhancing the country' s testing capabilities by importing test kits, it is imperative to adopt suggested score card based assessment, to reduce the load on the testing centers all across the country. this will be very beneficial in small villages and towns to adopt a bottom up approach and ease the already over stretched testing facilities for management, treatment and care of the suspected covid-19 patients. basing on the above mentioned factors, the over burdening of the health system can be controlled with a systematic filtering of the suspect cases, where the parameters discussed have been given due weightage to assess the total score of the suspect to filter him/her for a probable test case or otherwise. key: cord-300095-a94j7vz4 authors: chan, lai gwen; kuan, benjamin title: mental health and holistic care of migrant workers in singapore during the covid-19 pandemic date: 2020-08-11 journal: journal of global health doi: 10.7189/jogh.10.020332 sha: doc_id: 300095 cord_uid: a94j7vz4 nan m igrant worker populations in singapore as well as other countries, despite advances in legislation and protections [1], continue to face longstanding issues of barriers to equal access to health care [2] , information and resources targeted at the host country's local population, and even exclusion from national crisis response plans particularly pandemic preparedness plans [3] . non-governmental organizations (ngos) have a vital role in filling this gap by providing accessible services (eg, welfare, health care, crisis), liaison between employers and financing agents, and advocacy by representation of their needs and concerns in multi-agency collaborations. specifically, mental health care for this population has been lacking because language and cultural barriers make it challenging for general health care services to incorporate this aspect. high levels of stigma towards mental illness in the home countries of migrant workers also add to the burden of unmet needs for focused mental health support. the scarcity of such services even among the ngo sector became amplified during the covid-19 pandemic in singapore when mass quarantine and isolation of migrant worker accommodations severely reduced ngos' access to them. healthserve [4] was one such ngo which, in the 14 years since it was founded, has established strong networks of friendship and goodwill between ministerial agencies, employers, migrant worker dormitory operators and migrant workers. healthserve operates low-cost primary care clinics including case work support to workers who had sustained workplace injuries, and commenced a mental health and counselling department, the first among the other migrant worker ngos, in 2019. when news broke in early april 2020 about the gazetting of 2 large migrant worker dormitories as isolation areas because of clusters of confirmed covid-19 cases there [5] , healthserve anticipated the unprecedented magnitude of mental health and psychosocial care needs and stepped forwards with a manual of recommendations on how to engage the migrant worker population as well as how to address the mental health and psychosocial care needs (an adaptation and application of the interim briefing note mental health and holistic care of migrant workers in singapore during the covid-19 pandemic this paper describes a collaborative model between a non-governmental organization and other governmental and healthcare stakeholders in addressing mental health and holistic care of migrant workers, as well as how the model evolved as more real-time experience about this population's needs and responses were gained. addressing mental health and psychosocial aspects of cov-id-19 outbreak developed by the iasc's reference group on mental health and psychosocial support in emergency settings [6]). (table 1) . this was circulated to governmental and community teams who were involved in migrant worker outreach. it describes a tiered model of care where the recommended interventions get increasingly specific and specialized as one moves up the tiers. for example, tier 1 recommends basic communication and connection strategies to meet basic needs for safety, and the highest tier describes specialized mental health services delivered by mental health professionals. this manual continues to be an evolving document as more is learnt and as policies change in real-time. the experience gained as described in this paper will be a critical reference for other healthcare systems where barriers remain in migrant workers' access to healthcare, especially in planning for future disease outbreaks. tier 1 • enable autonomy over simple daily routines that are culturally and religiously appropriate: -provide resources/equipment needed to maintain dignity in lifestyle eg, housekeeping necessities, toiletries, food for cooking comfort foods (within appropriate social distancing measures & contexts) social considerations in basic services and security • provide freedom, space, resources for religious rituals • ensure basic, positive daily communications through any broadcasting system in appropriate languages basic themes in establishing sense of safety: • give adequate advanced notice and information about any upcoming transitions, eg: -transfers from dormitory to hospital or isolation facility or discharge back -explain their medical condition, reason for transition, what to expect after transition etc • repeat and reinforce information post-transition similarly • sensual comforts (eg, preferred foods) • have staff trained in psychological first aid to look, listen and link • provide a means for feedback and concerns to be raised and addressed eg, -message boards, -whatsapp chat groups, -daily face-to-face check-ins, and -ensure timely updates on the concerns raised • habitual comforts (eg, familiar routines) • provide information and access to covid19 specific information, eg, https://covid19.healthserve.org.sg/ • provide information and access to self-help resources, eg, healthserve hotline • hearing and feeling heard • written information in the form of care cards or health booklets can be helpful but audio-visual forms are preferred because verbal comprehension abilities are generally stronger than reading comprehension • ensure access to chronic disease management tier 2 • healthserve website to be regularly refreshed with mental wellness content • encourage self-enablement and empowerment • provide resources for suggested appropriate pleasurable activities, eg, -games (playing cards, carrom, chess, etc) -craft work, art/drawing -outdoor movie screening -etc strengthening personal resilience and community and family supportsactivating social networks, supportive spaces • plan special activities, foods, occasions to be looked forward to • enable celebration of significant cultural/religious festivals in appropriate ways • encourage helping and looking out for each other who are in the same cohorted space, and have autonomy over their space (eg, 'cleanest room / corridor / block' competitions) basic themes: • encourage ground-up initiatives and ideas on activity scheduling and system improvements • connection • communication • announce and celebrate achievements • contribution • harness technology to enable new ways of expression, communications and communal activities • meaning tier 3 hospitalized or quarantined workers • prepare a pool of available translators and have a low threshold for calling on them for help • develop communications scripts for use between patient/healthcare worker and healthcare worker/ patient's next of kin • include aspects from tier 1 and tier 2 in admissions orientation (such as sources of information and self-help) non-specialised supports -basic emotional and practical support by community workers • posters and informational materials on healthserve's hotline to be displayed prominently for awareness and self-help • referral pathways for onsite teams to refer cases to healthserve tele-befriender service or onsite teams to allow access to healthserve to provide outreach -all attending teams (medical and non-medical) are advised to proactively detect signs of emotional distress dormitory workers healthserve "tele-befriender" service in the form of 1:1 or group sessions, fronted by volunteers and supervised by mental health experts • posters and informational materials on healthserve's hotline to be displayed prominently at medical post • referral pathways for onsite teams to refer cases to healthserve tele-befriender service or onsite teams to allow access to healthserve to provide outreach -all attending teams (medical and non-medical) are advised to proactively detect signs of emotional distress • employers and dormitory managers can also refer to healthserve tele-befriender service by sending a text message to the healthserve hotline tier 4 • cross-referral across health care institutions to accord appropriate care for individuals requiring more intense intervention specialised services -mental health care by mental health specialists • early involvement of skilled resource from tertiary hospitals and national institutes for just-in-time care • proposed workflows for referral and escalation (to be developed according to jurisdiction) additional strategies were adopted by healthserve and these are the ones with the greatest impact: 1. proactively approaching the inter-agency task force [7] that had been set up to provide support to dormitory operators and the migrant workers living there in order to be a representative voice for migrant workers as well as offer recommendations on how best to engage this population. this was made possible through pre-existing networks with ministerial agencies and a high level of trust between parties. this collaboration continues to be active and deepen and ensured that mental health care continues to be a priority. 2. partnered medical teams providing on-site medical care to dormitories to conduct small group engagement with migrant workers for needs assessment. concerns and feedback were systematically gathered and resulted in rapid improvements to care and services provided on the ground as well as future planning. these concerns included issues related to food provision, fears of covid-19 transmission, lack of timely information, fears of deportation etc. 5. healthserve's communications team also set up a specific covid-19 information webpage [8] accessible in different languages of the migrant workers, with information regarding the pandemic, social support that is available, as well as mental wellness information. a separate team of volunteers also prepared a pipeline of content to regularly refresh the webpage. from experience, migrant workers tended to use social media platforms more frequently, hence healthserve also ensured its social media pages [9] were regularly refreshed with content and the relevant links to further online information. healthserve also engaged the partnership of the country's major telecommunications providers to send out sms (short messaging system) blasts pointing the migrant worker population to these online resources and worked with social media companies to target relevant information specific to migrant workers. one key learning was that this population tended to consume information via video and audio rather than text and health-serve hence worked closely with media houses to produce content in these formats. videos featuring celebrities from the workers' home countries were particularly well-received. 6. outreach to and partnerships were made with the national centre for infectious diseases (ncid, where the bulk of covid-19 cases were given acute care) and the community isolation facilities (where covid-19 patients were decanted from acute hospitals) so as to provide support on how to apply the manual's recommendations in the specific settings. for example, creating videos to be broadcast in hospital rooms on what to expect in their journey as a patient traversing through the health care system, creating simple and pictorial health booklets in native languages to empower migrant workers to take charge of their own health and mental well-being, setting up of remittance booths/kiosks for online remittance, supporting muslim migrant workers who wanted to observe ramadhan (setting up prayer corners, providing prayer mats, specific foods and timings to break fast), and even encouraging ground-up initiatives such as providing haircuts. there was much positive qualitative feedback about these. 7. psychiatric departments of different hospitals and the country's tertiary psychiatric hospital also reached out to establish partnerships, referral pathways and escalation protocols for migrant workers identified to require more specialised mental health assessment and interventions. these have proven to be useful especially as cases of major mental illness and serious self-harm began to emerge and the numbers requiring psychiatric intervention are rising. 8. healthserve also actively "walked the ground" for outreach to migrant workers who were not living in established purpose-built dormitories. such workers were usually living in factory-converted dormitories or private rental apartments, and a smaller group were those given a special permit to remain in singapore while awaiting workmen's injury compensation or salary disputes to be resolved. this had the impact of reaching even the most marginalized migrant workers who would otherwise have fallen through the cracks in the system. "walking the ground" also provided opportunities to engage with the dormitory teams and managing agents of care facilities, who did not have prior experience with engaging migrant workers, to build trust and establish the informal networks that were essential for access and timely responses. 9. chronic disease management began to emerge as an important health care need for discharged migrant workers who had been diagnosed whilst being treated for covid-19. healthserve agreed to receive these referrals to its primary care clinics and worked with the different health care providers on referrals and continuity of care. this aspect was also identified as a health care need that will continue to exist beyond the covid-19 pandemic and will require further conversation with stakeholders and policy changes regarding their health care financing. 10. finally, continued mental health commitment by the healthserve board beyond co-vid-19 was important for both partners and management. the board determined that mental health services would be needed for the longer term to not only address the longer term sequelae of covid-19 but also to respond to the heightened awareness of mental health and psychological well-being of the migrant workers and committed further resources to sustain the services established during this time and to expand them. mrcpsych(uk) department of psychiatry tan tock seng hospital 11 the views expressed in the submitted article are authors' own and not an official position of the affiliated institution.funding: none. lgc contributed to the intellectual content and the writing of the manuscript. bk contributed to the intellectual content. the authors completed the icmje unified competing interest form (available upon request from the corresponding author), and declare no conflicts of interest.it is now almost three months since the spike in covid-19 cases among migrant workers, and mental health and suicide prevention have now become one of the key priorities on the task force's agenda. this experience has demonstrated how a medical ngo can engage in a functional, effective, and evolving collaboration with both governmental and non-governmental stakeholders as recommended by the world health organization in its interim guidance [10], so as to ensure that the voice of the migrant worker population is represented and balanced policies regarding their management are made. it is neither too early nor too late to address mental health and psychosocial concerns of the migrant worker population. nevertheless, it is hoped that this capacity would be built in sooner rather than later in future pandemics and that this paper would serve as a crucial guidance for other jurisdictions. key: cord-339689-pemyxewv authors: moran, alexander; mphahlele, matsie; mvusi, lindiwe; dlamini, cindy; ahmedov, sevim; almossawi, hala jassim; kak, neeraj title: learning from tuberculosis: covid-19 highlights the need for more robust infection control policy date: 2020-07-28 journal: journal of global health doi: 10.7189/jogh.10.020328 sha: doc_id: 339689 cord_uid: pemyxewv nan c oronavirus disease 2019 (covid19) represents an unprecedented challenge in modern public health practice. having spread to over 180 countries and having affected millions of individuals, the covid-19 pandemic requires a coordinated, effective response without sacrifice to quality or availability of other essential medical services [1] . this rapidly-moving pandemic has laid bare the importance of effective surveillance, quarantine, testing and diagnosis, contact tracing and hospital infection prevention and control measures. certain countries, including singapore, have effectively contained community spread of the virus through early and broad quarantine, testing and contact tracing measures [2] [3] [4] . in countries like italy and spain -where responses were slower, narrower in focus and less consistently implemented -covid-19 transmission has spread widely in the community, and responses have shifted from containment to mitigation [4, 5] . in these countries where containment measures have failed, health systems must plan to ration life-saving medical equipment like mechanical ventilators [6] [7] [8] . as covid-19 spreads to more countries daily, governments begin to prepare for community spread and start to impose travel restrictions, quarantines and physical distancing measures in an effort to "flatten the curve" and to minimize health system strain [9, 10] . minimizing nosocomial (hospital-based) infections is integral to an effective covid-19 response. the world health organization (who) has published interim covid-19 infection prevention and control (ipc) guidance, which focuses on administrative controls (including policy, guidance, training and triage practices), environmental controls (including ventilation and waste management) and personal protective equipment (ppe, including rational use thereof) [11] . as more patients become sicker and require hospitalization, public health leaders must look toward existing hospital-based ipc programs to ensure a broad, consistent prevention and control effort. tuberculosis (tb) ipc programs are uniquely prepared for this challenge and can be leveraged to mobilize already-trained health care workers, to adapt existing tb ipc guidance documents and to implement existing administrative controls, environmental controls and ppe practices. learning from tuberculosis: covid-19 highlights the need for more robust infection control policy the covid-19 pandemic highlights the need for supporting airborne infection prevention and control programs to improve preparedness for future public health threats. aside from responding to this global emergency, countries must also prepare for future outbreaks and continue to support and strengthen existing infectious disease programs [12] . in this viewpoint, we discuss the readiness of world health organization (who) africa region countries for covid-19 ipc implementation, offer an example of a successful tb ipc intervention in south africa, and describe how this intervention can be adapted for the covid-19 response. we also discuss the need for continued momentum and sustainability for ipc programs before, during and after a pandemic threat. who recently published interim ipc guidance for covid-19 describes standard airborne ipc practices for hospital settings, which mirror the general who minimum requirements for ipc programs [11, 13] . the interim guidance includes the following components, with example interventions described within each component: • establish a well-equipped triage station at the entrance of health facilities which is supported by trained staff • use screening questionnaires according to the most updated case definition • post signs in public areas asking symptomatic patients to alert health care workers (hcws) • ensure social distancing (ie, a minimum of 1m between people) or screening people as they enter • ensure that patients cover their nose and mouth with a tissue or elbow, scarf or home-made mask • offer a medical mask to patients with suspected covid-19 in waiting rooms or in cohorting areas • encourage good hand hygiene with handwashing with soap and water or alcohol gel • provide adequate training to hcws with weekly in-service training • establish a surveillance process for possible covid-19 infection among hcws • monitor hcw compliance with standard ipc precautions • restrict visiting hours to facilities as well as the number of people that can visit health facilities • ensure posters, patient education and handwashing/sanitizing. • ensure adequate ventilation in rooms where aerosol-generating procedures are performed • limit room capacity to the absolute minimum for patient care and support • implement standard ppe precautions • implement additional contact and droplet precautions before entering the room of a patient with suspected or confirmed co-vid-19 • use particulate respirators (at least as protective as n95 or ffp2). in the context of these interim guidelines, who published a dashboard summarizing the readiness of countries in the who african region for covid-19 response [14] . these questions aim to describe ipc readiness and are presented in table 1 . we have separated the questions into the three ipc domains: administrative, environmental and ppe. most questions (n = 7) reflected readiness for implementing administrative con-photo: usaid tuberculosis south africa project staff and the area manager for the tb ward at pretoria west hospital conduct a chart audit as part of the fast intervention (from the collection of university research co., llc., used with permission). in the midst of an unprecedented public health emergency, we must adapt and strengthen existing infection prevention and control programs to reduce the spread of covid-19 while preventing a resurgence of other infectious diseases like tuberculosis. trols, and the remaining three questions describe readiness to implement ppe (n = 2) and environmental controls (n = 1). countries were overall least prepared for administrative control implementation, with an average 58% of countries (n = 48) responding "yes" to administrative control readiness questions. within administrative controls, countries were overall least prepared for the following questions: "is there an ipc team responsible to follow up on exposed hcws? what policies are in place for confirmed cases of hcws in contact with patients?" (n = 24 responded yes, 51%) and "is there a triaging system that can be applied to ari [acute respiratory infections, upper-or lower-respiratory tract infections which include the common cold, pneumonia and influenza] in the health facilities" (n = 26 responded yes, 54%). countries were more prepared for environmental controls (n = 48 countries, 77% responded yes to n = 1 question) and ppe measures (n = 44 to n = 48 countries, 67% responded yes to n = 2 questions) [15] . in examining readiness for covid-19 spread, we now review the outbreak in south africa, currently the largest on the continent [1, 2] . south africa responded "yes" to all readiness questions except one administrative control question: "is there a triaging system that can be applied to ari in the health facilities?" even in a country like south africa which is relatively well-prepared for covid-19, we must examine any additional resources which can be leveraged for an even more effective response. as the country rapidly prepares for mitigating community spread through actions like a nationwide lockdown and travel restrictions, ensuring a coordinated infection prevention and control response at the facility-level can further improve these gains and can ensure that south africa leverages all possible resources [16, 17] . south africa is uniquely positioned to respond swiftly and broadly to emerging community transmission of covid-19. with the largest hiv burden in the world and a high tb and mdr-tb burden, ipc practices are well understood and buy-in from providers, health officials and other stakeholders is high. to most effectively prepare for covid-19 spread in hospital facilities, however, south africa must look at current innovations within the national tb control program and those of tb technical assistance partners. according to the most recent who global tb report, south africa is one of eight countries accounting for two thirds of the global tb burden (3% alone) and is listed as one of the 30 high tb burden countries [18] . tb is the leading infectious cause of death globally, killing over one million people in 2018 alone [18] . the disease is caused by mycobacterium tuberculosis, which spreads when someone with tb expels the bacteria into the air, most commonly through coughing. the national tb control program in south africa, along with key technical assistance partners like the usaid tuberculosis south africa project, continue to develop and implement innovative tb ipc policies and interventions. one of these interventions is an administrative control measure meant to improve triage practices for patients with suspected tb while reducing time from hospital presentation to tb testing, from testing to diagnosis and from diagnosis to treatment initiation. this strategy, known as finding cases actively, separating safely and treating effectively (fast), is currently implemented in 84% (n = 86) of hospitals in eleven priority districts in south africa, including or tambo, sarah baartman, nelson mandela health metro, waterberg, sekhukhune, mangaung, fezile dabi, johannesburg health metro, tshwane health metro, ethekwini and umkhanyakude [19] . finding cases actively: the first pillar of the fast strategy is to identify patients with suspected tb upon entry to a supported hospital. upon entering a facility, a health care worker greets each patient and identifies those with tb symptoms, including those with an active cough, into an area separate from the general waiting area for patients. this process is conducted regardless of hospital ward and is not restricted to tb clinics in order to find as many patients with tb symptoms as possible, even those who may be at the hospital for an unrelated reason. separating safely: after identifying symptomatic patients, these patients are separated into a waiting area which is separate from the general waiting area, are given a surgical mask and are educated on cough hygiene. patients are then asked to produce a sputum sample which is used for molecular testing (generally genexpert mtb/rif assay) for identification of tb and resistance to rifampicin, a common first-line tb treatment. after the sample is given to laboratory technicians, a nurse will further separate patients into a separate waiting area. laboratory technicians then test the sample immediately, and results are available on the same day, sometimes in as little as four hours (in which the sample result is available in two hours, and the result is delivered within four hours after performing internal quality checks and reporting) [20] . treating effectively: if a sputum sample indicates presence of active tb, a nurse will then explain the test result to the patient and begin anti-tb treatment. if rifampicin resistance is indicated, further drug susceptibility testing (dst) including line probe assay (lpa) and other testing may be indicated. patients are generally started on treatment on the same day before leaving the facility and are referred to a lower-level health center for local, decentralized follow up care. the fast approach has identified 12 636 additional tb cases which would have otherwise been missed. additionally, the tuberculosis south africa project has achieved high screening, testing and treatment initiation rates among patients entering supported facilities as shown in table 2 . additional facilities have aside from the fast initiative, the tuberculosis south africa project works extensively in governance and policy guidance, contact management, environmental controls and awareness building activities to reduce stigma surrounding tb and to encourage people to get tested and start tb treatment. taken together, these tb-specific ipc interventions serve as useful entry points for covid-19 ipc responses. importantly, these tb interventions are functional, have political buy-in and funding, have trained staff and facility-level champions, and have proven results. health officials must look to functioning programs like these to mount a wide-ranging, agile response to the public health emergency that is covid-19. while south africa serves as one example, other countries will necessarily be affected by the covid-19 pandemic. other studies including ecological analyses should be implemented to understand possible country-level associations between tb and covid-19 burden, especially among high tb burden countries. as the body of evidence grows, more specific recommendations can be made to more effectively prepare for future airborne infection threats. covid-19 represents an unprecedented challenge for infection prevention and control. as shown in settings like south africa, however, there are successful and functional tb ipc programs in place which can be mobilized quickly and universally to prevent widespread hospital-based infections. in using these strategies, tb program managers and other stakeholders must harness this opportunity for a sustained focus on acute respiratory infections and airborne infection control programs. tb is the biggest infectious disease killer globally and, while covid-19 is a global public health emergency, we must maintain this urgency and momentum for tb ipc after the threat has passed. as the world comes together to tackle the covid-19 pandemic, it is important to ensure that essential services and operations for dealing with long-standing health problems continue to protect the lives of people with tb and other diseases or health conditions. health services, including national programs to combat tb, need to be actively engaged in ensuring an effective and rapid response to covid-19 while ensuring that tb services are maintained [21] . in funding and bolstering these existing tb ipc strategies for covid-19 responses, country governments can improve airborne ipc interventions in general, to improve tb case detection, to reduce nosocomial infections and to reduce tb deaths generally. while the initial benefit in expanding these programs lies in preventing wide community transmission of covid-19, we must recognize the opportunity in maintaining this level of response against tb to continue to reduce new tb infections and deaths from tb. as covid-19 continues to spread globally, we must look to existing health system capacity for a rapid and robust response. as shown by who, ipc readiness on the african continent varies and shows only moderate preparedness for impending outbreaks, in which south africa represents the ideal scenario. in high tb burden countries like south africa, ipc interventions, especially like those implemented by the usaid tuberculosis south africa project, offer a ready-made entry point to broad airborne ipc responses with trained providers, guidance documents and facility-level champions. these programs must be expanded and resourced to minimize nosocomial infection and death. in expanding these programs, however, we must keep the future in mind and realize the 2-fold benefit of ipc programs: the immediate benefit of preventing covid-19 outbreaks, and the long-term benefit of reducing ari death in general, including deaths form tb. in the wake of world tb day and in the context of a rapidly moving pandemic, there is no better resource for high burden tb countries than national tb control programs. we must rapidly expand and resource these programs to evade unnecessary death and suffering due to covid-19 and other aris. johns hopkins coronavirus resource center novel coronavirus. (2019-ncov) situation reports preparing for covid-19: early experience from an intensive care unit in singapore covid-19 in singapore-current experience: critical global issues that require attention and action case-fatality rate and characteristics of patients dying in relation to covid-19 in italy. jama. 2020. online ahead of print fair allocation of scarce medical resources in the time of covid-19 rational use of personal protective equipment for coronavirus disease 2019 (covid-19). geneva: world health organization the toughest triage -allocating ventilators in a pandemic considerations for quarantine of individuals in the context of containment for coronavirus disease covid-19 -the law and limits of quarantine infection prevention and control during health care when novel coronavirus (ncov) infection is suspected responding to covid-19 -a once-in-a-century pandemic? world health organization. minimum requirements for infection prevention and control. geneva: world health organization who african region covid-19 readiness response sheets: infection prevention and control. geneva: world health organization disease control priorities in developing countries escalation of measures to combat coronavirus covid-19 pandemic | south african government department of home affairs -corona virus information geneva: world health organization /usaid diagnose over 3 thousand patients with tb using facility-based screening strategy who information note: ensuring continuity of tb services during the covid-19 pandemic we would like to thank the staff of the usaid tuberculosis south africa project and their the authors completed the icmje unified competing interest form (available upon request from the corresponding author), and declare no conflicts of interest. alexander moran, msph 5404 wisconsin ave. suite 800, chevy chase, md, 20815 usa amoran@urc-chs.com key: cord-328321-7e37hhia authors: olapoju, olabisi michael title: estimating transportation role in pandemic diffusion in nigeria: a consideration of 1918-19 influenza and covid-19 pandemics date: 2020-07-28 journal: journal of global health doi: 10.7189/jogh.10.020501 sha: doc_id: 328321 cord_uid: 7e37hhia background: the focus of the study is to assess the role of different transport means in the importation and diffusion of 1918-19 influenza and a novel 2019 corona virus designated as covid-19 in nigeria. methods: the study provides a review of the means by which the two pandemics were imported into the country and the roles the transport means of each period played in the local spread of the epidemics. results: the study notes that seaports and railways, being the emerging transportation modes in the country were significant to the importation and local diffusion of 1918-19 influenza, respectively, while air transport is significant to the importation of the current covid-19 pandemic. conclusions: the study concludes that increasing preference for the transport at a given epoch is significant to the diffusion of prevailing epidemic in the epoch. for most of human history, population have been largely relatively dispersed both at regional and continental scales. however, recent centuries have witnessed an extensive human contact as a result of development in means of transportation, accompanying trade expansion, population boom and city expansion. while development in transport technology till date continues to enhance peoples' socio-economic and political existence, movement of disease has also been associated with increasing human movement through development in transportation network. specifically, records of disease diffusion in the last 500 years had provided numerous examples of how the establishment and expansion of worldwide transport networks has facilitated global pandemics of communicable diseases. for instance, the black death of 14th century revealed accounts of transmission and eventual death that was consistent with the arrival of travellers in sicily in 1347 [1] and whose further transmission was halted by limiting transportation and movement patterns. there was the 1817 cholera outbreak in india which later became global pandemic as it spread across many countries of the world along trade routes reflecting the expanding reach of the global transport system and increased movement of people [2] . the influenza pandemic of 1918-19 presented one of the world' s most devastating short-term demographic disasters, killing an estimated 40 million people in about 12 months globally [3, 4] . the speed of transmission of this infectious disease was greatly influenced by growing transport network in the world. viewpoints research theme 1: exactly one century away, at the end of 2019, an infectious disease known as coronavirus named as sars-cov-2) by international committee on taxonomy of viruses (ictv) and now tagged covid-19 (arising from the family of the virus and the year of emergence) broke out in wuhan, china. since discovery, and as at the time of writing, covid-19 has spread to over 214 countries and territories with a total case of 1438994 confirmed cases and 85 586 deaths globally. high transmission efficiency of covid-19 is attributed to convenience of global travel. the objective of this study is to provide an assessment of the nature and role of transport in the importation, traffic and spread of 1918-19 influenza and covid-19 in nigeria. this is with a view to examining changing significance associated with prevailing transportation at the period of epidemics. the study reviews historical data of 1918-19 influenza in nigeria as well as report of cases of current pandemic known as covid-19 in the country. next sections provide review of the 1918-19 influenza in nigeria, situation of covid-19 in nigeria, comparative narration of the nature and role of transport in diffusion of 1918-19 influenza and covid-19 in nigeria, discussion of the comparative review and conclusion. the influenza pandemic of 1918-19 was one of the most pervasive and devastating biological disasters ever recorded in the world. though there were contentions on the origins of 1918-19 influenza pandemic, its spread however, was typical of that of human travel, as it traveled from place to place. major diffusion began in europe to the rest of the world. africa recorded its first hit from a ship that had docked in a british port from where it carried persons infected by influenza to freetown, sierra leone in august 1918 [5] . in a similar vein, an american vessel s.s. shonga, which made a brief stop in freetown carried influenza victims in freetown to cape coast. the ship which anchored for a few days in cape coast continued its journey to accra with virtually all its crew down with influenza. however, by september 14, 1918 , the influenza hit lagos through lagos seaports by an ocean liner, s.s. bida which carried already infected passengers from accra, gold coast, who, on arrival in lagos passed the disease to lagos residents. inhabitants around the seaports of marina and apapa, especially seamen working on ships docked on harbour ports were one of the first sets of people to be infected with this virus. the epidemic spread quickly into the hinterland especially lagos mainland and then followed trade routes, such as railway lines, motor roads, rivers and caravan routes. the progress of spread of the epidemic was based on the speed of normal transport prevailing on each highway [6] . but since the train was the major means of local transportation back then, locations such as abeokuta, ibadan, illorin, bida, jebba, zaria, kano, and bauchi which were linked to the existing rail lines were quickly affected by the epidemic [7] . while populations along the western railway continued to be stricken by this disease, passenger vessels continued to bring infected people into other coastal towns of nigeria. for instance, by 28 september, another vessel called s.s. batanga had arrived calabar port with a man suspected to be a victim of influenza. also, forcados was not spared as ocean liner s.s. ravenston brought crew and passengers already infected by the disease to forcados on 27 september. other ports affected included burutu, warri, port-harcourt and bonny with this epidemic penetrating various residential districts and neighbouring towns by roads. by december 1918, it had spread all over the country right from the first outbreak in lagos. by the end of 2019, an infectious disease known as coronavirus named as sars-cov-2) by international committee on taxonomy of viruses (ictv) and now tagged covid-19 (arising from the family of the virus and the year of emergence) broke out in wuhan, china. by january 30, 2020, who (world health organization) declared covid-19 epidemic as a public health emergency of global concern [8] . according to who report on 19th march, 2020, there are 209 839 confirmed cases of covid-19, 8778 confirmed deaths across 169 countries of the world. as at the time of writing this manuscript, there was a global record of 1438 994 cases of infection and over 85 586 deaths across over 214 countries and territories of the world [8] . though intermediate source of origin of this disease as well as clinically approved drug or vaccine have not been determined, there is a clear evidence that it assumes high human-to-human (hence, h2h) transmission mode. in addition, international travelling was adjudged to have heightened the importation risk of this virus especially from the affected locations in china thus making most countries vulnerable to the epidemic. more vulnerable is african continent because china at present is africa' s leading commercial partner as large travel volumes through which the epidemic could reach the continent already exist. however, africa recorded its first case in egypt on february 14, 2020 through viewpoints research theme 1: covid-19 pandemic travellers returning from hotspots in asia, europe and the united states [8] . since then, more than 50 countries have reported cases, initially, mainly confined to capital cities, and now spreading to a multiple provinces. historical data has provided evidence of the role of transport, cross-border movement and regional flow of humans as veritable means of disease importation and spread. assessment of 1918-19 influenza and covid-19 revealed that water transport (ocean and inland waterways) and air transport played significant gateway roles in the importation of the two pandemics. whereas, railway and road ways played significant role in lateral spread of both pandemics, respectively. the evolution and growth of nigeria' s seaports belong to contrasting historical periods -the pre-modern and modern periods [10] . these periods were made up of some phases of alternating port concentration or spatial consolidation and port diffusion or dispersed port development in nigeria. the interest of this study is the period of port development that coincided with the outbreak of 1918-19 influenza in nigeria. this period was between 1910-1950, the fifth stage of development and a period of port concentration. at this period, lagos, akassa, old calabar, sapele, warri and degema ports had become the dominant ports in the hierarchy of all the ports in nigerian space economy. specifically, in 1912, lagos port had become more dominant handling about 41% of the total port traffic in the country, while burutu and calabar ports were handling 15% and 11% of total traffic respectively. the significance of this was seen in the diffusion of 1918-19 influenza through these ports. it is noteworthy that concentration of nigerian trade in lagos ports, burutu, calabar, warri, port-harcourt and bonny ports were responsible for the penetration of the epidemics into the country. however, with the import of the epidemic into the national territory, local transmission took its turn with rail, road and inland water transports playing significant roles in the diffusion of the epidemic locally. viewpoints research theme 1: the significance of rail transport in internal spread of 1918-19 influenza in nigeria was apparent because it coincided with the periods when network of railways were being constructed across the country between 1898 and 1965 [11] primarily to facilitate economic exploitation and administrative control of their regions. the raging of the influenza along the railway lines was such as if railway network was planned in preparation for the epidemic. railway influence on local transmission of the epidemic was underscored by the report of the occurrence of the epidemic in virtually all northern towns and villages, commencing with settlements along ilorin-kano railway, with kano becoming primary point of diffusion in northern part of nigeria. the influenza moved southward along the course of niger river. by october 14, the epidemic was brought to onitsha through lokoja and later spread to entire towns and villages [7] . the spread continued eastward to reach owerri, okigwe and enugu-ngwo and many other towns along the eastern railway. the influence of rail transport was also significant in the spread of the epidemic to benin kingdom, though this region was also adjudged to be bedeviled from coastal area of forcados, warri and sapele. however, with severe damage that was done to transport infrastructure during the civil war coupled with the post reconstruction and building preference given to road ways over railways, as well as perennial operational and organizational challenges, preference for rail transport has reduced to its abysmal minimum and major traffic greatly reduced. since then, nigeria railway remains static in structure and highly dormant to emerging transport dynamics across the globe in the last 3 to 4 decades, especially considering modernization, and advancement in railway infrastructure and equipment which have enabled railway fulfill its role efficiently and effectively. though recently, governments have mustered some efforts at revamping the railway system in some parts of the country, its present state may account for its non-significance to local transmission of recent epidemic in the country. on the contrary, air transport plays the most significant role in the importation of covid-19 in nigeria as is the case with virtually all the countries that are affected by the epidemic. the significance of air transport in today' s global endeavours is imprinted in most socio-economic calculations, political negotiations and environmental considerations in all of the world' s deliberations. this is reflective of barnes' prediction of air transport becoming a vital component of the economies of major cities, as it provides fast personal access for business, social, or recreational purposes, as well as fast physical access to resources and markets [12] . it is informing to note that air transport is yesterday' s future transport. the role played in the diffusion of covid-19 is unavoidably significant, especially considering the humongous passenger traffic it handles in recent times. according to airports council international (aci), global airports handled 5.4 billion passengers in 2011 [13] and this is expected to be more than double, exceeding 12 billion by 2031 [14] . over the past few decades, air transport networks have developed and internationalized though very unevenly, overall technological development, internationalization of economic development, increasing purchasing power, increasing tourism activities among other issues have led to sharp rise in air connections both at regional and international scales. it is thus significant to note that attendant asymbiotic relationship exists between global ease of travel provided by air transport and the spread of epidemic and disease. the ease with which inter-regional and inter-continental travel is been achieved in the recent period is sine qua non to the ease of importation of covid-19. the role of transportation in the diffusion of epidemics has not been unnoticed at different times of outbreak of epidemics. this study assessed the significance of mode of human transportation to importation and local diffusion of two epidemics which occurred century apart-1918-19 influenza and current covid-19 epidemics. the study observed that though both epidemics have not their origin in nigeria, the first case recorded for each of the pandemic were both imported into the country through lagos state which provides a veritable gateway to nigerian economy. however, while the 1918-19 influenza came through seaport, covid-19 came through airport. both presenting major international assess to the country. each pandemic reflects the expanding reach and efficiency of the global transport system and increased movements of people [2] . for instance, the significance of seaports in the importation of 1918-19 influenza was based on the development of seaports in the country which provided the only option for international movement as pioneer commercial air transport which was to provide a new way of moving goods and passengers around the earth did not start until 1920s-a period after the epidemic. whereas, the efficiency, speed and reach of air transport networks was responsible for the importation of covid-19, a completely new disease. this is supporting the view of ever-expanding air transport network as significant to the extent and speed of spread of disease [15] [16] [17] . thus, the prominence gained by air transport in the importation of covid-19 above seaports as an alternative gateway to nigerian economy suggests that the transport of the future has significant role to play in the diffusion of the disease of the future. fevers in the tropics nature's biological weapon updating the accounts: global mortality of the 1918-1920 "spanish" influenza pandemic public record office. the influenza epidemic of 1918-19 in the southern provinces of nigeria report of ag. senior sanitary officer novel coronavirus (covid-19) situation report-22 patterns and problems of seaport evolution in nigeria the tools of empire: technology and european imperialism in nineteenth century the economic role of air transportation aci 2011 world airport traffic report, press release aci global traffic forecast severe acute respiratory syndrome (sars): a year in review spread of a novel influenza a (h1n1) virus via global airline transportation severe respiratory syndromes: travel history matters though, the study highlighted the role of railway in the intra-national diffusion of 1918-19 influenza, it is not certain it has any role in local spread of covid-19. this may be due to very low traffic patronizing rail transport because of its dormancy for a very long time until recent time when attention is being paid to its resuscitation. it may also be due to the suspension of rail transport activities by nigerian railway corporation (nrc) (independent news online, the 21 st march 2020) as a way of checking the spread of covid-19. 1918-19 influenza and covid-19 happened a century apart with both having debilitating impact on human health with attendant death records. the significance of transportation in the importation and local transmission of the two epidemics were obvious. it was evident that the efficiency of spread of each epidemic was determined by the origin of the epidemic and efficiency of the prevailing transport means. it thus means that future transport may have significant influence on the efficiency with which likely future epidemic or disease will be diffused.the limitation of this study is that while one of the epidemics considered had happened about a century ago, the other epidemic is still very much around and fresh with us. thus, current figures on the confirmed cases, death and discharge cases will be needed for further study. also similar study may be carried out to look into a comparative study of the distinctive role of existing transport means in the importation and diffusion of epidemics in sub-saharan african countries as a whole. acknowledgement: i want to acknowledge national centre for disease control (ncdc), nigeria, for regular update of covid-19 cases.funding: this research work received no funding from any agency or organization.authorship contributions: i certify that this paper was solely written by me. no co-author(s). the author completed the icmje unified competing interest form (available upon request from the corresponding author), and declares no conflicts of interest. key: cord-303909-9xr7i1p5 authors: joachim, clarisse; vestris, mylène; marous, miguelle; almont, thierry; ulric-gervaise, stephen; dramé, moustapha; contaret, cédric; smith-ravin, juliette; escarmant, patrick; sylvestre, emmanuelle; véronique-baudin, jacqueline title: modeling the future of cancer registration and research: the martinique cancer data hub platform date: 2020-09-11 journal: journal of global health doi: 10.7189/jogh.10.020352 sha: doc_id: 303909 cord_uid: 9xr7i1p5 nan t he number of clinical data research networks (cdrn) focused on creating large collections of data from multiple digital sources, has vastly increased in the last few years. these cdrn are particularly relevant in outlying island regions, where they make it possible for those involved to communicate and contribute, thereby facilitating remote collaborations, despite the physical distance. we propose an innovative and robust organizational networking platform with advanced digital tools and strong partners, to boost a collaborative medical network of public health and health surveillance, in close connection with clinical research, and population-based cancer registries. a multifunctional information and communication technology (ict) platform is proposed. this platform will provide institutions and health care professionals with a "cancer data hub", which will offer a wide range of accurate cancer data (patterns of cancer care, quality of life, onco-pharmaco-epidemiology…), fostering collaborative and innovative public health research activities (eg, observational studies in real life practice and clinical trials). blockchain modelization will be adapted with interconnected workpackages in the area of cancer. a completely secure environment, with powerful, simplified interfaces for software and hardware will be created, with interoperability of interfaces, databases managed in big-data, e-learning, research and a social network interface for online access. development of innovative electronic tools is also ongoing for patientreported outcomes. this platform addresses the challenges that need to be resolved in the caribbean area, with a view to improving overall quality of life and survival, by increasing capacity to implement telemedicine technologies and health care tools, also with a focus on research. the objective of the "martinique cancer data hub" interactive platform is the achievement of an efficient analysis of health data in the context of public health surveillance and cancer research. population-based cancer registries (pbcrs) participate in epidemiological surveillance and in the evaluation of cancer types worldwide by enabling analysis of incidence and survival data over time. thanks to continuous, exhaustive recording of all cancer diagnoses, and follow-up of all cases until death occurs, studies of cancer incidence and survival data can be performed to describe the spatio-temporal distribution of cancer localisations, and to evaluate the efficacy of management by the health care system [1, 2] . not all countries in the caribbean have population-based cancer registries to evaluate the extent of disease [3, 4] . it would therefore be beneficial if other, existing registries could contribute to producing international epidemiological statistics for this area. cooperation among the islands of the caribbean, and with the latin-american zone would make it possible to meet these objectives with the support of the international agency for research development and global initiative for cancer registry development worldwide [5, 6] . martinique, a french west indies overseas territory, has an exceptional heritage of reliable cancer data since 1983, thanks to the martinique cancer registry. this registry is a high-quality pbcr classified among the french overseas territories, and officially certified by the french registry evaluation committee (comité d'evaluation des registres). this committee awarded our registry the top grade (grade a -excellent) for the quality of its data, its expertise in public health, and for the quality of its research at national and international levels [7] . clinical data research networks are becoming increasingly widespread because of their ability to offer a collaborative environment for researchers localized across disparate organizations [8, 9] . the pcornet initiative launched in the united states in 2014 [8] is one of the most prominent examples. the aim of these networks is to support effective and sustainable research infrastructures based on electronic health data, and to facilitate multi-site community-engaged research. through dedicated interconnected interfaces and an integrated database system, it will offer a unique and high-quality experience and interactive framework for health professionals, patients, families and regional authorities. although cdrn have become an integral part of research practice in the usa, heralding a paradigm shift regarding the use of electronic health records (ehr) for research [10] , there are still very few such cdrn outside of the usa, and none in the caribbean region, despite the geographical proximity. this is why the implementation of the "martinique cancer data hub" is innovative and unique in these territories. this project is an opportunity to develop collaborative programs with patients, patient associations and health professionals. this challenge will consolidate existing experience, in close connection with the competence and cooperation of pbcrs, and in collaboration with other stakeholders in the cancer information domain. this process can be supported by the mobilisation of external knowledge initiatives, such as professional societies, collaborative research partnerships and implementation networks (international agency for research on cancer -iarc, international association of cancer registries -iacr) [11] . we designed the platform concept and content in iterative cycles, with a bottom-to-top approach, by consulting future users from different backgrounds (scientists, clinicians, patients…), experts and project partners, and finally software developers. various developments in terms of database organization and security are planned, in accordance with internationally recognized standards. the platform will also have an e-learning component with all published articles of the partners and massive open online courses (mooc). access to the platform will be carefully controlled by a secure research portal with full traceability features. finally, a social network interface will allow patients and health professionals to engage with each other. we will also propose access to open databases and evaluation interfaces. the martinique cancer data hub will propose interactive digital tools for data-mining and data-visualization of health data, digital training tools (e-learning), digital tools of m-health (health via smartphones and connected objects) and modeling of life and aging trajectories (figure 1 ). this secure internet platform should enable health professionals to better evaluate health care pathways through modeling of health and data visualization, thanks to a laboratory generated for the exploitation of health data in oncology. the proposed solution will allow geographically dispersed teams to leverage clinical and biological information, enabling all participants to view and share on any device, the flexible and interactive content of each conversation field, in order to increase efficiency and productivity. the collaborations set up will make it possible to avail of comparative data to initiate research on topics such as cancer inequalities, surveillance of infectious cancers, and role of environmental factors or specific exposures in our geographical area, and to identify the determinants of health states in cancer patients in martinique. ultimately, the martinique cancer data hub platform should facilitate monitoring and data collection as part of population monitoring. establishing legal frameworks for health technology innovations is thus, in a context of highly sensitive data, the preliminary step to initiating large-scale projects within the framework of potential multicenter projects. the e-learning and e-health platform, developed in close collaboration with the clinical data warehouse project of the university hospital of martinique, is an innovative and polyvalent technology. expertise in training in the area of public health will increase the attractiveness and the opportunities for collaboration in an environment where the mutualisation of means and resources is strongly encouraged. in a second stage, this federating project could be extended to other countries participating in cancer surveillance. this challenge will increase the number of innovative digital products including the transfer of technologies in the field of "e-health", including the axes of aging. public health actions will therefore have to be implemented in the coming years, given the foreseeable impact of aging on the demographic and health profile. this platform will represent a strategy dedicated to the emergence of new research topics with high economic potential, for the benefit of patients, medical communities and health care actors. as an example of a project involving patients, we propose to invite senior citizens to join an online community with a view to creating an online "living space", a forum for exchange of ideas and practices oriented towards improving quality of life in older persons. the participants in this initiative will have access to quality of life research projects thanks to the development of a social network integrating older persons, patient communities and caregivers. the aim is to constitute a group of older experts who will engage in quality of life initiatives for seniors. this project meets several different public health goals, namely public health plans targeting successful aging, and solidarity with older citizens. it will promote a life-course prevention approach to achieve successful aging, and is notably in line with actions targeting the physical health and physical environment of older people, with local and environmental participative activities, in addition to maintaining social links. helis is a programme with potential public health benefit in the quality of life domain, specifically dedicated to older persons in martinique. it has strong potential to modelize life trajectories and aging pathways, thanks to longitudinal analysis of quality of life data. the impact of preventive measures and physical activity on quality of life is key to evaluating health status in older persons in martinique via the development of e-health. other similar ongoing projects will be accessible to health care professionals, and to patients who desire to participate in research. a study of the quality of life of patients with prostate cancer is currently ongoing in the university hospital of martinique. the quality of life in prostate cancer (pca) cohort will assess quality of life and patient outcomes in martinique using the digital platform for patient-reported outcome measures. this study will provide insights into the high rates of incidence and survival of pca observed in martinique, as compared with other caribbean countries. the quality of life pca cohort will be constituted in the context of our established and internationally recognized cancer registry, thus promoting high-quality data verification and recording. data on clinical stage at diagnosis, blood prostate-specific antigen level at diagnosis, gleason score, primary treatment, quality of life, urinary incontinence and erectile dysfunction prior to treatment will be analysed, where applicable, at 1 and 5 years after treatment. there were 205 incident cases of breast cancer per year in martinique from 2007 to 2014. we will conduct a prospective study including female patients who start treatment for breast cancer at martinique university hospital between 2020 and 2022. the main aim of the study is to detect adverse drug reactions related to breast cancer treatments in martinique, using two types of sources: 1) patient reported outcomes from two quality of life (qol) questionnaires and 2) clinical reported outcomes from two databases, namely the french nationwide claims and hospitalization database (système national des données de santé, snds) and the clinical data ware house used at martinique university hospital.qol will be measured using the european organisation for research and treatment of cancer quality of life questionnaire core 30 (eortc qlq-c30) and the breast cancer module qlq-br23, which have both been validated for completion via electronic means. the questionnaires will be administered by the caregiving team, or may also be self-completed by the patient via an online link to the digital platform for data collection and quality control. this will ensure the exhaustiveness of the variables included in the database, by using data quality control programmes to verify that these data are collected systematically. available training modules will be integrated into the online digital platform, focusing on the epidemiology of cancer, the study of cancer survival according to identifiable risk factors, and methods for data collection from digital sources. this new approach to cancer registration will be based on the ability to extract data from the clinical data warehouse project at the university hospital of martinique. the first phase of learning will cover data extraction models, and this will serve as a basis for the development of data integration algorithms for individual projects. this project will reveal the potential of new information and communication technologies to cross-reference nominative data directly for the purposes of cancer surveillance. all the training modules will be available online in french, english and spanish, to enable maximum interaction and exchange with other countries in the caribbean and in latin-america. among the challenges of implementing digital projects in the field of public health, access to digital patient files is a major issue. indeed, one of the attractions of the digital platform is to enable cross-referencing and analysis of digitally processed data. the platform is therefore logically limited by the available of digital source data within the sites of health care delivery. indeed, identifying gaps in the information technology and digitalization of the sites of care is one of the aims of the project, so that we can identify the specific types of data that need to be processed digitally, and prepare a roadmap for going fully digital, using appropriate software. the year 2020 saw a pandemic of covid-19 that called on health care teams worldwide to make rapid, yet profound adjustments to their working environment to introduce telemedicine and tele-reporting features at short notice. the health care system should have the capacity to deal with unprecedented situations that require rapid implementation of e-health solutions to record health data during a health care crisis. finally, in terms of research, another major challenge of our digital platform is that one needs to take into consideration the age of the patients, and how this may affect their understanding of, and ability to use the digital tools that are made available to them. indeed, paper forms remain the preferred format for many people, depending on their age. in addition, the material and social conditions of the patients included also deserve consideration. digital processing of data collected in paper format is feasible, but requires research teams to allocate time and human resources for this task. furthermore, the quality of the internet connection, and the provision of access in the island context are also important factors to consider, in order to ensure access for the widest possible audience. digital data platforms are garnering increasing interest around the world, for the purposes of collaboration, research and dissemination of knowledge. the french "compare" project (https://compare.aphp.fr/) (community of patients for research)is a prime example of patients and researchers coming together. this model of publicising ongoing research and disseminating knowledge on various topics is a rich source of data and of scientific output. another study platform for comparative outcome, quality-of-life, and translational research for genitourinary cancer was created in seoul, an supports a variety of research regarding comparative outcomes, qol studies, and translational research [12] . in a collaborative project bringing together denmark, norway, portugal, spain, sweden and the uk, i-o optimise is a multinational program providing real-world insights into lung cancer management. this project will provide a broad, robust and dynamic research platform to continually address numerous research objectives in the lung cancer arena from more than 45 000 patients per year [13] . finally, the korea cancer big data platform (k-cbp) is a further example of a multidatabase framework that collects clinical, genomic, imaging, and biobank data for cancer research [14] . currently, there is no platform that includes real-time input of research data in patients with cancer in the french west indies. our project will meet this need, and demonstrate that e-health solutions provide a unique opportunity to reduce inequalities in outcomes and care among cancer patients, in line with the public health objectives of the french national anti-cancer plan. the authors thank santé publique france (national public health agency), institut national du cancer (french national cancer institute -inca), international agency for research on cancer, global initiative for cancer registry development, university hospital of martinique and all those who contributed to the recording of cancer data in the registries: the hospitals, the laboratories and departments of anatomy, cytology, and pathology; the departments of medical informatics of the public and private hospitals; the local offices of the national social security service; and general practitioners and specialists and the national authorities. we thank the pbcrs of guadeloupe, french guyana, puerto rico and cuba. we thank fiona ecarnot, phd (ea3920, university hospital besancon, france) for editorial assistance. funding: this project was funded by the european regional development fund erdf mq0019171 and the martinique territorial authority (ctm, collectivité territoriale de la martinique). the funding source had no involvement in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. the only role of the funding body was to peer-review the study protocol. planning and developing population-based cancer registration in low-and middle-income settings, iarc technical publications the role of cancer registries in cancer control leading causes of cancer mortality -caribbean region global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries planning cancer control in latin america and the caribbean progress and remaining challenges for cancer control in latin america and the caribbean cancer burden in the caribbean: an overview of the martinique cancer registry profile launching pcornet, a national patient-centered clinical research network references conclusion this project will enhance partnership in the fight against cancer, using patient and clinical-reported outcome measures. future plans, beyond the present cohort, aim to pursue this research work as a tool to inform policy in the areas of population health and health services research. we hope that using e-health tools such as online surveys and the clinical data warehouse will help to improve the standards of care for cancer treatment in our overseas territories, despite the remote location.shared needs in terms of public health include cancer surveillance and public health surveillance; and the evaluation of public health programmes in cancer. the needs in terms of scientific research are similar across the region, despite the fact that the socio-economic level of the french west indies is higher than that of the majority of other countries in the caribbean. the role of national and regional decision-makers is clearly essential: strong political enthusiasm is a sine qua non and will always be the key prerequisite for the success of this platform. references correspondence to: clarisse joachim registre général des cancers de la martinique uf 1441 registre des cancers the mid-south clinical data research network iarc caribbean cancer registry hub establishment of the seoul national university prospectively enrolled registry for genitourinary cancer (super-guc): a prospective, multidisciplinary, bio-bank linked cohort and research platform optimise: a novel multinational real-world research platform in thoracic malignancies the korea cancer big data platform (k-cbp) for cancer research authors' contributions: cj, jvb, es were major contributors in writing the manuscript, made substantial contributions to conception and design, agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. es, md, jsr, cc, ta revising it critically for important intellectual content. es, mm, md, ta, sug, mv, pe and jsr made substantial contributions to conception and design; been involved in drafting the manuscript and revising it critically for important intellectual content. all authors read and approved the final manuscript. the authors completed the icmje unified competing interest form (available upon request from the corresponding author), and declare no conflicts of interest. key: cord-292898-6m97l2uz authors: ríos-silva, mónica; murillo-zamora, efrén; mendoza-cano, oliver; trujillo, xóchitl; huerta, miguel title: covid-19 mortality among pregnant women in mexico: a retrospective cohort study date: 2020-09-23 journal: journal of global health doi: 10.7189/jogh.10.020512 sha: doc_id: 292898 cord_uid: 6m97l2uz background: pregnant women have been classified as at risk for covid-19 due to previous experience with influenza and other coronaviruses. the objective of this study was to identify risk factors for the complications and death in women of childbearing age and pregnant women with suspected covid-19. methods: this retrospective cohort study was conducted from the beginning of the epidemic in mexico until may 25, 2020. all women of childbearing age (13-49 years) from the open national covid-19 database from the ministry of health of mexico were considered for eligibility. sars-cov-2 infection was confirmed or ruled out by rt-qpcr. we performed a bivariate and multivariable analysis to estimate mortality risk. results: ten (2.2%) pregnant women with confirmed covid-19 died. positive pregnant patients did not have a higher risk of complications (admission to the icu, pneumonia, or requirement for mechanical ventilation) or death than the controls. in the multivariate analysis, only history of diabetes and chronic kidney disease remained independently associated with death in the positive cohort. seven (0.6%) pregnant women with a negative test died. in bivariate analysis, pregnant patients with a positive test had a higher risk of death than pregnant patients with a negative test (relative risk (rr) = 3.87, 95% confidence interval (ci) = 1.48-10.12), but no higher risk was found than in non-pregnant women with a positive test (rr = 0.82, 95% ci = 0.44-1.53), and 60-day mortality did not significantly differ among pregnant patients with or without a positive test (hazard ratio (hr) = 0.40, 95% ci = 0.12-1.30) or between covid-19-positive patients who were pregnant or not pregnant (hr = 0.74, 95% ci = 0.35-1.56). conclusions: pregnant patients do not have a greater risk of complications or death from covid-19 than non-pregnant patients. the presence of diabetes mellitus and chronic disease increases the risk of death in women of childbearing age, but not specifically in pregnant patients. the covid-19 pandemic caused by sars-cov-2 has generated worldwide alarm and mobilized all health services. sectors of the population that are particularly vulnerable to serious disease and increased mortality have been identified, including patients with chronic degenerative diseases [1] . in addition, pregnant patients have been classified as high risk due to previous experience viewpoints research theme 1: covid-19 pandemic in pandemic influenza [2] and other diseases caused by other coronaviruses [3] , but epidemiological studies have not conclusively demonstrated increased mortality in pregnant women compared to non-pregnant women [4] . to date, no specific authorized treatment is available for covid-19, and some promising drugs do not have enough information regarding their safety during pregnancy. furthermore, some therapeutic supportive measures, such as the prone position, are not possible in the last trimesters of pregnancy [5, 6] . in mexico, the general maternal morbidity and mortality has been estimated as a maternal mortality ratio (mmr) of 34.5 deaths for every 100 000 estimated births [7] . risk factors, such as teenage pregnancies, diabetes, obesity, and hypertension, have a higher prevalence [8, 9] . mexican health authorities have reported less use of health reproductive services by women of childbearing age, suggesting that the presence of sars-cov-2 infection could increase maternal morbidity and mortality rates. this increase in maternal mortality due to indirect factors of the use and availability of health services is estimated to range from 8.3 to 38.6% per month in low and middle income countries [10] . given that covid-19 is an emerging disease, information on its epidemiology in pregnant women is limited. thus, the objective of the present study was to identify risk factors for the presence of complications and death in women of childbearing age and pregnant women with suspected covid-19. this retrospective cohort study included women of childbearing age (13 to 49 years) [11] from the open national database of covid-19 [12] from the ministry of health of mexico. all women of childbearing age included from the beginning of the epidemic in mexico until may 25, 2020, were considered for eligibility. data were extracted from the open database, which includes anonymous information on cases studied by the general directorate of epidemiology of the ministry of health for epidemiological surveillance purposes; it includes suspected cases, negative cases, and confirmed cases. suspicious cases were cataloged according to the operational definition issued by the ministry of health of mexico, which includes the presence in the last 7 days of at least two of three symptoms, cough, fever, or headache, in addition to at least one of the following symptoms: dyspnea, arthralgia, myalgia, sore throat, runny nose, conjunctivitis, or chest pain. sars-cov-2 infection was confirmed or ruled out by laboratory tests utilizing quantitative reverse transcription polymerase chain reaction (rt-qpcr). the epidemiological surveillance network established that the tests would be carried out in 10% of the suspected cases cataloged as mild and 100% of severe cases (ie, anyone who meets the definition of a suspected case and also has difficulty breathing and is hospitalized). the database includes all cases in which a blood test was performed. the variables included in this database were sex; age; whether the patient received outpatient care or required hospitalization; presence of pregnancy; smoking history; date of onset of symptoms, admission to hospital, and death if applicable; history of diabetes mellitus (dm), chronic obstructive pulmonary disease (copd), asthma, immunosuppression, hypertension, cardiovascular disease, obesity, chronic kidney disease, or diagnosis of other unspecified comorbidity; presence of complications, such as diagnosis of pneumonia, mechanical ventilation required, and intensive care in intensive care unit (icu). the database also reports demographic variables corresponding to the geographic distribution of the cases. women with missing clinical or epidemiological data were excluded. the database is available under an international license, cc-by-nd 4.0. the main outcome was to establish whether pregnant women with laboratory-confirmed covid-19 have a higher risk of mortality vs non-pregnant women of childbearing age with laboratory-confirmed covid-19 and pregnant women with suspected covid-19 but with a negative test. the secondary outcomes were to establish whether the presence of chronic degenerative diseases increases the mortality rate in pregnant women with laboratory-confirmed covid-19. we performed a descriptive analysis of the data; the continuous variables were expressed as medians and interquartile ranges (iqrs) and the categorical variables as frequencies and proportions (%). first, statistical analyses were performed in pregnant women with sars-cov-2 positive tests using non-pregnant wom-en of childbearing age as the control group. next, statistical analyses were performed in pregnant women with suspected covid-19 using pregnant women with a negative sars-cov-2 test as the control group. in the bivariate analysis, a χ 2 test was used to establish the association between the presence of pregnancy or a positive test and the presence of comorbidities reported in the database (dm, copd, asthma, immunosuppression, hypertension, obesity, cardiovascular disease, chronic kidney disease, smoking, and other comorbidity), as well as the association of pregnancy with the presence of complications (pneumonia, admission to icu, need for mechanical ventilation, and/or death), the association between the presence of comorbidities and the type of care required by the patient (outpatient vs hospitalization), and the association of comorbidities and death. we estimated the relative risk (rr) with 95% confidence intervals (cis). for the quantitative variables, the data distribution was estimated using the kolmogorov-smirnov test. for a non-parametric distribution we used the mann-whitney u test. for the multivariate analysis, cox proportional risk models for the risk of 60-day covd-19 mortality in women of childbearing age considering the time from the onset of symptoms included all comorbidities adjusted for age and pregnancy status. cox proportional risk models were also used to establish the risk of a positive test in pregnant women considering the time form the onset of symptoms until health service contact. we also estimated average hazard ratios using mantel-haenszel estimators. all statistical tests were two-tailed, and significance was set at α = 0.05. statistical analysis was performed with spss version 20.0 (ibm corporation,armonk ny, usa), for the realization of the graphs was used graphpad prism 6.01(graphpad software, san diego ca, usa). between february 28, 2020 (the first confirmed case in mexico) and may 25, 2020, a total of 225 650 suspected cases of covid-19 were identified, 48% corresponding to women. the median age of women with a positive test was 36 years (iqr = 29-43), and 448 (2.49%) of these women were pregnant ( figure 1 ). the cohort included 19 636 women; 1486 (7.5%) had dm, 83 (0.4%) copd, 853 (4.3%) asthma, 259 (1.32%) immunosuppression, 1710 (8.3%) hypertension, 3724 (18.9%) obesity, 209 (1.06%) cardiovascular disease, 209 (1.06%) chronic kidney disease, 1093 (5.5%) smoking, and 773 (3.9%) other not specified comorbidity. the median age of pregnant women was significantly lower than that of non-pregnant controls. the most frequent chronic condition in both pregnant and non-pregnant women was obesity, but pregnant patients had a higher risk of having another not specified comorbidity (rr = 1.98, 95% ci = 1.39-2.81; table 1 ). in the bivariate analysis, hospitalized patients were older than those who received outpatient treatment (41 years, iqr = 33-46 vs 36 years, iqr = 29-42; p < 0.001). this was also seen with the control group, in which the significant difference in age was maintained between those who received outpatient treatment (36 years, iqr = 30-42) and those who were hospitalized (41 years, iqr = 34-46; p < 0.001). viewpoints research theme 1: however, no significant differences in age were found between outpatients and hospitalized patients in the pregnant group. on the other hand, pregnant patients had a higher risk of being hospitalized (rr = 2.10, 95% ci = 1.82-2.55). however, significant differences in the frequency of comorbidities were not found between ambulatory and hospitalized patients ( table 2) . ten (2.2%) of the pregnant women died. in both pregnant and non-pregnant patients, age was significantly higher among patients who died; the median age of pregnant patients who died was 34.5 years (iqr = 25.5-39) vs 29 years (iqr = 25-32; p < 0.001). nine of the pregnant patients who died had pneumonia, nine were hospitalized, three were in the icu, and two were managed with mechanical ventilatory assistance; they did not have a higher risk of complications (admission to the icu, pneumonia, or requirement for mechanical ventilation) or death than the controls in both the bivariate analysis (rr = 0.82, 95% ci = 0.44-1.53) (table 3) and the survival analysis (hazard ratio (hr) = 0.74, 95% ci = 0.35-1.56) (figure 2 ). in the multivariate analysis, each comorbidity was entered into the model with age and pregnancy status, but only the history of dm and chronic kidney disease remained independently associated with death for sars-cov-2 in the positive cohort ( table 4) . we compared pregnant patients with suspected covid-19 and a positive test vs those with a negative test. bivariate analysis showed that pregnant patients with a positive test were older than patients with a negative test, and they had a higher frequency of obesity ( table 1) . regarding clinical evolution, we did not find differences in the type of medical care received by patients with or without a positive test. seven (0.6%) pregnant women with a negative test died; these patients had fewer days from the beginning of symptoms until admission or death and from admission to death with respect to pregnant women with a positive test ( table 3) . three of these patients were diagnosed with pneumonia, two were admitted to the icu, and one required mechanical ventilation. in bivariate analysis, patients with a positive test had a higher risk of death than patients with a negative test (rr = 3.87, 95% ci = 1.48-10.12), but we found no significant difference in 60-day mortali(figure 3) . in the multivariate analysis, obesity remained a risk factor for the risk of a positive test in pregnant patients ( table 5) . the analysis presented here represents the largest cohort of pregnant women laboratory-tested for covid-19 from a single country. in our results, we found a lethality of 2.2% among pregnant women. we also found that pregnant women positive for covid-19 did not have an increased risk of mortality or complications with respect to a control group of women of childbearing age who were not pregnant but viewpoints research theme 1: positive for covid-19. similarly, pregnant women with confirmed covid-19 had no higher risk of death than pregnant women with a negative test. most previous publications have been case series with a very low number of patients [13] , and some systematic reviews were carried out analyzing these case series. a systematic review of 108 pregnant patients included mostly women from china, with some cases from sweden, the usa, korea, and honduras, with ages similar to our cohort. in this review, 3% of patients were admitted to the icu and no deaths were reported [14] . in another systematic review, elshafeey et al. [15] analyzed 33 studies including 385 pregnant women; they reported one maternal death and lower frequencies of admission to the icu or requirement for mechanical ventilation than our cohort. however, they did not make a comparison with a control group and the risk of complications could not be estimated. another case series [16] compared the evolution of pregnant patients with covid-19 and their positive contacts; they observed a more torpid evolution in pregnant women than their contacts but could not reach conclusions due to a low case number. we identified that pregnant patients with a positive test have a higher risk of being hospitalized than non-pregnant patients with a positive test, which could be due to, in addition to the respiratory symptoms associated with covid-19, they had obstetrics indications for hospitalization as indicated by the mexican guidelines for the care of pregnancy, childbirth, and the puerperium during the covid-19 pandemic [17] . unfortunately, the obstetric characteristics of the patients are not specified in the database. the presence of chronic degenerative diseases is related to an increased risk of complications and death from covid-19 [18] , including in mexico [19] . however, as other authors indicated previously [20] , the impact of these highly prevalent diseases on the clinical evolution of covid-19 in pregnant women has not been analyzed. we found that dm and chronic kidney disease are risk factors for death among patients of childbearing age with a positive test, but were not found as risk factors for mortality among pregnant patients with or without a positive test. however, obesity was a risk factor for a positive test in pregnant women with suspected covid-19. moreover, we identified that the patients with a negative test had a shorter duration from the onset of symptoms until death than pregnant women with positive test, which may be because the causes of death in these patients were not related to respiratory symptoms, which were classified as suspicious. unfortunately, the causes of the deaths were not registered, yet the pregnant patients with a positive test had a higher risk of death than the patients with a negative test. therefore, it seems that pregnant patients with a negative test die less frequently but more quickly than pregnant patients with a positive test. in addition, only data from pregnant women suspected of covid-19 are included in this study, and could not be compared to other causes of mortality in pregnant women with negative tests and without respiratory disease. because of this, we consider it more appropriate to compare the risk of pregnant patients with a positive test and non-pregnant patients with a positive test, which showed that pregnancy does not increase the risk of death. this study has several limitations. first, information on the obstetric characteristics of the pregnant patients, such as gestational age, resolution of pregnancy, obstetric diseases and complications, and perinatal history, was missing. in addition, the symptoms presented by the patients were unknown. other causes of hospitalization, icu admission, and death could not be analyzed because the database only includes women suspected of having covid-19. therefore, the role of covid-19 in the general mortality of pregnant women was not established. on the other hand, this study is a large cohort from a single country to analyze the risk of complications and mortality in pregnant patients with rt-pcr-confirmed covid-19, and we performed a comparison with two control groups: covid-19-positive women of childbearing age and pregnant women with respiratory symptoms but a negative test for sars-cov-2. we also estimate the association between the presence of complications and death and the history of pre-existing comorbidities, mainly chronic-degenerative diseases. we found that pregnancy is not a risk factor for covid-19 mortality, but pregnant women had a higher risk of being hospitalized and a higher frequency of icu admission than non-pregnant women, and they had a lower median age and reduced non-specified comorbidities. in cox regression analysis, diabetes and chronic kidney disease remain risk factors for mortality in the cohort. since the beginning of the pandemic, pregnant patients have been identified as a vulnerable group for complications and risk of death from covid-19 due to previous experiences, such as pandemic influenza. this is likely why medical staff decide more frequently on the hospitalization when pregnant patients ask for medical attention, and they may be more careful in identifying covid-19 complications earlier. these results offer solid evidence of sars-cov-2 infection, how severe it is, and outcomes in the specific context of pregnancy. we provide evidence supporting specific guidelines for pregnancy care during sars-cov-2 infection. in mexico, pregnant patients with laboratory-confirmed covid-19 do not have a greater risk of complications or death from covid-19 than non-pregnant patients with laboratory-confirmed covid-19 or pregnant patients with a negative test. however, the presence of dm and chronic kidney disease increases the risk of death in women of childbearing age, but not particularly in pregnant patients. the causes of death in pregnant patients with symptoms suspicious of covid-19 but a negative test need to examined more thoroughly, as these patients present with a faster evolution toward death. comorbidity and its impact on 1590 patients with covid-19 in china: a nationwide analysis a call for action for covid-19 surveillance and research during pregnancy. lancet glob potential maternal and infant outcomes from (wuhan) coronavirus 2019-ncov infecting pregnant women: lessons from sars, mers, and other human coronavirus infections a review of initial data on pregnancy during th)e covid-19 outbreak: implications for assisted reproductive treatments novel corona virus disease (covid-19) in pregnancy: what clinical recommendations to follow? coronavirus disease 2019 (covid-19) and pregnancy: what obstetricians need to know maternal metabolic diseases related to pre-pregnancy overweight and obesity in mexican women with high risk pregnancy national panorama of adolescent pregnancy in mexico: lessons learned in a six-year period early estimates of the indirect effects of the covid-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study world health organization. reproductive health indicators reproductive health and research guidelines for their generation, interpretation and analysis for global monitoring información referente a casos covid-19 en méxico the real impact of the coronavirus disease 2019 (covid-19) on the pregnancy outcome. o impacto real da doença do coronavirus 2019 (covid-19) no desfecho da gestação maternal and perinatal outcomes with covid-19: a systematic review of 108 pregnancies a systematic scoping review of covid-19 during pregnancy and childbirth maternal death due to covid-19 guidelines for the prevention and mitigation of covid-19 in the care of pregnancy, childbirth, the puerperium and the newborn does comorbidity increase the risk of patients with covid-19: evidence from meta-analysis predicting mortality due to sars-cov-2: a mechanistic score relating obesity and diabetes to covid-19 outcomes in mexico maternal health and non-communicable disease prevention: an investment case for the post covid-19 world and need for better health economic data acknowledgments: this study was done without grants. we thank all front-line medical staff and public health workers in the epidemiology surveillance system of general epidemiology directorate of the mexican health ministry who collected these important data. funding: all authors are employed and all expenses covered by federal state or publicly university institutions. no specific funding was received for this study.author contributions: mrs, omc, and mh contributed to the study design, the literature search, and writing the report; mrs, emz, and xt contributed with data collection, data analysis, and data interpretation. all authors reviewed and approved the final version of the report.competing interests: "the authors completed the icmje unified competing interest form (available upon request from the corresponding author), and declare no conflicts of interest. key: cord-320002-25ivll3q authors: mathew, joseph l.; singhi, sunit; ray, pallab; hagel, eva; saghafian–hedengren, shanie; bansal, arun; ygberg, sofia; sodhi, kushaljit singh; kumar, b v ravi; nilsson, anna title: etiology of community acquired pneumonia among children in india: prospective, cohort study date: 2015-10-21 journal: journal of global health doi: 10.7189/jogh.05.020418 sha: doc_id: 320002 cord_uid: 25ivll3q background: childhood community acquired pneumonia (cap) is a significant problem in developing countries, and confirmation of microbial etiology is important for individual, as well as public health. however, there is paucity of data from a large cohort, examining multiple biological specimens for diverse pathogens (bacteria and viruses). the community acquired pneumonia etiology study (capes) was designed to address this knowledge gap. methods: we enrolled children with cap (based on who imci criteria of tachypnea with cough or breathing difficulty) over 24 consecutive months, and recorded presenting symptoms, risk factors, clinical signs, and chest radiography. we performed blood and nasopharyngeal aspirate (npa) bacterial cultures, and serology (mycoplasma pneumoniae, chlamydophila pneumoniae). we also performed multiplex pcr for 25 bacterial/viral species in a subgroup representing 20% of the cohort. children requiring endotracheal intubation underwent culture and pcr of bronchoalveolar lavage (bal) specimens. findings: we enrolled 2345 children. npa and blood cultures yielded bacteria in only 322 (13.7%) and 49 (2.1%) children respectively. in npa, streptococcus pneumoniae (79.1%) predominated, followed by haemophilus influenzae (9.6%) and staphylococcus aureus (6.8%). in blood, s. aureus (30.6%) dominated, followed by s. pneumoniae (20.4%) and klebsiella pneumoniae (12.2%). m. pneumoniae and c. pneumoniae serology were positive in 4.3% and 1.1% respectively. multiplex pcr in 428 npa specimens identified organisms in 422 (98.6%); of these 352 (82.2%) had multiple organisms and only 70 (16.4%) had a single organism viz. s. pneumoniae: 35 (50%), cytomegalovirus (cmv): 13 (18.6%), respiratory syncytial virus (rsv): 9 (12.9%), other viruses: 6 (8.7%), s. aureus: 5 (7.1%), and h. influenzae: 2 (2.9%). bal pcr (n = 30) identified single pathogens in 10 (s. pneumoniae–3, cmv–3, s. aureus–2, h. influenzae–2) and multiple pathogens in 18 children. there were 108 (4.6%) deaths. the pattern of pathogens identified did not correlate with pneumonia severity or mortality. conclusions: the majority of children with cap have multiple pathogens (bacteria and viruses). s. pneumoniae and s. aureus predominate in npa and blood respectively. cmv and rsv were the dominant respiratory viruses in npa and bal. the presence of multiple pathogens, especially organisms associated with nasopharyngeal carriage, precludes confirmation of a causal relationship in most cases. pneumonia is a leading cause of childhood morbidity and mortality globally. it is estimated that there were over 120 million episodes of pneumonia among children younger than five years during 2010-11; of which over 10% were severe episodes [1] . a recent systematic review estimated 0.22 pneumonia episodes per child-year in developing countries alone [2] , with nearly one in eight cases progressing to severe disease. yet another systematic review estimated nearly 12 million hospitalizations in 2010 due to severe pneumonia and 3 million due to very severe disease [3] . pneumonia is also estimated to be responsible for almost 1 million deaths among children under 5 years old [4] , with maximum burden in africa and south asia [3] . india has a high burden of childhood pneumonia and the disease accounts for about a quarter of the under-five mortality in the country [5] . recognizing this burden, the world health organization (who) developed and disseminated a simple case definition for identification and treatment of pneumonia, which could be used by field-workers in resourcepoor settings [6] [7] [8] [9] . it relies on the physiological principle that parenchymal lung disease results in compensatory tachypnea; therefore any tachypnea indirectly indicates parenchymal disease including pneumonia. this case definition is highly sensitive, and does not require chest radiography. traditional teaching attributes most cases of childhood community acquired pneumonia (cap) to a few micro-organisms, mostly bacteria [8] . in recent decades, developed countries have witnessed a shift from bacterial to viral predominance on account of hygiene, sanitation, infection control, and vaccination policies. recent systematic reviews of childhood pneumonia etiology suggest that in developing countries, a few bacteria (s. pneumoniae and h. influenzae) and viruses (respiratory syncytial virus, influenza virus) are associated with majority of childhood cap [3, 5, [10] [11] [12] . a systematic review from india suggested that about 15-24% of bacterial pneumonia in south asian countries can be attributed to s. pneumoniae [13] . similarly data from the invasive bacterial infection surveillance (ibis) network in india suggests that invasive pneumococcal disease could be a significant public health problem in the country, contributing to significant morbidity and mortality [14] . however these data were not based on studies designed to determine pneumonia etiology. the pneumonia research for child health (perch) project [15] is a 7-site case-control study to identify the cause of pneumonia among children in developing countries. however, none of the sites is located in india. pilot data from perch reported 152 potentially pathogenic isolates among 108 hospitalized cases, using multiple microbiologic techniques on various body fluids. viruses represented over 80% of the pathogens detected [16] . conventional methods for determining etiology, such as bacterial culture of blood or nasopharyngeal swabs, and/or selective application of serological tests for a few organisms, are limited by poor sensitivity, or low specificity, or both. on the other hand, diagnostic techniques with greater specificity are limited by technical difficulty, invasive procedures, and high cost. accurate, reliable and rapid determination of etiology in childhood cap is important because it would influence individual treatment decisions, antibiotic policy in the community, and also rational immunization policy at a national level. currently, there is no study from india reporting etiology of cap in a large cohort of children, using multiple biological samples, and various sensitive as well as specific microbiologic methods. we initiated the community acquired pneumonia etiology study (capes) to address this knowledge gap by determining the microbiologic etiology of cap in a cohort of indian children using multiple biological specimens (blood, nasopharyngeal aspirates, bronchoalveolar lavage) and the relationship between etiology and pneumonia severity. this prospective study was carried out in the union territory of chandigarh (located in north india with a population of 1.05 million residing in urban, rural and urban-slum areas, of whom 11.3% are children), over 24 consecutive months from 1 april 2011 to 31 march 2013. the study was coordinated from the advanced pediatrics centre (apc) at pgimer chandigarh, a tertiary care centre with nearly 20 000 annual in-patient admissions and 100 000 out-patient visits. enrolment of children aged 1 month to 12 years, fulfilling the who imci case definition of cap designed for children <5 years [6] [7] [8] , was carried out through active and passive surveillance (figure 1) . tachypnea was defined as respiratory rate >60/min for infants <2 months; >50/min for infants 2-12 months; >40/min for children >12-60 months; and >30/min for children >60-144 months. active surveillance was conducted in 30 anganwadi clusters, selected to represent the population of chandigarh, where trained research team members visited households daily, inquiring for clinical symptoms of pneumonia. passive surveillance was carried out by research staff stationed in the out patient and emergency departments of the apc, by evaluating clinical signs of cap in children presenting to these departments. if symptoms were reported and tachypnea confirmed, the child was presented to a medical officer for confirmation and inclusion. children with duration of illness >7 days; those who had received antibiotics for >24 hours at presentation or those with previous hospitalization within the preceding 30 days, were excluded. children with wheeze received a single dose of bronchodilator (salbutamol 0.15mg/ kg by nebulization), and those whose symptoms disappeared were excluded. all children received standard treatment including antibiotics, other medications as required and supportive care as per institution guidelines. confirmation of the diagnosis by a medical officer was required. children whose symptoms of cap disappeared with a single dose of bronchodilator were excluded. after obtaining written parental consent to participate, a total of 2345 children were enrolled in the study and included in analysis. each child underwent a detailed history for demographic data, presence of risk factors for pneumonia, and immunization status. after physical examination, pneumonia severity was categorized based on the who classification [6] [7] [8] . in addition, all children underwent chest radiography. the radiographs were subsequently independently read by two trained investigators and scored as per the who criteria [17] . discordant results were resolved through mutual discussion. in addition, children who required endotracheal intubation were also offered fiber-optic bronchoscopy and bronchoalveolar lavage (bal), based on clinical need. a blood sample was drawn by venepuncture for routine investigations (hemogram, blood biochemistry). one to three ml blood was processed for bacterial culture using bactec 9240 (becton dickinson, haryana, india) in peds plus/f culture media (becton dickinson) [18] . the bottles were incubated at 37 °c for seven days and isolates were identified to species level by conventional biochemical and serological tests. a nasopharyngeal aspirate (npa) specimen was obtained from all children using a sterile, disposable suction catheter [19] . one aliquot was processed for bacterial culture and one aliquot was mixed with 3 ml saline and frozen at -80 °c for subsequent pcr analysis. bal samples were similarly processed for bacterial culture and pcr. the department of medical microbiology at pgimer is accredited by the government of india' s national accreditation board for testing and calibration laboratories (nabl). serum was stored at -80 °c for m. pneumoniae and c. pneumoniae igm serology performed using commercially available kits (calbiotech inc usa) according to the manufacturer' s instructions [20, 21] and analyzed with an automated elisa reader (spectrostar nano, bmg labtech, germany) [22] . serological tests were run in duplicate and only concordant results were labeled as positive or negative. multiplex pcr was performed on a subset of samples representing 20% of the cohort, selected through a randomization procedure stratifying by age, pneumonia severity and season. pcr was performed for detecting a panel of respiratory bacteria and viruses (table s1 in online supplementary document) at xcyton diagnostics pvt ltd, bangalore, also nabl accredited, using the syndrome evaluation system (ses) for pneumonia. the ses was standardized to attain 100% sensitivity and specificity using quantified virus panels available from quality control for molecular diagnostics (qcmd), uk [23] . (table s2 in online supplementary document). limit of detection for all dna viruses was 250 virions/ml and 100 virions/ml for cmv and adenoviruses. for rna viruses, qcmd proficiency panels of 2011 were used. samples were thawed, centrifuged (3000 rpm×10 min) and re-suspended in 1 ml sample supernatant. nucleic acids were extracted using commercially available qiagen kits and cdna was prepared using a commercial cdna archive kit (abi, usa) [24] , both according to the manufacturer' s instruction with the addition of pathogen specific primers. amplification was carried out in bio-rad ptc200 thermal cycler and the detection of amplified products was facilitated using biotin labeled primers. samples were categorized as negative or positive for any pathogen with internal controls (human housekeeping genes β2-microglobulin and β-actin) included in each run as control for dna and rna extraction respectively. descriptive statistics of cohort characteristics and duration of various symptoms are presented with proportional distribution and median (iqr) respectively. ordinal categorical data and mortality status was analyzed using test of linear association. data analysis was conducted in ibm spss statistics 22.0 [25] . the funding agency had no role in study design, data collection, data analysis, data interpretation, writing of the manuscript or decision to submit for publication. all authors had access to the data in the study and approved the decision to submit for publication. a total of 36 676 children underwent active or passive surveillance for cap. figure 1 shows the step-wise process used to enrol children. a total of 2345 children were enrolled and comprised the cohort included in the analysis. similarly, absent or deficient breastfeeding (defined as duration of breastfeeding <6 months for infants older than six months, or less than infant' s age in those <6 months old) was more common in those enrolled through passive surveillance. these children were also more likely to be exposed to solid fuels as well as tobacco smoke in their homes. there were no major differences in gender, history of wheeze, previous history of infections, or family history of tuberculosis in children enrolled through active or passive surveillance. table 2 presents symptoms reported by parents, clinical findings and radiography. almost all children presented with cough, fever and fast breathing with median duration of symptoms being similar in those enrolled through active or passive surveillance. parents reported wheezing during the current episode in approximately one-third of the children. symptoms/signs suggesting greater severity of pneumonia were more frequently identified in those enrolled through passive surveillance. a larger proportion of these children also had who class i and class ii chest x-rays. there were 108 (4.6%) deaths; of these 107 occurred among those enrolled through passive surveillance (mortality rate 9.2%) and one among those enrolled through active surveillance (0.1%). based on disease severity, the mortality rate was 1.2% for pneumonia, 4.7% for severe pneumonia and 15.8% for very severe pneumonia. a comparison between fatal and non-fatal cases suggested that age <12 months, oxygen saturation <95% and radiographic finding of consolidation (who class i) were associated with mortality. figure 2 ). a single bacterium or a single virus was found in only 42 (9.8%) and 28 (6.5%) children respectively. s. pneumoniae dominated (n = 35) followed by s. aureus (n = 5) and h. influ-enzae (n = 2). the single viruses identified were cmv (n = 13) and rsv (n = 9) followed by rhinovirus (n = 2), and one each of influenza, parainfluenza, enterovirus and hmpv. s. pneumoniae was the dominant organism identified in npa culture as well. a comparison of the bacterial yield from npa by pcr and culture is shown in panel b in figure 2 . among the 428 children with npa pcr results, 25 died and pcr showed diverse organisms distributed in a pattern similar to the 428 children (panel c in figure 2) . among intubated children undergoing bronchoscopy as part of clinical care (n = 30), only 2 samples were negative on pcr and the remainder showed organisms in a similar pattern to npa pcr (panel d in figure 2 ). since most npa pcr samples yielded multiple pathogens, the data were analyzed with respect to etiology patterns rather than individual pathogens. these included combinations of two bacteria, two viruses, one bacterium plus one virus, or mixed i.e more than one bacteria and/or virus (panel e in figure 2) . the most common combination of pathogens in individual samples was s. pneumoniae and cmv (n = 100) followed by 2 bacteria or 2 viruses. in bal samples, the single pathogens identified were s. pneumoniae (n = 3), s. aureus (n = 2), h. influenzae (n = 2) and cmv (n = 3); the majority of samples (n = 18) showed multiple organisms (panel f in figure 2 ) that were distributed in a pattern almost similar to npa samples. the complex microbial patterns on pcr were further analyzed with respect to disease severity (defined according to who criteria) but there were no apparent differences (figure 3) . to our knowledge, this is one of the largest single-centre studies of cap etiology in children from a resource-limited setting. our data suggest that cap is associated with a number of pathogens or combinations of viral and bacterial pathogens. further, no single pathogen or combination could be related to disease severity. our findings also confirm that infants <12 months old are particularly vulnerable in terms of disease severity and outcome. as expected, s. pneumoniae was the predominant isolate in npa by culture as well as pcr, although mere detection does not establish a causal role. we could not do serotyping due to resource constraints. it can be argued that the isolation rate by culture in our cohort is lower than expected [26, 27] , especially as pcr identified s. pneumoniae much more frequently. it is possible that clinical pneumonia due to other pathogens masks the presence of s. pneumoniae on routine culture. the major difficulty in attributing etiology to s. pneumoniae is its frequent presence in asymptomatic children also, although a similar argument could be raised for s. aureus too [28, 29] . detection of multiple pathogens in npa by pcr makes it difficult to ascribe a causal role to any one organism. our culture and pcr data also suggest that nasopharyngeal specimens may perhaps be inappropriate for confirming microbial etiology in cap. indeed, this is in concordance with several recent studies showing the presence of various viruses in asymptomatic children as well as those with upper respiratory tract symptoms [19, 30, 31] . it appears that even m. pneumoniae can be identified in the nasopharynx of healthy children [32] . somewhat surprisingly, cmv was the most common virus in our cohort, where none had immune-suppressive therapy, known primary immune-deficiency and where the hiv prevalence during the study period is reported to be <0.25% in the community [33] . while cmv is well-recognized as a pathogen in these latter settings, its frequent occurrence in cap raises the possibility that it may contribute to pneumonia pathogenesis singly or with other pathogens [34] . this novel finding also emphasizes that although pcr is highly sensitive, it can detect only those organisms that are looked for-a limitation that is being overcome by next generation sequencing. after cmv, rsv was most frequently identified as previously reported also [2] while influenza a and b were less frequent. unfortunately, even bal samples in a limited number of children could not ascertain etiology as most children had multiple organisms. further the time-lag between presentation and obtaining bal samples in the majority of children raises the possibility that some of the organisms could represent secondary infection. how to interpret the detection of multiple organisms in respiratory tract samples from a given child? it is possible that infection by one (potential) pathogen facilitates other pathogens, or that mild infection with one organism becomes more severe in the presence of additional organisms. this is well documented with influenza infection [35, 36] and suggested for other organisms also [2] . however, the pattern of pcr findings did not differ with disease severity which is in concordance with initial data from the perch project also [16] . in our cohort, a single organism (bacteria or virus) was identified by npa pcr in only a minority of children. further npa data may be skewed on account of nasopharyngeal carriage. the limited bal data suggests that s. pneumoniae, cmv, s. aureus and h. influenzae may be the dominant pathogens in severe cases of cap. in children with fatal outcome, the same pathogens were identified along with rsv. in the small number of positive blood cultures, s. aureus predominated, rather than s. pneumoniae or h. influenzae, expected in a vaccine-naïve pediatric population such as our cohort. clinical experience suggests that s. aureus is frequently re-sponsible for community acquired infections in india, although it has not previously been documented as the most frequent cause of bacteraemia in childhood pneumonia. in contrast, it is the most frequently recovered pathogen in parapneumonic effusions/empyema complicating pneumonia [37] [38] [39] and also commonly isolated in blood cultures from infants with bacteraemia [40] . therefore it is reasonable to conclude that s. aureus may be an important pathogen in childhood pneumonia as well. however, international and national antibiotic treatment protocols for childhood cap do not use specific antibiotics against this organism. the data presented in this study raise some important points for further research on childhood cap. first, the mere identification of organisms by highly sensitive techniques may not confirm etiology. even comparing the yield among cases vs controls, as planned in the perch project [41] can at best suggest an association, but not causation. in an individual child, even the presence of organisms commonly associated with pneumonia may be of limited value for predicting pneumonia severity/ outcome. the presence of potential pathogens in the respiratory secretions of apparently healthy children also raises the possibility that microbes may not be solely responsible for disease. it is likely that combinations of host immune status and/ or response to infection/inflammation tip the balance from asymptomatic colonization to disease in a given child. although this study had several methodological strengths limiting the risk of bias, it also had limitations. the dispropor-tionately large number of severe and very severe pneumonia cases attest to greater enrolment through passive surveillance. lack of controls is a limitation since it would have provided data on nasopharyngeal carriage of pathogens in asymptomatic/ healthy children in this population. further, research team members could not be stationed in a given anganwadi throughout the study period, hence pneumonia incidence could not be calculated. we could perform only qualitative pcr, and that too in a small proportion (20%) of the cohort. this large cohort study (capes) identified multiple pathogens in various biological samples of children with cap. our data suggest that it is difficult to attribute etiology to a single pathogen in the majority of cases as co-infection is common and independent of disease severity. multiplex pcr proved to be highly sensitive in identifying potential pathogens from respiratory samples; but lacked specificity for establishing a causal relationship. a novel finding of cmv carriage/infection in nasopharyngeal secretions was observed. our findings suggest that clinical practice guidelines for management of suspected bacterial pneumonia in developing countries should additionally consider anti-staphylococcal therapy. rational vaccination policies against s. pneumoniae, h. influenzae and (in the future) rsv could decrease overall burden of childhood pneumonia morbidity and mortality. global burden of childhood pneumonia and diarrhoea epidemiology and etiology of childhood pneumonia in 2010: estimates of incidence, severe morbidity, mortality, underlying risk factors and causative pathogens for 192 countries global and regional burden of hospital admissions for severe acute lower respiratory infections in young children in 2010: a systematic analysis global, regional, and national causes of child mortality in 2000-13, with projections to inform post-2015 priorities: an updated systematic analysis acute respiratory infection and pneumonia in india: a systematic review of literature for advocacy and action: unicef-phfi series on newborn and child health world health organization. technical bases for the who recommendations on the management of pneumonia in children at first-level health facilities integrated management of childhood illness (imci) technical seminar -acute respiratory infections world health organization. handbook imci. integrated management of childhood illness. geneva, switzerland: world health organization the definition of pneumonia, the assessment of severity, and clinical standardization in the pneumonia etiology research for child health study a literature review and survey of childhood pneumonia etiology studies epidemiology, aetiology and management of childhood acute community-acquired pneumonia in developing countries-a review community-acquired pneumonia in children: what's old? what's new? burden of invasive pneumococcal disease in children aged 1 month to 12 years living in south asia: a systematic review invasive pneumococcal disease associated with high case fatality in india lower respiratory infections among hospitalized children in new caledonia: a pilot study for the pneumonia etiology research for child health project standardized interpretation of paediatric chest radiographs for the diagnosis of pneumonia in epidemiological studies automated blood culture bactec. #9240/9120/9050 clinical utility of pcr for common viruses in acute respiratory illness available ibm spss statistics 22.0. available nasopharyngeal carriage, antibiogram & serotype distribution of streptococcus pneumoniae among healthy under five children epidemiology of nasopharyngeal colonization by s. pneumoniae in indian infants in the first 2 years of life clinical characteristics of children with lower respiratory tract infections are dependent on the carriage of specific pathogens in the nasopharynx community epidemiology of human metapneumovirus, human coronavirus nl63, and other respiratory viruses in healthy preschool-aged children using parent-collected specimens human bocavirus detection in nasopharyngeal aspirates of children without clinical symptoms of respiratory infection carriage of mycoplasma pneumoniae in the upper respiratory tract of symptomatic and asymptomatic children: an observational study department of aids control, ministry of health and family welfare, government of india. state hiv epidemic fact sheets prevalence of herpes and respiratory viruses in induced sputum among hospitalized children with non typical bacterial community-acquired pneumonia predominant role of bacterial pneumonia as a cause of death in pandemic influenza: implications for pandemic influenza preparedness insights into the interaction between influenza virus and pneumococcus empyema thoracis in children: a short term outcome study clinico-bacteriological profile and outcome of empyema empyema thoracis in children: still a challenge in developing countries etiology of bacteremia in young infants in six countries the pneumonia etiology research for child health project: a 21st century childhood pneumonia etiology study the investigators are grateful to ms kerstin thurdin (chair of the astrid lindgren children' s founkey: cord-258812-svw6z4bf authors: hu, haifeng; du, hong; li, jing; wang, yage; wu, xiaoqing; wang, chunfu; zhang, ye; zhang, gufen; zhao, yanyan; kang, wen; lian, jianqi title: early prediction and identification for severe patients during the pandemic of covid-19: a severe covid-19 risk model constructed by multivariate logistic regression analysis date: 2020-09-04 journal: journal of global health doi: 10.7189/jogh.10.020510 sha: doc_id: 258812 cord_uid: svw6z4bf background: as an emergent and fulminant infectious disease, corona virus disease 2019 (covid-19) has caused a worldwide pandemic. the early identification and timely treatment of severe patients are crucial to reducing the mortality of covid-19. this study aimed to investigate the clinical characteristics and early predictors for severe covid-19, and to establish a prediction model for the identification and triage of severe patients. methods: all confirmed patients with covid-19 admitted by the second affiliated hospital of air force medical university were enrolled in this retrospective non-interventional study. the patients were divided into a mild group and a severe group, and the clinical data were compared between the two groups. univariate and multivariate analysis were used to identify the independent early predictors for severe covid-19, and the prediction model was constructed by multivariate logistic regression analysis. receiver operating characteristic (roc) curve was used to evaluate the predictive value of the prediction model and each early predictor. results: a total of 40 patients were enrolled in this study, of whom 19 were mild and 21 were severe. the proportions of patients with venerable age (≥60 years old), comorbidities, and hypertension in severe patients were higher than that of the mild (p < 0.05). the duration of fever and respiratory symptoms, and the interval from illness onset to viral clearance were longer in severe patients (p < 0.05). most patients received at least one form of oxygen treatments, while severe patients required more mechanical ventilation (p < 0.05). univariate and multivariate analysis showed that venerable age, hypertension, lymphopenia, hypoalbuminemia and elevated neutrophil lymphocyte ratio (nlr) were the independent high-risk factors for severe covid-19. roc curves demonstrated significant predictive value of age, lymphocyte count, albumin and nlr for severe covid-19. the sensitivity and specificity of the newly constructed prediction model for predicting severe covid-19 was 90.5% and 84.2%, respectively, and whose positive predictive value, negative predictive value and crude agreement were all over 85%. conclusions: the severe covid-19 risk model might help clinicians quickly identify severe patients at an early stage and timely take optimal therapeutic schedule for them. viewpoints research theme 1: currently, corona virus disease 2019 which caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is rapidly spreading and wreaking havoc all over the world [1] . as of may 24, 2020, more than 5 000 000 covid-19 patients and asymptomatic sars-cov-2 infected individuals had been reported in more than 200 countries and regions [2] . with the accumulation of clinical experience, more and more detailed information about covid-19 has been revealed. although previous studies have shown that most covid-19 patients have a favorable clinical outcome, some severe patients may manifest dyspnea and hypoxemia within 1 week after illness onset, and which may quickly progress to acute respiratory distress syndrome (ards) or respiratory failure [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] . additionally, the surging patients have caused a significant shock and challenge to the entire health care system. consequently, the efficient triage of patients according to the severity of covid-19 so as to choose appropriate treatment is vital for the rational use of the limited medical resources [6] . previous studies have shown that older age, comorbidities, hypertension, lymphopenia, and elevated d-dimer, lactate dehydrogenase (ldh), serum ferritin, il-6, sofa score, mulbsta score were associated with the disease progression, ards present or poor prognosis of covid-19 patients [4] [5] [6] [7] [8] [9] [10] 12, 14] . however, some of the studies [4, 5, 7, 12] mentioned above were univariate analysis-based studies, and lack of the delineation of virological transformation course and the identification or evaluation of early predictors for severe in this study, we elaborated the details of clinical features and virological transformation course of the enrolled patients, as well as ascertained potential early predictors and further constructed a prediction model for severe covid-19. we hope the results of this study could help the clinicians implement the triage of patients with covid-19 more efficiently and choose the best treatment schedule for the patients. in this retrospective non-interventional study, we enrolled all patients with covid-19 admitted by the second affiliated hospital of air force medical university from january 24, 2020 to march 26, 2020. all enrolled patients were over 18 years old and had a definite clinical outcome (discharged or death), and were confirmed by positive sars-cov-2 rna in nasopharyngeal swab specimens using real-time reverse-transcriptase polymerase chain reaction assay. the confirmative examination was conducted by xi'an municipal center for diseases prevention and control according to the same protocol which has been described previously [11] . all patients were diagnosed and clinically typed according to the "diagnosis and treatment protocol for novel coronavirus pneumonia (trial version 7)" issued by the national health commission of china [16] , and were divided into a mild group (patients of mild type and moderate type) and a severe group (patients of serious type and critical type). the classification of all patients was confirmed by their attending physicians respectively. (the specific grouping criteria were showed in table s1 of the online supplementary document) the clinical data of demographic, epidemiological, symptoms and signs, laboratory, treatments and outcomes were extracted from the electronic medical records by two physicians who had been involved in the treatment of covid-19 patients, and which were confirmed independently by at least two researchers. in order to protect the privacy of patients, we hid the identity information of all patients in the process of data collection. laboratory data in this study mainly include routine blood tests, biochemistry tests, blood clotting tests and infection-related indices. most of these laboratory tests were conducted on admission, and the frequency of subsequent detections was determined by the attending physician according to the patient's condition. the initial and extreme values of these laboratory indexes were collected for analysis in this study. the initial values of laboratory tests on admission were used to explore early predictors and construct prediction model for severe covid-19. all of the initial values were obtained before the date when the clinical classification of patients was determined. the nasopharyngeal swab specimens of patients were obtained every other day after hospitalization, which were used to sars-cov-2 rna re-examination by the clinical laboratory department of our hospital, but only qualitative results were obtained. viewpoints research theme 1: covid-19 pandemic exposure history was defined as with a definite history of travelling to wuhan or exposure to individuals with confirmed or suspected sars-cov-2 infection within two weeks before the onset of illness. the incubation period was defined as the interval from exposure to illness onset, which was estimated among the patients who could provide the exact date of intimate contact with confirmed or suspected sars-cov-2 infection individuals. comorbidity was defined as having at least one of the followings: hypertension, diabetes, coronary heart disease, chronic obstructive pulmonary disease (copd), cerebral infarction, anemia and carcinoma. since not all laboratory tests could be performed immediately after admission, the initial value was the result of the first test within 48 hours after admission. extreme value referred to the maximum or minimum value of laboratory tests during hospitalization. the negative results of two consecutive sars-cov-2 rna detections which were taken apart more than 24 hours were considered as viral clearance. viral clearance, axillary temperature below 37.3°c for more than 3 days, obvious alleviation of respiratory symptoms, and significant improvement of exudative lesions on pulmonary imaging were the discharge criteria of patients, all of which were indispensable. this retrospective non-interventional study was approved and granted a waiver of written informed consent by the ethics committee of the second affiliated hospital of air force medical university, and which was performed in accordance with the helsinki declaration. given the small sample size of this study, continuous and categorical variables were presented as median (interquartile range) and numbers (percentage), and were compared by mann-whitney u test and fisher exact test, respectively. the demographics and initial laboratory indexes with significant differences between the two groups were assessed by univariate and multivariate logistic regression analysis to explore the independent early predictors and risk factors associated with the disease severity of covid-19. the kaplan-meier survival analysis and cox regression analysis were used to investigate the independent adverse factors which could obstruct the recovery and discharge of patients with covid-19. the independent risk factors and early predictors for severe covid-19 were finally ascertained based on the results of the above statistical analyses. the predictive efficacy of each early predictor was measured by receiver operating characteristic (roc) curves. a two-sided p < 0.05 was considered statistically significant. all statistical analyses were performed using spss statistics 23.0 software (ibm inc, chicago il, usa). a total of 40 patients with a median age of 51.0 (42.0-66.8) years were enrolled in this study, including 16 females and 24 males ( table 1) . according to the grouping criteria mentioned above, there were 19 mild cases and 21 severe cases. the median age of severe group was older than that of the mild, and also with a higher proportion of over 60 years old ( table 1 ). nearly half of the patients suffered from comorbidities, with hypertension being the most common comorbidity, and which was more prominent in severe patients ( table 1 ). the median incubation period was 5.5 (3.0-10.0) days, which was estimated based on the information submitted by the patients who could provide accurate exposure date ( table 1) . the most common symptoms were fever, fatigue and cough, followed by polypnea, which was adherent to the majority of severe patients ( table 1 ). in addition, the duration of fever and respiratory symptoms was longer in severe group than that in mild ( table 1 and figure 1 ). not only that, hypoxic symptoms had more priority in severe patients. a total of 36 (90.0%) patients had findings of bilateral infiltration on radiographic imaging (chest x-ray or computed tomography scan), while 2 (5.0%) patients had unilateral infiltration ( table 1) . we tracked the changes in laboratory indexes of all patients from hospital admission to discharge or death. initial lymphocyte count on admission in severe group was significantly lower than that of the mild. lymphopenia occurred in almost all severe patients during hospitalization, whereas in less than half of the mild viewpoints research theme 1: table 1 ). in the severe patients, lymphocyte count was lowest on day 13 after illness onset and the lymphopenia could last for more than 20 days (figure 1 ). approximately one-third of all patients got a decrease of serum albumin on admission, which was more common in severe patients. the initial values of neutrophil count, neutrophil lymphocyte ratio (nlr), alanine aminotransferase, aspartate aminotransferase, and c-reactive protein (crp) were higher in severe patients than in mild ( table 1 ). the dynamic changes of lymphocyte count, nlr, albumin, and crp during hospitalization in mild and severe patients were elaborated by line chart (figure 2 ). most severe patients underwent different degrees of anemia during hospitalization, but which was extremely rare in mild patients. furthermore, ldh, fibrin degradation product (fdp), and d-dimer during the clinical course were significantly higher in severe patients than in mild, and which were far beyond the range of reference values. given these laboratory tests were not performed within 48 hours after admission in some mild patients, there was no initial value for contrastive analysis between the two groups. (the differences of extreme values between the two groups were showed in table s2 of the online supplementary document) of all the enrolled patients, 2 (5.0%) severe patients died during hospitalization and the rest were recovered and discharged. the median duration of hospitalization for all discharged patients was 26.5 (16.5-37.5) days, which for severe and mild was 37.0 (26.0-42.0) days and 17.0 (12.0-27.0) days, respectively ( table 1 and figure 1) . approximately three-quarters of the enrolled patients received at least one mode of oxygen treatments, the most common of which was highflow nasal cannula oxygen therapy. 13 (61.9%) severe patients received mechanical ventilation, while none of the mild. 39 (97.5%) patients received antiviral treatment (lopinavir/ ritonavir or arbidol), with a median duration of 7.5 (4.0-10.0) days. the median interval from illness onset to viral clearance in severe patients was 21.0 (13.0-41.0) days, which was longer than that of the mild ( figure 1 ). it must be noted, however, the virus was continuously detectable until death in 2 non-survivors. of all the severe patients, the most common complications were ards and respiratory failure, followed by secondary infection. more detailed information about treatments and clinical outcomes were showed in table 1 . early predictors and the prediction model for severe covid-19 the univariate logistic regression analysis showed that the age, comorbidity, hypertension, lymphocyte count, neutrophil count, nlr, albumin and crp were associated with the disease severity of covid-19. subsequently, all the above parameters with statistical significance in the univariate analysis were incorporated into the multivariate logistic regression model for in-depth analysis. considering the relatively small sample size and the possibility of overfitting in the multivariate logistic regression model, we adopted a forward stepwise method (probability for stepwise: entry p < 0.05, removal p > 0.1) for logistic regression analysis to reduce the number of independent variables entering the model, so as to reduce the probability of model overfitting. the results showed that lymphocyte count and albumin on admission were the independent early predictors for severe covid-19 (table 2), and the severe covid-19 risk model was constructed as following: logit(p) = 15.779 − 2.531 × initial lymphocyte count ( × 10 9 /l) − 0.346 × initial albumin (g/l). in order to reduce overfitting of the model, we adopted the forward stepwise method mentioned above for logistic regression analysis to reduce the number of independent variables entering the model, while some important predictors might be excluded from the small sample size logistic regression model and be identified as non-independent predictors. for the above reason, we also conducted kaplan-meier survival analysis and cox regression analysis to assess the effect of the above indicators on the prognosis of patient with covid-19, so as to explore the potential independent predictors for severe covid-19. the results of kaplan-meier survival curves with log-rank test showed that venerable age (≥60 years old), comorbidity, hypertension, lymphopenia, hypoalbuminemia, elevated nlr and viewpoints research theme 1: covid-19 pandemic crp could obstruct the recovery and discharge of patients ( table 3 and figure 3) . further univariate and multivariate cox regression analysis showed that venerable age (≥60 years old), hypertension, lymphopenia, and elevated nlr were the independent adverse factors affecting the recovery and discharge of patients with covid-19 ( table 3) . through the combination utilization of the statistical analysis methods mentioned above, we finally ascertained that venerable age (≥60 years old), hypertension, lymphopenia, hypoalbuminemia and elevated nlr were the independent high-risk factors associated with the disease severity of covid-19, and the age, initial lymphocyte count, initial albumin and initial nlr could severe as the independent early predictors for severe covid-19. in addition, the severe covid-19 risk model (constructed by multivariate logistic regression analysis) might be a helpful tool for the early prediction and identification of severe patients during the pandemic of covid-19. predictive efficacy of the severe covid-19 risk model and early predictors roc curves were used to assess the predictive efficacy of the severe covid-19 risk model and each early predictor. according to the order of area under roc curve from large to small, these early predictors were the severe covid-19 risk model (0.920), albumin (0.867), nlr (0.835), lymphocyte count (0.826), and age (0.747), successively ( table 4 and figure 4) . the predictive value of the severe covid-19 risk model which combined with multiple parameters was the best, whose sensitivity and specificity was 90.5% and 84.2%, respectively, and its positive predictive value, negative predictive value and crude agreement were all over 85% ( table 4) . covid-19 pandemic the exponential increasing number of patients with covid-19 has brought a heavy burden to the medical health service systems in countries with large outbreaks. as reported by zhang et al [17] , the effective triage and hierarchical medical system and timely supplement of medical resources played an important role on reducing the mortality of covid-19 in the pandemic inundated regions. therefore, it is essential to ascertain the early predictors which could help clinicians to identify the severity of patients with covid-19 quickly at an early stage. in this retrospective cohort study, we identified several independent risk factors for severe covid-19, which were venerable age, hypertension, lymphopenia, hypoalbuminemia and elevated nlr. some of these risk factors have been identified in previous studies, while the hypoalbuminemia and elevated nlr have not been reported so far. the majority of previous studies have reported that elderly patients with covid-19 were more likely to progress to severe stage and the mortality of elderly patients was higher than that of the young and middle-aged [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] . the results of our study also confirmed that venerable age was an independent risk factor of severe covid-19. the weakness of immunity and the decline of compensatory function of visceral organs in elderly patients may be one of the reasons why they were prone to develop severe covid-19 after sars-cov-2 infection. lymphopenia is a widespread manifestation in patients with covid-19, especially in severe patients and the deceased. in a multicenter study which described the clinical characteristics of 1099 patients with covid-19, lymphopenia was reported in 82.1% of patients [4] . in present study, we not only reported that lymphopenia was associated with the severity of covid-19, but also compared the dynamic changes of lymphocyte count during hospitalization in mild and severe patients. the lower lymphocyte count and the longer duration of lymphopenia, the condition of patients with covid-19 may more serious and the prognosis of whom might more worse. similarly, the elevation of neutrophils in patients with covid-19 has been reported in several previous studies. wu et al [12] have reported that neutrophilia is a risk factor associated with the development of ards and progression from ards to death in patients with covid-19. in our study, although the neutrophil count might be associated with the severity of covid-19 in univariate analysis, multivariate analysis indicated that it was not an independent early predictor for severe covid-19, and the results of roc curve analysis also showed that the predictive efficacy of which was unsatisfactory. in view of the relatively limited predictive efficacy of the lymphocyte count and neutrophil count, we innovatively introduced neutrophil lymphocyte ratio (nlr) to statistical analysis. excitingly, the results showed that nlr was not only an independent early predictor for severe covid-19, which also got a better predictive performance than lymphocyte count. in addition, several previous studies have shown that patients with covid-19 were often accompanied by albumin reduction, and the level of serum albumin in severe patients were lower than that in mild [3, [12] [13] [14] . coincidentally, all of these studies did not elucidate the role of albumin in the prediction on disease severity or prognosis of covid-19. considering that the therapeutic measures such as intravenous albumin infusion may mask the true serum albumin levels of patients with covid-19, we selected the initial albumin on admission for analysis. the results showed that the initial albumin on admission was an independent early predictor with a good predictive performance for severe covid-19. several previous studies have showed that not only capable of causing pneumonia, covid-19 may also cause damage to other organs such as the heart, the liver, and the kidneys, as well as to organ systems such as the blood and the immune system [3, [13] [14] [15] [16] . based upon our results viewpoints research theme 1: and the clinical experience about covid-19, we conjectured that the decrease of albumin may be related to the low nutritional status, hypo-function of liver synthesis and acute kidney injury after sars-cov-2 infection. for all that, the mechanism of serum albumin reduction is still unclear and need further study. on the aspect of the viral dynamic changes, liu et al [18] reported that the mean viral load of severe cases was around 60 times higher than that of mild, which indicated that higher viral loads might be associated with severe clinical outcomes. in present study, we elaborated the details of virological transformation course in patients with covid-19. we observed that the duration of viral carrying (from illness onset to viral clearance) was longer in severe patients than that in mild, and the virus was continuously detectable until death in 2 non-survivors. the above findings of us coincided with the results of zhou et al [14] , and the later described the duration of viral shedding in survivals and non-survivals for the first time. the early viral clearance strategy might be benefit to the recovery of patients with covid-19 and reduce the transmission probability of sars-cov-2 [19] . all the above findings on virological transformation course might have important implications on patient isolation decision making and the guidance around the length of antiviral treatment. this study has several limitations. first, this is a single-center, small-sample, retrospective study. there were a total of 120 covid-19 patients in xi'an city, and only 40 of them were treated in our center which was one of the designated hospitals for covid-19 patients in xi'an. considering this was a retrospective study and the relatively small number of patients in our center, so we enrolled all patients into the analysis data set without calculating the sample size in advance. given the small sample size of this study, the continuous variables between the mild group and the severe group were compared by mann-whitney u test, which may reduce the statistical power of the analysis. due to the small sample size, our logistic model only incorporated two early predictors and excluded some important predictors such as age. for the above reasons, the findings of us might be limited by the sample size. second, not all laboratory indicators were detected in all patients, and not all laboratory tests should be performed immediately after admission. therefore, the initial values of some laboratory indicators such as ldh, il-6, procalcitonin, fdp and d-dimer, were absent in several mild patients, and the predictive value of which were not evaluated in this study. third, there was a great possibility of overfitting in the severe covid-19 risk model which we constructed, so the prospective cohort studies are needed to further confirm the reliability of the early predictors and to construct a new predictive model or scoring criteria of severe covid-19 for clinical application in the future. last but not least, the estimated duration of viral carrying might be limited by the frequency of respiratory specimen collection and the lack of quantitative viral rna detection. in summary, we elaborated the clinical features and virological transformation course of covid-19, identified several independent early predictors (age, lymphocyte count, albumin, nlr), and constructed a prediction model with a favorable predictive efficacy for severe covid-19. all these findings may have important implications on the early warning of severe covid-19, the decision making of patient isolation, and the guidance around the length of antiviral treatment, and which may help clinicians to identify the severe patients quickly at an early stage and reasonably allocate medical resources, so as to improve the therapeutic effect of severe covid-19. a review of the 2019 novel coronavirus (covid-19) based on current evidence e-pub ahead of print coronavirus disease (covid-2019) situation reports: situation report-125. available epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study. lancet. 2020. e-pub ahead of print clinical characteristics of coronavirus disease 2019 in china clinical characteristics of non-critically ill patients with novel coronavirus infection (covid-19) in a fangcang hospital prediction for progression risk in patients with covid-19 pneumonia: the call score clinical feature of covid-19 in elderly patients: a comparison with young and middle-aged patients clinical features of covid-19 clinical features predicting mortality risk in patients with viral pneumonia: the mulbsta score host susceptibility to severe covid-19 and establishment of a host risk score: findings of 487 cases outside wuhan clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china. jama. 2020. e-pub ahead of print risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet. 2020. e-pub ahead of print clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study comorbidities and multi-organ injuries in the treatment of covid-19 covid-19 pandemic 16 national health commission of china. diagnosis and treatment protocol for novel coronavirus pneumonia wuhan and hubei covid-19 mortality analysis reveals the critical role of timely supply of medical resources viral dynamics in mild and severe cases of covid-19 early antiviral treatment contributes to alleviate the severity and improve the prognosis of patients with novel coronavirus disease (covid-19) we thank hongyu yi and xiaofei yang for article revision and submission assistance. we also thank the entire health-care team of our center for the diagnosis and treatment of patients with covid-19. this study was approved by the ethics committee of the second affiliated hospital of air force medical university. authorship contributions: jql and wk designed the study and had full access to all of the data in the study, and they take responsibility for the integrity of the data and the accuracy of the data analysis. acquisition or interpretation of data: jl, ygw, xqw and cfw. statistical analysis: hfh, hd, gfz and yyz. manuscript drafting: hfh and hd. critical revision: hd, yz, wk and jql. writing editing and submission: hfh, hd and jl. study supervision: jql and wk. all authors have made substantial contributions to this study, and all of them read and approved the final manuscript. hfh and hd contributed equally and share the first authorship.competing interests: all authors have completed the icmje unified competing interest form (available upon request from the corresponding author), and declare no conflicts of interest. key: cord-281406-d7g0pbj4 authors: chen, yifei; zhao, meizhen; wu, yifan; zang, shuang title: epidemiological analysis of the early 38 fatalities in hubei, china, of the coronavirus disease 2019 date: 2020-04-24 journal: journal of global health doi: 10.7189/jogh-10-011004 sha: doc_id: 281406 cord_uid: d7g0pbj4 background: since the emergence of coronavirus disease 2019 (covid-19) in hubei province of china by the end of 2019, it has burned its way across the globe, resulting in a still fast-growing death toll that far exceeded those from severe acute respiratory syndrome (sars) in less than two months. as there is a paucity of evidence on which population is more likely to progress into severe conditions among cases, we looked into the first cluster of death cases, aiming to add to current evidence and reduce panic among the population. methods: we prospectively collected the demographic and clinical data of the first 38 fatalities whose information was made public by the health commission of hubei province and the official weibo account of china central television news center, starting from 9 january through 24 january 2020. the death cases were described from four aspects (gender and age characteristics, underlying diseases, the time course of death, symptoms at the incipience of illness and hospital admission). results: among the 38 fatalities, 71.05% were male, and 28.95% were female, with the median age of 70 years (interquartile range (iqr) = 65-81). persons aged 66-75 made up the largest share. twenty-five cases had a history of chronic diseases. the median time between the first symptoms and death was 12.50 days (iqr = 10.00-16.25), while the median time between the admission and death was 8.50 (iqr = 5.00-12.00) days. in persons aged over 56 years, the time between the first symptoms and death decreased with age, and so did the time between the admission and death, though the latter increased again in persons aged over 85 years. the major first symptoms included fever (52.63%), cough (31.58%), dyspnea (23.68%), myalgia and fatigue (15.79%). conclusions: among the death cases, persons with underlying diseases and aged over 65 made up the majority. the time between the first symptoms and death decreased with the advanced age. in all the age groups, males dominated the fatalities. viewpoints research theme 6: covid-19 pandemic rocketing up, the death toll of the coronavirus disease 2019 (covid19) outbreak has overtaken that of the severe acute respiratory syndrome (sars) during the 2002-2003 epidemic. the covid-19 outbreak has wreaked havoc on all sectors in china, resulting in city lockdown, traffic restrictions, work shutdown, and school cancellation, etc., first in wuhan, then later in many other cities. many countries have imposed travel restriction, suspended flights, and barred entry of chinese nationals. the sudden shock of the covid-19 has had a significant impact on the chinese economy [2] . containment of virus transmission has become a top priority to global public health security. researchers have been racing against time since the outbreak of the covid-19, as little was known regarding covid-19 virus initially. two viral genome studies had indicated that the novel virus is closely related to sars-cov (one research revealing 79.5% and the other 89.1% nucleotide similarity, respectively) [3, 4] , which is reminiscent of the calamitous sars outbreak 17 years back. aside from viral genome studies, researchers also looked into the clinical features and epidemiologic characteristics of covid-19 cases. clinical manifestation of covid-19 ranges from mild symptoms (low-grade fever, fatigue, sore throat, etc.) that resemble a common cold [5] , to severe and even fatal respiratory diseases such as acute respiratory distress syndrome [6] . a study that collected more than 70 000 cases across china also reported asymptomatic cases of covid-19 virus infection, accounting for 1.2% of total confirmed cases [7] . after emergence, the virus spread rapidly through human-to-human transmission [8] , which was substantiated by a modeling study from los alamos national laboratory indicating the median basic reproductive number (r0) for covid-19 virus was 5.7 (95% confidence interval (ci) = 3.8-8.9) [9] . the mechanism behind the high infectivity of the covid-19 virus could be explained by a study revealing that covid-19 virus spike glycoprotein had around 10 to 20-fold higher affinity with angiotensin converting enzyme ii (ace2) receptor that is widely distributed in human organs, than sars-cov spike glycoprotein [10] . in addition, the covid-19 virus spreads mainly from person-to-person contacts via respiratory droplets or contact with infected surfaces or objects [11] . with a combination of high infectivity and easy transmission, the covid-19 virus poses a great threat to anyone who has close contacts with an infected person, especially within families and to frontline medical staffers [12] . to make things worse, transmission from asymptomatic patients was confirmed by a case report covering a german businessman being infected by his asymptomatic chinese business partner from shanghai [13] . who issued a warning against possible transmission of covid-19 virus from infected people before they developed symptoms. these findings have raised concerns across the globe, sounded the alarm of a dire situation, and prompted authorities to ramp up quarantine measures. to what extent covid-19 kills remains vague, as literature in terms of case fatality rate is in scarcity. based on the data compiled by who, the overall case fatality rate of covid-19 globally was initially estimated at around 2% [14] , similar with an overall case fatality rate of 2.3% from a study which collected more than 70 000 cases in mainland china as of 11 february 2020 [7] . however, the two case fatality rate figures were much lower than the result yielded from the study of wang et al. on a case series of 138 consecutive hospitalized covid-19 patients (mortality: 4.3%) in a hospital in wuhan, china [15] . the reason that the study of wang et al. had higher case fatality rate can be attributed to the large scale of the infection in the epicenter of the outbreak (more than 40 000 cases in early february 2020), the heavily strained medical system, the lack of protective suits and medical equipment (such as masks, goggles, gloves, and disinfectants). based on the fact that the death toll of covid-19 topped that of the sars outbreak during 2002-2003 in less than two months, covid-19 virus infection will deal a more substantial blow to the globe and can be more fear-mongering, than sars. a look into deaths cases may provide more information to the public and sooth panic, as studies suggested that misinformation and inadequate information contribute to unnecessary public panic and subsequent undesirable responses [16, 17] . as there is a paucity of evidence on which population is more likely to progress into severe conditions among covid-19 cases, here, we poured over the first batch of 38 death cases whose information were made public by health commission of hubei province as of 24 january 2020, one day into city lockdown in wuhan, with the purpose to add a new facet to current evidence. data of covid-19 death cases in hubei were extracted prospectively from the website of health commission of hubei province [18] and the official weibo (china' s equivalent of twitter) account of china central television news center [19] , starting from 9 january 2020, when the first deceased patient was reported, through 24 january 2020, when the 38 th was registered. since 25 january 2020 the number of death cases has been surging, and the health commission of hubei province has stopped making public the information of death cases. therefore, data collection was terminated at that point. microsoft excel 2016 (microsoft, redmond, wa, usa) and spss 23.0 software (ibm corp., armonk, il, usa) was used for data analysis. the death cases were described from four aspects (gender and age characteristics, underlying diseases, death time distribution, and symptoms at the incipience of illness and hospital admission). frequencies (%) and median (interquartile ranges [iqr]) were used to describe the data. as of 24 january 2020, the overall case fatality rate for covid-19 was 5.3% in hubei. among the fatalities, there were 27 males, and 11 females, with a male to female ratio of 2.45:1. the youngest age was 36 years, and the oldest age was 89 years, with the median age being 70 years (iqr = 65-81). the median age for females and males both stood at 70, though iqr ranged from 66 to 80 for the former, and from 65 to 81 for the latter, respectively. distribution of 38 fatalities by genders and age groups was shown in figure 1 . there were 14 cases aged 66-75 years, making up the largest share of 36.84%. coming next was 10 cases aged 76-85, accounting for 26.31%. the same pattern was found for genders, with 66-75 years forming the largest share of 33.33% in males, vs 45.46% in females alone, and 76-85 years the second largest (22.22% in males, vs 36.36% in females alone). among the death cases, 25 had underlying diseases, including 16 males and nine females, accounting for 65.78% of the total. there were 15 cases of hypertension, 11 cases of diabetes, four cases of coronary heart disease, three cases of chronic bronchitis, two cases of cerebral infarction, and two cases of parkinson disease. other diseases included chronic obstructive pulmonary disease, tuberculosis, frequent ventricular premature beats, colon cancer, gallstone, cirrhosis, chronic renal insufficiency, fracture, hip replacement, etc., all keeping a tally of one case, respectively ( table 1) . among all the death cases, 17 had one or two underlying diseases, and eight had more than three underlying diseases. among the 38 fatalities, the first case died on 9 january, and the last in the batch died on 24 january 2020, with the period stretching 15 days, during which, the death toll didn't show apparent regularity. to understand the evolution of death, we defined the first symptom day fell on the date on which the patients started to feel their symptoms. we described the period between the first symptom day and the death date as days from the first symptom to death and the period between the date of admission and death as days from admission to death. the median time from the first symptom to death was 12.50 days (iqr = 10.00-16.25). as for male dead patients, the median time from the first symptom to death was 13.00 days (iqr = 11.00-17.00), and for the females, the median time from the first symptom to death was 11.00 days (iqr = 9.00-14.00). the median time from admission to death was 8.50 days (iqr = 5.00-12.00). as for male dead patients, the median time from admission to death was 9.00 days (iqr = 5.00-13.00), and for the females, the median time from admission to death was 7.00 days (iqr = 5.00-11.00). days from the first symptom to death tailed off over the age groups of 56-65, 66-75, 75-85, and >85, while the days from admission to death had a similar pattern over the age groups of 56-65, 66-75, 75-85, but rebounded in persons aged over 85 (figure 2) . 66% of the cases died within nine to 15 days since they felt the first symptoms. fever and cough were the main reported symptoms at the onset of illness among the 38 early death cases. twenty patients first complained of a fever, 12 of coughs, 9 of dyspnea, 6 of chest tightness, 6 of myalgia and fatigue, accounting for 52.63%, 31.58%, 23.68%, 15.79%, and 15.79%, respectively. other symptoms included headache, dizziness, chills, and intermittent diarrhea, each keeping a tally of one case. fever and dyspnea were the main reported symptoms at hospital admission among the 38 early death cases. twenty-five patients complained of a fever, 23 of dyspnea, 16 of coughs, 10 of chest tightness, and 6 had the complaints of myalgia and fatigue, accounting for 65.79%, 60.53%, 42.11%, 26.32%, and 15.79%, respectively. other symptoms are shown in table 2 . as of 24 january 2020, the initial overall case fatality rate in hubei province reached 5.3%. later on, newly reported cases in china saw a sharp rise, but the overall case fatality rate has dwindled. as of 11 february, the overall fatality rate in hubei province was 2.9% [7] , which was far lower than the results of our study. the later declining overall case fatality rate was on one part attributed to the effective treatment of covid-19 as thousands of medical workers from other parts of china poured into hubei province to aid their fellow workers battling the coronavirus. on the other part, there was viewpoints research theme 6: covid-19 pandemic a substantial shortage of test kits at the early stage of the covid-19 outbreak, making it challenging to identify the infected cases [20] . afterward, the test kits were supplied in a large amount, making the number of confirmed patients grow significantly. besides, with a continuous flow of medical resources and personnel into the epicenter and the sweeping screening of infected persons in the communities, the infections were identified and admitted to the hospitals (including fangcang shelter hospitals) speedily, reducing the possibility of becoming severe and preventing the widespread of the coronavirus in communities. we discussed the epidemiological characteristics of 38 cases in the early stage of the disease from the following four parts. gender and age characteristics 71.05% of the deaths were male, considerably more than female, which is consistent with the findings of wang w et al. [21] . single-cell sequencing of covid-19 virus receptors at tongji university found that asian men were more likely to be infected with covid-19 virus [22] , and a study of 8866 cases nationwide also found that the death rate of men was more than three times that of women [23] . the reason that male dominated the fatalities could be explained by the fact that percentage of ace2 level in men is higher than in women [23] , rendering men more susceptible to covid-19 virus. in addition, covid-19 virus-infected people tend to be older ones [24] . in a recent lancet article (15 february 2020) [6] , 53% of the confirmed cases had chronic underlying diseases, and the median age was 55.5 years, indicating that the middle and old aged patients with chronic underlying diseases were more likely to contract the covid-19 virus. from experience, we can see that patients with chronic underlying diseases are indeed more likely to have disease deterioration or even death. among the death cases, persons with underlying diseases and aged over 65 made up of the majority. hence, we developed a speculation that covid-19 could worsen in elderly persons with underlying diseases and even more easily progress to death. this is mainly due to the dwindling immunity in the elderly, especially in those with underlying diseases, which directly renders senior people more likely to be in a state of frailty and more vulnerable to infections [25] , and subsequently leads to worsening of the disease [26] . among the death cases, persons with hypertension and /or diabetes made up the largest share, which could be explained by the fact that hypertension and diabetes top the chronic disease chart in china [27] . ace2 is a crucial regulator of the renin-angiotensin system, and plays a regulatory role in the central regulation of blood pressure and cardiovascular function and could become an attractive target for the treatment of hypertension [28, 29] . covid-19 virus uses the receptor ace2 to enter into target cells [30] , precisely the same as sars-cov. turner et al. [31] found that sars-cov infection affects the function of ace2, so we speculate that the covid-19 virus will also impair the function of ace2, and then manipulate the regulation of blood pressure, and have a negative impact on patients with hypertension. on the other hand, hypertension can cause vascular damage. in patients with hypertension, increased vascular stiffness and decreased elasticity are common, followed by vascular remodeling and stenosis [32] . the pathological results of patients with covid-19 showed that pulmonary vessels endothelial swelling, luminal stenosis and occlusion, leading to acute lung dysfunction [31] . the coexistence of hypertension and covid-19 is a very unfavorable factor to induce lung dysfunction, which is prone to aggravate the condition and even result in death. ace2 gene can also be expressed in the pancreatic islets. a study showed that the binding of sars-cov to ace2 damages islets and causes acute diabetes [33] . covid-19 virus may also exert such a negative effect on islets through the same mechanism. in persons with preexisting diabetes, the damage of islets by covid-19 virus could be more severe, and even fatal [4, 34, 35] . in addition, ace2 is rich in the lungs, heart, kidney, intestine, and testicles, etc. once covid-19 virus gains entry into the human body, more organs could be attacked by the virus through blood circulation over time [36] . therefore, early diagnosis of covid-19 before it progresses into severe conditions is an important measure for older people who have developed a fever and respiratory symptoms [24] . other measures including reducing chances of exposure to infected cases (eg, banning visits to nursing home residents, avoiding gatherings), early isolation and treatment of symptomatic confirmed cases can be beneficial to the elderly population, especially those with preexisting underlying diseases. viewpoints research theme 6: in this study, the number of deaths did not show obvious regularity with time within two weeks. in addition, the covid-19 virus infection rate has been spiking up since 20 january. according to the data of the national health and health commission [37] and the results from our study, we make the following speculation: the cases gradually became infected around the end of december according to a median 7-day incubation period and a median 12.5-day period from the first symptom to death [20] . if we take the later reported maximum incubation period of 38 days into account [38] , a considerable part of them may have been infected in november. besides, the difference in immune resistance between different genders and ages is also an important reason for the irregular distribution of the time of death [39] . however, from figure 2 , it can be concluded that with the increase of age, the days from hospital admission to death and the days from the first symptom to death gradually reduced indeed, which shows that covid-19 poses a great threat to elderly patients [40] . our study also shows that the days from hospital admission to death rebounded in persons aged over 85 years. since there were only 4 cases aged over 85 years, the finding needs further validation from long-term, large-scale cohort studies. studies have indicated that viral infection in the early stage mainly shows upper respiratory tract infection, manifested as fever, headache, and cough [41] . huang et al. found a similar result that 98% of the patients with covid-19 experienced fever, 76% had a cough, and 55% had dyspnea as the first symptom, respectively [42] . however, among the deaths up to 24 january, 52.63% had a fever, 31.58% had a cough, and 23.68% had dyspnea, as the first symptom. it can be seen that not all infected cases have high body temperature as the first symptom, and the temperature change of old people is not very significant compared with young ones even when they have infectious diseases [43] . among the severely infected elderly, 20% ~ 30% of them have no fever or slow response to fever, which is often a sign of poor prognosis [44] , and hinders early detection of infection and brings more potential risks to the elderly. therefore, the early repeated examination is a valid response [45] . however, symptoms changed at the time of admission, with 65.79% of patients showing fever, 60.53% dyspnea, 42.11% cough, indicating dyspnea became the second major symptom. as for the covid-19 virus infection, severe patients will have chest discomfort, progressive dyspnea, or acute respiratory distress syndrome symptoms [46] , which indicates the aggravation of the disease. as a result, the proportion of dyspnea symptoms was slightly higher than other symptoms in our deaths. also, although there were cases with limb myalgia and fatigue, headache, and other initial symptoms came in a small quantity, it does not mean that covid-19 cases presenting the symptoms are in mild condition. there is still the possibility of progression to death, which should arouse the vigilance of medical staff [47] . the emergence of a new infectious disease poses a particular challenge to epidemiologic research, as identifying the characteristics of the disease and infection prevention and control of an epidemic is a step-by-step process. during the period from 17 to 20 january 2020, the number of confirmed cases of covid-19 increased 10-fold [48] , indicating high infectivity of the novel coronavirus [49] . such a disease needs to be contained, or at least the spread of it needs to be reined in time. otherwise, the medical system will face enormous pressure, and a large number of infected patients will inevitably die due to the lack of timely treatment. during the covid-19 outbreak, it is necessary to strengthen the training of medical personnel from all levels of medical institutions, especially those serving at hospitals designated as the treatment center for the disease. at the same time, it is necessary to invest a multitude of resources in outpatient and emergency departments to detect patients to improve the treatment conditions and the capacity to house severe cases. since the elderly and people with underlying diseases are most vulnerable to the attack of coronavirus, and often have serious consequences [50] , it is urgent to ramp up protection and prevention measures for the elderly, especially those with chronic underlying diseases. it also warns us that in the face of an unknown disease, the protection of vulnerable people is essential. this study has some limitations. first, the data of this study came from the panel data of the official website of the health commission of hubei province, so the clinical information of the cases collected is limited. second, as our study focused on the deaths in the early stage of the outbreak, and the fatalities constitute only a tiny fraction of the overall still-hiking death toll, the specific relationship between male and female, and the variations in the time window from onset to death, and from admission to death among different age groups needs more large-scale studies . the 2019-ncov outbreak joint field epidemiology investigation team, li q. notes from the field: an outbreak of ncip (2019-ncov) infection in china -wuhan economic turning point to appear in march despite coronavirus a pneumonia outbreak associated with a new coronavirus of probable bat origin a new coronavirus associated with human respiratory disease in china coronavirus disease (covid-19): symptoms and treatment. clinical manifestation of covid-19 epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study chinese center for disease control and prevention. the epidemiologic characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19) in china clinical characteristics of coronavirus disease 2019 in china high contagiousness and rapid spread of severe acute respiratory syndrome coronavirus 2. emerg infect dis. 2020. epub ahead of print cryo-em structure of the 2019-ncov spike in the prefusion conformation diagnosis and management of covid-19 (7th version-revised importation of rare but life-threatening and highly contagious diseases. current situation and outlook transmission of 2019-ncov infection from an asymptomatic contact in germany novel coronavirus (2019-ncov) situation report clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china. jama. 2020. epub ahead of print developing pandemic communication strategies: preparation without panic what have we learned about communication inequalities during the h1n1 pandemic: a systematic review of the literature briefing on covid-19 by hubei health commission the official microblog of cctv news center early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia updated understanding of the outbreak of 2019 novel coronavirus (2019-ncov) in wuhan, china single-cell rna expression profiling of ace2, the putative receptor of wuhan 2019-ncov. biorxiv. 2020. epub ahead of print epidemiological and clinical features of the 2019 novel coronavirus outbreak in china. mdrxiv. 2020. epub ahead of print early epidemiological analysis of the coronavirus disease 2019 outbreak based on crowdsourced data: a population-level observational study. lancet. 2020. epub ahead of print the burden of frailty among u.s. veterans and its association with mortality evaluation of mhla-dr expression rate on immune function and prognosis in elderly patients with pneumonia study of the prevalence and disease burden of chronic disease in the elderly in china study on the ace2 pathway in the mechanism of exercise reduction in hypertension mechanisms of mas1 receptor-mediated signaling in the vascular endothelium structure of dimeric full-length human ace2 in complex with b0at1. biorxiv. 2020. epub ahead of print vascular fibrosis in aging and hypertension: molecular mechanisms and clinical implications clinical pathology of critical patient with novel coronavirus pneumonia (covid-19) ace2: from vasopeptidase to sars virus receptor binding of sars coronavirus to its receptor damages islets and causes acute diabetes management suggestions for patients with diabetes and novel coronavirus pneumonia the single-cell rna-seq data analysis on the receptor ace2 expression reveals the potential risk of different human organs vulnerable to wuhan 2019-ncov infection. front med. 2020. epub ahead of print china news; national wei jian committee. novel coronavirus pneumonia incubation period averages about 7 days be vigilant! 38 days! asymptomatic! enshi diagnosed cases of extra long incubation period expert group on novel coronavirus pneumonia prevention and control of china preventive medicine association. the latest understanding of novel coronavirus pneumonia epidemiology a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster coronavirus infections and immune responses clinical features of patients infected with 2019 novel coronavirus in wuhan watch out for fever-free older adults most of the old people have no fever clinical course and outcomes of critically ill patients with sars-cov-2 pneu-references monia in wuhan, china: a single-centered, retrospective, observational study single-cell analysis of ace2 expression in human kidneys and bladders reveals a potential route of 2019-ncov infection. biorxiv. 2020. epub ahead of print novel coronavirus outbreak in wuhan, china, 2020: intense surveillance is vital for preventing sustained transmission in new locations preliminary prediction of the basic reproduction number of the wuhan novel coronavirus 2019-ncov coronaviruses: an overview of their replication and pathogenesis key: cord-289520-i6pv90s9 authors: harris, carlyn; carson, gail; baillie, j kenneth; horby, peter; nair, harish title: an evidence-based framework for priority clinical research questions for covid-19 date: 2020-03-31 journal: journal of global health doi: 10.7189/jogh.10-011001 sha: doc_id: 289520 cord_uid: i6pv90s9 background: on 31 december, 2019, the world health organization china country office was informed of cases of pneumonia of unknown aetiology. since then, there have been over 75 000 cases globally of the 2019 novel coronavirus (covid-19), 2000 deaths, and over 14 000 cases recovered. outbreaks of novel agents represent opportunities for clinical research to inform real-time public health action. in 2018, we conducted a systematic review to identify priority research questions for severe acute respiratory syndrome-related coronavirus (sars-cov) and middle east respiratory syndrome-related coronavirus (mers-cov). here, we review information available on covid-19 and provide an evidenced-based framework for priority clinical research in the current outbreak. methods: three bibliographic databases were searched to identify clinical studies published on sars-cov and mers-cov in the outbreak setting. studies were grouped thematically according to clinical research questions addressed. in february 2020, available information on covid19 was reviewed and compared to the results of the sars-cov and mers-cov systematic review. results: from the research objectives for sars-cov and mers-cov, ten themes in the literature were identified: clinical characterisation, prognosis, diagnosis, clinical management, viral pathogenesis, epidemiological characterisation, infection prevention and control/transmission, susceptibility, psychosocial, and aetiology. for covid19, some information on clinical presentation, diagnostic testing, and aetiology is available but many clinical research gaps have yet to be filled. conclusions: based on a systematic review of other severe coronaviruses, we summarise the state of clinical research for covid-19, highlight the research gaps, and provide recommendations for the implementation of standardised protocols. data based on internationally standardised protocols will inform clinical practice real-time. viewpoints research theme 6: outbreaks, especially of novel agents, create a pressing need to collect data on clinical characterization, treatment, and validation of new diagnostics to inform rapid public health response. in 2018, we conducted a systematic review to identify the most common clinical research questions asked during outbreaks of sars-cov and mers-cov. we identified ten major clinical questions and provided recommendations for standardised protocol study designs that should be designed in the case of a new outbreak of a novel respiratory pathogen. here, we review the currently available information on covid-19 to determine which clinical questions from the systematic review findings have already been addressed, what information is lacking, and compare covid-19 to sars-cov and mers-cov. we included any original study included conducted in a clinical setting during an acute outbreak of mers and sars but limited the sars studies to those published during the sars epidemic and (16 november 2002 through 5 july 2003) and 18 months thereafter to identify clinical questions relevant during the acute phases of the outbreak. therefore, for sars studies, the last publication date considered for full text review was 31 december 2004. there was no publication date restriction for mers studies as outbreaks were ongoing. search terms to capture observational study designs such as cohort studies, cross-sectional studies, case-control studies, and case series were adapted from the scottish intercollegiate guidelines network (sign) search filters [4] . search terms on diagnosis and prognosis were adapted from pubmed clinical query search filters provided in the pubmed help manual [5] . to capture studies that were conducted in the epidemic or outbreak setting, subject headings such as "disease outbreaks", "epidemics", "pandemics", etc. were included. we applied our inclusion and exclusion criteria ( table 1) for both title and abstract screening and subsequently full text screening. following data extraction, the objectives of the included studies were grouped thematically. within each theme, articles with objectives that represented similar research questions were summarised. studies must be: 1) the main objective was not the study of sars-cov or mers-cov -focused sars-cov or mers-cov 2) the study was not conducted primarily in a clinical setting (ie, population epidemiology studies, in-vitro studies, surveillance studies were excluded) -conducted in a clinical setting 3) the study was not conducted in an outbreak setting or did not analyse data that was collected in an outbreak setting -conducted on humans 4) non-human studies study designs considered: observational studies (prospective cohort, retrospective cohort, case-control, case-series) and cross-sectional studies. 5) the sample size was less than 4 6) the study was not original as this outbreak is in its initial stages, we reviewed resources such as: the world health organization disease outbreak news, ministry of health websites from affected countries, the center for disease control' s morbidity and mortality weekly report (mmwr), promed, and publications found on pubmed. for pubmed searches, the search term "novel and coronavirus" was used, with a date range starting at 1 january 2020. the search was conducted on 20 february 2020. references of articles found through these searches were also reviewed. only studies conducted in the clinical settings were included and single case reports were excluded. we compared our findings to the 2018 systematic review on sars and mers to determine which questions have already been addressed, what information is lacking, and provide recommendations for data sharing and clinical study designs to be conducted during the current outbreak. we grouped the results thematically from reviewing available resources on the novel coronavirus based on their relevance to the previously identified ten clinical questions. viewpoints research theme 6: covid-19 pandemic no funding body had any role in study design, in the collection, analysis, and interpretation of data; in the writing of the report; nor in the decision to submit the paper for publication. a total of 124 studies (71% on sars) were included for the final review and data extraction. all were conducted in a hospital setting. after thematically coding the objectives of the 124 studies, ten key themes emerged: clinical characterisation, prognosis, diagnosis, clinical management, viral pathogenesis, epidemiological characterisation, infection prevention and control/transmission, susceptibility, psychosocial, and aetiology. originally, infection prevention and control and transmission were grouped separately. however, they were combined as most of the papers in the "transmission" category were concerned with transmission to hospital workers. of note, only 16% of sars articles were published before the end of the outbreak. table 2 defines the key clinical research questions identified from each theme. this table was modelled after a publication describing harmonisation of zika virus protocols [6] . themes appear in order based on how many sars and mers articles attempted to address a question within that theme. determine effect of illness, treatment, and isolation procedures on the psychological and social well-being of those infected current state of knowledge for 2019-covid-19 here, we answer what clinical information is currently known about the novel coronavirus, using the above questions as a framework. what is the clinical presentation and spectrum of disease? the first aggregated patient data comes from a publication by chaolin huang and colleagues, who described clinical features of 41 admitted hospital patients, 6 of whom died. they collected data using an adaptation of international severe acute respiratory and emerging infection consortium' s (isaric) / world health organisation (who) internationally standardised data collection forms, updated for use with the novel coronavirus (https://isaric.tghn.org/novel-coronavirus/). they report that the novel coro-viewpoints research theme 6: navirus presentation resembles that of sars: a viral pneumonia with fever, cough, dyspnoea, and fatigue. they also found a high concentration of cytokines in critically ill patients, compared to less severe cases [7] . chen one report of pregnant patients demonstrated similar symptomology to non-pregnant patients. they also established that there was no evidence of vertical transmission to the child [11] . in the only study of infants with covid-19, wei et al. reported fever and upper respiratory symptoms common among nine infants. all infants were infected via family clusters [12] . finally, radiological studies attempted to characterise the course of disease in chest imaging. pan et al. report peak lung involvement at 10 days on ct studies [13] . of note is a case series by xie et al. that reported ground glass opacity in five patients with initial negative rt-pcr findings but suspected covid-19. they were later confirmed to be infected [14] . overall, clinical characterisation studies commonly found bilateral involvement with ground glass opacity, though a range of presentations were reported [8] [9] [10] 15] . what are the risk factors for death or severe illness? while risk factors for death and severe illness cannot be firmly established without large groups of patient data and multi-variable adjusted methods, some studies report similar risk factors among cohorts. [17] . it includes indexes such as multi-lobular infiltration, lymphopenia, bacterial co-infection, smoking, hypertension, and age. in the publication by chaolin huang and colleagues, antibiotics and oseltamivir, and oxygen support were administered to some patients. corticosteroids were used if patients were diagnosed with severe community acquired pneumonia [7] . chen et al. reported antiviral, antibiotic, and non-invasive mechanical ventilation use but did not provide comparisons or suggestions for guidelines [8] . kui et al. determined that use of systemic corticosteroids in their cohort did not show benefits, but early respiratory support improved outcomes [10] . in addition to a randomised controlled trial of lopinavir/ritonavir in adults hospitalised with covid-19 (trial registration number: chictr2000029308) [18] , over 80 clinical trials are expected to determine therapeutic options [19] . several diagnostic tests for the novel coronavirus have been developed. of note are those by corman and colleagues [20] and by hong kong university school of medicine [21] . the world health organization has provided preliminary guidance on specimen collection and shipment as well as reporting [22] . all information on diagnostic testing can be found at the who' s technical guidance site. zou et al. obtained upper respiratory specimens from 18 patients in zhuhai, china. highest viral loads were detected soon after symptom onset, with higher loads in the nose and throat. they suggest that the shedding pattern of sars-cov-2 resembles patients with influenza. asymptomatic patients were also found to have nasopharyngeal viral loads similar to symptomatic patients [23] . additionally, y. zhang et al. found live virus in stool samples [24] . zhou the world health organization has provided a case definition in their interim surveillance guidance for the novel coronavirus [28] . the definition includes patients with a severe acute respiratory infection (sari) with relevant travel history within 14 days of illness or a health care worker caring for those with sari. currently, there are no data on what clinical activities are associated with an increased risk to health care workers. as of 14 february 2020, over 1700 health care workers have been infected [29] . the world health organization has provided interim guidelines for infection prevention and control [30] . currently, it is unclear whether certain demographics of the population are more susceptible to infection with the novel coronavirus. most initial cases had contact with wuhan' s huanan seafood market, the suspected source of the outbreak, or had contact with those who had visited the market [1] . what is the causative agent of disease? sequencing analysis from lower respiratory tract samples from bronchoalveolar lavage identified the novel coronavirus. genomes were released on gisaid.org. due to similarities with related viruses, a bat reservoir is suspected [25] . currently, there are no data on the psychosocial impacts of infection, hospitalization, or quarantine among affected patients and health care workers. we summarise the available clinical information on covid-19, using results from a systematic review on sars and mers as a framework. as highlighted by david heymann in a recent lancet commentary, rapid action by clinicians and scientists to share data has made it possible to identify a causative agent, design and implement a diagnostic test, as well as begin to understand patient presentation [31] . as outlined above, there is much work to be done on understanding the clinical picture of the novel coronavirus. the world health organization r&d research blueprint and the global research collaboration for infectious disease preparedness (glopid-r) have identified similar research priorities as those we identified from our systematic review. overlapping priorities include understanding viral pathogenesis, clinical characterisation studies, infection prevention and control, and candidate therapeutics [32] . to facilitate answering these key clinical questions, we suggest the following study designs ( table 3) . notably, the world health organization released a cases and contacts investigation protocol called "the first few x (ffx)". it involves prospective case finding and follow-up to gain an early understanding of key clinical, epidemiological, and virologic characteristics of the first cases of covid-19 in a given country. they have also released a protocol to assess risk factors for infection among health care workers. in terms of clinical presentation, early recognition of symptoms and disease progression also allows for rapid isolation, early clinical care and limits onward transmission. who and isaric have released an updated version of their case report form (crf) specifically for covid-19. this can be used to collect anonymised, standardised clinical data to start to inform our understanding of the presentation and natural history of covid-19. this crf is being rolled out as a tool for public health and may or may not require ethical approval according to local regulations. a more in-depth characterisation, with the collection of serial biological samples through a research protocol and informed consent can be obtained through the isaric/who clinical characterization protocol. this a standardised, prospective, observational study for the rapid investigation of patients with severe acute infections. the protocol was designed to characterise host and pathogen features, triage and treatment of disease [33] . the who ffx protocol, described above, may be used for the earliest cases to identify key clinical characteristics in real-time. the current clinical characterisation articles are a start to our understanding of the clinical presentation and spectrum viewpoints research theme 6: covid-19 pandemic of disease but much larger cohorts are needed for greater precision around estimates and to undertake prognostic and risk factor analyses. based on the sars and mers systematic review, further clinical research in this area should include if and how symptomology, laboratory findings, and imaging studies differ between demographic groups (ie. adults vs children, immunosuppressed patients). what are risk factors for death or severe illness? based on recent data, male gender, advancing age and co morbidities seem to be associated with death and severe illness [16] . understanding prognostic factors for death or severe illness helps hospitals and public health authorities determine resource allocation [34] [35] [36] . during the sars epidemic, risk factors for mortality were advanced age, co-morbidities, and initial high inflammatory laboratory markers [37, 38] . similarly, for mers, advanced age and co-morbidities are predictors of severe illness and death [39] . many studies identified from the mers and sars systematic review were retrospective cohort studies and poor outcomes were assessed 21-30 days from symptom onset. in designing protocols for mortality or severe illness risk factors for covid-19, case-control studies or prospective cohort studies should be used with an end-point at 90 days, so as not to miss late deaths. whatever the optimal end-point for assessing outcome, standardising this outcome measure across studies will allow researchers to contribute to core data sets. while there is some preliminary descriptive data on clinical management, randomized controlled trials are needed to determine the best treatment options for covid-19. for now, the world health organization has issued interim guidelines for clinical management, adapted from their guidance for mers-cov. it includes recommendations for early recognition, early supportive therapy (oxygen, fluids, empirical antimicrobials) and against routine use of systemic corticosteroids unless indicated for another reason. they also provide guidelines for cases of septic shock [30] . clinical trials to test therapeutic efficacy are ongoing, such as a trial of lopinavir/ritonavir (https://www.pharmaceutical-technology.com/analysis/coronavirus-mers-cov-drugs/). more studies are expected soon [19] . most of studies identified in the sars and mers review were descriptive treatment studies. these observational studies are practical in the fast-paced outbreak setting, as they are easier than randomised controlled the first few x (ffx) who protocol https://www.who.int/publications-detail/the-first-few-x-(ffx)-cases-and-contact-investigation-protocol-for-2019-novel-coronavirus-(2019-ncov)-infection) what are the risk factors for death or severe illness? case-control study or prospective cohort with outcome of death or another defined poor outcome what treatments are effective? randomised controlled trials or adaptive trial designs what is the role of antivirals in treatment? who master protocol: https://www.who.int/blueprint/priority-diseases/key-action/multicenter-adaptive-rct-of-investigational-therapeutics-for-covid-19.pdf?ua=1 what is the role of steroids in treatment? what is the optimal diagnostic test for detecting the virus? what is the causative agent of disease? laboratory based study with clinical specimens, fulfilling koch' s postulates viewpoints research theme 6: covid-19 pandemic trials (rcts) to design and require less administrative effort. however, when it comes to treatment, rcts provide the best primary evidence for medical practice [40] . among these studies, there was great heterogenicity for testing efficacy of specific treatments. this reflects the lack of global research coordination in delivering medical countermeasures during the mers outbreaks and the sars epidemic. this should be kept in mind when designing treatment protocols for covid-19 and is being addressed by who. the rct on ebola therapeutics in the democratic republic of the congo is evidence that conducting clinical therapeutics research is possible in the context of an outbreak [41] . the who has released a master protocol for a multi-centre, adaptive, randomized, double-blind placebo-controlled clinical trial to evaluate safety and efficacy of therapeutic agents for the treatment of hospitalized patients with covid-19. using a master protocol across international sites can speed the implementation of clinical trials and quickly inform treatment options (https://www.who.int/blueprint/ priority-diseases/key-action/multicenter-adaptive-rct-of-investigational-therapeutics-for-covid-19.pdf?ua=1). what is the optimal diagnostic test? the rapid development of a diagnostic test for covid-19 was a critical development and the result of international collaboration. as the outbreak progresses, it is important to continue monitoring diagnostic validity, such as sensitivity, specificity, positive predictive value, and negative predictive value. during an outbreak or epidemic, it is important to also validate diagnostic tests in low prevalence areas, as predictive values may change [42] . what is the duration of viral shedding? understanding the duration of viral shedding and the shedding profile from different anatomical sites are key for both diagnosis and instituting infection prevention and control measures [43] . current data suggest that sars-cov-2 viral loads are high at the beginning of symptom onset, are found in upper respiratory specimens and stool specimens, and are detectable in asymptomatic patients at levels similar to symptomatic patients [23] . one sars study revealed that viral detection peaked at 2 weeks after onset for respiratory specimens and 2-3 weeks for stool and rectal specimens. the shedding peak in urine occurred around weeks 3-4. rarely did patients shed virus 6 weeks after onset, however it was documented in a few stool specimens [44] . to evaluate the shedding profile during the covid-19 outbreak, the isaric/who clinical characterization protocol can be adapted to prospectively and systematically collect serial samples from patients with suspected infection [33, 45] . as with studies on sars and mers, serial samples should be collected from multiple body sites, including urine, faecal, and nasopharyngeal samples. what characteristics define a "case"? in an outbreak, if multiple sites adopt a standardised protocol such as the isaric/who clinical characterization protocol to describe cases, case definitions could be created rapidly to inform accurate reports on incidence and prevalence. developing criteria for confirmed cases is usually based on laboratory diagnosis. the world health organization has provided an interim case definition, and it will likely evolve as more data are shared on patient presentation. what risk factors pre-dispose health care workers to infection or transmission? over 1700 health care workers in wuhan have been diagnosed with covid-19 and there is no research available as to how this happened. both mers and sars viruses showed nosocomial transmission amplification in the health care setting [46] . during the sars epidemic, 21% of the infected patients were health care workers, and in some countries, this rate was as high as 50% [47] . risk of sars infection was associated with inconsistent use of personal protective equipment, and less than 2 hours of infection control training [48] . during the 2015 south korea mers outbreak, 44% of the 186 cases were patients that had been exposed to nosocomial transmission in hospitals, and 83% of total transmission events were due to five super spreading events in hospitals [49] . the recently released who protocol for evaluating risks to health care workers should be implemented as soon as possible to prevent future health care worker infections. viewpoints research theme 6: what are the risk factors for infection (in patient population)? the suspected major risk factors for covid-19 are visiting the wuhan market or being in contact with someone who had visited the market. the above-mentioned who ffx protocol can be used globally to assess risk factors for infection. in the 2018 sars and mers systematic review, only three studies with a psychosocial focus were identified. however, integrating social science research into clinical and epidemiological research during an outbreak can help inform the need for psychologists, psychiatrists, and social workers. especially in diseases with human-to-human transmission, the effect of stigma and quarantine on mental health cannot be underestimated. psychosocial manifestations can be explored with mixed methods studies. what is the causative agent of disease? because of rapid data sharing and laboratory protocols by the chinese health officials and the world health organization, the causative agent of the novel coronavirus was rapidly identified. our systematic review summarises the questions that are answered in the context of new outbreaks, but this methodology cannot tell us what questions should be answered. however, we propose this as a proxy for ensuring key clinical questions are addressed early in an outbreak. we have summarised key knowledge gaps for covid19, but we do not intend to suggest that this is an exhaustive list. many of the most important discoveries hinge on the creativity and innovation to identify new questions. in this new outbreak, we need new ideas to build on the foundations that we have comprehensively summarised in this article. the suggested study designs above can be used to inform standardised research protocols and define data sets that should be collected by hospitals around the world, if they are affected by covid-19. as in any outbreak setting, priorities of local clinicians and public health authorities should be considered, especially in countries that integrate traditional medicine with western medicine. researchers may consider adopting a tiered approach as isaric has with the clinical characterisation protocols. the tiered approach allows sites to determine how much data or samples they can collect given their (limited) resources. this allows health care centres in low and middle-income countries to be represented in the data. global solidarity is needed in the clinical research community as we may face the next pandemic of the 21st century. we all benefit from the data collected and shared. who have launched a clinical data collection platform for covid-19 via the international health regulations and hope that member states will share their data. this uses an isaric who co-created crf for covid 19. thanks to lessons learned from sars and mers, the international public health and research community has been able to rapidly respond to the emergence of this novel coronavirus. based on a 2018 systematic review of sars and mers common clinical research questions, we provide a summary of the state of current clinical knowledge for the covid-19, demonstrate what clinical research gaps still need to be filled, and provide recommendations on study designs. many of the identified gaps, such as viral pathogenesis, clinical characterisation, infection prevention, and candidate therapeutics overlap with gaps identified the who' s r&d blueprint research roadmap. if health care facilities around the world collect standardised patient data and quickly share it, it is likely that these core clinical research questions can be answered in real-time to inform clinical practices for covid-19. world health organization. novel coronavirus (2019-ncov) situation report-1 a novel coronavirus from patients with pneumonia in china a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster scottish intercollegiate guidelines network harmonisation of zika virus research protocols to address key public health concerns clinical features of patients infected with 2019 novel coronavirus in wuhan epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan clinical characteristics of novel coronavirus cases in tertiary hospitals in hubei province clinical characteristics and intrauterine vertical transmission potential of covid-19 infection in nine pregnant women: a retrospective review of medical records novel coronavirus infection in hospitalized infants under 1 year of age in china initial ct findings and temporal changes in patients with the novel coronavirus pneumonia (2019-ncov): a study of 63 patients in wuhan, china chest ct for typical 2019-ncov pneumonia: relationship to negative rt-pcr testing epidemiologic and clinical characteristics of novel coronavirus infections involving 13 patients outside wuhan, china the novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19) -china clinical features predicting mortality risk in patients with viral pneumonia: the mulbsta score a novel coronavirus outbreak of global health concern more than 80 clinical trials launch to test coronavirus treatments diagnostic detection of 2019-ncov by real-time rt-pcr detection of 2019 novel coronavirus (2019-ncov) in suspected human cases by world health organization. laboratory testing for 2019 novel coronavirus (2019-ncov) in suspected human cases interim guidance sars-cov-2 viral load in upper respiratory specimens of infected patients notes from the field isolation of 2019-ncov from a stool specimen of a laboratory-confirmed case of the coronavirus disease 2019 (covid-19) discovery of a novel coronavirus associated with the recent pneumonia outbreak in humans and its potential bat origin molecular and serological investigation of 2019-ncov infected patients: implication of multiple shedding routes consistent detection of 2019 novel coronavirus in saliva surveillance case definitions for human infection with novel coronavirus (ncov) interim guidance v1 clinical management of severe acute respiratory infection when novel coronavirus (ncov) infection is suspected data sharing and outbreaks: best practice exemplified covid 19 public health emergency of international concern (pheic) global research and innovation forum: towards a research roadmap open source clinical science for emerging infections critically ill patients with severe acute respiratory syndrome risk factors for middle east respiratory syndrome coronavirus infection among healthcare personnel severe acute respiratory syndrome: clinical outcome and prognostic correlates world health organization. consensus document on the epidemiology of severe acute respiratory syndrome (sars) clinical manifestations, laboratory findings, and treatment outcomes of sars patients mers transmission and risk factors: a systematic review finding the evidence: a key step in the information process a randomized, controlled trial of ebola virus disease therapeutics understanding and using sensitivity, specificity and predictive values viral shedding patterns of coronavirus in patients with probable severe acute respiratory syndrome laboratory diagnosis of sars clinical characterization protocol transmission characteristics of mers and sars in the healthcare setting: a comparative study guide to infection control in the hospital. international society for infectious diseases sars transmission among hospital workers in hong kong middle east respiratory syndrome: what we learned from the 2015 outbreak in the republic of korea we extend our deepest thanks to emily phipps and jecko thachil of oxford university. with gail carson in 2012, they first proposed the idea of identifying key clinical questions asked in respiratory outbreaks as a means of epidemic preparedness and to emphasize the importance of data sharing. this work would not have been possible without them. authorship contributions: gc, ph, hn, and ch contributed the idea for the review. ch designed the study, conducted the review, and wrote the report. gc, ph, hn, and kb contributed to the critical review of the report. all authors reviewed and approved the final version.competing interests: all authors declare no competing interests. gc and ph are involved in the operation of isaric. kb is the isaric ccp technical lead. the authors have completed the icmje unified competing interest form and declare no further competing interests. key: cord-311210-q92xft2b authors: van empel, giovanni; mulyanto, joko; wiratama, bayu satria title: undertesting of covid-19 in indonesia: what has gone wrong? date: 2020-07-28 journal: journal of global health doi: 10.7189/jogh.10.020306 sha: doc_id: 311210 cord_uid: q92xft2b nan . comparison of number test per 1 million populations with neighbouring countries (per april 29, 2020). data source: worldometers [2] . number of covid-19 cases in indonesia is likely to be significantly underreported. asian countries. to draw a comparison, singapore and malaysia have nearly 20 000 and 4700 tests per million residents, respectively. a country of 267 million and the fourth largest in the world, indonesia reports a relatively small number of confirmed covid-19 cases compared to other affected countries. until 29 april 2020, official data showed that indonesia had 9771 confirmed cases and 784 confirmed deaths [1] . with a case fatality rate of 8.0%, this puts indonesia at the top among neighbouring countries, and 9th globally [2] . this raises a lot of questions surrounding the general capacity of covid-19 testing in indonesia. many experts believe that the low number of cases were massively underreported due to our low testing capacity. this concern is substantiated by the low number of tests by the indonesian health authority. moreover, throughout the first month following the first reported case, indonesia had only averaged around 27 tests per day. reports of downplaying the risk of covid-19 by indonesian authorities is well documented [3] . weeks before the first reported case, on one occasion at a parliament hearing, the indonesian health minister said that strategies and measures to prevent covid-19 are in place [4] . the reality seems to be the opposite. the first official testing protocol for covid-19 was published on march 16, just two weeks after the ministry of health reported the first case. the protocol requires all specimens to be examined at the central laboratory of the national institute of health research and development, ministry of health located in the capital jakarta. this means hospitals throughout indonesia were required to send the specimen to jakarta, creating significant delays -up to 10 days -for the results to be finalised. this requirement also created a massive bottleneck of the testing process due to mismatches in the resource capacity and the demand for high volume testing. not long after the first protocol was published, the ministry of health (moh) expanded designated test centres to ten moh owned laboratories across indonesia. while this move looks like a proper response, there were questions on the non-involvement of non moh owned experienced laboratory centres available within the indonesian medical schools. research suggests that health laboratory infrastructure is one weak link in the health system [5] . the reluctance by the health authority to decentralise the testing process persists amid enormous public pressure and even when provincial leaders have shown initiative in assisting the testing process. only after the president formally instructed to expand the testing capacity in the early april 2020 (4 weeks after the initial confirmed case was recorded), then the health authority started to decentralise the testing process to 48 public-owned laboratories. the government has set an ambitious target to achieve 10 000 tests per day in immediate time albeit no clear timeline for the target. while the number of rt-pcr machines are relatively sufficient, there is a shortage of the testing kits such as reagent and virus transport media which likely need to import from outside indonesia. these shortages are foreboding with the demand for tests increasing to around 2000 tests per day (a number which is yet still far below the aimed target). testing protocol is also a contributing factor to the low number of testing. contrary to who guidelines, the official national guidelines [6] distinguishes suspect cases into two different categories. the first category is called person under surveillance which is defined as individuals who have mild acute respiratory infection symptoms with travel history from outbreak area or history of close contact to confirmed cases. per april 29, there are more than 200 000 cases identified in this category. the second category is patients under surveillance which de-lack of testing capacity is a result of delayed policy response. photo: image by michal jarmoluk from pixabay. fined as individuals who have moderate or severe acute respiratory infection such as pneumonia with similar travel history or close contact. as of april 29, almost 21 000 people categorized as patients under surveillance. only individuals in the latter category are eligible to be tested. this very strict criteria limit the number eligible of testing. the guidelines have subsequently led to a failure in testing suspected cases who only have mild symptoms or asymptomatic. there is a need for fundamental policy changes to adequately address the covid-19 pandemic in indonesia. first, we need to provide a stronger stewardship to contain covid-19 through a more concerted effort. this means continuously expanding the testing capacity by involving private laboratories. strategically encouraging domestic production of the testing kit may be a sustainable solution. this means accurately identifying the real capacity parallel with ensuring efficient distribution of tests and testing resources. there are other areas of improvement as well. publication of genomic sequencing, for instance, could provide better understanding of the type of virus indonesia is facing. lastly maintaining the broader testing criteria introduced in the latest version of national protocol and effectively collaborating with all stakeholders will be key to survive this pandemic wave. situasi perkembangan covid-19 di indonesia. badan nasional penanggulangan bencana covid-19 coronavirus pandemic review and analysis of current responses to covid-19 in indonesia: period of it's insulting': indonesia criticizes us study concerns over no coronavirus cases. the jakarta post the republic of indonesia health system review pedoman kesiapsiagaan menghadapi novel corona virus (covid-19) revisi ke-4. jakarta: kementerian kesehatan republik indonesia we receives no funding for this study.authorship contributions: all authors contributed equally in this manuscript. the authors completed the icmje unified competing interest form (available upon request from the corresponding author) and declare no conflicts of interest key: cord-331405-1opm5onj authors: pessa valente, emanuelle; cruz vaz da costa damásio, lia; luz, leonardo sérvio; da silva pereira, marília francisca; lazzerini, marzia title: covid-19 among health workers in brazil: the silent wave date: 2020-06-17 journal: journal of global health doi: 10.7189/jogh.10.010379 sha: doc_id: 331405 cord_uid: 1opm5onj nan a ccording to the most recent who estimates, brazil has the highest number of diagnosed covid-19 cases in the americas region after the united states [1] . community transmission has been documented throughout all federal units (26 states and federal district). since the beginning of pandemic, many organizations have raised concerns with the lack of personal protective equipment (ppe), low observance of social distancing measures, and scarce availability of diagnostic tests in brazil [2, 3] . moh recommended use of diagnostic swabs be reserved for severe cases with acute respiratory distress syndrome (ards) [4] . no specific federal recommendations on case finding among health workers (hw) currently exist. data from other countries have clearly indicated that hw are disproportionally affected by covid-19 and can be carriers of the disease. in italy, 20 618 covid-19 cases have been reported so far among hw (10.4% of total cases) [5] . the italian national federation of medical doctors and odontologists has reported 151 deaths among doctors [6] . these data do not include other hw categories such as nurses or midwives. in us, the centers for disease control and prevention (cdc) reported 9282 covid-19 cases confirmed among hw [7] among these 723 (8%-10%) were hospitalized and 184 (2%-5%) required intensive care unit (icu) admission. in defense of hw safety, the brazilian federal council of medicine (fcm) has taken several measures. hw safety guidelines have been widely circulated, with hospital inspections carried out to verify their implementation. an online platform has been established for professionals to report shortcomings of resources, such as lack of ppe in workplaces, either public or private. finally, the fcm is advocating for expanding criteria for covid-19 diagnostic tests to all symptomatic hw [8] . yet frontline workers are dangerously ill-equipped due to decades of underinvestment in the public health sector and limited access to appropriate ppe and training [9, 10] . the brazilian federal council of nursing highlighted around 4800 reports of lack of ppe made by associate members since the beginning of pandemic. in the same time period, there have been more than 4600 sick leaves for "influenzalike symptoms" and 32 deaths among nurses, numbers significantly higher than usual trends [10] . brazilian media have claimed that the numduring the covid-19 pandemic, brazilian frontline workers are dangerously illequipped due to decades of underinvestment in the public health sector and limited access to appropriate personal protective equipment and training. ber of covid-19 cases and related deaths among hw, in particular in selected states such as são paulo and maranhão, is rapidly increasing [11] . open knowledge brazil (okbr), a civil society organization that operates in support of open-access data of public interest, ranked brazilian states with a "transparency index", evaluating 13 criteria related to content, format and level of detail of information disclosed via official portals during covid-19 pandemic [12] . despite improvements in the last weeks, on 22 april only four (15.3%) brazilian states published data on the availability of covid-19 diagnostic tests, while 11 (42.3%) provided data on incidence of new ards cases [12] . the "transparency index" had a major impact on public opinion in brazil, and civil public legal action was taken against san paulo state using these data. however, the transparency index does not include availability of data on covid-19 among hw to evaluate states. we report here the results of a rapid review performed by systematically screening each of the 27 federal health department websites and covid-19 dedicated portals in order to identify specific policies for hw health screening and testing, and related hw morbidity and mortality data. data collection procedures were integrated by research on social networks. data are updated on 27 april 2020. results indicated that pernambuco, a state in northeast, was the first to develop a policy to perform diagnostic swabs among all symptomatic hw on 4 april 2020, giving priority to hw in icus and emergency departments. policies in other states were less clear, with limited availability on official websites. major investments were made in rapid tests for qualitative antibody detection whose accuracy is still unclear. information regarding covid-19 confirmed cases among hws was available in the official bulletins of only six (22.2%) brazilian federal states (figure 1) . as expected based on current policies, a significantly higher number of cases was detected in pernambuco compared to other states, with a high prevalence in hw (30.8% of total cases). as many states are currently implementing massive rapid test programs, increased numbers of covid-19 cases among hw are expected in coming weeks. these data demonstrate a lack of a homogeneous, transparent, and comprehensive surveillance system for covid-19 cases among brazilian hw during the current pandemic. coordinated policies are needed to increase hw protection, and availability of surveillance data, to protect both hw and the entire brazilian population. world health organization. coronavirus disease (covid-2019) situation reports nota pública: cns defende manutenção de distanciamento social conforme define oms paho director calls for "extreme caution" when transitioning to more flexible social distancing measures diretrizes para diagnóstico e tratamento da covid-19. versão 1. secretaria de ciência, tecnologia, inovação e insumos estratégicos em saúde -sctie sorveglianza integrata covid-19 in italia elenco dei medici caduti nel corso dell'epidemia di covid-19 characteristics of health care personnel with covid-19 -united states conselho federal de medicina. pandemia covid-19: notas e esclarecimentos do cfm profissionais de saúde estão expostos e sem proteção mais de 4 mil profissionais foram contaminados pela covid-19 sindicato registra morte de 16 trabalhadores da saúde pela covid-19 em são paulo índice de transparência da covid-19 covid-19. secretaria de estado da saúde do maranhão (boletim atualizado até às 18h -26/04/2020. portal da saúde painel covid-19 do espírito santo informe epidemiológico coronavírus (covid-19) covid-19: nota orienta testagem de profissionais gerência executiva de vigilância em saúde. covid-19 ses-pb secretaria de saúde do distrito federal. boletins informativos sobre coronavirus (covid-19) (svs/divep/cieves) references correspondence to: emanuelle pessa valente, md, ob&gyn, phd institute for maternal and child health -irccs "burlo garofolo" trieste via dell the authors would like to thank rebecca lundin for the english language review. key: cord-300022-2wfo6yql authors: ammar, walid; kdouh, ola; hammoud, rawan; hamadeh, randa; harb, hilda; ammar, zeina; atun, rifat; christiani, david; zalloua, pierre a title: health system resilience: lebanon and the syrian refugee crisis date: 2016-12-14 journal: journal of global health doi: 10.7189/jogh.06.020704 sha: doc_id: 300022 cord_uid: 2wfo6yql background: between 2011 and 2013, the lebanese population increased by 30% due to the influx of syrian refugees. while a sudden increase of such magnitude represents a shock to the health system, threatening the continuity of service delivery and destabilizing governance, it also offers a unique opportunity to study resilience of a health system amidst ongoing crisis. methods: we conceptualized resilience as the capacity of a health system to absorb internal or external shocks (for example prevent or contain disease outbreaks and maintain functional health institutions) while sustaining achievements. we explored factors contributing to the resilience of the lebanese health system, including networking with stakeholders, diversification of the health system, adequate infrastructure and health human resources, a comprehensive communicable disease response and the integration of the refugees within the health system. results: in studying the case of lebanon we used input–process–output–outcome approach to assess the resilience of the lebanese health system. this approach provided us with a holistic view of the health system, as it captured not only the sustained and improved outcomes, but also the inputs and processes leading to them. conclusion: our study indicates that the lebanese health system was resilient as its institutions sustained their performance during the crisis and even improved. across lebanon in houses among the lebanese population, while 17% is residing in informal tented settlements [6] . the unprecedented influx of refugees has placed a considerable burden on the lebanese government, society and economy, which are facing many other challenges. for example, while the gross domestic product (gdp) of lebanon grew by 8% in 2010, it fell sharply to 1.5% in 2013 [7] , constraining the government' s ability to continue financing the expanding population needs in the presence of stagnant economic growth. a refugee crisis of such a large magnitude is a severe shock to the health system, and threatens continuity of service delivery, destabilizing governance and limiting access to care [8] . to date, however, the lebanese health system (box 1) has been able to accommodate and adjust to the refugee crisis [11] . resilience is the ability of a health system to sustain or improve access to health care services while ensuring longterm sustainability [12, 13] . a resilient system has high tolerance to uncertainty and relies on a variety of resources in its response to shocks [14, 15] . despite calls for strengthening policy capacity in this important area [16, 17] resilience of health systems to external and internal shocks remains understudied [18, 19] . lebanon is currently facing an acute crisis [20] due to an unprecedented influx of refugees from syria with multiple health needs, which has placed a rapid and an unprece-dented demand on the health system [21, 22] . the extraordinary situation of the refugee crisis offers a unique setting to study resilience of lebanon's health system to an external shock, combined with internal shocks due to economic and political instability. the aim of this study is to assess the resilience of the lebanese health system in the face of an acute and severe crisis and in the context of political instability. while many conceptual frameworks for resilience exist [23] there is no unified definition of health system resilience, or an established method to measure it [24] . one framework offers 5 dimensions to assess the potential of health system resilience to an emerging crisis, but a standardized set of internationally accepted indicators for these dimensions have yet to be developed and tested empirically [25] . for the purpose of this study, we have used the following working definition of a resilient system: "a resilient system has the capacity to absorb change due to external or internal shocks, maintain original functions and ensure long-term sustainability" [26] [27] [28] [29] . when studying the resilience of the lebanese health system we drew on insights from studies of health systems that have faced refugee crises -studies which have considered the ability of a health system to maintain service delivery, prevent major outbreaks and sustain improvements in population level outcome indicators including utilization, service coverage, morbidity and mortality rates, as measures of success [30] [31] [32] [33] . the indicators used in these earlier studies are in line with the definition of resilience we have used. this definition stresses the ability of a system to reorganize and adapt to change while maintaining original functions and ensuring long-term sustainability [26] [27] [28] . the study employs a case study approach and draws on data from multiple sources. we use an input-process-output/outcome model of a health system [30] , where inputs, processes and outputs measure the capacity of the health system while outcomes measure its performance [30] . this approach allows for a comprehensive and holistic analysis of the lebanese health system and offers enough flexibility to capture both the contextual characteristics of the system and factors in place during the acute crisis that have affected the health system response and resilience. the study, which took place from january 2014 to july 2015, consisted of two main components: a literature review on resilience and how to measure it, and analysis of secondary data to document the impact of the refugee crisis and the health system response in lebanon. for the literature review, we undertook a search using the following databases: ovid medline, the cochrane library, box 1. lebanese health system -a brief overview the health system in lebanon is a public-private partnership with multiple sources of funding and channels of delivery. almost one half of the population is financially covered by the national social security fund (nssf), an autonomous public establishment or by other governmental (civil servants cooperative and military schemes) or private insurance. all those schemes provide financial coverage with variable patient copays. the non-adherents are entitled to the coverage of the ministry of public health (moph) for secondary and tertiary care at both public and private institutions. palestinian refugees are covered through the united nations relief and work agency for palestinian refugees (unrwa) for their health care services [9] . although the moph does not cover ambulatory care services, it provides in kind support to a national network of primary health care (phc) centers all over lebanon [2] . the centers provide consultations with medical specialists at reduced cost, as well as medicines for chronic illness and vaccines funded by the ministry of health [2] . around 68% of the primary health care centers in the national network are owned by ngos while 80% of hospitals belong to the private sector [2] . the strong presence of the private sector in service delivery has led to an oversupply of hospital beds and technology [2] . while there is an oversupply of physicians, there is a shortage of nurses [10] . and health systems evidence. in addition, we searched gray literature databases such as reliefweb, mednar, oais-ter, open doar, prospero and opengrey. local data were obtained from multiple sources, namely the lebanese ministry of public health database which included data on service utilization, human resources, immunization coverage, and epidemiological surveillance. we also used national health accounts data (that uses the system of health accounts 1.0) and maternal mortality observatory data. the moph information systems and the maternal mortality observatory data sets are designed to incorporate ongoing assessment and reporting related to displaced syrians, including for immunization coverage, disease surveillance and utilization of health services in addition to maternal and child mortality. other sources included statistics from the lebanese ministry of finance, bank of lebanon and the central administration for statistics (cas), un agency publications, world bank assessments, and international and local ngos publications. human resources. the fluctuating pattern in the number of physicians started before the syrian refugee crisis as a result of a mismatch in supply and demand, with persistent oversupply [34] . by contrast, the number of nurses working in lebanese health system increased steadily and was not affected by the syrian crisis [34] . the steady rate of increase in number of nurses occurred as a result of deliberate moph policies, such as the establishment of a career path for nurses, financing of training of more nurses by the lebanese university, supporting the bridging between vocational and academic training, and increasing nursing wages in the public sector [2] . financing. in 2013-14, there was no substantial change in patterns of public spending on health, the budget of the moph, and all public funds rose at the same rate of yearly increase as in the preceding years [1, 35] . however, throughout the crisis, the levels of funding from international donors were erratic and far below the amounts required to meet the health needs of the refugees. for example, in 2013, less than 50% of funding requirement was met [36] , declining in 2014 to 33% of the funding amount needed [4] . the funds from international donors are managed by united nations (un) agencies and are channeled through different international and local ngos. the moph was not a recipient of these funds but worked with international entities to influence effective application of the funds to priority areas and populations. throughout the crisis, the lebanese health system was able to sustain the level of financing of services at primary-, sec-ondary-and tertiary-care levels. the moph contracts with primary health care centers were maintained. the moph was able to uphold and improve its contracting terms with private hospitals by including performance measures in the contracts to achieve required service volumes at specified quality levels. additionally, all the public funds and private insurance companies continued to provide cover to their respective beneficiaries, notwithstanding delays in reimbursement. despite financial constraints, the moph managed to increase its expenditure on drugs, which helped to effectively meet the higher demand that arose in recent years [1] . this expenditure of funds to increase expenditure on drugs was coupled with collaboration with different donors in order to direct external funds to priority areas. for syrian refugees, primary care has been partly subsidized by the united nations high commission for refugees (unhcr). however, for secondary care the financial assistance provided by unhcr has been limited to vulnerable groups, and for life-threatening conditions with copayments provided by refugees [36] . the limited financing of secondary care services has resulted in a major gap in service coverage, however leading to heavy financial burden on refugees seeking secondary and tertiary care services [36] . governance. at the start of the crisis, there was no clear government policy regarding the displaced syrian population. while the moph began to offer displaced syrians the same immunization schedule and primary health care services offered to lebanese citizens, unhcr and other relief agencies sought to create their own delivery channels and their own mechanism of financing coverage which operated in parallel to the existing health system. the parallel systems established by international agencies led to fragmentation and poor coordination of the health system response to the refugee crisis. in the absence of a clear government policy, the fragmentation of health system governance prompted the moph to call upon international agencies to consider a more integrated approach to planning, financing and service delivery by embedding refugee health care within the national health system. to develop an integrated approach, the moph established a steering committee that includes major international and local partners to guide the response. the steering committee, led by the moph, develops strategic plans and coordination mechanisms and monitors the response [4] . all partners in the refugee health response including moph, un agencies, international and local non-governmental organisations (ngos) held regular meetings and set up yearly response plans such as the "lebanon crisis response plan". these response plans detailed all funding sources, activities performed and coordination efforts. these plans were regular-ly updated and tracked, and the results were shared in dissemination workshops and on the websites of these partners. the inclusive model of governance, based on participation, transparency and accountability, was critical in mounting an effective emergency response and in creating health system resilience, and in establishing an effective surveillance system (box 2). during the crisis, the participation of the private sector and civil society, and networking with different donors, international stakeholders and un agencies was not only important for health system governance but also for the development of multi-sectoral health strategies. examples of successful partnerships included the engagement of the primary health care national network and private hospitals in health care delivery to mount a unified and effective response [37] . service provision. provision of health care has been sustained at all levels throughout the crisis. primary health care centers and hospitals from both public and private sectors have remained operational. health programmes, such as those for epidemiological surveillance, immunization, medication for chronic illnesses, tuberculosis, hiv/aids and reproductive health, among others, are functioning effectively [38] . other programs, such as the accreditation of primary health care centers and integration of non-communicable disease management within primary health care, progressed as planned despite the crisis [38] . nationwide vaccination campaigns for polio and measles have been routinely conducted as needed, and services provided to all those in lebanon irrespective of nationalities [39] . these immunization campaigns were conducted in accordance with the district physicians, municipalities, civil society and schools. community health workers, including volunteers from universities and schools, participated in the door-to-door immunization campaigns [38] . additionally, the epidemiological surveillance program was able to sustain and even enhance its functions, including measurement and monitoring disease burden, detecting outbreaks, investigating emerging infections and implementing early warning and response system [4] . staff trainings were conducted by moph health experts and adequate precautionary measures were taken at airports and seaports against pandemic threats, such as ebola and mers coronavirus [39, 40] . in addition to the primary care centers across lebanon that were providing health services for syrians refugees and the public health response, at the hospital level, unhcr contracted with public and private hospitals to provide for registered displaced syrians selected secondary care services, covering 75% of the fees [41] . the additional services financed by unhcr enabled the moph to maintain the functioning of existing units to meet the needs of displaced syrian refuges while allocating additional dedicated health workers for those living in informal tented settlements [6] . health service utilization. since 2013, the number of primary health care centers in the national network as well as the number of beneficiaries steadily rose [38] . in 2014, the total beneficiaries of the primary health care network exceeded 1.2 million, compared to about 700 000 in 2009 [38] . these beneficiaries include both lebanese and syrian nationals. in 2014, syrian nationals made up around 35% of the beneficiaries for the primary health care national network [38] . private and public hospitals continue to deliver quality services. while the moph has sustained its coverage of hospital admissions for uninsured lebanese, admissions for insured lebanese have not been disrupted by the syrian refugee crisis [1] (figure 1) . meanwhile, the proportion of syrian beneficiaries in rafic hariri governmental university hospital has continued to increase from 2% in 2010 to 33% in 2014 (figure 2 ) [42] . in terms of immunization coverage, vaccination rates for measles and diphtheria, pertussis and tetanus (dpt) are considered important indicators of health system performance [43] . the vaccination campaigns achieved high vaccination rates for both lebanese and syrian beneficiaries [38] (figure 3) . in response to the rapid rise in demand for human health resources, the moph, in collaboration with unhcr, who and unicef, recruited a limited number of health workers to strengthen its surveillance system and emergency response capability and to cater for the needs of displaced syrians living in the informal tented settlements, in addition to a limited number of administrative employees at central and peripheral levels. a total of 92 new staff was recruited in phc, in dispensaries' and in public hospitals. due to financial constraints, however, this number diminished gradually to 42 by the end of 2015. retention of the remaining staff will largely depend on the evolution of the crisis. embedded in each program of work were a set of monitoring and evaluation tools that made the stretched activities run smoother. each program approached the crisis as if they were dealing with an enlarged population of 30%. immunization activities, phc services, and secondary care provision were all maintained and effectively expanded while monitoring and maintaining quality standards. to ensure uninterrupted financial coverage, the moph developed and implemented a reform strategy in 1998 to rationalize health expenditures targeting the high financial burden on households. this strategy resulted in lower out of pocket expenditures from 60% in 1998 to 34% in 2013, at the peak of the syrian crisis [2, 35, 44] . [45] . similarly, the maternal mortality ratio decreased from 140 per 100 000 live births in 1990 to 16 in 2013 [45] [46] [47] . child and maternal mortality observatory data confirm the downward trend in these indicators over the recent years [1, 45, 46] . the influx of syrian refugees has increased the risk and exposure to communicable diseases, including those that previously did not exist in lebanon [23] . communicable diseases, such as polio, measles and waterborne infections, are considered the greatest public health risks in refugee situations [48] . outbreak prevention and control, therefore, represent an important measure of the resilience of a health system. lebanon effectively managed several outbreaks including for measles. in 2013, the number of reported measles cases was 1760, compared to 29 cases in 2015 [49] . the spread of leishmaniasis, an infection which was previously not noted in lebanon, was also avoided despite the existence of its vector, the sand fly, in north lebanon and the bekaa, and the presence of infected syrians as a human reservoir [49] . the number of leishmaniasis cases fell substantially between 2013 and 2015 (1033 to 32 cases), with only three lebanese citizens contracting the disease during the crisis [49] . additionally, lebanon was able to stay polio-free despite reemergence of the disease in syria [38] . the moph ensured that the vaccination campaigns reached the maximum number of children by conducting school field visits, by having an moph vaccination team at every unhcr refugee registration entry point, by coordination with the moph officers at district level, and primary care centers and by providing door-to-door coverage. syrian refugees have also received routine immunizations and other vaccinations, such as polio and measles through the vaccination campaigns spearheaded and coordinated by the moph, unicef and who. as for cholera, and despite it being considered a public health threat in lebanon by who due to the refugee crisis, lebanon was cholera-free from 2013 to 2015 [49] . case notification rate of tuberculosis (tb) in lebanon had been declining until 2011. in 2012, the case notification rate increased by 27%, however [50] (figure 4) . this increase was attributed to a rapid rise in the number of syrian refugees, as only 48% of notified tb cases was among non-lebanese [50] . early detection, isolation, and treatment of tb cases in specialized centers and hospitals among the displaced populations prevented an outbreak in host communities [51] . in 2014, the treatment success rate was 76%, with one half of the tb cases receiving treatment completely cured [51] . our findings indicate that the health system in lebanon was able to maintain service delivery for both refugees and lebanese citizens, prevent communicable diseases and sustain improvements in morbidity and mortality levels in the presence of major external and internal shocks, despite relatively limited increase in system inputs. the health system was "able to adapt to change and retain functionality" of governance, financing and service delivery "while maintaining achievements" [26] [27] [28] . as the crisis evolves, the resilience of health care service delivery in lebanon will be continuously monitored, as the health system comes under increasing pressure. the resilience of the lebanese health system could be attributed to four major factors. first, networking with the multitude of partners in the health sector [52] and the mobilization and support of regional and global partners, were at the core of the response to the syrian refugee crisis. this integrated approach was evident in the refugee response plan that was developed by key actors and implemented by a wide array of service providers, including from the private and public sectors and ngos [25] . additionally, the lebanese health system was able to draw upon diverse sources of funding and multiple conduits for service delivery. although multiple financing sources and service providers can lead to fragmentation, good governance based on a public private partnership helped to secure a constant stream of funds, primarily through both reallocation of resources and internal resource mobilization, which allowed patients to bypass government bureaucracy and partially compensate for the delayed and scarce international aid. integration and smart dependency achieved in lebanon is a key feature of resilient health systems [25] . second, adequate infrastructure and sufficient supply of health human resources was vital in absorbing the additional numbers of refugees. resilient health systems have the ability to tap in to excess capacities for an optimal health response during a crisis [25, 53] . lebanon, which had a diverse set of providers also had an oversupply of hospital beds and technology that was used to meet the increased demand during the crisis [2, 54] . an adequate supply of a committed and responsive workforce is a precondition for resilience [25, 53] . in lebanon, the health workforce is well accustomed to crisis situations [55] . this experience ensured a regular supply of health human resources that catered to both refugee and lebanese populations. third, a comprehensive communicable disease response helped combat outbreaks, a major health priority during a refugee crisis [48] . the ebola crisis in west africa has highlighted the importance of epidemiological surveillance as part of an "aware" system in outbreak control [25, 53] . in lebanon, the primary health care department, along with the epidemiological surveillance unit, played an important role in ensuring effective and ongoing surveillance. widespread immunization campaigns, with augmented community engagement activities, were employed in a timely manner and synchronized with regional levels to achieve high coverage rates. effective immunization coverage, coupled with the early warning and response system, allowed for prevention and control of the spread of communicable diseases. fourth, integration of refugee health care within the national health system, made possible by the settlement of refugees within lebanese communities rather than camps, was also an important factor. although this approach may have been problematic for the host communities, it reduced administrative and set-up costs, and enabled more responsive service delivery. it also shifted the burden to several geographic areas in lebanon and to several different players in the lebanese health system. the benefits of the integrated health system approach over the approach, which creates multiple parallel service delivery and financing systems, have been documented in other refugee crises [56] . our findings suggest a resilient response by the lebanese health system to the refugee crisis. despite the limited resources and the turmoil caused by the war in syria, lebanon has been able to cope with an unprecedented influx of refugees, maintain improvements in mortality and morbidity outcomes in the country and achieve the mdg targets. our observations in a real empirical setting lead us to suggest a revised definition of resilience of health systems: "resilience is the capacity of a health system to absorb internal and external shocks, and maintain functional health institutions while sustaining achievements." we believe that this revised definition describes a real life and tested experience of resilience in an unprecedented setting. we identified four major factors that enabled resilience: (i) networking with stakeholders (ii) diversification of the health system that provided for adequate infrastructure and health human resources (iii) a comprehensive communicable disease response and (iv) the integration of refugees into the health system. a question that remains unanswered is the longer-term sustainability of the current response. although, thus far, lebanon has sustained achievements in morbidity and mortality levels, the magnitude and the chronic nature of the crisis continues to pose a threat to the health system. the study has three main strengths. first, to our knowledge, this is the first study to investigate the resilience of a health system during an ongoing major refugee crisis. sec-ond, the use of the input-process-output-outcome model to analyze the data and to categorize the health system resilience has helped to frame the system as a whole, and shed light on the possible contributing factors to achieving resilience. third, the study used multiple sources of information, including the public, private, civil society and humanitarian sectors, to provide a comprehensive view of the lebanese health system. several limitations are also acknowledged. first, the literature lacks a rigorous and scientifically validated method for measuring and proving resilience in health systems. we used a model that included several dimensions of resilience identified from published and gray literature, in addition to health system performance indicators which we considered to be important measures relating to resilience. second, the study was limited by the availability of data on the dispersed refugee population and the ongoing influx of refugees. third, the dynamic nature of the refugee situation means data need to be regularly updated. notwithstanding limitations, however, our study contributes to an area of global importance and helps empirically to illuminate effective response from a health system that has shown resilience in spite of the most severe refugee crisis of recent times experienced anywhere in the world. ministry of public health l. statistical bulletins of the ministry of public health health beyond politics. world health organization eastern mediterranean regional office. lebanon: ministry of public health syria regional response plan -midyear update unchr. regional public health and nutrition strategy for syrian refugees egypt, iraq lebanon crisis response plan 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global burden of disease study p2-347 10 years of polio/afp surveillance in lebanon: 2000-2009 world health organization current health event tuberculosis national tuberculosis program, ministry of public health. tuberculosis treatment outcomes a network based theory of health systems and cycles of well-being building resilient health systems and learning from the ebola crisis. oxford, united kingdom informal politics and inequity of access to health care in lebanon summer 2006 war in lebanon: a lesson in community resilience postemergency health services for refugee and host populations in uganda acknowledgments: this work would have never been possible without the efforts of various dekey: cord-330395-2qoyrqmj authors: huq, samin; biswas, raaj kishore title: covid-19 in bangladesh: data deficiency to delayed decision date: 2020-04-15 journal: journal of global health doi: 10.7189/jogh.10.010342 sha: doc_id: 330395 cord_uid: 2qoyrqmj nan l ower middle-income countries are not heavily presented in global media on covid-19. bangladesh, a densely populated nation, have conducted only 1759 tests in last one month with 9 reported deaths. the decisions of cluster-wise lockdown or social distancing, or even preparing the health system to respond to the pandemic are made without the availability of adequate data. this is fuelling panic in local community and giving an obscure picture in the global data. with major discussions around covid-19 pandemic focused on china, usa and europe, few media reports have acknowledged that it has also silently paved its way into lower middle-income countries. in bangladesh, as per the 5 th of april 2020, only 88 diagnosed cases and 9 deaths have been associated with covid-19 with first case detected on the 8th of march [1] . as of the 1st of april, the number of tests conducted was 1759 since the detection of the first covid-19 case. in a country of 164 million and with 155 898 overseas arrivals between the 8 th of march and the 5 th of april, which included some hard-hit countries such as italy, a total of less than 3000 tests in the first 4 weeks of transmission were likely insufficient to illustrate the viral transmission in bangladesh [1] . although scarcity of test kits and lack of awareness from the general public certainly contributed to the crisis, bangladesh is one of the few countries which had more than two months to prepare for covid-19 crisis. it could have been both aware and prepared, because of its close business ties with china. due to the shortage of test kits, authorities had to set strict eligibility parameters for the test. thus, only those with direct contact with foreign returnees were tested. there was a refusal to consider the possibility of any community transmission, which created confusion. furthermore, there was a rather strong opposition to the development of rapid diagnostic kits on diagnostics attributes such as sensitivity and specificity, without careful consideration on affordability and subsequent accessibility. this problem has contributed to a reduced availability of baseline information on the degree of transmission of covid-19 in bangladesh. the situation forced the government to enforce measures without being able to rely on substantial data. in bangladesh, the covid-19 crisis was therefore a game of "catching up". the government has undertaken measures iteratively, in response to the situational development in the country. it promoted hand hygiene and other protective measures, such as social distancing, airport screening, quarantine wherever necessary, and restricted movement during government holidays [2] . as the final step, the government decided on a nation-wide shutdown, with army deployed to ensure a proper lockdown. the crisis has already started in the form of limited availability of disinfectants and personal protective equipment in the health care facilities. this led to el-covid-19 in bangladesh: data deficiency to delayed decision samin huq 1 , raaj kishore biswas 2 evated perceived risk on covid-19 infection in the hospitals. many facilities are now refusing to admit patients who suffer from other routine complications. lack of testing also limited quarantines of close contacts of the suspected cases. these resulted to country-wide fear and an avalanche of reports on deaths with pneumonia/flu-like symptoms. the fear soon turned to a panic, as some villages or entire local areas were locked down by local authorities over untested possible covid -19 related deaths. the only testing facility during the first 3 weeks of the crisis (the 8 th to the 25 th march) received over 420 629 phone calls to request testing, but was only able to test 0.3% of those who raised a concern over their status [3] . this shows the extent of the burden that the authorities in bangladesh had to deal with. the lack of information fuelled the panic. on the 24 th of march, the government extended testing to multiple facilities following a supply of 40 500 test kits from china. however, the rush towards testing in absence of a careful planning within these facilities for sample collection and diagnosis created more confusion. this is because some facilities with test kits did not have laboratories with biosafety level 2 or no trained personnel who could adhere to a standardized protocol [4] . the crisis worsened with increases in prices due to shortages of essential items. such a scenario can result in limited affordability in a capitalistic economy, where families are dependent upon the single-wage earners. in the era of free-flowing online information, "discoveries" based on weak evidence and related comments had a massive influence on the decision making at the individual level. this led to, for example, overstocking of medications such as hydroxychloroquine and azithromycin, which created an artificial scarcity. partial lockdown aimed at social distancing may allow virus containment for a period of time [5] . however, it comes at a cost as resource-intensive and demands meticulous contact testing. furthermore, widespread testing becomes difficult to replicate in a resource-limited health care infrastructure. bangladesh has inequitable distribution of health care workforce concentrated in the major urban areas. this is coupled with one of the lowest availability of health care workforce in the world, with only 7.4 skilled workers per 10 000 population [6] . aligning the situation with the dimension of access by penchasky and thomas [7] , limited availability coupled with reduced accessibility in the peri-urban and rural health care settings may contribute to a health care catastrophe in addressing the control of covid-19. the recent surge of daily testing has managed to uncover more cases and traces of transmission at the community level. despite the surge, the testing rate is too low to uncover the true burden of covid-19 in bangladesh, considering the population size (13 tests per million) [8] . on the other hand, the surge on daily testing has only managed to expose some hotspots which were already known to be the densely populated areas of the capital. therefore, the recent opening of the manufacturing industries, with subsequent closure due to criticism, contributed to migration to the overcrowded areas of the city [9] . such initiatives can lead to a dual burden of risk transmission, to both the rural community and the urban community. this happens at a greater pace, owing to the mass migration of the factory workers. also, decision making based on the current prevalence of covid-19 can undermine the photo: the distribution of positive covid-19 cases across the districts of bangladesh (8 april 2020), data source: https://iedcr.gov.bd/. the lack of data has led to unplanned decision making and contributed to skewing global data. issue of the health system preparedness without a careful understanding of the dynamics of covid-19 evidenced worldwide. it can include premature lifting of restricted movement and sanctions and lower concentration of testing and contact tracing in the rural areas. these can impact not only the health system planning and response in terms of financial input, but also appropriate service delivery and required supply to address the covid-19 due to the changing dynamics of population density in the event of reduced sanctions. additionally, it can lead to a surge on heightened risk of exposure due to minimized health response priorities, efforts and initiatives -such as contact tracing and testing in the rural areas and considering their movement to the urban areas. while pandemics hardly give opportunities to many countries to prepare, developed nations will have the data to at least trace their progress and assess their position on the curve. unfortunately, the curve for bangladesh seems flat with only one case detected in a period of 72 hours (the 28 th to the 30 th march). this could be because either bangladesh is extremely lucky, or this scarcity of databased on appropriate testing now obscures an ominous death toll that is to follow. directorate of health services goverment of bangladesh directorate of health services goverment of bangladesh. daily and monthly call report situation analysis of novel covid-19 feasibility of controlling covid-19 outbreaks by isolation of cases and contacts world health organization. the global health observatory data repository the concept of access: definition and relationship to consumer satisfaction coronavirus cases rmg workers asked to go back from factory gates no funding source to declare.authorship contributions: sh reviewed literature, compiled data and drafted the manuscript. rkb conceptualised the study, coded the map, critically reviewed and revised the manuscript. both authors read and approved the final manuscript. the authors completed the icmje unified competing interest form (available upon request from the corresponding author), and declare no conflicts of interest. key: cord-340663-zylk61ll authors: singh, devendra raj; sunuwar, dev ram; adhikari, bipin; szabo, sylvia; padmadas, sabu s title: the perils of covid-19 in nepal: implications for population health and nutritional status date: 2020-06-17 journal: journal of global health doi: 10.7189/jogh.10.010378 sha: doc_id: 340663 cord_uid: zylk61ll nan c ovid-19, an infectious disease from a highly contagious coronavirus (sars-cov-2), continues to spread rapidly around the globe since its outbreak as an unknown respiratory infections from wuhan city of china in december 2019 [1] . as of may 31, 2020, globally there were more than 6.1 million cases of covid-19 confirmed with a death toll surpassing 371 000. in nepal, over 1400 cases of covid-19 were confirmed with six deaths reported as of may 31, 20 20 [2] . in the absence of an effective antiviral or immunomodulatory treatment for covid-19, current pandemic control and management rely heavily on public health interventions such as social distancing and locking down the cities to prevent further spread [3] . by the end of march 2020 more than 100 countries have decided to implement either partial or full lockdown, thus compelling millions of people to stay at home [4] . nepal implemented full lockdown since march 24, 2020 initially for 12 days [5] , and since then extended for an additional four week period and further until june 14, closely following the epidemiological patterns in and outside nepal, particularly neighboring india. although nepal has already closed down its borders with india and china, transnational migration of workers returning from india and those stranded at the border elevates the risk of disease transmission. there is a growing concern that the long-term extension of lockdown strategy can severely affect the health and nutrition security of the poor and vulnerable population in nepal. nepal continues to be vulnerable to extreme poverty, severe malnutrition, and infections. the country is yet to recover from the adverse impact of the devastating aftermath of the 2015 earthquakes [6] . the current lockdown has already exacerbated the health risks and health care resources, and are likely to continue beyond the covid-19 pandemic. even after the exit from the lockdown, the current global public health crisis will have a long-lasting cataclysmic impact on the lives of the people and societies at national and global levels (figure 1) . the framework provides an illustration of the underlying factors and the potential mitigating interventions for health and nutrition outcomes. we examine how covid-19 lockdown impacts public health systems and nutritional outcomes in nepal. the perils of covid-19 in nepal: implications for population health and nutritional status first, nepal has a high burden of maternal mortality (239 maternal deaths per 100 000 live births) and child mortality (39 deaths per 1000 live births) [7] . these indicators are likely to worsen following the lockdown measures due to challenges in accessing emergency and regular health services. the major public health challenge for nepal is the lack of access to health care against the backdrop of weak and inadequate public health infrastructure [8] . despite the government' s efforts to set up hospitals for treating covid-19 patients, the majority of private health care services have halted their services. this has had a negative impact on health care, severely affecting reproductive, maternal, and child health services and those with chronic health conditions and non-communicable diseases. a recent report from the government source confirmed the death of a 22 year-old female who had postpartum hemorrhage following a home birth but could not seek timely care as the nearest health facility was closed [9] . due to covid-19 and the lockdown, an increasing number of women are giving birth at home, where unsafe delivery methods and unhygienic conditions continue to elevate infection risks and maternal complications, while others are at risk of dying at home due to lack of ambulance and emergency care services [9] . a few patients with co-morbid conditions developing infection symptoms have lost their lives because of tepid response from private hospitals such as declined admissions, negligence, and unnecessary referrals, apparently due to fear of covid-19. also, routine immunization services have been suspended. approximately, three million nepalese children aged nine months to five years have missed their regular vaccination schedules. during this lockdown, an outbreak of measles with 150 cases and two deaths have been reported from a rural region in dhading district [9] . as health systems continue to combat covid-19, nepal is at high risk of facing detrimental effects on (public) health care, further constraining the health resources of the country. second, prolonged exposure to hunger and malnutrition can trigger infections, cognitive-developmental deficit (in young children), behavioral and mental dysfunctions such as stress, suicides, and depression in both minors and adults; and can aggravate chronic conditions such as asthma, obesity, hypertension, diabetes, and hyperlipidemia [10, 11] . the consequences of the covid -19 crisis on mental health are profound among nepalese who are already struggling with the adverse impact of poverty, hunger, and natural disasters. due to the loss of wages, the most vulnerable elderly and children living in poor households are left with no choices but skip their meals and risk chronic health conditions [11] . as the uncertainty associated with covid-19 looms large, an effective health intervention would be to train and devolve responsibility to primary health care providers to provide treatment, referral, follow-up, and mental health counseling, targeting those at high risk including pregnant women, children and elderly. the government has limited capacity and expertise to chart any emergency measures to address these pertinent health issues, as the available resources are fully channeled towards combatting covid-19. prolonged exposure to malnutrition can weaken the immune system, especially during an epidemic outbreak. in nepal, the coexistence of the double burden of malnutrition aggravates covid-19 exposure and can perpetuate the vicious cycle of weakened immunity and infection [12] . historically, nepal has been facing food and nutrition security challenges with the highest prevalence of double and triple burden of malnutrition [13] . the prevalence of stunting, underweight, wasting among under-five children, and anemia among women of reproductive age are already among the highest in nepal when compared to other south asian countries [7] . the covid-19 outbreak may exacerbate the extensive losses related to food production and food supply chain, thus putting the migrant and labor population at risk of hunger and malnutrition. the covid-19 pandemic is evolving at different stages across the countries, and it is difficult to predict when it will be over. a recent report suggested that approximately an additional 130 million people will face starvation due to the covid-19 crisis [12] . national and international stakeholders and government authorities should take urgent actions to ensure food and nutrition security to the population. it is crucial to ensure the availability, accessibility, and affordability of a healthy and nutritious diet in the food system. for example, during the ebola outbreak in guinea, the humanitarian community together with the government ensured household food security, by providing super cereal+ and other commodities including rice, lentils, peas, beans, oil salt, and sugar [14] . ready-to-use therapeutic foods (rutf) for severe acute malnutrition and replacement milk for children who could not be breastfed were also provided [14] . in addition, strict monitoring and regulating food prices are critical. e-commerce and online home delivery systems can be an effective alternative. in rural regions, however, subsistence farming can be encouraged and supported to prevent food shortages. nepal suffers from an unequal distribution of health care services in hard-to-reach rural areas, especially in hill and mountainous regions [15] . most private health care institutions in nepal are urban-centric, and seem reluctant to show any empathy and commitment to people during the current crisis. we urge the government of nepal to enforce legislation to ensure accountability and responsibility of private health care sectors in responding to the current health crisis, and fast-tracking provision of essential medical supplies and human resources. equally important, health systems should ensure critical care interventions to screen, diagnose, and treat covid-19 patients across the country. as the uncertainty associated with covid-19 looms large, an effective health intervention would be to train and devolve responsibility to primary health care providers to provide treatment, referral, follow-up, and mental health counseling, targeting those at high risk including pregnant women, children and elderly. the government of nepal should take urgent steps to continue routine immunization programs and maintain essential maternal and child health care services photo: empty streets of kathmandu city due to nationwide complete lockdown, the capital of nepal (used from the collection of pramod bhattarai photo gallery with permission). covid-19 pandemic, public health preparedness in nepal and one health approach covid-19 coronavirus pandemic. worldometer how will country-based mitigation measures influence the course of the covid-19 epidemic? the world in lockdown in maps and charts. british broadcasting corporation ministy of communication and information technology. notice. government of nepal disaster preparedness and response during political transition in nepal: assessing civil and military roles in the aftermath of the 2015 earthquakes new era; and icf. nepal demographic and health survey tackling antimicrobial resistance in low-income and middle-income countries experts call for equal emphasis on other infectious diseases amid covid-19 crisis food insecurity and mental health status: a global analysis of 149 countries food insecurity is associated with chronic disease among low-income nhanes participants food security information network. 2020 global report on food crises prevalence and factors associated with double and triple burden of malnutrition among mothers and children in nepal: evidence from 2016 nepal demographic and health survey implications of the ebola virus disease outbreak in guinea: qualitative findings to inform future health and nutrition-related responses correspondence to: devendra raj singh msc, health promotion and public health ma the authors thank pramod bhattarai for providing photograph for this work. the authors received no specific funding for this work.authorship contributions: drsi and drsu conceived the idea. all authors contributed to writing, review, and editing the manuscript. all authors read and approved the final manuscript. the authors completed the icmje unified competing interest form (available upon request from the corresponding author), and declare no conflicts of interest. key: cord-351384-z6t7csg8 authors: montesó-curto, pilar; sánchez-montesó, laura; maramao, fabio stefano; toussaint, loren title: coping with the covid-19 pandemic in italy and spain: lessons in response urgency date: 2020-07-28 journal: journal of global health doi: 10.7189/jogh.10.020326 sha: doc_id: 351384 cord_uid: z6t7csg8 nan in italy, on friday, february 21, 2020, the first cases of infection were reported in the province of lodi, 45 km from milan. codogno, a town of 15 000 inhabitants, placed the so-called "patient 1" of italy, a 38-year-old male, on the world covid-19 map [1] . until that moment the coronavirus was geographically distant. within just 24 hours a "red zone" was established isolating 10 villages. a penal sanction of up to 12 years in prison was established for anyone who violated the isolation. in a little more than two weeks, the mayor of codogno, francesco passarini, showed his satisfaction because there were no infections [2] . nevertheless, on february 23, the italian prime minister giuseppe conte signed a ministerial decree with the "confinement" measures for the regions of lombardy and veneto [2]. on saturday, march 7, [3] , a ministerial decree was approved by which the whole country was in a "red zone," an area that was quarantined and had strict social distancing rules. a rumor about the decree having been leaked 3 or 4 hours before the official announcement allowed thousands of inhabitants of the affected area in the north of the country, especially lombardy, to hastily return to their homes in other areas of the country with the risk of spreading the epidemic. for giuseppe conte, italy was experiencing the most serious crisis since the second world war [1]. march 4, italy closed all universities of all grades and majors and began teaching over the internet [3] . it took the italian government just two weeks to react firmly with the laws enacted on march 7 to establish a "red zone" throughout the country, which is when it closed all shops, except pharmacies and food stores, and banned entry and exit from the country. on march 9, italian citizens were banned from leaving their homes except for a justified reason. the ministry issued a document to be carried by each citizen to justify any departures. on march 10 all but the most basic services such as hospitals, food stores, banks, kiosks and tobacconists were closed [3] . indeed, italy had already recorded 69 176 cases and 6820 deaths as of march 25, and it had become the european focus of the outbreak [4] . an overview of the timeline of events in italy can be found in figure 1 , panel a. coping with the covid-19 pandemic in italy and spain: lessons in response urgency pilar montesó-curto 1 , laura sánchez-montesó 2 , fabio stefano maramao 2 , loren toussaint 3 both the language and the response to the pandemic were more direct and forceful in italy, as they perceived the focus of northern italy as a great threat. spain documented its first case of covid-19 on january 31, 2020. however, it wasn't until march 12 that spain took significant action. in fact, not quite one week prior, madrid hosted the "8th international women's day" which italian professor walter ricciardi, a who executive and advisor to the comte government, described as madness due to italy's previous experience [1]. on march 12, the catalan government, chaired by torra, ordered the closure of educational centers to stop the coronavirus epidemic. at the same time, the president of the catalan government asked for more measures, as those already taken seemed insufficient to him. at that time, 316 positive cases of covid-19 had been reported. all educational centers were closed, including universities, where teaching would be provided virtually, as well as civic centers and meeting centers for retired people, and also toy libraries. on march 13, by order of the catalan ministry of health, bars, restaurants, and all commercial spaces that are not necessities (ie, not dedicated to the sale of food) were ordered closed. also the ski slopes, gyms, and entertainment venues such as discos were ordered closed. to contain the pandemic. then, on march 13, the government of catalonia decreed the "confinement" of several municipalities due to a cluster within the epidemic that caused an exponential increase in cases of covid-19 in igualada, vilanova del camí, santa margarida de montbui i òdena [5] . the departure of people who were not permanent residents in these affected municipalities was restricted. the march 14 decree arrived late, the measures were announced on friday, march 13, they were approved on saturday, march 14, so many citizens "escaped" in search of other homes and villages of origin. a "state of emergency" in spain was finally declared through a royal decree (463/2020) [6] on march 14 for a period of 15 calendar days. to carry out all the measures involved, it required a high degree of coordination in all its health policies, since 17 very diverse regions were included. the "state of emergency" was declared by the spanish government appealing to the unity of the spanish state affirming the harshness and difficulty that would be required to stop the spread of covid-19. to this end, it announced the mobilization of "all the resources" of the state, public, private, civil, and military entities. article 116.2 of the constitution empowered the government to apply this measure, using a decree agreed upon by the council of ministers, and for a maximum period of 15 days. on march 14, all face-to-face educational activities were suspended, leaving the home was allowed only for the purchase of basic necessities and work in activities declared essential. for the approval of the extension of the "state of emergency", the state needs the authorization of the congress of deputies. for this reason, on march 22, sánchez met with the presidents of the autonomous communities or regions by video conference. he was accompanied by the three ministers who formed the delegated authority in this crisis; the head of health, salvador illa, the head of defence, margarita robles, and the head of the grande-marlaska interior and transport and mobility and urban agenda, josé luís ábalos [7] . as of april 4, spain was the second country in the world in infected people after the usa and the second in deaths after italy with 11 744 deaths [1]. with a total of 809 deaths recorded on april 3, spain recorded the lowest number of deaths per day for a week. the president of the government sánchez called pablo casado, leader of the opposition, to inform him rhetoric surrounding the pandemic has been important in each countries response. recognizing the threat and talking about it very realistic, grounding ways can be a key motivator for stimulating behavioral change that promotes health, decreases infectious spread, and limits peak demands within healthcare. of his intention to extend "the state of emergency" from april 11. an overview of the timeline of events in spain can be found in figure 1, panel b . spain and italy have had two different responses to the same crisis. the spanish government' s response has been considered late by many [1] . in contrast to the direct, swift, and decisive action taken by the italian government, the response in spain was much more protracted. however, in the catalan region of spain the catalan government attempted to implement policies before the royal decree by the government of spain chaired by pedro sánchez (463/2020) [6] to curb the spread of covid-19. as of march 26, 2020, spain had 56 188 cases of covid-19, the fourth highest number in the world, and 4089 deaths, the second highest in the world. the spanish government held a plenary session in congress on march 25 to address the covid-19 crisis. the aim was to extend "the state of emergency" for an additional 15 days [8] . meanwhile, italy, which was ahead of spain at the time of infection with covid-19 and with the harshness of its policies in the face of the great impact of northern italy, proposed a "confinement." this confinement period was longer than the 15 days of the quarantine ordered in spain, until may 2 and then a progressive return to normal life little by little from may 16 [9] . the united states, which entered the covid-19 pandemic later, claimed that new york was experiencing a "near-war atmosphere." also trump recognized that "this is not a flu, this is ruthless. we are going to have a very hard two weeks. it is going to be painful, very painful for two weeks" [10] . did the united states learn lessons about message framing and urgency of response? perhaps, but were those lessons learned too late? the usa had the dubious distinction of leading the world in infections as of april 6, 2020, and continues to lead the world in cases at present. italy' s rhetoric was much more direct and discomforting and focused on "war" and that they must find the "ammunition," that is, the resources to resolve it. in short, italy used metaphors that reflect the danger detected and the necessary ways of managing the pandemic. other countries should understand that the language that defines their policies is related to the actions that accompany them. governments should be attentive to their rhetoric and metaphors and learn from previous experiences. response urgency is crucial and should be reflected in government response and discourse. el mapa del coronavirus: más de 419.000 casos y más de 18.700 muertos en 186 países. [the coronavirus map: over 419,000 cases and over 18 el govern decreta el confinament dels municipis d'igualada, vilanova del camí, santa margarida de montbui i òdena. [the government establishes the confinement of the municipalities of igualada the resilience of the spanish health system against the covid-19 pandemic el congreso debatirá el 25 de marzo si se prorroga el estado de alarma sánchez llamará a casado para informarle de la prórroga del estado de alarma coronavirus en italia hoy 4 abril: 119.827 casos de covid-19. el plural el coronavirus provocará entre 100.000 y 240.000 muertes en ee uu, según las proyecciones de la casa blanca. el país the authors completed the icmje unified competing interest form (available upon request from the corresponding author), and declare no conflicts of interest. pilar montesó-curto avda remolins 13-15 43500, tortosa spain mariapilar.monteso@urv.cat key: cord-286958-e1ey31eo authors: patel, urvish; malik, preeti; mehta, deep; shah, dhaivat; kelkar, raveena; pinto, candida; suprun, maria; dhamoon, mandip; hennig, nils; sacks, henry title: early epidemiological indicators, outcomes, and interventions of covid-19 pandemic: a systematic review date: 2020-08-15 journal: journal of global health doi: 10.7189/jogh.10.020506 sha: doc_id: 286958 cord_uid: e1ey31eo background: coronavirus disease-2019 (covid-19), a pandemic that brought the whole world to a standstill, has led to financial and health care burden. we aimed to evaluate epidemiological characteristics, needs of resources, outcomes, and global burden of the disease. methods: systematic review was performed searching pubmed from december 1, 2019, to march 25, 2020, for full-text observational studies that described epidemiological characteristics, following moose protocol. global data were collected from the jhu-corona virus resource center, who-covid-2019 situation reports, kff.org, and worldometers.info until march 31, 2020. the prevalence percentages were calculated. the global data were plotted in excel to calculate case fatality rate (cfr), predicted cfr, covid-19 specific mortality rate, and doubling time for cases and deaths. cfr was predicted using pearson correlation, regression models, and coefficient of determination. results: from 21 studies of 2747 patients, 8.4% of patients died, 20.4% recovered, 15.4% were admitted to icu and 14.9% required ventilation. covid-19 was more prevalent in patients with hypertension (19.3%), smoking (11.3%), diabetes mellitus (10%), and cardiovascular diseases (7.4%). common complications were pneumonia (82%), cardiac complications (26.4%), acute respiratory distress syndrome (15.7%), secondary infection (11.2%), and septic shock (4.3%). though cfr and covid-19 specific death rates are dynamic, they were consistently high for italy, spain, and iran. polynomial growth models were best fit for all countries for predicting cfr. though many interventions have been implemented, stern measures like nationwide lockdown and school closure occurred after very high infection rates (>10cases per 100 000population) prevailed. given the trend of government measures and decline of new cases in china and south korea, most countries will reach the peak between april 1-20, if interventions are followed. conclusions: a collective approach undertaken by a responsible government, wise strategy implementation and a receptive population may help contain the spread of covid-19 outbreak. close monitoring of predictive models of such indicators in the highly affected countries would help to evaluate the potential fatality if the second wave of pandemic occurs. the future studies should be focused on identifying accurate indicators to mitigate the effect of underestimation or overestimation of covid-19 burden. viewpoints research theme 1: there are 935 197 confirmed cases worldwide with 47 192 (5.04%) deaths and 193 989 (20.7%) recovered cases [2] . new york is the current epicenter of covid-19 (102 863 cases and 2935 deaths) of united states of america (usa) (215 003 cases, 5102 (2.37%) deaths and 8878 (4.13%) recovered patients) while italy (13 155 deaths) and spain (10 003 deaths) being worst affected countries [2, 3] . globally, the epidemiological scenario of covid-19 is changing on a daily basis. the origin of severe acute respiratory syndrome coronavirus (sars-cov-2) virus was linked to a seafood market in wuhan from the handling and close contact with animals [4] . in usa, the first case was reported on january 20, 2020, with a recent travel history to wuhan [5] . according to emerging literature, covid-19 symptoms can range from mild respiratory illness causing fever, dry cough, dyspnea, myalgia and fatigue to more severe manifestation of pneumonia, cardiac complications requiring intensive care unit (icu) admission and mechanical ventilation [6] . the median incubation period is around 5 days (range:2-14 days), requiring prolonged monitoring in extreme cases [7, 8] . real-time reverse transcriptase polymerase chain reaction (rt-pcr) of nasopharyngeal and/or oropharyngeal swabs are usually used to confirm the diagnosis [9, 10] . preliminary demographic data of the infected patients suggests that most patients have mild disease, with older adults (≥65 years) appearing to be more susceptible to severe illness requiring hospitalization [11, 12] . covid-19 shows evidence of human to human transmission via respiratory droplets and from contact with contaminated surfaces or objects, with estimated median basic reproduction number (r0) of 2.28 (range: 2.06-2.52) [13] , making the spread of the disease tough to contain. while recently published observational studies have provided insights on the epidemiology of this pandemic, their sample sizes are too limited for any definitive conclusions. hence, we sought to conduct a systematic review and analysis of all available studies comparing outcomes. primary aim of the study is to evaluate the epidemiological characteristics, needs of resources, and patients' outcomes. secondary aim is to evaluate the global burden and interventions. we evaluated epidemiological characteristics, risk factors, laboratory and imaging findings, complications and treatment utilized. we also calculated the mortality, recovery, and needs of resources like icu beds and mechanical ventilators. in order to evaluate the primary outcome, we performed a systematic review of these observational studies according to moose guidelines [13, 14] . we searched the pubmed database for original observational studies that described any details on epidemiological characteristics on patients with covid-19. the database was searched from december 1, 2019, to march 25, 2020 . the search was conducted using the following keyword/mesh terms: ((covid-19[title/abstract]) or coronavirus [title/abstract]) or sars-cov-2 [title/abstract] or 2019-ncov [title/abstract]. all studies that compared outcomes of interest in covid-19 patients were included. any literature other than observational studies was excluded. non-english literature, non-full text, and animal studies were excluded. abstracts were reviewed, and articles were retrieved accordingly. two independent reviewers performed the search and literature screening (up, pm), with disputes resolved by consensus following discussion with a third author (cp). for the ease of understanding, we used a flow diagram to describe literature search and study selection process in figure s1 in the online supplementary document. a prespecified data collection excel sheet was used to collect the data relating to study characteristics and outcomes of interest by two authors (pm and cp), and discrepancies were solved by a discussion with a third author (up). the following study characteristics were extracted: publication year, country of origin, sample size, age, sex, direct exposure to infection, travel history, signs and symptoms, risk factors and comorbidities, laboratory and radiology findings, treatment utilized, and complications. data on the following outcomes were extracted: mortality, recovery, need for icu beds and mechanical ventilators. viewpoints research theme 1: covid-19 pandemic all analysis was done in excel (microsoft inc, seattle wa, usa) and sas 9.4 (sas institute, cary, nc, usa). the frequencies and percentages of epidemiological characteristics and outcomes were calculated. we evaluated the global burden of covid-19 including case fatality rates (cfr), strength of association between deaths and cases to predict cfr, case doubling time, covid-19 specific mortality rates, and control measures by governments to prevent spread among usa, china, italy, iran, spain, germany, india, and south korea. for this purpose, data were taken from the johns hopkins university corona-virus resource center [3] , kff.org [14] , world health organization-covid-2019 situation reports [15] , and worldometers.info [2] up until march 31, 2020. we evaluated changes in cases and deaths, cfr, created a predictive modeling for cfr, covid-19 specific mortality rate, and doubling time for cases and deaths. cfr was defined as the number of cases divided by the number of the diagnosed patients with covid-19, and covid-19 specific mortality rate was defined by deaths due to covid-19 infections divided by total population of the country in 2020, counted per 100 000 population [16] pearson correlation coefficient (r) was obtained to establish the strength of association between deaths and cases for individual countries. to predict cfr, we modelled the epidemic curves with simple linear regression, exponential growth, and polynomial growth models and used a coefficient of determination (r 2 ) for model selection. the time of reporting the first death was used as the starting point for that country for all three models. we utilized government websites, national media, and other standard open sources to evaluate the governments' interventions during covid-19 pandemic, infection rate [(diagnosed cases/country' s population in 2020) per 100 000 population] [16] at the time of interventions like nationwide school closure and lockdown, and effects of such measures to predict the dates of peak number of cases in each country. our search resulted in 1956 studies, out of which 1688 non-human studies and other than observational studies, 64 non-full text and articles with non-english language information were excluded. 224 full-text studies were screened and 45 studies with insufficient clinical information or outcomes-related information were excluded. 166 full-text articles were assessed for eligibility. the final analysis included 21 fulltext observational studies, presented in table 1 , including a total of 2747 patients. [19] china jan 23, 2020 -feb 5, 2020 19 0 0 young, mar 2020 [20] singapore jan 23, 2020 -feb 3, 2020 18 -0 chang, feb 2020 [21] china jan 16, 2020 -jan 29, 2020 13 13 0 wang, feb 2020 [22] china jan 1, 2020 -jan 28, 2020 138 47 6 ng, mar 2020 [23] singapore jan 2, 2020 -feb 29, 2020 100 -0 spiteri, mar 2020 [24] europe jan 24, 2020 -feb 21, 2020 38 -1 covid-19 national incident room surveillance team, mar 2020 [25] australia 7 mar 2020 71 22 2 xu, feb 2020 [26] china jan 10, 2020 -jan 26, 2020. 62 -0 bajema, feb 2020 [27] usa jan 20, 2020 11 --ki, feb 2020 [28] south korea jan 20, 2020 28 --chen, jan 2020 [29] china jan 1, 2020 -jan 20, 2020 99 31 11 zhang, feb 2020 [30] china jan 16, 2020 -feb 3, 2020 140 --yang, feb 2020 [31] china figure s2 in the online supplementary document. several models, including a simple linear regression, exponential and polynomial (quadratic) growth models, were used to determine the type of association between cumulative deaths and cumulative cases to predict cfr ( table 3) . the polynomial growth model had the best fit (higher r 2 ) and indicates that for all countries the death rate increases with the number of cases, and this increase is steeper than a linear relationship. interestingly, while for the usa, italy, iran, spain, and india this association is always positive, for china, south korea, and germany the initial slope is negative but then is reversed as the number of cases continues to increase (figure 1 ). figure s3a in the online supplementary document). the daily covid-19 specific death rate is highest in spain (daily 1.6 deaths per 100 000 population) and italy (daily 1.38 deaths per 100 000 population) followed by usa (daily 0.27 deaths per 100 000 population) ( figure s3b in the online supplementary document). the county-specific timeline of doubling time for cases and deaths is shown in table 4 and the increment in cases and deaths are plotted in (figure 4 in the online supplementary document). 20 march barred entry of foreign nationals who had been to 28 european countries within last 14 days [46] 22 march nationwide schools closed [47] , lockdown in new york [45] 27 march a us$ 2 trillion coronavirus stimulus bill was passed and signed by the president [48] 30 march more than half of us states underwent lockdown [45] china: 22 january response to public health emergency launched by hubei [49] 23 january the central government of china imposed a lockdown in wuhan and other cities in hubei province; public transport suspended. the wuhan airport, railway stations and metro were closed, not allowing residents to leave the city without permission [50] ; public health emergency response announced by mainland province of zhejiang [51] 29 january mainland china has initiated public health emergency response [52] ; quarantined whole hubei province [53] ; curfew laws implemented in huanggang,wenzhou and other mainland cities [54] south korea: an unlicensed covid-19 test authorized by the korea centers for disease control and prevention (cdc) [55] ; travel denied to foreign nationals from hubei province into south korea [56] 23 february all kindergartens, elementary schools, middle schools, and high schools were announced to delay the semester start [57] 26 february entire country opened drive-through testing [58] italy: 31 january state of emergency declared, flights to and from china suspended [59] 22 february the council of ministers announced a new decree-law to quarantining more than 50 000 people from 11 different municipalities in northern italy [60] 4 march nationwide schools and universities closed [61] 10 march prime minister imposed nationwide quarantine lockdown [62] 11 march all commercial activities except pharmacies and supermarkets ordered to shut down [63] ; €25billion allocated by the government [64] 1 april drive-through testing began [65] iran: all concerts and other cultural events cancelled for one week by ministry of islamic culture and guidance [66] ; closure of educational institutions in several cities and provinces announced by the ministry of health and medical education [67] 5 march checkpoints placed between cities to limit travel [68] 16 march fatima masumeh shrine, jamkaran mosque in qom city, and imam reza shrine in mashhad closed [69] viewpoints research theme 1: germany: new health security measures enacted to regulate air and sea travel that required passengers from china, south korea, japan, italy and iran to report their health status before entry [70] ; federal police stepped up checks within 30 km of the border [70] 16 march bavaria declared a state of emergency for 14 days and measures to limit public movement and additional funds for medicine supplies were introduced [71] ; all flights from iran and china stopped by german ministry of transport [72] ; travelling in coaches, attending religious meetings, visiting playgrounds or engaging in tourism prohibited [73] 17 finance minister announced us$24 billion stimulus package [88] infection rate at the beginning of the major intervention (nationwide closure of school or major table 6 mentions the predicted dates of the peak number of cases based on strict interventions. in china and south korea, it took 16-21 days and 11-14 days respectively in order to achieve the peak of the pandemic before the new number of cases began to decline. we have used a 16-21 days post-interventional model to calculate the peak of the pandemic keeping in mind the effect of china' s model of interventions. covid-19 has significantly impacted the entire world both socially and economically. the rapid human-to-human transmission has posed a great public health threat. across 21 studies included in this review, we found 2747 confirmed cases of covid-19 with the majority of the published studies from china. 47% of the cases had a history of direct exposure or being exposed to the seafood market in wuhan, 44% were china residents and 24% had a travel history to china. initially the virus was limited to only wuhan and despite travel restriction, the virus continued to spread across the world at a rapid rate from china, likely due to asymptomatic transmission in the initial stages of the outbreak with a median incubation period of only 5 days [7, 17] , before travel restrictions. the covid-19 cases are increasing exponentially but underestimated due to mild symptoms in a portion of cases, long incubation periods, and shortage of testing kits. in concurrence with other studies [18, 29] , we found that clinical characteristics of covid-19 are similar to those of sars and influenza virus. fever (91%), cough (68%) and myalgia or fatigue (48%) were the most prominent symptoms. 24% of patients reported dyspnea and sputum production/expectoration. major comorbidities were hypertension, smoking, diabetes mellitus, and cardiovascular disease. patients with these comorbidities are at high risk for complications including pneumonia, ards and cardiovascular complications. we found that patients had increased inflammatory markers including elevated crp in 50%, lymphopenia in 36% and elevated esr in 25% which is similar to other respiratory infections (sars, influenza). few studies [18, 91] , have reported abnormal liver function in covid-19 patients, and we found 20% of patients had elevated alt and ast. additionally, increased ldh (42%), d-dimer(29%) may indicate the severity of the disease [92] . some studies have also reported elevated neutrophil count and cytokine storm induced by virus leading to coagulation activation and sustained inflammatory response [22] associated with higher mortality [29] . there is no proven therapy available as of now for covid19 [95] . large scale clinical trials for these drugs are under way. 50% patients received oxygen and antibiotics (69%), antivirals (49%) and steroids (26%) as supportive therapies. the prognosis of patients after receiving these treatments is not yet clear. in people with compromised immune systems such as older age, hiv, malignancy, diabetes, chronic pulmonary disease if treated promptly with antibiotics, convalescent plasma to increase the immune support might reduce the risk of complications and mortality [96] . in our analysis, 15% of the patients required icu admission, 15% needed mechanical ventilation, 8% died and 20% recovered and were discharged from the hospital. these findings are consistent with guan et al. and wang et al that present similar rates [11, 22] . currently in the usa, covid-19 is in the acceleration phase surpassing china and italy, and a national emergency was declared by the president, but the viewpoints research theme 1: duration and severity may vary depending on the virus characteristics and public health response [97] . if confirmed cases continue to grow with this trend, soon the covid-19 pandemic will cause shortages of ventilators. as per institute for health metrics and evaluation (ihme) projections, on a peak day in the usa, there would be a shortage of icu beds by 19 863 and a need of 31 782 ventilators [98] . the growing number of cases will place a burden on the current capacity of hospitals and hence it is essential to develop and implement strategies to mitigate the gap by increasing capacity and fair allocation of available resources. as of march 31, cfr in italy was 11.75% and 4.01% in china. according to onder et al. [99] , cfr stratification by age, shows similar rates for 0-60 years (0%-3.6%) but higher in >70 years(8%-20.2%). this difference might be due to high cfr reported in people >90 years in italy and no data from china for the same age group [99] . other reasons might be demographics differences between two countries (≥65 years population: italy-22.8% vs china-10.9%), overwhelming health care system, and shortage of icu beds and ventilators, which might lead to prioritizing treatment to younger and otherwise healthy patients over older patient [100] . in our analysis cfr in italy increased from 1.94% on february 23 to 8.57% on march 20, possibly due to the implementation of a strict policy of testing only suspected cases with severe symptoms [99] . though widespread and drive-through testing is becoming more available in usa, cumulative tests conducted per million population lags behind compared to germany, italy, south korea, and spain. our data driven polynomial growth model predicts more deaths in future with an increase in cases in usa [98] , italy, iran, spain, and india. as per our model predictions, doubling time of cases in the usa, germany and india is decreasing suggesting that they are inching towards the peak. different countries undertook interventions at different points in the timeline of spread of virus. the infection rates in the usa, italy, iran, spain, and germany were higher when they undertook substantial measures compared to china, south korea, and india, suggesting a delayed response and failure to undertake timely measures. the aforementioned timelines for peaks look optimistic because multiple other factors may influence the trajectory of spread, ie, population density, economy, demographics, health care, religious beliefs, and legislation. for instance, despite the growing number of cases, iran continued to keep its shrines open to pilgrims for a long time, but recently closed them, and no stringent curfew laws were imposed. also, many states in usa have still not implemented strict quarantine measures. such practices can seriously impede the efforts at containing the spread and skew the projection in many ways. restrictions have neither been homogeneously imposed nor simultaneously adopted throughout the country, making it difficult to predict the exact model of the spread. also, covid-19 testing capacity of the nations are limited and the true number of the infected people might have been higher than the estimated numbers at the time of our analysis. hence, an early phase covid-19 specific death rate would be a better estimate than cfr to compare the severity of the disease. many factors contribute to the accurate estimation of cfr such as testing capacity, care seeking and lack of understanding of the proportion of asymptomatic and pre symptomatic cases [101, 102] . limited knowledge of these factors in the early covid-19 phase might have contributed to overestimation of cfr in our study. the use of serological testing for presence of igm or igg antibodies against sars-cov-2 will provide a better estimate of cumulative prevalence of covid 19 infection [103] . as recommended by who, measuring the seroprevalence of antibodies to covid-19 is crucial and will contribute to determine accurate cfr and help plan adequate public health response [104] . the research on covid-19 is rapidly evolving and new publications are becoming available daily. the majority of the epidemiologic data are coming from single center with limited sample sizes. to overcome this limitation and provide a global view of the covid-19 pandemic, we have analyzed data on over 2500 patients from 21 peer-reviewed studies. as a result, we provided more generalizable estimates of laboratory findings, clinical symptoms and complications of covid-19 patients. we have included data from several countries/regions; however, one limitation is that the majority of cohorts are from china, and as more data from other countries become available, additional meta-analyses would be essential. this is the first study rigorously tracking the timing of government interventions across multiple countries; however, as mentioned earlier, the adherence to those interventions could vary from one country to another, making the projections of the potential effectiveness challenging. we have not evaluated the duration of strict interventions in all these countries. the population prevalence data are based on the symptomatic patients with confirmed rt-pcr testing. since some patients can be infected and present mild or no symptoms, or have not undergone rt-pcr testing, serological antibody testing in the future may allow a viewpoints research theme 1: covid-19 pandemic more accurate understanding of the disease prevalence and death rates. despite all the limitations, this is the first study in our knowledge, highlighting and explaining epidemiological indicators, testing capacity, interventions, and expected burden of the covid 19 at early phase. we have reviewed the burden of this pandemic and steps taken by the governments of different countries. though the governments can continue strict lockdowns, it is not a long-term solution. good hand hygiene, widespread testing, detection and isolation of new cases, rigorous contact tracing in low-prevalence settings, early vaccine development and its quick distribution, strengthening the overburdened health care system, and protecting frontline health care workers may help to gradually relax the strict lockdowns and cope with covid-19 pandemic. this would only be possible by a collective approach undertaken by responsible governments, wise strategy implementation, and receptive populations. the future studies should be focused on identifying accurate indicators to mitigate the effect of underestimation or overestimation of covid-19 burden. close monitoring of such indicators in highly affected countries is very crucial to evaluate the potential fatality if the second wave of pandemic occurs. who director-general' s opening remarks at the media briefing on covid-19 -11 coronavirus covid-19 global cases by the center for systems science and engineering (csse) at johns hopkins university. 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mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study statement from the press secretary regarding the president' s coronavirus task force trump declares coronavirus a public health emergency and restricts travel from china trump signs emergency coronavirus package, injecting $8.3 billion into efforts to fight the outbreak trump administration announces measures to speed coronavirus testing here' s what trump' s coronavirus emergency declaration does new york launches drive-thru testing site for covid-19 see which states and cities have told residents to stay at home dhs notice of arrival restrictions on china, iran and certain countries of europe map: coronavirus and school closures. 2020 house passes $2 trillion coronavirus stimulus bill, which includes direct payments to americans and business loans notice of the people ' s government of hubei province on strengthening the prevention and control of pneumonia infected by new coronavirus china coronavirus: lockdown measures rise across hubei province zhejiang: 17 newly diagnosed cases of new coronavirus infection and pneumonia were launched, and the first-level response to major public health emergencies was initiated all 31 provinces in mainland china have initiated first-level response to public health emergencies xiangyang railway station is closed, and the last prefecture-level city "hubei" in hubei province ningbo have implemented the most restrictive order south korea learned its successful covid-19 strategy from a previous coronavirus outbreak: mers korea bars foreigners traveling from hubei province s ministry of education opening on march 9 south korea pioneers coronavirus drive-through testing station italy suspends all china flights as coronavirus cases confirmed in rome ten lombard municipalities: 50 thousand people forced to stay at home. quarantine at the milanese hospital in baggio. 2020 italy orders closure of all schools and universities due to coronavirus italy extends emergency measures nationwide merkel warns virus could infect two-thirds of germany coronavirus emergency, the government' s plan rises to 25 billion. gualtieri to the eu: 'stimulus is needed'. 2020 we will make 300 a day long holiday' to contain coronavirus, as sixth victim dies coronavirus: iran limits travel and urges banknote avoidance. 2020 shiite hardliners in iran storm 2 shrines that were closed to stop coronavirus spread germany enacts new health security measures against coronavirus infections these rules apply in bavaria. 2020 germany halts flights from iran and china over coronavirus: bild. 2020 deutschland im shutdown-modus -die alternativlos-kanzlerin kehrt zurück. 2020 bayern impose curfew! 2020 contact bans on more than two people, hairdressers too -the federal and state governments have agreed on this spain prohibits all direct flights from italy until the community of madrid decrees the mandatory closure of bars, restaurants and clubs until spain to 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protocol for coronavirus 2019 (covid-19) infection key: cord-309377-5pusd2pc authors: tran, thi phuong thao; le, thanh ha; nguyen, thi ngoc phuong; hoang, van minh title: rapid response to the covid-19 pandemic: vietnam government’s experience and preliminary success date: 2020-07-28 journal: journal of global health doi: 10.7189/jogh.10.020502 sha: doc_id: 309377 cord_uid: 5pusd2pc background: the covid-19 pandemic has hit all corners of the world, challenging governments to act promptly in controlling the spread of the pandemic. due to limited resources and inferior technological capacities, developing countries including vietnam have faced many challenges in combating the pandemic. since the first cases were detected on 23 january 2020, vietnam has undergone a 3-month fierce battle to control the outbreak with stringent measures from the government to mitigate the adverse impacts. in this study, we aim to give insights into the vietnamese government’s progress during the first three months of the outbreak. additionally, we relatively compare vietnam’s response with that of other southeast asia countries to deliver a clear and comprehensive view on disease control strategies. methods: the data on the number of covid-19 confirmed and recovered cases in vietnam was obtained from the dashboard for covid-19 statistics of the ministry of health (https://ncov.vncdc.gov.vn/). the review on vietnam’s country-level responses was conducted by searching for relevant government documents issued on the online database ‘vietnam laws repository’ (https://thuvienphapluat.vn/en/index.aspx), with the grey literature on google and relevant official websites. a stringency index of government policies and the countries’ respective numbers of confirmed cases of nine southeast asian countries were adapted from the oxford covid-19 government response tracker (https://www.bsg.ox.ac.uk/research/research-projects/coronavirus-government-response-tracker). all data was updated as of 24 april 2020. results: preliminary positive results have been achieved given that the nation confirmed no new community-transmitted cases since 16 april and zero covid-19 – related deaths throughout the 3-month pandemic period. to date, the pandemic has been successfully controlled thanks to the vietnamese government’s prompt, proactive and decisive responses including mobilization of the health care systems, security forces, economic policies, along with a creative and effective communication campaign corresponding with crucial milestones of the epidemic’s progression. conclusions: vietnam could be one of the role models in pandemic control for low-resource settings. as the pandemic is still ongoing in an unpredictable trajectory, disease control measures should continue to be put in place in the foreseeable short term. the covid-19 outbreak which originated from wuhan city, china has widely expanded to 211 countries and had been declared as a public health emergency by the world health organization. as of 24 april, the total number of confirmed cases and deaths with covid-19 globally was 2.626.321 and the review on vietnam' s country-level responses was conducted by searching for relevant documents issued by the government on the online database 'vietnam laws repository' (https://thuvienphapluat.vn/ en/index.aspx) [5] . search terms were 'coronavirus' or 'covid-19'. in addition, grey literature on google and relevant official websites were searched. inclusion criteria was documents focusing on national-level regulations in response to the covid-19 pandemic that were published up until 24 april 2020. for the cross-comparison of policies among southeast asian countries (including brunei, laos, indonesia, malaysia, myanmar, philippines, singapore, thailand and vietnam), a stringency index of government policies and the countries' respective numbers of confirmed cases were adapted from the oxford covid-19 government response tracker (https://www.bsg.ox.ac.uk/research/research-projects/coronavirus-government-response-tracker) [6] . the stringency index was calculated based on nine indicators of government' s responses, including school closing, workplace closing, cancellation of public events, restriction on gathering size, public transport closure, "shelter-in-place" and home confinement orders, restriction on domestic/internal movement, restriction on international travel and public information campaign. the stringency index ranged from 0 to 100 in which the higher the score, the stricter the government policies. the stringency index is not intended to measure the appropriateness or effectiveness of a country' s response but rather to provide a stringency indicator of the governments' policies. the data was updated as of 24 april 2020. the daily cumulative number of confirmed cases and recovered cases of covid-19 in vietnam from 23 january to 24 april were entered into excel (microsoft inc, seattle, wa, usa). we downloaded the excel file comprising of the stringency index and the number of confirmed cases for all southeast asian countries from the oxford covid-19 government response tracker. in order to provide an overview of the covid-19 pandemic in vietnam, changes in the cumulative number of confirmed cases, number of recovered cases and stringency index during the 3-month period are illustrated in figure 1 . additionally, fluctuations of stringency indexes of each southeast asian country by increasing confirmed cases were presented to compare policy responses among these nations. all figures were drawn through excel. viewpoints research theme 1: covid-19 pandemic the first 3-month progress of the covid-19 outbreak in vietnam can be temporarily divided into three stages (figure 1) . stage i was from 23 january (the first case detected) to 25 february, during which the number of confirmed cases with covid-19 increased slowly to 16 on 25 february. most of the cases in this stage were people with recorded travels from china. in stage ii, the new cases were initially those identified with traveling histories to south korea and european countries, but later served as the sources of community transmission, ramping up the total number of confirmed cases to 268 on 15 april. in stage iii, only 2 new cases were reported, 225 out of 270 cases (83.3%) had recovered as of 24 april. there were no deaths recorded as of 24 april 2020. vietnam has gained preliminary promising achievements in controlling the covid-19 pandemic given that the nation has maintained a clean record of new covid-19 cases for eight days since 16 april and has had zero deaths for three months straight. these are attributable to the rapid, strong and decisive efforts of the government in the wake of the outbreak. this is a commendable accomplishment, given that vietnam shares a long and bustling border with china -the initial hotspot of the outbreak. however, vietnam may confront further challenges in the upcoming months due to the vast flows of vietnamese citizens returning home from abroad and the number of patients who are tested positive again after being discharged from hospital. vietnamese government's response to the covid-19 pandemic in hindsight, the epidemic is still relatively under control in vietnam thanks to the continued prompt and proactive precautions taken by the government. the stringency index, which simply reflects the strictness in counter-measures, has changed over time to correspond with crucial progression milestones during the three stages of the pandemic. in stage i which marks the initial period of the outbreak, the government took a step-by-step operationalization of intensive regulations to combat the outbreak and this approach continued to be reinforced during the first haft of stage ii. rapid community transmissions of the virus in the second haft of stage ii prompted the government to put in place the strictest counter-measures, resulting in the 15-day national social distancing with the highest level of stringency (scored nearly 100 in stringency index). in the ongoing stage iii as of 24 april, the epidemic has been relatively controlled, enabling social distancing measure relieves ( table 1) . viewpoints research theme 1: [20] . • on 7 march, the health ministry required all arrivals from march 1 to self-isolate at home if they had not been quarantined in a centralized zone in the past 14 d [21] . • on 21 march, vietnam announced a mandatory quarantine for all passengers from all countries and regions upon entry to vietnam. for passengers holding diplomatic or official passports, if he/she was in normal health condition, had no signs of illness and was guaranteed by the embassies or representative offices who ensured the quarantine conditions, he/she may undergo quarantine at the representative office or place of residence for 14 d from the arrival date [22] . • on 1 april, vietnam government enacted the directive no. 16/ct-ttg on implementing strict social distancing rules nationwide for 15 d to prevent the spread of covid-19. the measures included self-isolation and people were only allowed to leave their homes for food and medicines. gathering of more than two people was also banned, together with a must two-meter distance rule between people in public areas. factories, businesses and service establishments producing and providing essential goods were allowed to remain open but must follow strict health guidelines [23] . • on 13 april, authorities ordered people working at a unit of samsung display in bac ninh province to be quarantined and the samsung factory was isolated after a worker was tested positive for covid-19 [24] . • certain localities continued to be locked down to curb the spread of covid-19, such as son loi (vinh phuc), truc bach ( [37] . • on 24 march, the people's committee of hcm city issued a decision to close all non-essential services like beauty clinics, karaoke, massage parlors, bars, entertainment venues in 24 districts, effective immediately [38] . • on 27 march, the government asked religious organizations to cancel religious festivals, entertainment activities and conferences that attract large crowds as a precaution; to suspend all non-essential business; ban on gathering of more than 10 people in outside areas [39] . • until 1 april, in line with the national quarantine, domestic flights were significantly reduced to only one round trip a day between hanoi and hcm city; hanoi and da nang; hcm city and da nang. passenger trains between hanoi and hcm city were also limited to two trips per day. public transport services were suspended while transport from region to region were minimized except for essential services [42] . • also on the same day, the ministry of transport issued the official dispatch no. 3064/bgtvt-vt to prohibit the transportation activities of domestic flights and inter-provincial transport routes, as well as the transportation activities of contract vehicles, tourist cars, taxis, buses in all provinces and cities [43, 44] . stage iii: • on 16 april, the minister of transport issued the official dispatch no. 3655/bgtvt-vt: adjusting the transportation plan accordingly in the three area groups at risk of covid-19 (i high-risk, ii at-risk and iii low-risk). specifically, with provinces in group i and group ii, no inter-provincial passenger transportation would be carried out until 22 april. vietnamese air passenger carriers were expected to resume regular domestic flights but stated that routes and flight frequency might be subject to change [45] . • on 23 april, the social distancing campaign was stopped in 28 cities and provinces and the prime minister implemented more relaxed restrictions than before: both hanoi and hcm city (now classified only as "at risk"), as well as 10 other localities would still have to stop socializing activities, which include all events of over 20 people and gatherings of 10 people or more outside workplaces, schools and hospitals. however, shops, street businesses and non-essential services were allowed to reopen [30]. • on 23 april, the frequency of domestic flights on the hanoi -hcm city route was increased, as well as reopening of other domestic routes with limitation [46, 47] . • from 23 april, several schools were reopened in some provinces [48] . improving capacity of health care systems • on 16 january, moh issued decision no. 125/qd-byt on the first guideline for diagnosis and treatment of coronavirus infection [49] . [63] . • on 18 april, moh launched an online-based medical examination and treatment system to support hospitals in remote areas regarding counseling, consultation, imaging diagnosis, pathology.. [64] . • in addition, moh issued numerous guidelines for quarantine at home, at quarantine zones, at residential areas for the prevention and control of the covid-19 spread [65] [66] [67] ; guidance on prevention and management of covid-19 infection for pregnant women and infants, for the elderly and people with chronic diseases [68, 69] ; recommendations on prevention and control of the covid-19 at apartment buildings, at workplaces, at shopping malls, restaurants… [70] [71] [72] . in the first stage, when the outbreak was only localized in china, on 23 january, the civil aviation authority of vietnam announced instruction no.358/ct-chk regarding a temporary ban of all citizens from wuhan city, the initial epicenter [7] . the ban was later extended to all flights to and from mainland china [9] . having a bustling border and a high volume of trade with china, vietnam was expected to be heavily affected due to the disease' s fast-spreading nature. recognizing the potential high risks of the disease and limited existing resources, the government focused mainly on preventive measures. stringent inspections were strictly implemented at airports and land border checkpoints in the form of tem• people in medical isolation areas including medical centers, concentrated quarantine facilities were given around 80 thousand vnd/d in allowance, and all direct medical fees were covered for vietnamese citizens [88] . other responses • on 24 march, vietnam stopped exporting rice to ensure national food security [89] . • in march, hue hospital invented robots to assist serving patients in quarantine areas [90] . • additionally, penalties of violations of covid-19 prevention and control policies were imposed including not wearing masks in public places, concealing health status, opening non-essential businesses, gathering of more than 10 people, spreading 'fake news' and others [91] . • in march and april, a series of meetings among national senior officers were held to discuss health information and updates, as well as to share experiences on covid-19 prevention, screening, and treatment across asean countries [92] . • vietnam transported 450 000 protective suits and 200 000 face masks to the united states, provided medical supplies valued us$ 100 000 to japan. in addition, 550 000 face masks were donated to european countries and 730 000 to neighboring countries [93] . [20] . all cases with suspicious symptoms were taken in for further diagnosis. on 12 february, vietnam and china governments agreed to ease the cross-border restriction to normalize trade in northern provinces: quang ninh, lai chau, lao cai, lang son, and ha giang [9] . these trade policy changes had to be carefully considered by the government to strive for the ideal balance between economic and public health security. trading activities put firm pressure on health workers in the prevention and treatment of covid-19 in the subsequent disease stages in vietnam. as the pandemic widely spread in deagu, south korea, the second hotspot after china, the entry ban was further applied to travelers coming from severely affected regions in south korea, in addition to a mandatory 14-day isolation for all other incoming korean travelers effective as of 25 february [10] . on 05 march, the civil aviation authority decided to temporarily suspend all flights to south korea [12] . in this period, a series of emergency and successive restrictions were carried out based on the complex evolution of the disease worldwide, particularly the outbreak in european countries [13] . all international flights were temporarily suspended beginning 19 march and there were considerable reductions in the number of domestic flights [14, 43] . besides, all visa issuance were suspended, except for those on official or diplomatic missions. the border closure timeline in vietnam was quite aligned with that of other countries in the southeast asian region, for example thailand (22 march in the first stage, the policy largely focused on preventing the penetration from the epicenter wuhan and china in general. in the second stage being aware of the pandemic danger, the government strictly implemented quarantine measures. on 1 march, citizens who entered the country from epidemic countries (china, korea, italy, iran) have to fill in a health declaration form and follow medical quarantine [20, 21] . the newly confirmed cases were mainly foreigners and vietnamese citizens who returned from european countries or had direct contact with positive patients. therefore, isolation and quarantine precautions were taken to curb the rise of disease transmission. several localities at potential high risks of community transmission in son loi-vinh phuc, truc bach-hanoi and some communities in hai phong, ha loi-me linh were placed in lockdown [25] [26] [27] [28] . bach mai, a leading hospital at central level with more than 5000 health care workers was locked down in late march after one staff was confirmed positive for covid19 [29] . a 15-day nationwide social distancing period began on 1 april led by the principle that "every province and city going into self-isolation" under the directive no.16/ct-ttg. accordingly, everyone -with the exception of essential workers -was required to "shelter in place" and not go out unless for bare necessities such as buying food or drugs [23] . although there were several considerable inconveniences in implementation of social distancing, most vietnamese citizens have complied with the government' s regulation. whereas in the philippines, the use of weapons had to be deployed to force habitants to follow the government' s measures. on 4 april, an unfortunate incident was recorded in the philippines as one protester who refused to follow the restriction orders was shot by the police [3] . back in vietnam, the number of confirmed cases during this period slightly increased, with over 250 cases in early april [2]. on 16 april, following 15 days of national social distancing, the government divided all localities of the country into 'high-risk', 'at-risk', and 'low-risk' zones to impose precautions accordingly. hanoi, ho chi minh city -the two biggest metropolitan cities and 10 other provinces had been implementing strict social distancing measures at least until 22. starting 23 april, most cities and provinces began loosening social distancing requirements to allow more daily routines while still having protective measures in place. under the guideline, hanoi and ho chi minh city were expected to intermittently operate daily services [30] . meanwhile in thailand, the prime minister announced plans to gradually relax restrictions by the end of april owing to the reduction of new confirmed cases. however, in other countries such as singapore, philippines and indonesia, the strict measures continued to be applied until there were clear signs of case decline [3]. the 15-day period had been considered a significant milestone in the prevention of disease transmission in vietnam. although there might have been some undiagnosed cases, it cannot be denied that vietnam' s approach has been well-organized and effectively reduced the speed of transmission. viewpoints research theme 1: shutdown non-essential business, school or workplace closure, suspended transportation in the first stage of the pandemic on 2 february, the ministry of education and training announced the closure of all public and private educational institutions across the country [35] . during this period, even though the outbreak was mainly confined to china, the prompt decision of school closing and banning public crowds had shown the advantages of limiting community transmission, which is in line with many other countries' outcomes [94] . however, the unexpected break has caused students and teachers difficulties in the learning and teaching process. in the meantime, the ministry of education and training was quick to launch innovative distant-learning programs on national television to support students in preparing for their entrance exams [95, 96] . during the second stage, restriction measures regarding public gathering were tightened. a series of government documents issued in mid-march had highlighted the importance of social distancing measures and vietnam' s coping strategies reached a climax of highest stringency levels when the 15-day national social distancing measures took effect on 1 april [23] . the prime objective of the measures was to urgently slow the number of infections or to "flatten the curve" of infection. one of the main priorities was to reduce and cease all non-essential business services, including restaurants, gyms, movie theaters, and religious, sports and cultural gatherings [38] . many companies and agencies had made the rational decision to allow their employees to work from home, which not only reduced the risk of disease transmission, but also maintained the income for employed individuals. in addition, buses and railroad services were suspended both within a province and between provinces [40] . upon entering a new phase with fewer new cases as of 23 april, the ministry of transport allowed the reoperation of domestic flights as well as reopening of essential transport activities in the whole country [44, 97] . in addition, since april 23 most schools were ready to welcome students to return after the long lockdown which had been prolonged since the lunar new year [48] . to make schools a safe environment to learn after an extended period of closure required much considerations from localities, which had different operating policies depending on each own economic and social context. at the domestic level, these efforts on limiting exposure dramatically showed positive impacts during a persistent process against the pandemic. the effective results of the epidemic control to date have been largely contributed by the moh and their drastic efforts in delivering rapid and decisive responses on all fronts from research, prevention, screening to diagnosis and treatment of covid-19. in the early days of the outbreak in china, the guideline for diagnosis and treatment of coronavirus infection for vietnam was already issued by moh on 16 january and has been continuously updated throughout the epidemic [49] [50] [51] . when the covid-19 outbreak hit vietnam on 30 jan, the national steering committee and 45 rapid response teams for outbreak prevention and control were established [53, 54] . in the wake of the outbreak, moh' s hotline numbers 19009095 and 19003228 were set up on 1 feb to address enquiries and concerns, in addition to the local hotlines for counseling provided by each province/city that were launched on 22 march [55, 56] . furthermore, vietnam has gained substantial achievements in scientific research and development relating to covid-19. on 7 february, vietnam became one of the few countries that successfully cultured and isolated the novel coronavirus strain in the laboratory, which would be the premise for further research and development of vaccines, as well as effective prevention interventions against covid-19 [57] . moreover, vietnam officially manufactured the virus detection test kits (rt-pcr and real-time rt-pcr) on 05 march, and was able to manufacture 10 000 test kits per day [60] . to date, the test kit has been approved by who and exported to many countries such as: sweden, ukraine, finland, germany, italy, cambodia [98] . the test kit plays a decisive role in the early diagnosis and timely treatment of covid-19, alongside contact tracing and mass screening in the communities. furthermore, a series of guidelines and recommendations on the prevention and control of covid-19 were released; for example, the guidelines on self-isolation and concentrated quarantine at medical facilities and hotels [65, 66, 99, 100] ; guidelines on the prevention and management of covid-19 for specific vulnerable groups: infants and pregnant women; the elderly and people with chronic diseases [68, 69] ; recommendations on the prevention of covid-19 infections in specific places such as apartment buildings, workplaces, public transports, shopping malls, restaurants and others [70] [71] [72] . moreover, the online-based system for medical examination and treatment of covid-19 infections were launched initially by the agency of health examination and treatment on 5 february. it was then, officially launched on 18 april by moh to support hospitals in remote areas regarding medical counselling, consultation, imaging diagnosis, pathology among others [59, 64] . the initiative has helped to eliminate geographical and social barriers, and enhanced diagnosis and treatment capacity for covid-19 in all health facilities. furthermore, the government facilitated a robust health care system through issuing a number of decisions requiring rapid production of medical equipment and suspending exports of anti-covid-19 drugs to ensure health system capacities during the complicated development of the pandemic [62, 63] . importantly, the government has executed a series of information and communication campaigns to keep the public updated on the most transparent and latest development of the epidemic. on 30 january, communication campaigns via radio, television, newspaper for the prevention and control of the pandemic were launched in all provinces/cities via cooperation between the department of health and department of information and communications [73] . on 2 february, the ministry of information and communications issued directive no.5/ct-btttt strengthening the information campaigns for the prevention and control of the new coronavirus outbreak [74] . therein, diverse communication channels were set up to reach the entire population. the campaigns consisted of sending text messages to mobile users; producing music videos and short films to widely disseminate anti-covid information via mass media channels and social networks such as facebook, zalo, youtube, lotus and trending the hashtag #ict_anti_ncov for raising awareness of the epidemic. through these different streams of media, promotion of awareness and behavioral changes such as wearing masks in public areas and washing hands, was especially timely during the outbreak. vietnam' s creative communication approach has gone viral and received much attention by viewers, including those from other countries. for example, the parody song 'ghen cô vy', which highlighted the importance of handwashing and personal hygiene to prevent coronavirus infection has gone viral all around the world and was broadcasted on american and french television channels [101] . in line with these activities, websites and applications were sequentially launched such as 'vietnam health', 'ncovi' 'vietnam health declaration', 'hanoi smart city' and 'bluezone' with the aim of widely disseminating the most updated findings, information, correct misinformation and supporting health care workers to promptly detect suspected cases [64, [75] [76] [77] . furthermore, q&a infographics and leaflets/posters on ncov infection prevention, which largely targeted drivers and passengers taking public transports, were created and distributed widely [79] . furthermore, guidance on the correct use of face masks in public was published nationally by moh on 24 march [78] . in response to the adverse socioeconomic impacts on businesses, society and individuals created by the epidemic, preferential economic policies and relief measures have been implemented [11] . on 7 february, the ministry of finance announced a list of medical supplies exempted from tax until the epidemic ended including face masks, hand sanitizers, protective suits [80] . subsequently, tax payment in some cases had been exempted or deferred and electricity tariffs have been reduced for three months for individuals and enterprises affected by the epidemic [81, 83, 85] . the covid-19 pandemic obviously has caused a stir for asean economies [102] . on par with other countries, vietnam launched several packages of economic stimulus to revive the economy. the prime minister issued directive no.11/cp on urgent objectives and solutions for assisting businesses facing difficulties and assurance of social welfare amid covid-19 pandemic on 4 march, in which a credit package of 250 vnd billion was debuted [82] . on 10 april, the government announced plans for an economic stimulus package valued 60.9 trillion vnd to assist people, numerous enterprises, household businesses and cooperatives facing difficulties due to the pandemic [86] , which was officially implemented by the prime minister' s decision on 24 april [87]. isolated people in health care centers and concentrated quarantine facilities are entitled to around 80 000 vnd in allowance per person per day (us $3.4) and all direct medical costs are covered for vietnamese citizens [88] . since 24 march, vietnam has stopped exporting rice to ensure national food security due to the outbreak [89] . applying the latest digital technology, the hue central hospital created robots that assisted health workers in serving isolated patients in quarantine areas [90] . to reinforce social distancing measures, penalties were imposed for noncompliance of measures including not wearing masks in public places, viewpoints research theme 1: covid-19 pandemic concealment or dishonesty in self-reporting of health, opening of non-essential businesses, gathering of more than 10 people and spreading 'fake news' about the covid-19 outbreak [91] . alongside the individual country attempts, asean countries were also united in the fight against the covid-19 pandemic. meetings among national senior officers were held in march and april to discuss and share country experiences on covid-19 prevention, screening and treatment [3, 92] . also, enhancement and strengthening of international cooperation on responses to covid-19 related health threats is one of the crucial points that were voiced by asean nations [3] . the meetings also convened external experts from the united states, south korea, japan and china to share state-of-art technical knowledge and to provide financial support to countries for the current and subsequent waves of the covid-19 outbreak. [3, 92] . vietnam also made strong efforts to coordinate with international communities in the fight against covid-19 with the spirit of solidarity -"there is no country alone in the fight against the pandemic". since the beginning of april, vietnam has been transferring medical supply aids to regional neighbors including cambodia, indonesia, laos as well as other developed nations such as the united states, japan and european countries [93] . comparison of governments' responses to the covid-19 pandemic among southeast asian countries [1] . to curb the number of confirmed cases, vietnam has issued a vast array of action policies, with the highest stringency level among southeast asian countries ( figure s1 in the online supplementary document). particularly, vietnam was evaluated as the top country ready to exit lockdown, which was based on the 4 out of 6 who recommendations in 'lockdown rollback' measures [103] . thus, the positive outcomes seen in vietnam could be attributable to the strict precautions taken by the government in the battle against covid-19. nevertheless, national level responses to the covid-19 pandemic vary greatly among countries, depending on each' s socio-economic background, health care capacity and political system. overall, vietnam' s covid-19 strategies could be considered an effective model for limited resource settings. it is fruition of the prompt, proactive and decisive steps taken by the government on all fronts including health care system, security force, economic policies, along with creative and effective communication campaigns. therefore, this preliminary success from vietnam may serve as a valuable case study for other countries in outbreak response. however, our research is merely a snapshot focusing on the government' s responses during the first three months of the covid outbreak. the pandemic is far from over and the country is expected to maintain precaution methods in the upcoming months. coronavirus disease (covid-2019) situation reports dashboard for covid-19 statistics available oxford covid-19 government response tracker, blavatnik school of government. data use policy: creative commons attribution cc by standard directive no.358/ct-chk -prevention of acute respiratory infections caused by new strains of corona virus to aviation activities in vietnam the civil aviation authority of vietnam. directive no.362/ct-chk -prevention of acute respiratory infections caused by new strains of corona virus to aviation activities in vietnam official dispatch no. 224/cð-ttg on the difficult removal of goods for import, export and transportation across borders the prime minister. directive no.10/ct-ttg on promotion covid-19 pandemic prevention activities income security during public health emergencies: the covid-19 poverty trap in vietnam vietnam airlines temporarily flights between vietnam and france, malaysia. 2020 vietnam airlines temporarily suspended international flights vietnam suspends border crossing from and to laos, cambodia official telegraph no.156/cð-ttg on strengthening prevention and control of acute respiratory infections caused by new strains of corona virus compulsory isolation citizens from the epidemic areas in korea document no.1637/bgtvt-vt on promptly implement the prime minister's directive no ttg on promoting the prevention and control of covid-19 epidemic ministry of transportation & civil aviation authority of vietnam. mandatory medical declaration for passengers entering vietnam since 0h 21 march, all people who enter vietnam must be isolated the prime minister. directive no.16/ct-ttg -implementation of social distancing nationwide bac ninh isolated 44 close contacts cases vinh phuc provincial people's committees. decision no.269/qð-ubnd on implementation of emergency responsibilities in decision no. 173 / qð-ttg of 1 february 2020 of the prime minister on announcing the emergency situation affected by a new chain virus in vinh phuc eligible to end isolation of truc bach street set up 9 medical isolation posts for ha loi village, me linh commune in 28 days hai phong isolates six localities as novel coronavirus inflicts mayhem viewpoints research theme 1: covid-19 pandemic 30 the prime minister. notice no.158/tb-vpcp the plan for social distancing from 16 april across the country the prime minister. the directive no.19/ct-ttg on continuing to implement covid-19 epidemic control measures in the new situation hanoi allows school closure until the end of 9 febuary city allows students are absent from school for a week to prevent corona the official dispatch no.156/cð-ttg on 2 february 2020 on strengthening prevention and control of acute respiratory infections caused by new stains of corona virus the ministry of education and training allows school closure to prevent and fight against ncov disease the official telegraph no. 396 / cd-bvhttdl on strengthening the preventive activities of covid-19 in communication activities, cultural and historical places the railway industry suspended many trains from today because of covid-19 ho chi minh city people's committee -food safety management authority of ho chi minh city. no.635/bqlattp-vp on temporarily stop some non-essential activities the prime minister. directive no.15/ct-ttg on drastically implementing the peak phase of covid prevention hanoi people' s committee -hanoi transport corporation ltd. document no.393/tct-vthkcc on plan to adjust bus transport activities during the peak of covid prevention the official dispatch no. 2917 / bgtvt-vt on continuing directive no.15/ct-ttg the airline has experienced unprecedented difficulties in history ministry of transportation. document no.3064/bgtvt-vt on implementing directive no. 16 / ct-ttg dated march 31, 2020 of the prime minister official dispatch no.3864/bgtvt-vt on implementing the prime minister's direction at the government's standing committee on prevention and combat of official dispatch no. 3655/bgtvt-vt on implementation of announcement no.158/tb-vpcp dated 16/04/2020 of the prime minister provinces and cities wait for the next instruction on social spacing airlines announced simultaneously deploying domestic flights from 16/4. 2020 update: return school schedule for students from 63 provinces and cities decision no.125/qð-byt on guideline for diagnosis and treatment for novel coronavirus infection decision no.322/qð-byt on guideline for diagnosis and treatment for novel coronavirus infection (2019-ncov) decision no.1344/qð-byt on guideline for diagnosis and treatment for sars-cov-2 (covid-19) the prime minister. directive no. 05 / ct-ttg on prevention and control of coronavirus outbreak decision no. 255 /qd-byt on the establishment of a rapid response team to control the novel coronavirus disease (ncov) the prime minister. decision no.170/qd-ttg on establishment national steering committee for control the novel coronavirus disease free calls for q&a about novel coronavirus disease covid-19 hotline of 63 provinces vietnam successfully cultured and isolated new coronavirus strain in laboratory the national steering committee for prevention and control the novel coronavirus disease. decision no. 80 / qd-bcdqg on establishment sub-committees to respond the novel coronavirus disease launching the online-based management and administration center to support covid-19 diagnosis and treatment vietnam officially produced the sars-cov-2 detection test kit with a capacity of 10,000 sets/day. 2020 references rapid response to the covid-19 pandemic in vietnam www the government office. announcement no. 143/tb-vpcp about the decision at the regular meeting on prevention and control the covid-19 epidemic qld-kd stopping anti-covid-19 drugs exports prime minister attended the opening of 2 technology products for prevention of covid-19 decision no. 879/qd-byt on interim guidance for the covid-19 quarantine at home and in residential areas decision no.344/qð-byt on guidance on quarantine at quarantine zones for prevention and control of novel coronavirus pneumonia (covid-19) decision no. 904/qd-byt on the manual for implementation of quarantine at quarantine zones decision no.1271/qd-byt on interim guidance on prevention and management of sars-cov-2 infection (covid-19) for pregnant women and infants decision no. 1588 / qd-byt on interim guidance on the health management for the elderly and people with chronic diseases at healthcare facilities in the context of the covid-19 epidemic; and guidance on health care and prevention covid-19 epidemic for the elderly in the communities health environment management agency. the official dispatch no. 1364/byt-mt on prevention and control the covid-19 at apartment buildings health environment management agency. the official dispatch no. 490/byt-mt on prevention and control the covid-19 at workplaces official dispatch no. 831/byt-mt on prevention and control the covid-19 epidemic in shopping malls, supermarkets, traditional markets, restaurants, hotels, parks and tourist areas official dispatch no. 369/byt-tt-kt on strengthening propaganda, advocacy of prevention and control of ncov ministry of information and communications. directive no. 5/ct-btttt on prevention and control of covid-19 smartcity application supports hanoi authorities to monitor suspected people with covid-19 official dispatch no. 1519 / byt-mt on guidance of wearing facial masks for people and communities infographic on covid-19 exempting all kinds of taxes for medical materials against ncov epidemic the general department of taxation. official letter no. 897 / tct-qln on extension of tax payment, exemption of late payment due to covid-19 epidemic directive no. 11/cp on urgent objectives and solutions for assisting businesses facing difficulties and assurance of social welfare amid covid-19 pandemic ministry of industry and trade. official dispatch no. 2698/btc-dtdl on cutting electricity bills hanoi people's committee. directive no.06/ct-ubnd on drastically implementing a number of solutions in investment and construction management to improve the efficiency of public investment, stabilize production and business, and ensure social security in hanoi city during covid-19 epidemic decree no.41/2020/nd-cp on tax and land rent deferral resolution no. 42/nd-cp on assistance for people affected by covid-19 pandemic how much is supported for people in quarantine zones due to covid-19? available vietnam has stopped exporting rice: it is necessary to ensure national food security robot helps patients with covid-19 in quarantine zones detailed penalties of 13 violations in covid-19 prevention and control policies 2020 vietnamese face masks radiate to the world school closures caused by coronavirus (covid-19) online teaching: effort and determination from disadvantaged localities official dispatch no.3863/bgtvt-cyt on guiding the medical conditions to prevent the covid-19 outbreak in vehicles covid-19 test kit produced in vietnam has been approved by who. 2020 decision no. 345/qd-byt on self-quarantine guidelines for prevention and control of covid-19 decision no.878/qð-byt on interim guidance for the covid-19 quarantine at health facilities vietnam' s anti-covid-19 song excites 'last week tonight' host, int'l viewers economic impact of covid-19 outbreak on asean lockdown rollback checklist: do countries meet who recommendations for rolling back lockdown the authors would like to thank phuong bich tran (department of global public health, karokey: cord-321800-0h28pg3b authors: klingelhöfer, doris; braun, markus; brüggmann, dörthe; groneberg, david a title: coronavirus: an insight into global research until outbreak of covid-19 and its implications for the future date: 2020-09-23 journal: journal of global health doi: 10.7189/jogh.10.020508 sha: doc_id: 321800 cord_uid: 0h28pg3b background: the currently prevailing global threat of covid-19 caused the publication numbers on coronaviruses to explode. the awareness of the scientific and public community is enormous. but what about the sense of all these undertakings and what can be learned about the future for a better understanding? these questions were answered with established bibliometric analyses of the time until the avalanche of publications unfolded. methods: chronological, geographical aspects of publication output on coronavirus were also evaluated under the influence of epidemiological and socio-economic parameters. results: the trend in publication and citation numbers shows the strong influence of the past pandemics sars and mers with an untypical decline afterward. research is becoming increasingly multidisciplinary over time. the usa and china, as the countries with the highest number of publications, are being displaced by other countries in the consideration of socio-economic and epidemiological aspects, which shows the effect of regional interest in corona research. a significant correlation was found between the number of sars cases per country and related publications, while no correlation was found for mers cases and articles. conclusions: the results underline the need for sustainable and forward-looking approaches that should not end with the containment of covid-19. in line with the aphorism: "only those who know the past can understand the present and shape the future", the present study provides background information of research on coronaviruses (cov) as a basis for the scientific situation of the global pandemic covid-19 and a source for a better understanding of research patterns from the time before covid-19. viewpoints research theme 1: were recognized as pathogens causing only mild infections such as common cold and their clinical significance was not recognized. by 2003, sars had infected more than 8000 people in 29 countries and killed 774 people. the pandemic ended abruptly, and no cases occurred later [3] . at an animal market in china, the sars-cov pandemic was found to be transmitted by palm civet cats [4] . more than 87% of all cases worldwide occurred in china. the second cov pandemic mers (middle-east respiratory syndrome) occurred in 2012, but unlike sars, mers did not end suddenly and cases continue to be recorded until now [5] . mers affected more than 2400 people and caused 912 deaths in 27 countries by 2019, according to heath authorities worldwide. more than 77% of the mers cases occurred in saudi arabia, transmitted by dromedary camels [6] . later studies have shown that bats are reservoir hosts for both of these former cov diseases [7, 8] . the current extremely rapid global spread of sars-cov-2 has led to the highly dangerous outbreak of the pandemic covid-19 with daily increasing numbers of new infections and deaths around the world. at this point in time, the peak of the infections has not yet been reached, so the final figures are not predictable -but it seems that they will reach devastating proportions and will certainly change world societies forever. there are no vaccines yet, and treatment options are still limited. only symptomatic treatment or support is possible [9] . due to the enormous spread of infections and the severe course of many cases, the appearance of covid-19 is accelerating research, which is certainly unique in the history of science. almost real-time results provide new insights from all areas of science, from basic to applied research. the financing of cov research is also picking up speed. for the dissemination of this rapidly generated knowledge, international communication is obligatory, and the most common way of disseminating it is the publication of results [10] . can we learn from previous research patterns regarding cov? what influence do they have on future research? how can we use past efforts, their intensification and the influences of research on cov positively to better understand the needs for sustainable and appropriate research? these are compelling questions in light of the currently exploding research output, which, in addition to interesting and meaningful approaches, appears in part excessive, arbitrary and not scientifically sound. although many scientists around the world are giving their best to solve and improve the pandemic, the current development also gives rise to the pressure to be the first to find the solution and not to be overtaken by colleagues. against this background, it is very important to know about previous research. therefore, we have analyzed the global research output on cov in the time before covid-19. in the present study, established bibliometric parameters on chronological and geographical aspects were combined with state-of-the-art visualization techniques based on density equalization principles. additionally, socio-economic, scientific and epidemiological parameters were related to the publication numbers to obtain an even more meaningful picture of the global landscape of cov research. the results may help to find more adequate approaches for future research in the financing, planning, implementation and networking of research based on quality and sustainability. the present study belongs to the established bibliometric platform new quality and quantity indices in science (newqis) [11] , which examines a broad range of biomedical questions with regard to their translational utility [11] [12] [13] . the underlying methodology is constantly evolving and adapted to changing circumstances in terms of global scientific, political and socio-economic characteristics [14] . standardized bibliometric parameters are combined with newly integrated indices and figures on the research topic in order to analyze and discuss the research landscape appropriately. in combination with state-of-the-art visualization, the results are provided convincingly. the default database for retrieving the needed metadata for all newqis studies is the core collection of web of science (wos). not only because of its status as one of the leading online databases for scientific literature, but also because of its listing requirements, which allow only quality work. moreover, the provision of the journal citation report (jcr) enables the analysis of citation-based parameters by specifying all citations received for each publication. viewpoints research theme 1: covid-19 pandemic the search was performed at 18/03/2020. to record the respective articles dealing with cov, the elaboration of an adequate search term is mandatory. the aim is to include as many related entries as possible and to exclude the false entries from the analysis database. therefore, the term must be a combination of all variants or synonyms of the names of the virus or its transmitted diseases. in order to find as many entries as possible, the resulting term was: "*corona virus" or "*coronavirus" or "sars" or "mers" or "covid-19" or "severe acute respiratory syndrome" or "middle east respiratory syndrome". wos offers different modes of search. we applied the title search mode here, because a lot of incorrect entries occur when searching with the topic search mode that also includes abstract and keywords. to further decimate unrelated entries, mostly due to different meanings of the abbreviations sars and mers, a specified topic search was added and combined with the boolean operator "and" searching for the terms: "virus" or "epidem*" or "cov" or "co-v" or "covid-19" or "patient*" or "*coronavirus" or "severe acute respiratory syndrome" or "middle east respiratory syndrome". this strategy ensures content linkage by querying the occurrence of one of these terms either in the abstract or the keywords of the publication. the resulting entries were subsequently filtered by the document type "articles" to include only original papers in this study. the metadata of the articles found in the manner described above were downloaded and recorded in a database that provides a variety of parameters according to the key information encoded by the wos tags. their analyses refer to chronological and geographical parameters, using data on the number of articles in relation to, eg, publication year or country of origin. other advanced parameters include socio-economic [15] [16] [17] and epidemiological data [3, 5] . for the epidemiological evaluation, sub-analyses were performed using the same search term, with the only difference that it was reduced to either sars or mers. furthermore, institutions and research foci were analyzed and the international network was presented. it has to be noticed that the sum of all assigned subject areas of wos must be higher than the number of articles due to multidisciplinary journals assigned to more than one subject area. in this study an article with more than one subject area assignment to assigned to each area and therefore counts several times. citation-based analyses provide information on the recognition of the articles in the scientific community. a threshold was applied to all valuation ratios to reduce distortions of extremely low values, eg, citation rate, and socio-economic ratios. in this way, a concise picture of the global landscape of cov publications and their development could be created. the geographical results were partially visualized with density equalizing map projections (demp) that are distorted maps according to an algorithm developed by gastner & newman [18] . depending on the value of the evaluation parameter, the countries were either enlarged or reduced in size according to the physical principle of density equalization. using the vosviewer application [19] , the results of the keyword analysis to determine research priorities are visualized with a network diagram showing clustered nodes and connections for all terms that occurred at least 150 times. every scientific methodology has some limitations that must be reported on. in this case, the first limitation to be mentioned is due to the characteristics of the data source, as wos does not list all publications in its core collection. wos requires special recognition for listed journals in order to ensure quality, but this led to the fact that some important articles on cov could not be included in the analysis as they are not provided by wos. the title search strategy applied in this study further reduces the database. the advantage, however, is that the included data represent a representative collection that can clearly be used for a valid evaluation. furthermore, the wos is said to give preference to english literature, so that the resulting dominance of english-speaking countries is supported by this fact. another point that should be mentioned is the manual correction method for metadata on institutions and authors. for this, a threshold had to be introduced to make the procedure feasible. as a result, the exact number of institutions and authors publishing on cov could not be given. however, the leading institutions and authors could be determined exactly in this way. viewpoints research theme 1: considering the limitations of citation analyses and their impact on meaningfulness in terms of the quality of publications, the use of several citation parameters is appropriate, which gives more weight to the importance of the analysis results for the resonance of the examined publications in the scientific community. in summary, the applied method has proven to be a valid strategy for the evaluation of bibliometric scientific questions. a total of 6905 articles (n) on cov could be added to the database and form the basis for all analyses except those valid for geographical analyses. analysis of the keywords used (threshold value: 150 occurrences) revealed four thematic clusters of cov articles (figure 1, panel a) . first, the molecular and biological topics form a cluster (red). the second cluster (blue) outlines the articles dealing with the sars epidemic, and the third cluster (yellow) combines the articles dealing with the mers epidemic. the fourth cluster (green) forms an intermediate group that mainly focuses on the spike protein that is characteristic of cov, its pathogenesis, and its connection to the other clusters. in terms of subject areas, the most frequently assigned research fields are virology (n = 2140), infectious diseases (n = 899), veterinary sciences (n = 720), microbiology (n = 622), and immunology (n = 558). looking at the developments over time, it can be seen that the research has become increasingly multidisciplinary ( figure 1 , panel b). especially since the beginning of the 2000s, a change can be observed. veterinary sciences and virology were relatively declining. the relative frequency of articles assigned to infectious diseases increased from this time onwards. other areas of cov research also became more popular. the first article about cov found in this study was published in 1970. from then on, articles were pubit is obvious that the articles from 2003 deal with the new cov and the related disease called sars, which appeared year. working groups from the usa, china, southeast asian countries, germany, france and the netherlands identified and characterized the new virus and its association with sars [20] [21] [22] [23] . canadian scientists worked on the genomic sequence [24] . viewpoints research theme 1: in 2012, the mers coronavirus appeared, leading to this year' s high-ranking publication of dutch and saudi arabian scientists [25] . the 2005 article, which ranks 10 th , stated that bats are natural reservoirs for sars-covs [7] . this was a collaboration between china, australia and the usa. all ten most frequently cited articles were published in renowned journals. the new england journal of medicine and science published four of them each. one each was published in the lancet and nature. the necessary information about the country of origin can be collected through affiliation data. before 1973 this information is not always available and the gaps are too large to be used. exactly n = 50 articles could not be assigned to any country of origin, so that n = 6855 articles are included in the geographical evaluations. from 1970 onwards, the usa was the country with the highest number of publications for the entire evaluation period (n = 2293), followed by china (n = 1707). by a larger margin, germany ranked third (n = 505), followed by canada (n = 488) and the united kingdom (uk) (n = 413) (figure 3 , the leading countries were also represented by the leading publishing institutions ( table 2 ). in terms of citation numbers (c), the landscape looks similar to that of article numbers (figure 4 , when looking at the world map when socio-economic parameters are included in the analysis, the distortion of country sizes shifts again. regarding the ratio of the number of articles and population size in million inhabitants (rpop) of countries with at least 30 articles on cov (threshold) the ranking another socio-economic parameter, the relation of the number of articles on cov to the gross domestic product (gdp) in 1000 billion us-dollars (rgdp) for countries with at least 30 articles (threshold), shows a similar ranking. the rankings of both socio-economic analyses were compromised in table 3 . the inclusion of parameters referring to the research infrastructure of the countries considers two values. first, the gross expenditure for research and development (gerd) in billion ppp$ (purchasing power parity in us-dollars) and the number of researchers in million fte (full time equivalents). again, the number of articles on cov for countries with at least 30 articles (threshold) was set in relation to these parameter (rgerd, rres). table 4 ). the socio-economic parameters gdp, gerd, and number of researchers were significantly correlated with the number of cov articles (p < 0.0001), with correlation coefficients (spearman r) ranging from 0.61 to 0.79. in order to show the publication performance of cov-affected countries in relation to the sars and mers epidemics, the relationship of articles on sars or mers to the respective cases per country was analyzed. according to who [3] 8096 sars cases occurred until the 2004 epidemic came to an abrupt halt. the sub-analysis of the present study resulted in 3039 sars-related articles corresponding to the affected countries. table 5 in total, the who reported 1511 cases of mers worldwide occurring with smaller boosts until today [5] . 1068 articles could be clearly assigned to mers. table 6 viewpoints research theme 1: of the total number of n = 6855 articles for the geographical analyses, n = 1716 articles were prepared in international cooperation. the maximum annual international partnerships for cov research took place in 2004 (n = 135, first publication peak) and in 2016 (n = 126, second publication peak) (figure 1 , panel a). in principle, however, an upward trend can be observed. the usa was at the center of the international network and was involved in the five strongest international collaborations (figure 7) . the most productive bilateral cooperation in cov research was between the usa and china with n = 290 cooperation articles, followed by usa/canada (n = 113), usa -uk (n = 77) and usa -netherlands (n = 75). the non-us partnership with the highest publication volume was between the netherlands and germany (n = 74). especially since the beginning of the covid-19 pandemic, which is causing many serious cases and deaths in many countries, the importance of research on cov has become clear. basic research to date, the identification of novel viruses of the two pandemics sars and mers, has influenced global research efforts. as more is learned about the background, incentives and impact of research, the impact of more focused and improved focus, planning, implementation, collaboration and communication of scientific projects becomes clearer, for all parties involved. this is also shown by the identified research foci, which were analyzed by the keywords used in the articles on cov. however, the proportion of human-related research has increased significantly since the outbreak of sars, and multi-disciplinarity has also become increasingly widespread over time. the currently rampant covid-19 disease and its impact on economic, political and social spheres will provide new impetus for cov research in other scientific fields in the future. the development of publication output on the cov clearly followed a different trend than that of other biomedical topics in general, which usually increase exponentially over the evaluation period [27] and could be shown in other studies on viral diseases [12, 13] . instead, the increase in the number of articles and citations corresponds to the occurrence of the two pandemics sars and mers in the past with peaks at the beginning of each. in 2003, the year in which sars emerged, publication numbers rose at an unprecedented rate in science, with an increase of about 500% within one year. chiu et al. also noted in a 2004 bibliometric study on sars publications that the high publication rate at the beginning of the pandemic resulted in high citation rates due to the immediate recognition in the scientific community [28] . now, 16 years later, the present study confirms this extremely high recognition by the scientific community at the time of the sars outbreak, which even shows a number of citations per publication year, even before the maximum peak in publication numbers is reached. in 2003, the highest citation rate was achieved with cr = 104.83, which means that each article on the cov was cited about 104 times on average. this is certainly an extraordinary result. almost at the same pace, however, the number of publications and citations decreases thereafter, resulting in a value that is below the average biomedical topic. this shows the decline of the scientific interest with the abrupt end of sars. the awareness of the importance of cov research as a preventive measure for future virus infections does not seem to have been present at this time. the progression curves of both publication and citation numbers showed a minimum level at exactly the time when the cited half-life (chl) of publications in biomedical publications is generally reached. basically, the chl is given as 7-8 years that a publication needs to reach half of the expected citations, resulting in a maximum peak of citations up to that point [29] . the outbreak of mers in 2012 caused a second increase, but this time it reached only about one third of the sars-related figures, due to the lower incidence rates compared to the sars pandemics. it also showed a declining trend, but only four years after the outbreak. the longer period during which mers cases occurred also led to a longer lasting interest, but at a significantly lower level. the timeframe of the evaluation was set until march 2020, so that the first months of covid-19 were included in the analysis. the expected exponentially increasing numbers could even be shown in this small time-interval by a further significant increase in the number of publications. the short-term effect of research efforts of earlier cov research and the strengthening of international networking could also be shown with regard to another emerging virus epidemic that occurred in south america in 2015: the zika virus infection. the publication patterns corresponded to those reported here and showed an unsustainable short-term effect of national and international efforts [30] . this similar publication pattern was reinforced by the enormous research incentives of short-term funding and public recognition due to the acute threat. this is also evident in the case of cov research, and the same influences must be considered in future approaches. the most frequently cited publications highlight the outstanding impact of the two pandemics and the years of their outbreaks. most of the ten articles dealing with the identification and characterization of the novel sars virus were published in 2003, which shows the importance of the first articles on sars in the scientific community. one article deals with the isolation of the mers virus, which was published in 2012, and another with the function of bats as natural reservoirs. these articles were from the countries that are considered to be the most publishing countries throughout the assessment period. viewpoints research theme 1: what is also true for the publication output of most life science and biomedical topics is the leading position of the usa in terms of the absolute number of publications. the rapid catch-up trend and the now high numbers of chinese scientists is also not unique for cov research. other bibliometric studies confirmed the ranking of the leading countries in terms of absolute publication figures. bonilla-aldana et al. found the usa publishing 34.9%, china 22.4%, and germany 6.8%. saudi arabia, as the country most affected by mers, contributed only 3.6% to cov publications [31] . in comparison, the percentages revealed in our study were similar: the usa (33.45%), china (24.90%), germany (7.37%), and saudi arabia (4.01%). in 2011, kostoff et al. found in another bibliometric study on sars the declining share of chinese and the increasing trend of us-american studies. they stated a higher percentage of highly cited publication authored by china compared to other research fields [32] . these findings have been confirmed by the present results showing also the percentage decrease of chinese articles. although, a relative downwards trend of us-american articles could also be shown. this is due not only to the decline in absolute figures but also to the efforts of an increasing number of countries worldwide. covid-19 will certainly continue to influence this trend enormously. although the study by chiu et al. showed a low level of international collaboration shortly after the outbreak of the sars pandemic in 2004 [28] , the pace at which international collaboration on cov was established thereafter was remarkable [32] and will certainly continue. as third most publishing country, germany has been involved in cov research from the very beginning in the 1970s, when only the usa and canada was interested in this topic. although germany had its highest share at the beginning of the 1980s, it has been able to maintain its position among the three leading countries to date. the most cited german article by drosten et al. from 2003 ranks second in the overall research on cov and identified a novel coronavirus in a patient with sars [21] . this was a german-french-dutch partnership. the following ranking consists of canada, the uk, taiwan, and the netherlands. all are involved in prominent research on cov and have sufficient scientific resources and infrastructure not only for research on cov. the netherlands -ranked 7 th in absolute numbers -took a leading position when it came to the results of citation-based, socio-economic and science-related parameters. it also participated in three of the most cited articles and thus also in the identification of sars-and mers-cov as a partner country of germany, the usa, and saudi arabia [21, 22, 25] . with a relatively high proportion of articles in the field of molecular biology, the dutch scientists contributed the main research on the structure of the spike glycoprotein, eg, they uncovered the three-dimensional structure [33] . nevertheless, other countries have led the way with respect to the inclusion of socio-economic and science-related. thailand received the highest citation rate, although with n = 38 it was only slightly above the required threshold of 30 articles. thailand' s participation in the most frequently quoted article is therefore responsible for this high value. the article by kziazek et al. [20] , which demonstrates the etiological role of a novel cov in sars, is a joint effort of the sars working group: usa, vietnam, china, thailand, singapore and taiwan. scientists from the center for disease control and prevention (cdc) worked in addition to them from the international emerging infectious disease program in bangkok (thailand) as partners in this study. this program was founded by the ministry of public health (thailand) and the cdc (usa) to establish a prevention and detection system that responds to emerging public health threats. vietnam was also a partner country in this cooperation, but with n = 29 it was just below the threshold and was therefore excluded from the analysis of citation rates. it should nevertheless be mentioned here. scientists from the vietnamese regional division of who were involved in the research. singapore, which was also involved in this successful cooperation via the singapore general hospital, could also be highlighted concerning the analysis of socio-economic and science-related parameters. it received the highest scores in terms of rpop, rgdp, rgerd, and rres. chahour et al. [34] conducted a bibliometric analysis of the first covid-19 publications, which confirmed the leading position of singapore in terms of its demographic characteristics. without applying a threshold, this study ranked mauritius first in terms of economic strength. we could not find an article from mauritius until march 2020, and the chahour study found one publication from mauritius. this shows how important threshold applied in our study is to avoid overestimating countries with such a low publication output. with 238 sars cases, singapore was one of the most affected countries. the resulting scientific interest and the possible in-si-viewpoints research theme 1: covid-19 pandemic tu investigation of the cases caused the publication figures to rise at the beginning of the sars disease and to fall rapidly thereafter. at the time of the covid 19 outbreak, however, the figures from singapore rose strongly again. tan tock seng hospital (ttsh) is at the heart of sars research in singapore, a place where 105 secondary cases mainly affected health workers [35] . the epidemiological impact and the incentive of in-situ research promoted research on both pandemics of the past and showed the clearly centered focus of the publishing countries. the exploding publication numbers in 2003 and the second peak starting after 2012 are clearly caused by the outbreaks of sars and mers. therefore, we defined both the number of sars-and mers-related articles and set them in relation to the number of disease cases of each country. in the case of sars, china had clearly the most cases worldwide and had also written the most articles about it. this was followed by the usa and taiwan. however, the ratio of sars articles from china and taiwan to cases was relatively low. in general, the countries with the most cases did not reach the top ranks, as case numbers varied widely among publishing countries, ranging from more than 7000 in china to only one case in eight countries. therefore, spain and switzerland reached the highest ratios. but with only one identified article, these high rates are not surprising, as both countries were among the 20 most publishing countries. the contribution of literature from both countries to the cov literature was relatively stable and has fluctuated only slightly since the early 2000s at an average level of about 10 articles per year. therefore, the publication efforts of both countries could not be directly linked to the outbreak of sars or mers. with regard to mers, most of the contributions came from the usa, which was also found in a 2016 study [36] . saudi arabia produced the second most articles on mers. as far as the relationship between mers publications and mers cases is concerned, the situation is similar to that of sars. saudi arabia also achieved a relatively low ratio with most mers cases. here, the usa and china are the highest-ranking countries, demonstrating their overall interest in cov research and also focusing on the mers pandemic, despite the relatively low case numbers. egypt also came into the focus of this analysis because of the occurrence of only one case and the associated high ratio. however, egypt' s interest is directly related to the outbreak of mers, as it has seen a significant annual increase in publication numbers from that point on. the occurrence of mers-cov in egyptian dromedary camels and its similarity to the human type influenced the regional research interest [37] . another causal factor is the strong cooperation partnership with saudi arabia and usa in cov research. in addition, egypt ranked 5 th in the inclusion of gerd as a marker of economic strength and was the only country that did not have a high-income status among the top 15 countries. the analysis by chiu et al. from 2004 [28] found no evidence of a correlation between the number of sars cases and the number of publications in the publishing countries [28] , while our results showed a significant correlation. the reason for this discrepancy seems to be the timing of evaluation. in contrast to chiu et al. who consider the beginning of publication activity on sars, the present study shows the results of development 16 years after the appearance of the pandemic. during this period, the affected nations seem to have created an awareness of the importance of sars research and the international interest in cov research that responds to it. however, with regard to mers, our study could not demonstrate a statistical correlation between the number of cases in countries and the number of publications. this could be due to the low number of mers-related cases and the resulting centered interest. taking into account the unusual patterns of previous cov research, the current situation of covid-19-related publication output must be evaluated and discussed accordingly. a short note on the most recent publication figures, which include the output of 2020, already shows 3930 publications on the cov that were found with the same search term (as of 19.05.2020). of these publications, only 1230 are articles (31.3%), which means that almost more than two-thirds of the publication includes other types of documents, especially editorial materials and early access, which are almost invisible in the previous period. as a rule, articles make up the largest share of document types. the most frequently assigned subject area in 2020 was general and internal medicine, which pushed back the fields of virology and infectious diseases as the most frequently assigned areas of previous research, viewpoints research theme 1: thus providing an indication of publication in more interdisciplinary journals. the field of public, environmental, and occupational medicine moved on to third place. these figures imply the enormous interest of the scientific community and the enormous willingness to publish. but it leaves one questioning the priority given to quality and shows the attitude of publishers to value the rapid publication of articles related to the cov. china has the largest share of articles in 2020, followed by the us and italy. this is due to the advance of chinese science and the high number of cases in both china and italy. the results of the present study show the need for sustainable, valid and high-quality research in global cooperation to address not only the current pandemic but also future threats. the increasing divergence of research areas allows for more interdisciplinary approaches, which should be completely free of any blinkered ambitions or dogmatic reservations about the big picture. what concrete effects the current covid-19 pandemic will have on the global landscape of cov research can currently only be estimated. funding is rising exorbitantly, and the first figures for 2020 show an equally exorbitant increase in publications. as a result, the development of vaccines and effective therapeutic methods can be expected in the near future. but the question arises whether this is a short-term effect which, once covid-19 is contained, will lead to an equally sharp decline in publication numbers as was observed with the earlier cov pandemics sars and mers? the need for continued interest and research efforts worldwide is characterized by the characteristics of the past, which lead to a lack of basic knowledge about cov, about advanced therapies and to difficulties in the search for vaccines. the present results show the development and incentives for research in the period before covid-19 and underpin the need for awareness and sustainable international relations for best possible strategies and the benefit of scientific projects. this is also important in view of the fact that the effects of the prevailing climate change will influence the incidence of zoonotic diseases caused by cov through human and animal accumulation. this will certainly lead to the need to combat new groups of viruses in the future. therefore, sustainable and climate-friendly approaches must also be pursued in science, especially if they focus on the newly emerging aspects of cov research in relation to political and economic issues. annual review of diseases prioritized under the research and develpment blueprint detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergencycommittee-regarding-the-outbreak world health organization. summary of prabable sars cases with onset of illness form 1 isolation and characterization of viruses related to the sars coronavirus from animals in southern china middle east respiratory syndrome coronavirus (mers-cov) any researcher with access to the web of science database can obtain the data using the methods described in the paper. readers that do not have access to web of science should contact clarivate analytics to obtain a license draft: dk; writing -review & editing: dk, mb, db, dag; visualization: dk. conflict of interest: the authors completed the icmje 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associated with severe acute respiratory syndrome identification of a novel coronavirus in patients with severe acute respiratory syndrome characterization of a novel coronavirus associated with severe acute respiratory syndrome coronavirus as a possible cause of severe acute respiratory syndrome the genome sequence of the sars-associated coronavirus isolation of a novel coronavirus from a man with pneumonia in saudi arabia world bank country and lending groups bibliometric analysis of severe acute respiratory syndrome-related research in the beginning stage journal citation reports: a potential tool for studying journals? 1. description of the jcr journal population based on the number of citations received, number of source items, impact factor, immediacy index and cited half-life the global scientific research response to the public health emergency of zika virus infection mers-cov and now the 2019-novel cov: have we investigated enough about coronaviruses? -a bibliometric analysis structure and infrastructure of infectious agent research literature: sars coronavirus spike protein and tropism changes a bibliometric analysis of covid-19 research activity: a call for increased output the outbreak of sars at tan tock seng hospital -relating epidemiology to control global research trends of middle east respiratory syndrome coronavirus: a bibliometric analysis mers coronaviruses in dromedary camels key: cord-298372-4pw1y404 authors: koch, lionel; lopes, anne-aurelie; maiguy, avelina; guillier, sophie; guillier, laurent; tournier, jean-nicolas; biot, fabrice title: natural outbreaks and bioterrorism: how to deal with the two sides of the same coin? date: 2020-08-18 journal: journal of global health doi: 10.7189/jogh.10.020317 sha: doc_id: 298372 cord_uid: 4pw1y404 nan f or the last three decades, the outbreak events have constantly increased and became more complex to prevent, predict and contain. nowadays, health authorities concern is to identify which ones are bioterrorist outbreaks. however, natural outbreaks and biological attacks have a too intertwined nature to be considered separately and hence, in the absence of any attack evidence, differentiate them is a delicate task requiring complex, long and rigorous scientific investigations. furthermore, and as demonstrated by the covid-19 outbreak, the effectiveness of the response to an outbreak is closely dependent on the timeliness of the response: the effort should thus rather focus on the development of early detection and preparation measures such as the development of global contingency plans organising the action of all entities (civilians, militaries, governmental and non-governmental) in a common effort. innovative artificial intelligence is becoming unavoidable to detect the crisis and to manage it, especially in the phases of preparedness and response effectiveness. this technology largest impact will be to complement and enhance human capabilities but cannot substitute them. the human experts monitoring new threats and able to work with these systems will stay at the centre of the stage. in the last thirty years, the pace of emerging infectious disease outbreaks has significantly increased [1] . the globalisation of international exchanges contributes to the inefficiency of common quarantine measures to contain the disease [2] . the last ebola outbreak in 2014 in west africa was regarded as a paradigm of the issues caused by emerging infectious diseases nowadays: this extremely deadly pathogen has naturally emerged in a large new area, and its overwhelming spread has subsequently impacted europe and the united states [3] . this observation was confirmed and emphasised by the coronavirus disease pandemic caused by the new human coronavirus sars-cov-2. the effectiveness of the ongoing lockdown of billions of people during the covid-19 will have to be evaluated and compared to other strategies. thus, outbreaks can no longer be considered as a local and distant issue but should be regarded as a global concern [4] . natural outbreaks and bioterrorism: how to deal with the two sides of the same coin? of course, in history, some outbreaks have been the starting point of biological attacks, even long before the discovery of microbiology. in 1346, mongols exploited the second plague pandemic by catapulting the bodies of soldiers died from plague over the city walls of caffa [5] . in the same lines, in the 18th century, the distribution of infected blankets from a smallpox hospital of english settlers probably caused the deadly smallpox outbreaks in the native americans population [5] . in the 20th century, after the discovery of microbiology, a period of extensive industrial biological weapon programs started with scenarios of massive biological attacks against military troops. since 2001, the threat is considered more focused on actions against the population or vital interest points of the nations. these biological attacks could be perpetrated by state or non-state groups in the context of low intensity or hybrid wars and bioterrorist attacks [6] . nowadays, when an outbreak occurs, one of the first concern of the authorities is to separate a natural outbreak [7] from an intentional act involving a biothreat agent [5] in order to adapt their management. even the sars-cov-2 did not escape the suspicion to have been laboratory-engineered [8, 9] . thus, this review will show that there are no easy ways to distinguish one from each other but that they share the same consequences and hence should have a shared management. accordingly, group together preparation measures and response tools against both the emergence of an unknown pathogen and an unpredictable attack will optimise the effectiveness of the response. the biological weapons convention signed in 1972 outlaws the use of biological weapons [10] . since then, the identification of a biological attack is a major international political and judiciary issue [11] . however, multiple nested events such as global warming [12] , natural catastrophes [13] , human actions [14] and conflicts [15] affect natural outbreaks in an unpredictable way [16] . several authors proposed algorithms to determine, during crisis or shortly after, if the biological event had natural or induced causes [17] [18] [19] . except for some criteria, like evidence of a release explicitly referring to attacks, the great part of the arguments should be carefully analysed before being attributed to a biological attack. the use of some spontaneously rare agents could denote a criminal origin, as it has been the case with the use of bacillus anthracis during the amerithrax crisis in 2001 [20] , and, to a lesser extent, with the aum shinrikyo sect in japan in 1993 [21] . however, the agent is not a sufficient criterion to identify natural or induced biohazard. for example, the rajneesh sect used a quite common salmonella enteric [22] to perpetrate attacks, and some bacterial toxins are considered as a potential warfare agent precisely because of their high prevalence [23] . in sharp contrast, recent natural outbreaks involved top select agents like ebola virus in west africa in 2014-2015 [3] or yersinia pestis causing pulmonary plague in madagascar in 2017 [24] . even the emergence of a peculiar new strain cannot be a stand-alone criterion to differentiate both events. indeed, even if there is no evidence of using such agents through history, natural agents can be modified by humans to increase their transmission, lethality or drug resistance capabilities [5] . at the same time, some natural outbreaks were caused by naturally altered pathogens like the escherichia coli o104:h4 in europe in 2011, a strain that acquired and combined unusual virulence factor and drug resistance genes [25] or in 2003 the new human coronavirus (sars-cov) identified with surprise in front of severe acute respiratory syndrome cases [26] . if a pathogen is detected in a location where it has never been detected before, it can constitute a hint for a biological attack suspicion. it was the case with the amerithrax crisis in 2001 when a texan b. anthracis strain was found on the east coast of the usa [20] . however, the biggest outbreak of the ebola virus occurred in a part of the continent recognised as free of the disease until then [27] . one other clue for biological attacks could be the seasonality, arguing that if an outbreak appears during a season not compatible with the pathogen time-life, human activity could be the cause [5] . here too, some natural outbreaks disrupted both experts and ai will have to learn how to work together and assist each other by developing collaborative intelligence. all rules like the influenza virus h1n1 pandemic in 2009, which appeared in april in north america with two epidemiological spikes [28] . it unusually emerged from infected pig populations and was followed by a unique global spread [29] . multiple starting points are commonly considered a sign of a biological attack like the five letters containing b. anthracis spores [20] as well as the several restaurants targeted by the rajneesh cult [22] . an attack can also occur in a single place, like the "shigella dysenteriae poisoning" in a laboratory in 1996 in the us, where one unique set of pastries has been deliberately contaminated by a laboratory strain [30] . in contrast, the natural tularaemia outbreak in kosovo in 1999-2000 reached several districts simultaneously in a tensed geopolitical context [31] and, in 2017, the plague outbreak in madagascar had multiple index cases [24] . even the assumption that an unusual swift spread or a large share of the population rapidly affected could be evidence for a biological attack is disputable: recent terrorist actions used non-contagious pathogen and hence reliable epidemiological data for the intentional use of a contagious disease do not exist [5] . by contrast, the influenza virus [28] , the 2003 sars-cov [26] and the sars-cov-2 [32] propagated very fast all around the world with more than 200 countries affected in one year for the first one and 30 countries in 5 months for the second. for the current covid-19 pandemic, the centre for systems science and engineering (csse) of johns hopkins university (baltimore, md, usa) created a website to visualise and track the reported cases in real-time [33] . in april 2020, less than five months after the first alert, 185 countries declared at least one case of infection (https://coronavirus.jhu.edu/map. html). in the same vein, the last zika virus natural outbreak showed an unusual spread, as it emerged in africa, travelled across the pacific ocean to finally trigger a pandemic in south america [34] . is there any interest to identify one from the other? thus, to characterise an infectious phenomenon, we should merge the most advanced technics with thorough epidemiological investigations. results have to be interpreted very carefully by taking into account contextual elements and technical biases to avoid any misunderstanding [35] . the list of common-sense items is beneficial to process data and improve awareness but should not be solely used to distinguish the origin of an ongoing event because of a lack of reliability (). it should be noted that all criteria and weightings have been determined retrospectively based on past outbreaks and bioterrorist attacks. one of these algorithms has been reviewed in the light of new infectious events but have not yet proven its effectiveness on a prospective basis [36] . the confusion surrounding these criteria confirms that both phenomena have intertwined nature. moreover, during a natural outbreak, depending on the knowledge about its hazardousness and transmission, the infectious agent can be secondarily regarded as a biothreat agent, like it is now the case with the us department of justice currently considering people who intentionally spread the sars-cov-2 as terrorists [37] . however, these political considerations are far away from health workers and do not consider the public health issues of quick detection and response. indeed, even if the substantial remaining risk in the case of an attack is the possibility of secondary actions aiming to maximise damages to the emergency infrastructure [38] , the real challenge for global safety remains the early detection, the accurate characterisation and the establishment of specific measures, whatever the outbreak origin [39, 40] . during the covid-19 crisis, it had been estimated that the early detection and isolation of cases would have been more efficient to prevent infections than travel restrictions and contact reductions [41] . the challenge of an early detection some diseases like influenza are internationally monitored [42] while some others are subject to active surveillance in an outbreak context, like the ebola virus during the last outbreak in west africa [43] . for such well-known diseases, the case definition is clear and an outbreak is declared when the number of cases exceeds what has been expected [44] . this classic and passive way of detection is efficient but has numerous drawbacks as it requires an expensive and complex public health network and is often activated with a certain delay. however, when it comes to a new disease or pathologies with polymorphic or nonspecific symptoms, the case definition and the outbreak declaration threshold are subject to debate [45] . the source of the infection can be as unpredictable as the local outbreak of anthrax in reindeers triggered by a permafrost melting [46] or the detection of the variola virus in ancient mummies [47] . most of the time, the high volatility lying in the infectious process complicates the record of the cases. for the same exposition, symptoms can differ according to individual variables like health status or genetic factors [48] or to collective variables involved, for example, in the chain of transmission [49] but also cultural or socio-economic factors: the most-disadvantaged individuals will develop more severe and hence more specific forms of the disease but will have a belated use of health care [50] . on the other hand, systematic environment monitoring for all diseases is, for now, impossible due to technological barriers and cost challenges. experts in biodefense suggested that more targeted measurements in delimited spaces or during a large gathering of people should be the priority to improve the sensitivity and specificity of the early detection of a biological attack but, also for a natural outbreak, while reducing the cost [51] . for example, the analysis of wastewater could be a good way to monitor the spread of sars-cov-2 in the community [52] . however, these measurements should always be paired with epidemiological investigations to avoid any misinterpretation of the results [51] . thus, for the moment, health workers would first notice an unusual event (disease or an unusual number of cases) and should be able to alert public health officials [44] as protecting themselves from contagiousness. given the importance of early detection, training has to be a building block in infectious diseases programs in order to promote unusual event awareness [53] . the implementation of information technologies leaves room for improvement in the outbreak detection process [54] as more and more stakeholders of the health care system use informatics tools in their daily practice. yet, considerable efforts have been made on information technologies and electronic query of a data set to improve the efficiency of surveillance [55] . it's an imperative prerequisite for the implementation of an electronically assisted surveillance. currently, data management tools can aggregate several inputs and are already used for epidemiological studies or trigger an alert [56] . internet-based surveillance systems offer a logistically and economically appealing extension to this traditional surveillance approach. the results are immediate and allow access to a paucisymptomatic population or people who are not using the health care system [57] . this methodology has been used in 2020 in china to reconstruct the progression of the sars-cov-2 outbreak [58] . despite ethical concerns and regulatory barriers, social networks appear to be a powerful data collection tool and can also be used as a medium to communicate sanitary messages or alerts [59] . however, here again, these data are subject to many biases and should be carefully interpreted. indeed, the simple act of online documentation is just an indi-rect marker of disease, and such detection system could trigger an alert just because a worldwide released blockbuster movie increases the anxiety of population or a massive hacking produces millions of requests. taken to its logical extreme, the next step of this epidemiologic watch would probably allow the contribution of the internet of things (iot) already used to follow chronic illness [60] and for biomedical research [61] . a smartphone or a smartwatch is now able to detect modifications of vital parameters like temperature or heart rate. the capability of crossing these types of information with, for example, geotracking solutions, could alert competent authorities on an ongoing infection and help them to implement more rapidly appropriate measures and focus on a possible source of contamination. this seems to be only the beginning of iot possibilities as the future could be even more connected with the development of projects like smart cities. nowadays, china is already using video surveillance systems to follow its citizens and detect incivilities [62] . likewise, criminality hot spots prediction by artificial intelligence (ai) is no more fictional in los angeles [63] . these new technologies already have some applications in epidemiology as the detection in real-time of restaurants with a higher risk to be sources of foodborne diseases [64] . in the medical field, computers start to help clinicians in the diagnostic of mental illness through the facial expressions and head gesture in a video [65] but could also be used to detect an infectious disease at the prodromal phase with potential highest efficiency than thermic portals. the crossing data obtained from surveillance systems combined with machine learning capabilities in prediction and diagnostic could be used to help early detection of an infectious phenomenon in a population. this early detection could guide further specific actions of screening to identify potential patients and even the source of the infection. in korea, during the covid-19 crisis, gps from cellular phone, credit card transaction log and video footage had been used to monitor the patient's contact and avoid further transmissions [66] . however, the implementation of such surveillance systems is not without legal and ethical issues and should be carefully considered. the privacy policy has to be carefully examined as well as the securing of the transmission and storage of sensitive medical data, not to mention the possible human rights abuses in non-democratic countries [67] . these concerns have already been raised during the current covid-19 pandemic [68] but there is still no international consensus on the use of personal data. pending the advent of ai tools, many initiatives have been recently proposed to facilitate the investigation of epidemics in the genomic era. the whole-genome sequencing already can help to determine the origin of an outbreak and also to explain the dispersion of the pathogen through its local evolution [69] . new tools may include online data processing [70] up to the development of original algorithms to aggregate spatial, temporal, epidemiological and genomic data [71] . the interactions of this technological surveillance system with the previously described classic one are also possible at the condition to continue to improve the data-sharing practices [72] . the use of the nextstrain tool [73] in the context of sars-cov-2 (https://nextstrain.org/ncov) perfectly illustrates the potential of such approaches in the context of spreading epidemics [74] . in the years to come, the epidemiological monitoring system of our societies will probably rely on economic capacities, technical development capabilities and societal choices, with the common objective to early detect outbreaks, regardless of their causes (). even if the epidemiological monitoring is the crucial step to respond to an outbreak, detection is useless if the resources to deal with the crisis are unavailable. being prepared includes but is not limited to health workers being trained to detect, react and alert the health authorities: quick and reliable equipment has to be available and health workers have to be used to work with them. dedicated infrastructures have to be prepared and ready for activation and personal protective equipment (ppe), intensive care devices and treatments have to be stockpiled. the covid-19 crisis revealed that the lack of simple ppe put the all health system at high risk [75] . several authorities (civilians or militaries, governmental or non-governmental entities) already have some contingency plans but the compartmentalisation between different governmental branches and the nebulous labelling of the means between natural outbreak or bioterrorist attack dedicated sometimes prevent an accurate global appreciation [76] . as it is, and as unfortunately still demonstrated during the covid-19 pandemic, if an outbreak would occur, there is a risk, even for the highly trained first aid service in the most developed countries, to get in each other's way. by learning how to work together, synergies could be developed to improve health response [77] . after the failure in the control of the last ebola virus outbreak by the who, international agencies called for better international preparation to respond to future outbreaks [78] . thus, international and european research networks managed to improve the speed and effectiveness of the present deployment on a validated diagnostic workflow for sars-cov-2 [79] . this demonstrating the response capacity that can be released through the coordinated action of academic and public laboratories like pre-pare [80] . in 2020, in china, coordination by the central authority allowed to deploy medical staff and built new hospitals in wuhan in a tight schedule. in europe, crisis management strategies were different among countries, but cooperation helped relieve overloaded intensive care units in some regions and saved lots of patients. in the meantime, other consortiums like grace may also help us to prepare the possible future sanitary crisis [81] . developments of ai do not only help for early detection, but make available a full set of possibilities in crisis management to the authorities. by using classic risk analysis documentation with ai tools, it is now possible to generate predictions to improve the resilience of a system and to mitigate the risk [82] . the preparation phase of the crisis can also benefit from ai tools by ordering the reuse of information from previous crises [83] , improving the stockholders' training with a serious game approach [84] , helping to design realistic plans [85] or even boosting the discovery of new drugs [86] . resources management can also be improved by the use of ai in terms of network structuration [87] as well as for the mean's allocation [88] . during the crisis, ai can also sort information from many sensors, merge it and make it relevant for the user responsible of the situation assessment [89] , which will be helped by a decision-support system [90] to design the best crisis response. for example, during the covid-19 crisis, social contact matrices had been used to project the benefit to maintain social distancing measures [91] . over the past ten years, epidemiological and mathematical modelling data were essential for risk characterisation and management during infectious disease outbreaks [92] but ironically, the rising power of ai systems will not erase the role of human experts [93] . indeed, intuition and emotions are known for a long time to be part of the decision-making process [94] . during crisis management, expert intuition developed through years of practice is described as more realistic than pure analytical thinking [95] . moreover, both intuition and creativity are part of the problem-solving process [96] . both experts and ai will have to learn how to work together and assist each other by developing collaborative intelligence, which will be the best way to solve complex problems (). this was experienced during the covid-19 crisis in which experts, assisted by simulations, had to make decisions to control the spread of a virus still little known. inevitably, to develop an anticipation-centred view required investment. the economic justification of such an investment was underlined for a long time (even before the amerithrax crisis) [97] , and recently, a panel of usa experts recommended reinforcing the biological threat characterisation research at a federal level with clear safety, ethical and practical guidelines [98] . splitting outbreaks into two causes is not cost-efficient and seems absurd as dangerous pathogens to human can be used for biological attacks but are first and foremost causing natural outbreaks [99] . however, studies about the burden-adjusted research intensity showed that diseases with a greater impact are still underfunded [100] in an economical context where citizens are more and more concerned by public expenses. indeed, if the vaccine policy implemented were economically profitable in the usa during the 2009 influenza pandemic [101] , a sim-ilar strategy caused substantial wastage in australia [102] . thus, authorities have to be very careful to dimension their actions appropriately, even though a delayed response is severely judged by public opinion as during the 2014 ebola outbreak [78] . hence, authorities and experts should improve the global contingency plans, especially on catastrophic biological risks, which represent a small portion of the biological threats but with substantial potential consequence for humanity [103] . for a health care system, the preparation for a biological attack [6, 104] or a natural outbreak [78, 105] is globally the same challenge. moreover, preparedness for biological attacks has a significant added value that helps to strengthen preparedness for natural outbreaks, and vice versa [104] . it is therefore economically interesting to consider the natural biological risk and the possibility of an attack as a single threat in the preparation of the response to an infectious event with epidemic potential. the crisis generated by the numerous deaths of covid-19 and the lockdown of billions of people will probably trigger a new evaluation of public policies to control outbreaks with the opportunity that the public opinion will look at it through fresh eyes. indeed, the uncertainty associated with scientific knowledge often challenges decision making and opens the way to the contestation of expertise [92] . sometimes, the best intentions can result in a health disaster, such as the deployment of a peacekeeping force and the cholera outbreak in haiti in 2010 [106] or the project of spreading some modified mosquitoes to fight against malaria [107] . technology allows us to modify organisms specifically leading to the reconstitution of the spanish influenza virus [108] or to unexpected results as a test for a new poxvirus vaccine resulted with an ultra-virulent strain able to neutralise the immune system [109] or, during research experiments mimicking natural phenomenon, the generation of highly-resistant b. anthracis spores [110] and viruses acquiring airborne transmission [111] . nowadays, these widely used technics appear to be almost obsolete in comparison with the new capacities of gene synthesis: a horsepox virus has been reconstructed using only internet-bought sequences [112] , and a new bacterium has been created de novo in a laboratory [113] . currently, the possibilities of genome editing technologies like crispr-cas9 seems to be limitless [114] . some malicious scenarios have already been imagined with a genetically modified virus infecting mosquitoes able to perform gene modification of crops in a field [115] . the south african â« coast â» project [116] that aimed at developing a bacterial agent able to selectively kill a part of the population could now be a terrifying technical possibility. thus, even if applications of some of these modified organisms may be highly beneficial, as the recycling complex wastes [117] , they are swamped in the middle of the wanderings reported by the media [118] . due to all these miscalculations and misguidances, society lost confidence in the authorities and national programs. it leads to society-born threats with notably the growing emergence of highly antibiotic-resistant bacteria due to the improper antibiotic use [119] or the re-emergence of nearly forgotten pathogens linked to the mistrust in public health programs like vaccination programs [120] . this lack of confidence extends to crisis management programs and can compromise outbreak management measures the same way it happened with the ebola outbreak in 2014 [121] or currently, with the beginning of the management of the covid-19 pandemic and the lockdown decision [122] . however, during the co-vid-19 pandemic, the transparency about its progress reported in real-time, for the first time in the outbreaks' history, lead to better comprehension and cooperation of people [123] . thus, every decision can have a dual nature and should be considered carefully before being implemented (). that is why, while encouraging research, technologies and their application must be controlled to avoid any misuse and major communication actions are needed to overcome the public reluctance. ethics in research and data publication must also be placed at the centre of researchers' concerns. the intricate nature of natural outbreaks and biological attacks is too important to consider them separately. to create an efficient way to detect and contain them, the first step is to anticipate them by performing continuous scientific and epidemiological monitoring. still, the most serious and unpredictable events are referred as "black swan events" and despite our inability to foresee their occurrence, knowledge keeps being the key concept to anticipate them [124] . thus, we need to continue and intensify networking at local, regional and global levels. stakeholders from a broader range of backgrounds must be involved to monitor the evolution of threats and update existing procedures by developing concrete and immediately applicable solutions in crisis. the biological crisis is becoming a field of expertise by itself, and it is no longer enough to be a specialist in crisis management, infectious disease or epidemiology to be able to understand the implications of their own decisions fully. new technologies and ai will have more impact on crisis management, and experts will have to better work with these tools to improve their preparedness. the evolution of threats as well as technologies developments will require permanent adjustments in the strategies to optimise the public health response. communication will also be a key point of the future strategies to promote the acceptance of financial and societal investment by both the public authorities and the population and to avoid false information spreading. current covid-19 crisis is the first pandemic to benefit from so much advanced research and several major articles are published every day. however, sars-cov-2 is probably not the deadliest virus we will ever have to fight. we must learn from this crisis while 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