Hospital-based autonomous pre-clinical screening of COVID-19: An emergency triage using a vital signs recording system, Paris-Ile de France region.

Abstract: The COVID-19 pandemic has had a dramatic toll worldwide on the populations but also has been essentially supported by the existing public health system, particularly hospital-based emergency wards and intensive care units. In France, the first cases were identified on the 24th of January 2020. The first epidemic sprout emerged in the Eastern part of the country and spread in two weeks towards the center to the Paris-region where it peaked on the 14th of April 2020. In Paris and the region around it, the intensity of the epidemic has increased significantly to have a strong impact on all public and private hospital systems in a few weeks. During France's 2020 COVID-19 epidemic, a private hospital went into a major organizational change of its Emergency Department which mainly included the use of a Telemedicine Booth for vitals automatic recording during triage procedures. The present study describes the organizational scheme adopted by the hospital and discusses the data of 1,844 patients that attended the facility over a month. While among them, 766 patients were engaged in an automated triage process supported by a Telemedicine Booth. Patients' clinical characteristics are comparable to those found in international literature during the COVID-19 pandemic. The use of the Telemedicine Booth as a screening process facilitated patients' flow. It usefully participated in the patient rapid orientation, relieving the hospital emergency department, actively contributes in a safe and secure environment highly trusted by the hospital staff and health workers. To our knowledge, the Telemedicine Booth use as a screening process during an epidemic constitutes the first contribution to such an innovative approach.


On the Front (Phone) Lines: Results of a COVID-19 Hotline in Northeast Ohio

Abstract: ABSTRACT Importance: Severe acute respiratory syndrome coronavirus (SARS-CoV-2) and the associated coronavirus disease of 2019 (COVID-19) have presented immense challenges for health care systems. Many regions have struggled to adapt to disruptions to health care practice and employ systems that effectively manage the demand for services. Objective: To examine the effectiveness of the first five weeks of a 24/7 physician-staffed COVID-19 hotline. Design: Cohort study using electronic health records. Setting: A single large health care system in Northeast Ohio. Participants: During 5 weeks of operation, 10,112 patients called the hotline (callers) and were evaluated by a registered nurse (RN) using standardized protocols. Of these, 4,213 (42%) were referred for a physician telehealth visit (telehealth patients). The mean age of callers was 42 years. 67% were female, 51% white, and 46% were on Medicaid or uninsured. Intervention: Physician telehealth visits for COVID-19. Main Outcomes and Measures: We describe clinical diagnosis, patient characteristics (age, sex race/ethnicity, smoking status, insurance status), and visit disposition. We use logistic regression to evaluate associations between patient characteristics, visit disposition and subsequent emergency department use, hospitalization, and SARS-Cov-2 PCR testing. Results: Common caller concerns included cough, fever, and shortness of breath. Most telehealth patients (79%) were advised to self-isolate at home, 14% were determined to be unlikely to have COVID-19, 3% were advised to seek emergency care, and 4% had miscellaneous other dispositions. A total of 287 (7%) patients had a subsequent ED visit, and 44 (1%) were hospitalized with a COVID-19 diagnosis. Of the callers, 482 (5%) had a COVID-19 test reported with 69 (14%) testing positive. Among patients advised to stay at home, 83% had no further face-to-face visits. In multivariable results, only a physician recommendation to seek emergency care was associated with emergency room use (OR=4.73, 95%CI 1.37-16.39, p=.014). Only older age was associated with having a positive test result. Conclusions and Relevance: Robust, physician-directed telehealth services can meet a wide range of needs during the acute phase of a pandemic, conserving scarce resources such as personal protective equipment and testing supplies and preventing the spread of infections to patients and health care workers.


Low albumin levels are associated with poorer outcomes in a case series of COVID-19 patients in Spain: a retrospective cohort study

Abstract: OBJECTIVE To describe the clinical characteristics and epidemiological features of severe (non-ICU) and critically patients (ICU) with COVID-19 at triage, prior hospitalization, in one of the main hospitals in The Balearic Islands health care system. DESIGN Retrospective observational study SETTING Son Llatzer University Hospital in Palma de Mallorca (Spain) PARTICIPANTS Among a cohort of 52 hospitalized patients as of 31 March 2020, 48 with complete demographic information and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive test, were analyzed. Data were collected between March 15th, 2020, and March 31th 2020, inclusive of these dates. MAIN OUTCOMES Clinical, vital signs and routine laboratory outcomes at the time of hospitalization, including symptoms reported prior to hospitalization. Demographics and baseline comorbidities were also collected. Mortality was reported at the end of the study. RESULTS 48 patients (27 non-ICU and 21 ICU) resident in Mallorca, Spain (mean age, 66 years, [range, 33-88 years]; 67% males) with positive SARS-CoV-2 infection were analyzed. There were no differences in age or sex among groups (p >.05). Initial symptoms included fever (100%), coughing (85%), dyspnea (76%), diarrhea (42%) and asthenia (21%). The majority of patients in this case series were hospitalized because of low SpO2 (SpO2 below 90%) and presentation of bilateral pneumonia (94%) at triage. ICU patients had a higher prevalence of dyspnea compared to non-ICU patients (95% vs 61%, p = .022). Acute respiratory syndrome (ARDS) was presented in 100% of the ICU-patients. All the patients included in the study required oxygen therapy. ICU-patients had lymphopenia as well as hypoalbuminemia. Inflammatory markers such as lactate dehydrogenase (LDH), C-reactive protein (CRP), and procalcitonin were significantly higher in ICU patients compared to non-ICU (p < .001).Lower albumin levels were associated with poor prognosis measured as longer hospital length (r= -0.472, p <.001) and mortality (r= -0.424, p=.003). Interestingly we also found, that MCV was lower among of those patients who died (p=.0002). As of April 28, 2020, 10 patients (8 ICU and 2 non-ICU) had died (21% mortality) and while 100% of the non-ICU patients had been discharged, 33% of ICU patients still remained hospitalized (5 in ICU and 2 had been transferred to ward). CONCLUSION Critically ill patients with COVID-19 present lymphopenia, hypoalbuminemia as well high levels of inflammation. Lower levels of albumin were associated with poorer outcomes in COVID-19 patients. Albumin might be of importance because of its association with disease severity in patients infected with SARS-CoV-2.


Simple triage scoring system predicting death and the need for critical care resources for use during epidemics.

Abstract: OBJECTIVES In the event of pandemic influenza, the number of critically ill victims will likely overwhelm critical care capacity. To date, no standardized method for allocating scarce resources when the number of patients in need far exceeds capacity exists. We sought to derive and validate such a triage scheme. DESIGN : Retrospective analysis of prospectively collected data. SETTING Emergency departments of two urban tertiary care hospitals. PATIENTS Three separate cohorts of emergency department patients with suspected infection, comprising a total of 5,133 patients. INTERVENTIONS None. MEASUREMENTS A triage decision rule for use in an epidemic was developed using only those vital signs and patient characteristics that were readily available at initial presentation to the emergency department. The triage schema was derived from a cohort at center 1, validated on a second cohort from center 1, and then validated on a third cohort of patients from center 2. The primary outcome for the analysis was in-hospital mortality. Secondary outcomes were intensive care unit admission and use of mechanical ventilation. MAIN RESULTS Multiple logistic regression demonstrated the following as independent predictors of death: a) age of >65 yrs, b) altered mental status, c) respiratory rate of >30 breaths/min, d) low oxygen saturation, and e) shock index of >1 (heart rate > blood pressure). This model had an area under the receiver operating characteristic curve of 0.80 in the derivation set and 0.74 and 0.76 in the validation sets. When converted to a simple rule assigning 1 point per covariate, the discrimination of the model remained essentially unchanged. The model was equally effective at predicting need for intensive care unit admission and mechanical ventilation. CONCLUSIONS If, as expected, patient demand far exceeds the capability to provide critical care services in an epidemic, a fair and just system to allocate limited resources will be essential. The triage rule we have developed can serve as an initial guide for such a process.


Critical care triaging in the shadow of COVID-19: Ethics considerations.

Abstract: Since the World Health Organization declared coronavirus disease 2019 (COVID-19) a Public Health Emergency of International Concern, COVID-19 infection and the associated mortality have increased exponentially, globally. South Africa (SA) is no exception. Concerns abound over whether SA's healthcare system can withstand a demand for care that is disproportionate to current resources, both in the state and private health sectors. While healthcare professionals in SA have become resilient and adept at making difficult decisions in the face of resource limitations, a surge in COVID-19 cases could place a severe strain on the country's critical care services and necessitate unprecedented rationing decisions. This could occur at two critical points: access to ventilation, and withdrawal of intensive care in non- responsive or deteriorating cases. The ethical dimensions of decision-making at both junctures merit urgent consideration.


Salivary gland disease in the era of COVID-19 pandemic

Abstract: Coronavirus disease 2019 (COVID-19) pandemic forced significant changes in current approach to outpatient evaluation of common otolaryngology complaints as hospitals around the world are trying to limit the spread of the virus and to preserve health care resources. These changes raise a lot of questions regarding patient triage and treatment decisions in clinical situations when it is unclear if the workup and management can be postponed. In this communication, we present our approach to evaluation and triage of new patients with complaints concerning for salivary gland disease.


Triaging moderate COVID-19 and other viral pneumonias from routine blood tests

Abstract: The COVID-19 is sweeping the world with deadly consequences. Its contagious nature and clinical similarity to other pneumonias make separating subjects contracted with COVID-19 and non-COVID-19 viral pneumonia a priority and a challenge. However, COVID-19 testing has been greatly limited by the availability and cost of existing methods, even in developed countries like the US. Intrigued by the wide availability of routine blood tests, we propose to leverage them for COVID-19 testing using the power of machine learning. Two proven-robust machine learning model families, random forests (RFs) and support vector machines (SVMs), are employed to tackle the challenge. Trained on blood data from 208 moderate COVID-19 subjects and 86 subjects with non-COVID-19 moderate viral pneumonia, the best result is obtained in an SVM-based classifier with an accuracy of 84%, a sensitivity of 88%, a specificity of 80%, and a precision of 92%. The results are found explainable from both machine learning and medical perspectives. A privacy-protected web portal is set up to help medical personnel in their practice and the trained models are released for developers to further build other applications. We hope our results can help the world fight this pandemic and welcome clinical verification of our approach on larger populations.


[Diagnosis and clinical management of 2019 novel coronavirus infection: an operational recommendation of Peking Union Medical College Hospital (V2.0)]

Abstract: Since December 2019, China has been experiencing an outbreak of new infectious disease caused by 2019 novel coronavirus (2019-nCoV). The clinical features include fever, coughing, shortness of breath, and inflammatory pulmonary infiltration revealed by X ray. China rapidly identified 2019-nCoV-related pneumonia a statutory infectious disease. To standardize the diagnosis and treatment of this new infectious disease, operational guidelines for the diagnosis and management of 2019-nCoV infection is accomplished by Peking Union Medical College Hospital.


Primary stratification and identification of suspected Corona virus disease 2019 (COVID-19) from clinical perspective by a simple scoring proposal

Abstract: In this Commentary, we would like to comment on the article titled "A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version)" as a featured article in Military Medical Research. In the guideline, except for "confirmed cases", "suspected cases", "close contact" and "suspicious exposure" were defined by clinical perspective based on epidemiological risk, clinical symptoms and auxiliary examination. Combined with our experience, we introduced a simple scoring proposal additionally based on not only CT imaging as strongly recommended by the guideline but also blood routine test, especially for primary screening of such patients in the out-patient department.


Revised Triage and Surveillance Protocols for Temporary Emergency Department Closures in Tertiary Hospitals as a Response to COVID-19 Crisis in Daegu Metropolitan City

Abstract: BACKGROUND: When an emergency-care patient is diagnosed with an emerging infectious disease, hospitals in Korea may temporarily close their emergency departments (EDs) to prevent nosocomial transmission. Since February 2020, multiple, consecutive ED closures have occurred due to the coronavirus disease 2019 (COVID-19) crisis in Daegu. However, sudden ED closures are in contravention of laws for the provision of emergency medical care that enable the public to avail prompt, appropriate, and 24-hour emergency medical care. Therefore, this study ascertained the vulnerability of the ED at tertiary hospitals in Daegu with regard to the current standards. A revised triage and surveillance protocol has been proposed to tackle the current crisis. METHODS: This study was retrospectively conducted at 6 level 1 or 2 EDs in a metropolitan city where ED closure due to COVID-19 occurred from February 18 to March 26, 2020. The present status of ED closure and patient characteristics and findings from chest radiography and laboratory investigations were assessed. Based on the experience from repeated ED closures and the modified systems that are currently used in EDs, revised triage and surveillance protocols have been developed and proposed. RESULTS: During the study period, 6 level 1 or 2 emergency rooms included in the study were shut down 27 times for 769 hours. Thirty-one confirmed COVID-19 cases, of whom 7 died, were associated with the incidence of ED closure. Typical patient presentation with respiratory symptoms of COVID-19 was seen in less than 50% of patients, whereas abnormal findings on chest imaging investigations were detected in 93.5% of the study population. The chest radiography facility, resuscitation rooms, and triage area were moved to locations outside the ED, and a new surveillance protocol was applied to determine the factors warranting quarantine, including symptoms, chest radiographic findings, and exposure to a source of infection. The incidence of ED closures decreased after the implementation of the revised triage and surveillance protocols. CONCLUSION: Triage screening by emergency physicians and surveillance protocols with an externally located chest imaging facility were effective in the early isolation of COVID-19 patients. In future outbreaks of emerging infectious diseases, efforts should be focused toward the provision of continued ED treatment with the implementation of revised triage and surveillance protocols.


Rapid De-Escalation and Triaging Patients in Community-Based Palliative Care

Abstract: CONTEXT: The coronavirus disease 2019 (COVID-19) pandemic created a rapid and unprecedented shift in our medical system. Medical providers, teams, and organizations have needed to shift their visits away from face-to-face visits and toward telehealth (both by phone and through video). Palliative care teams who practice in the community setting are faced with a difficult task: How do we actively triage the most urgent visits while keeping our vulnerable patients safe from the pandemic? MEASURES: The following are recommendations created by the Palo Alto Medical Foundation Palliative Care and Support Services team to help triage and coordinate for timely, safe, and effective palliative care in the community and outpatient setting during the ongoing COVID-19 pandemic. Patients are initially triaged based on location followed by acuity. Interdisciplinary care is implemented using strict infection control guidelines in the setting of limited personal protective equipment resources. We implement thorough screening for COVID-19 symptoms at multiple levels before a patient is seen by a designated provider. CONCLUSIONS/LESSONS LEARNED: We recommend active triaging, communication, and frequent screening for COVID-19 symptoms for palliative care patients been evaluated in the community setting. An understanding of infection risk, mutual consent between designated providers, patients, and their families are crucial to maintaining safety while delivering community-based palliative care during the COVID-19 pandemic.


Risk factors for disease severity, unimprovement, and mortality in COVID-19 patients in Wuhan, China

Abstract: OBJECTIVE: In December 2019, coronavirus disease (COVID-19) emerged in Wuhan. However, the characteristics and risk factors associated with disease severity, unimprovement and mortality are unclear and our objective is to throw some light on these. METHODS: All consecutive patients diagnosed with COVID-19 admitted to the Renmin Hospital of Wuhan University from January 11 to February 6, 2020, were enrolled in this retrospective cohort study. RESULTS: A total of 663 COVID-19 patients were included in this study. Among these, 247 (37.3%) had at least one kind of chronic disease; 0.5% of the patients (n = 3) were diagnosed with mild COVID-19, while 37.8% (251/663), 47.5% (315/663), and 14.2% (94/663) were in moderate, severe, and critical conditions, respectively. In our hospital, during follow-up 251 of 663 patients (37.9%) improved and 25 patients died, a mortality rate of 3.77%. Older patients (>60 years old) and those with chronic diseases were prone to have a severe to critical COVID-19 condition, to show unimprovement, and to die (p <0.001, <0.001). Multivariate logistic regression analysis identified being male (OR = 0.486, 95%CI 0.311-0.758; p 0.001), having a severe COVID-19 condition (OR = 0.129, 95%CI 0.082-0.201; p <0.001), expectoration (OR = 1.796, 95%CI 1.062-3.036; p 0.029), muscle ache (OR = 0.309, 95%CI 0.153-0.626; p 0.001), and decreased albumin (OR = 1.929, 95%CI 1.199-3.104; p 0.007) as being associated with unimprovement in COVID-19 patients. CONCLUSION: Male sex, a severe COVID-19 condition, expectoration, muscle ache, and decreased albumin were independent risk factors which influence the improvement of COVID-19 patients.


Proposed Modifications in the 6-minutue Walk Test for Potential Application in Patients with mild Coronavirus Disease 2019 (COVID-19): A Step to Optimize Triage Guidelines


Organizing a COVID-19 triage unit: a Swiss perspective

Abstract: Background: With the rapid global spread of the acute respiratory syndrome coronavirus 2, urgent health-care measures have been implemented. We describe the organizational process in setting up a coronavirus disease 2019 triage unit in a Swiss tertiary care hospital. Methods: Our triage unit was set-up outside of the main hospital building and consists of three areas: 1. Pre-triage, 2. Triage, and 3. Triage plus. The Pre-triage check-points identify any potential COVID-19-infected patients and re-direct them to the main Triage area where trained medical staff screen which patients undergo diagnostic testing. If testing is indicated, nasopharyngeal swabs are performed. If patients require further investigations, they are referred to Triage plus. At this stage, patients are then discharged home after additional testing or admitted to the hospital for management. Observations: A total of 1265 patients were screened between 10 March 2020 and 12 April 2020 at our Triage unit. Of these, 112 (8.9%) tested positive. 73 (65%) of the positively-tested patients were female and 39 (35%) were male. The mean age for all patients was 43.8 years (SD 16.3 years). Distinguishing between genders, mean age for females was 41.1 (SD 16.5) and mean age for males was 48.6 (SD 14.9), with females being significantly younger than males (p < 0.001). Conclusion: Our triage unit was set-up as part of a large-scale restructuring process. Current challenges include low sensitivity for test results as well as limited staff and resources. We hope that our experience will help other health care institutions develop similar triage systems.


Luchtwegklachten in tijden van corona./ [Respiratory complaints in the time of COVID-19]

Abstract: The current guidelines for diagnosis and treatment of primary respiratory infections are still useful during the COVID-19 epidemic.Telephone triage of patients with respiratory complaints aims to identify patients with complications or an increased risk of complications.There are no indications to test for SARS-CoV-2 virus in general practice.During this COVID-19 epidemic, protective clothing is recommended in all physical contacts with patients with respiratory complaints.There is no reason to be cautious about using NSAIDs in patients suspected of COVID-19.Amoxicillin is first choice treatment for respiratory infections during the COVID-19 epidemic; there is lack of evidence to support azithromycin as a first choice.Respiratory rate > 24 / min or saturation <92-94% indicate imminent respiratory decompensation and may be reasons for referral.


Risk factors for adverse clinical outcomes with COVID-19 in China: a multicenter, retrospective, observational study

Abstract: Background: The risk factors for adverse events of Coronavirus Disease-19 (COVID-19) have not been well described. We aimed to explore the predictive value of clinical, laboratory and CT imaging characteristics on admission for short-term outcomes of COVID-19 patients. Methods: This multicenter, retrospective, observation study enrolled 703 laboratory-confirmed COVID-19 patients admitted to 16 tertiary hospitals from 8 provinces in China between January 10, 2020 and March 13, 2020. Demographic, clinical, laboratory data, CT imaging findings on admission and clinical outcomes were collected and compared. The primary endpoint was in-hospital death, the secondary endpoints were composite clinical adverse outcomes including in-hospital death, admission to intensive care unit (ICU) and requiring invasive mechanical ventilation support (IMV). Multivariable Cox regression, Kaplan-Meier plots and log-rank test were used to explore risk factors related to in-hospital death and in-hospital adverse outcomes. Results: Of 703 patients, 55 (8%) developed adverse outcomes (including 33 deceased), 648 (92%) discharged without any adverse outcome. Multivariable regression analysis showed risk factors associated with in-hospital death included ≥ 2 comorbidities (hazard ratio [HR], 6.734; 95% CI; 3.239-14.003, p < 0.001), leukocytosis (HR, 9.639; 95% CI, 4.572-20.321, p < 0.001), lymphopenia (HR, 4.579; 95% CI, 1.334-15.715, p = 0.016) and CT severity score > 14 (HR, 2.915; 95% CI, 1.376-6.177, p = 0.005) on admission, while older age (HR, 2.231; 95% CI, 1.124-4.427, p = 0.022), ≥ 2 comorbidities (HR, 4.778; 95% CI; 2.451-9.315, p < 0.001), leukocytosis (HR, 6.349; 95% CI; 3.330-12.108, p < 0.001), lymphopenia (HR, 3.014; 95% CI; 1.356-6.697, p = 0.007) and CT severity score > 14 (HR, 1.946; 95% CI; 1.095-3.459, p = 0.023) were associated with increased odds of composite adverse outcomes. Conclusion: The risk factors of older age, multiple comorbidities, leukocytosis, lymphopenia and higher CT severity score could help clinicians identify patients with potential adverse events.


Clinical characteristics and risk factors associated with COVID-19 disease severity in patients with cancer in Wuhan, China: a multicentre, retrospective, cohort study

Abstract: BACKGROUND: COVID-19 has spread globally. Epidemiological susceptibility to COVID-19 has been reported in patients with cancer. We aimed to systematically characterise clinical features and determine risk factors of COVID-19 disease severity for patients with cancer and COVID-19. METHODS: In this multicentre, retrospective, cohort study, we included all adult patients (aged ≥18 years) with any type of malignant solid tumours and haematological malignancy who were admitted to nine hospitals in Wuhan, China, with laboratory-confirmed COVID-19 between Jan 13 and March 18, 2020. Enrolled patients were statistically matched (2:1) with patients admitted with COVID-19 who did not have cancer with propensity score on the basis of age, sex, and comorbidities. Demographic characteristics, laboratory examinations, illness severity, and clinical interventions were compared between patients with COVID-19 with or without cancer as well as between patients with cancer with non-severe or severe COVID-19. COVID-19 disease severity was defined on admission on the basis of the WHO guidelines. Univariable and multivariable logistic regression, adjusted for age, sex, comorbidities, cancer type, tumour stage, and antitumour treatments, were used to explore risk factors associated with COVID-19 disease severity. This study was registered in the Chinese Clinical Trial Register, ChiCTR2000030807. FINDINGS: Between Jan 13 and March 18, 2020, 13â077 patients with COVID-19 were admitted to the nine hospitals in Wuhan and 232 patients with cancer and 519 statistically matched patients without cancer were enrolled. Median follow-up was 29 days (IQR 22-38) in patients with cancer and 27 days (20-35) in patients without cancer. Patients with cancer were more likely to have severe COVID-19 than patients without cancer (148 [64%] of 232 vs 166 [32%] of 519; odds ratio [OR] 3·61 [95% CI 2·59-5·04]; p<0·0001). Risk factors previously reported in patients without cancer, such as older age; elevated interleukin 6, procalcitonin, and D-dimer; and reduced lymphocytes were validated in patients with cancer. We also identified advanced tumour stage (OR 2·60, 95% CI 1·05-6·43; p=0·039), elevated tumour necrosis factor α (1·22, 1·01-1·47; p=0·037), elevated N-terminal pro-B-type natriuretic peptide (1·65, 1·03-2·78; p=0·032), reduced CD4+ T cells (0·84, 0·71-0·98; p=0·031), and reduced albumin-globulin ratio (0·12, 0·02-0·77; p=0·024) as risk factors of COVID-19 severity in patients with cancer. INTERPRETATION: Patients with cancer and COVID-19 were more likely to deteriorate into severe illness than those without cancer. The risk factors identified here could be helpful for early clinical surveillance of disease progression in patients with cancer who present with COVID-19. FUNDING: China National Natural Science Foundation.


Policies and Guidelines for COVID-19 Preparedness: Experiences from the University of Washington

Abstract: The Coronavirus Disease 2019 (COVID-19) pandemic initially presented in the United States in the greater Seattle area, and has rapidly progressed across the nation in the past 2 months, with the United States having the highest number of cases in the world. Radiology departments play a critical role in policy and guideline development both for the department and for the institutions, specifically in planning diagnostic screening, triage, and management of patients. In addition, radiology workflows, volumes and access must be optimized in preparation for the expected COVID-19 patient surges. This article discusses the processes that have been implemented at the University of Washington in managing the COVID-19 pandemic as well in preparing for patient surges, which may provide important guidance for other radiology departments who are in the early stages of preparation and management.


The ultrasound guided triage: a new tool for prehospital management of COVID-19 pandemic


Ethics in the Covid-19 emergency: Examining rationing decisions

Abstract: Early last month, the Italian Society of Anaesthesia was forced to publish the above guideline (1) for the country's hospitals. Besides the rising cases of infection, the doctors realised that patients required up to 15-20 days of intensive care as the disease progressed (2). In the face of medical resource scarcities, the guideline established that everyone could not be saved from the coronavirus. And a massive death toll ensued.


Rapid design and implementation of an integrated patient self-triage and self-scheduling tool for COVID-19

Abstract: OBJECTIVE: To rapidly deploy a digital patient-facing self-triage and self-scheduling tool in a large academic health system to address the COVID-19 pandemic. MATERIALS AND METHODS: We created a patient portal-based COVID-19 self-triage and self-scheduling tool and made it available to all primary care patients at the University of California, San Francisco Health, a large academic health system. Asymptomatic patients were asked about exposure history and were then provided relevant information. Symptomatic patients were triaged into 1 of 4 categories-emergent, urgent, nonurgent, or self-care-and then connected with the appropriate level of care via direct scheduling or telephone hotline. RESULTS: This self-triage and self-scheduling tool was designed and implemented in under 2 weeks. During the first 16 days of use, it was completed 1129 times by 950 unique patients. Of completed sessions, 315 (28%) were by asymptomatic patients, and 814 (72%) were by symptomatic patients. Symptomatic patient triage dispositions were as follows: 193 emergent (24%), 193 urgent (24%), 99 nonurgent (12%), 329 self-care (40%). Sensitivity for detecting emergency-level care was 87.5% (95% CI 61.7-98.5%). DISCUSSION: This self-triage and self-scheduling tool has been widely used by patients and is being rapidly expanded to other populations and health systems. The tool has recommended emergency-level care with high sensitivity, and decreased triage time for patients with less severe illness. The data suggests it also prevents unnecessary triage messages, phone calls, and in-person visits. CONCLUSION: Patient self-triage tools integrated into electronic health record systems have the potential to greatly improve triage efficiency and prevent unnecessary visits during the COVID-19 pandemic.


The role of triage in the prevention and control of COVID-19

Abstract: OBJECTIVE: To prevent and control public health emergencies, we set up a prescreening and triage workflow and analyzed the effects on coronavirus disease 2019 (COVID-19). METHODS: In accordance with the requirements of the level 1 emergency response of public health emergencies in Shaanxi Province, China, a triage process for COVID-19 was established to guide patients through a 4-level triage process during their hospital visits. The diagnosis of COVID-19 was based on positive COVID-19 nucleic acid testing according to the unified triage standards of the Guidelines for the Diagnosis and Treatment of Novel Coronavirus Pneumonia (Trial version 4),4 issued by the National Health Commission of the People's Republic of China. RESULTS: The screened rate of suspected COVID-19 was 1.63% (4 of 246) in the general fever outpatient clinic and 8.28% (13 of 157) in the COVID-19 outpatient clinic, and they showed a significant difference (P = .00). CONCLUSIONS: The triage procedure effectively screened the patients and identified the high-risk population.


The good, the bad and the ugly: pandemic priority decisions and triage

Abstract: In this analysis we discuss the change in criteria for triage of patients during three different phases of a pandemic like COVID-19, seen from the critical care point of view. Availability of critical care beds has become a hot topic, and in many countries, we have seen a huge increase in the provision of temporary intensive care bed capacity. However, there is a limit where the hospitals may run out of resources to provide critical care, which is heavily dependent on trained staff, just-in-time supply chains for clinical consumables and drugs and advanced equipment. In the first (good) phase, we can still do clinical prioritisation and decision-making as usual, based on the need for intensive care and prognostication: what are the odds for a good result with regard to survival and quality of life. In the next (bad phase), the resources are mostly available, but the system is stressed by many patients arriving over a short time period and auxiliary beds in different places in the hospital being used. We may have to abandon admittance of patients with doubtful prognosis. In the last (ugly) phase, usual medical triage and priority setting may not be sufficient to decrease inflow and there may not be enough intensive care unit beds available. In this phase different criteria must be applied using a utilitarian approach for triage. We argue that this is an important transition where society, and not physicians, must provide guidance to support triage that is no longer based on medical priorities alone.


A novel risk score to predict diagnosis with coronavirus disease 2019 (COVID-19) in suspected patients: A retrospective, multicenter, and observational study

Abstract: The aim of the study was to explore a novel risk score to predict diagnosis with COVID-19 among all suspected patients at admission. This was a retrospective, multicenter, and observational study. The clinical data of all suspected patients were analyzed. Independent risk factors were identified via multivariate logistic regression analysis. Finally, 336 confirmed COVID-19 patients and 139 control patients were included. We found nine independent risk factors for diagnosis with COVID-19 at admission to hospital: epidemiological exposure histories (OR:13.32; 95%CI, 6.39-27.75), weakness/fatigue (OR:4.51, 95%CI, 1.70-11.96), heart rate less than 100 beat/minutes (OR:3.80, 95%CI, 2.00-7.22), bilateral pneumonia (OR:3.60, 95%CI, 1.83-7.10), neutrophil count less than equal to 6.3 × 109 /L (OR: 6.77, 95%CI, 2.52-18.19), eosinophil count less than equal to 0.02 × 109 /L (OR:3.14, 95%CI, 1.58-6.22), glucose more than equal to 6 mmol/L (OR:2.43, 95%CI, 1.04-5.66), D-dimer ≥ 0.5 mg/L (OR:3.49, 95%CI, 1.22-9.96), and C-reactive protein less than 5 mg/L (OR:3.83, 95%CI, 1.86-7.92). As for the performance of this risk score, a cut-off value of 20 (specificity: 0.866; sensitivity: 0.813) was identified to predict COVID-19 according to reciever operator characteristic curve and the area under the curve was 0.921 (95%CI: 0.896-0.945; P < .01). We designed a novel risk score which might have a promising predictive capacity for diagnosis with COVID-19 among suspected patients.


Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations

Abstract: As coronavirus disease 2019 (COVID-19) spreads across the world, the intensive care unit (ICU) community must prepare for the challenges associated with this pandemic. Streamlining of workflows for rapid diagnosis and isolation, clinical management, and infection prevention will matter not only to patients with COVID-19, but also to health-care workers and other patients who are at risk from nosocomial transmission. Management of acute respiratory failure and haemodynamics is key. ICU practitioners, hospital administrators, governments, and policy makers must prepare for a substantial increase in critical care bed capacity, with a focus not just on infrastructure and supplies, but also on staff management. Critical care triage to allow the rationing of scarce ICU resources might be needed. Researchers must address unanswered questions, including the role of repurposed and experimental therapies. Collaboration at the local, regional, national, and international level offers the best chance of survival for the critically ill.


Triage of patients with COVID-19


Enhancing the triage and cohort of patients in public primary care clinics in response to the coronavirus disease 2019 (COVID-19) in Hong Kong: an experience from a hospital cluster


Updating the diagnostic criteria of COVID-19 "suspected case" and "confirmed case" is necessary

Abstract: On 6 February 2020, our team had published a rapid advice guideline for diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infection, and this guideline provided our experience and make well reference for fighting against this pandemic worldwide. However, the coronavirus disease 2019 (COVID-19) is a new disease, our awareness and knowledge are gradually increasing based on the ongoing research findings and clinical practice experience; hence, the strategies of diagnosis and treatment are also continually updated. In this letter, we answered one comment on our guideline and provided the newest diagnostic criteria of "suspected case" and "confirmed case" according to the latest Diagnosis and Treatment Guidelines for COVID-19 (seventh version) that issued by the National Health Committee of the People's Republic of China.


Extracorporeal Membrane Oxygenation for Pediatric Patients With Coronavirus Disease 2019-Related Illness

Abstract: OBJECTIVE: To describe current hospital guidelines and the opinions of extracorporeal membrane oxygenation leaders at U.S. children's hospitals concerning the use of extracorporeal membrane oxygenation for coronavirus disease 2019-positive pediatric patients. DESIGN: Confidential, self-administered questionnaire. SETTING: One hundred twenty-seven U.S. pediatric extracorporeal membrane oxygenation centers. SUBJECTS: Extracorporeal membrane oxygenation center program directors and coordinators. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In March 2020, a survey was sent to 127 pediatric extracorporeal membrane oxygenation centers asking them to report their current hospital extracorporeal membrane oxygenation guidelines for coronavirus disease 2019-positive patients. Respondents were also asked their opinion on three ethical dilemmas including: prioritization of children over adults for extracorporeal membrane oxygenation use, institution of do-not-resuscitate orders, and the use of extracorporeal cardiopulmonary resuscitation for coronavirus disease 2019-positive patients. Forty-seven extracorporeal membrane oxygenation centers had enacted guidelines including 46 (100%) that offer venovenous-extracorporeal membrane oxygenation and 42 (89%) that offer venoarterial-extracorporeal membrane oxygenation for coronavirus disease 2019-positive pediatric patients. Forty-four centers (94%) stated that the indications for extracorporeal membrane oxygenation candidacy in coronavirus disease 2019 disease were similar to those used in other viral illnesses, such as respiratory syncytial virus or influenza. Most program directors (98%) did not endorse that children hospitalized with coronavirus disease 2019 should be made do-not-resuscitate and had variable opinions on whether children should be given higher priority over adults when rationing extracorporeal membrane oxygenation. Over half of program directors (60%) did not support the use of extracorporeal cardiopulmonary resuscitation for coronavirus disease 2019. CONCLUSIONS: The majority of pediatric extracorporeal membrane oxygenation centers have proactively established guidelines for the use of extracorporeal membrane oxygenation for coronavirus disease 2019-related illnesses. Further work is needed to help guide the fair allocation of extracorporeal membrane oxygenation resources and to determine the appropriateness of extracorporeal cardiopulmonary resuscitation.


Prevention of respiratory outbreaks in the rehabilitation setting

Abstract: BACKGROUND: Respiratory viral (RV) outbreaks in rehabilitation facilities can jeopardise patient safety, interfere with patient rehabilitation goals and cause unit closures that impede patient flow in referring facilities. PROBLEM: Despite education about infection prevention practices, frequent RV outbreaks were declared each year at our rehabilitation facility. METHODS: Before and after study design. The primary outcome was the number of bed closure days due to outbreak per overall bed days. Process measures included delays in initiation of transmission-based precautions, RV testing and reporting of staff to occupational health and safety (OHS). Balancing measures included the number of isolation days and staff missed work hours. INTERVENTIONS: Based on comprehensive analysis of prior outbreaks, the following changes were implemented: (1) clear criteria for initiation of transmission-based precautions, (2) communication to visitors to avoid visitation if infectious symptoms were present, (3) exemption of staff absences if documented due to infectious illness, (4) development of an electronic programme providing guidance to staff about whether they should be excluded from work due to infectious illness. RESULTS: The number of bed closure days due to outbreak per overall bed days dropped from 2.8% to 0.5% during the intervention season and sustained at 0.6% during the postintervention season (p<0.001). There were fewer delays in initiation of droplet and contact precautions (28.8% to 15.5%, p=0.005) and collection of RV testing (42.9% to 20.3%, p<0.001), better reporting to OHS (9 vs 28.8 reports per 100 employees; p<0.001) and fewer isolation days (7.8% vs 7.3%; p=0.02) without a significant increase in missed work hours per 100 hours worked (4.0 vs 3.9; p=0.12). CONCLUSION: This Quality Improvement study highlights the process changes that can prevent respiratory outbreaks in the rehabilitation setting.


Updated rapid risk assessment from ECDC on the outbreak of COVID-19: increased transmission globally


Background Information: Isolation Routines

Abstract: The isolation of patients with suspected or documented infections—to not spread to others—has been discussed for hundreds of years. Guidelines are many, methods are different, attitudes show vide variations, routines and procedures are still changing, regulations by law may be absent, and some healthcare professionals may be afraid of adverse outcomes of isolation [1–44]. Microbes that are spread in the environment, on the hands and equipment are invisible. The invisible agent does not call on attention before the infection; clinical disease, hospital infection or nosocomial infection is a factum that can be registered [23, 28, 29, 35–37]. How to stop the transmission is often “to believe and not believe” in infection control.


Infection Control and the Need for Family-/Child-Centered Care

Abstract: Patient- and family-centered care (FCC) has become central to the delivery of medical care over the last 20 years and has been shown to improve patient outcomes. Infection control practices have the potential to greatly influence family centeredness and care providers, and hospital personnel must consider the potential impacts of isolation and the use of personal protective equipment (PPE). Approaching infection control with the perspective of FCC requires balancing patient safety and overall patient well-being. In this chapter, authors consider infection control and the benefits of FCC, family and sibling visitation, the use of playrooms, animals in healthcare settings including animal-assisted interventions, the potential adverse effects of infection control practices, and strategies to mitigate these impacts.


CDC updates quarantine rules


Surge Capacity


Disaster Mitigation


Chemical, Biologic, and Nuclear Quarantine


An outbreak of Severe Acute Respiratory Syndrome in a nursing home: Lessons to learn

Abstract: Hong Kong experienced an epidemic of Severe Acute Respiratory Syndrome (SARS) from March to June 2003. Nursing homes were a potential area of cross‐infection because of the crowded living space, substandard environmental hygiene, inadequate ventilation, low working staff to resident ratio, and staff who lacked knowledge of infection control. The mortality in elderly SARS patients was high because of their atypical presentations, their multiple comorbidities, and that they are more susceptible to the side‐effects of treatment. The community geriatric assessment team need to work closely with the hospitals and the primary health care system to provide surveillance of the disease, infection control, and management of sub‐acute clinical problems, in order to reduce unnecessary hospital admissions in nursing home residents during an epidemic outbreak.


Home-based exercise note in Covid-19 quarantine situation for office workers: A commentary.

Abstract: Staying at home for the prevention of Covid-19 virus is an accepted fact for everyone. Office workers are a group of people, who had to wake up early in the morning and at least had a fixed pattern of sleeping and working. In this situation, complaints about neck, shoulder and lower back tend to increase and this is a good time to learn and do some practical exercise at home. This letter presents some of the home-based exercise notes for prevention of musculoskeletal disorders among office workers, following the guidelines prepared by American College of Sports Medicine.


Delivering healthcare remotely to cardiovascular patients during COVID-19: A rapid review of the evidence.

Abstract: BACKGROUND Although attention is focused on addressing the acute situation created by the COVID-19 illness, it is imperative to continue our efforts to prevent cardiovascular morbidity and mortality, particularly during a period of prolonged social isolation which may limit physical activity, adversely affect mental health and reduce access to usual care. One option may be to deliver healthcare interventions remotely through digital healthcare solutions. Therefore, the aim of this paper is to bring together the evidence for remote healthcare during a quarantine situation period to support people living with cardiovascular disease during COVID-19 isolation. METHODS The PubMed, CINAHL and Google Scholar were searched using telehealth OR digital health OR mHealth OR eHealth OR mobile apps AND COVID-19 OR quarantine search terms. We also searched for literature relating to cardiovascular disease AND quarantine. RESULTS The literature search identified 45 potentially relevant publications, out of which nine articles were included. Three overarching themes emerged from this review: (1) preparing the workforce and ensuring reimbursement for remote healthcare, (2) supporting mental and physical health and (3) supporting usual care. CONCLUSION To support people living with cardiovascular disease during COVID-19 isolation and to mitigate the effects of quarantine and adverse effect on mental and physical well-being, we should offer remote healthcare and provide access to their usual care.


Home monitoring for COVID-19.

Abstract: Cleveland Clinic recognized the importance of mitigating community transmission of COVID-19 by keeping people at home. Patient-care activities quickly pivoted to remote touches, preserving continuity through a variety of digital and telephonic modalities. As the number of confirmed cases grew, standardizing home-based care became critical to managing high-risk patients, moderating the risk of exposure for healthcare workers, and reducing the amount of community spread through appropriate education on home-based care for exposed or infected individuals. This novel, team-based approach to caring for patients with COVID-19 incorporates a self-monitoring app for patient engagement, monitors symptoms for early intervention, and promotes a holistic view of care.


Effectiveness of quarantine measure on transmission dynamics of COVID-19 in Hong Kong

Abstract: The rapid expansion of COVID-19 has caused a global pandemic. Although quarantine measures have been used widely, the critical steps among them to suppress the outbreak without a huge social-economic loss remain unknown. Hong Kong, unlike other regions in the world, had a massive number of travellers from Mainland China during the early expansion period, and yet the spread of virus has been relatively limited. Understanding the effect of control measures to reduce the transmission in Hong Kong can improve the control of the virus spreading. We have developed a susceptible-exposed-infectious-quarantined-recovered (SEIQR) meta-population model that can stratify the infections into imported and subsequent local infections, and therefore to obtain the control effects on transmissibility in a region with many imported cases. We fitted the model to both imported and local confirmed cases with symptom onset from 18 January to 29 February 2020 in Hong Kong with daily transportation data and the transmission dynamics from Wuhan and Mainland China. The model estimated that the reproductive number was dropped from 2.32 to 0.76 (95% CI, 0.66 to 0.86) after an infected case was estimated to be quarantined half day before the symptom onset, corresponding to the incubation time of 5.43 days (95% CI, 1.30-9.47). If the quarantine happened about one day after the onset, community spread would be likely to occur, indicated by the reproductive number larger than one. The results suggest that the early quarantine for a suspected case before the symptom onset is a key factor to suppress COVID-19.


Forecasting the impact of the first wave of the COVID-19 pandemic on hospital demand and deaths for the USA and European Economic Area countries

Abstract: Summary Background: Hospitals need to plan for the surge in demand in each state or region in the United States and the European Economic Area (EEA) due to the COVID-19 pandemic. Planners need forecasts of the most likely trajectory in the coming weeks and will want to plan for the higher values in the range of those forecasts. To date, forecasts of what is most likely to occur in the weeks ahead are not available for states in the USA or for all countries in the EEA. Methods: This study used data on confirmed COVID-19 deaths by day from local and national government websites and WHO. Data on hospital capacity and utilisation and observed COVID-19 utilisation data from select locations were obtained from publicly available sources and direct contributions of data from select local governments. We develop a mixed effects non-linear regression framework to estimate the trajectory of the cumulative and daily death rate as a function of the implementation of social distancing measures, supported by additional evidence from mobile phone data. An extended mixture model was used in data rich settings to capture asymmetric daily death patterns. Health service needs were forecast using a micro-simulation model that estimates hospital admissions, ICU admissions, length of stay, and ventilator need using available data on clinical practices in COVID-19 patients. We assume that those jurisdictions that have not implemented school closures, non-essential business closures, and stay at home orders will do so within twenty-one days. Findings: Compared to licensed capacity and average annual occupancy rates, excess demand in the USA from COVID-19 at the estimated peak of the epidemic (the end of the second week of April) is predicted to be 9,079 (95% UI 253-61,937) total beds and 9,356 (3,526-29,714) ICU beds. At the peak of the epidemic, ventilator use is predicted to be 16,545 (8,083-41,991). The corresponding numbers for EEA countries are 120,080 (119,183-121,107), 32,291 (32,157-32,425) and 28,973 (28,868-29,085) at a peak of April 6. The date of peak daily deaths varies from March 30 through May 12 by state in the USA and March 27 through May 4 by country in the EEA. We estimate that through the end of July, there will be 60,308 (34,063-140,381) deaths from COVID-19 in the USA and 143,088 (101,131-253,163) deaths in the EEA. Deaths from COVID-19 are estimated to drop below 0.3 per million between May 4 and June 29 by state in the USA and between May 4 and July 13 by country in the EEA. Timing of the peak need for hospital resource requirements varies considerably across states in the USA and across regions of Europe. Interpretation: In addition to a large number of deaths from COVID-19, the epidemic will place a load on health system resources well beyond the current capacity of hospitals in the USA and EEA to manage, especially for ICU care and ventilator use. These estimates can help inform the development and implementation of strategies to mitigate this gap, including reducing non-COVID-19 demand for services and temporarily increasing system capacity. The estimated excess demand on hospital systems is predicated on the enactment of social distancing measures within three weeks in all locations that have not done so already and maintenance of these measures throughout the epidemic, emphasising the importance of implementing, enforcing, and maintaining these measures to mitigate hospital system overload and prevent deaths.


How to improve adherence with quarantine: Rapid review of the evidence

Abstract: Objectives: The January 2020 outbreak of coronavirus has once again thrown the vexed issue of quarantine into the spotlight, with many countries asking their citizens to self-isolate if they have potentially come into contact with the infection. However, adhering to quarantine is difficult. Decisions on how to apply quarantine should be based on the best available evidence to increase the likelihood of people adhering to protocols. We conducted a rapid review to identify factors associated with adherence to quarantine during infectious disease outbreaks. Study design: Rapid evidence review. Methods: We searched Medline, PsycINFO and Web of Science for published literature on the reasons for and factors associated with adherence to quarantine during an infectious disease outbreak. Results: We found 3163 papers and included 14 in the review. Adherence to quarantine ranged from as little as 0 up to 92.8%. The main factors which influenced or were associated with adherence decisions were the knowledge people had about the disease and quarantine procedure, social norms, perceived benefits of quarantine and perceived risk of the disease, as well as practical issues such as running out of supplies or the financial consequences of being out of work. Conclusions: People vary in their adherence to quarantine during infectious disease outbreaks. To improve this, public health officials should provide a timely, clear rationale for quarantine and information about protocols; emphasise social norms to encourage this altruistic behaviour; increase the perceived benefit that engaging in quarantine will have on public health; and ensure that sufficient supplies of food, medication and other essentials are provided.


A study on control of novel corona-virus (2019-nCoV) disease process by using PID controller

Abstract: In this paper, the SEIR dynamic model will be used to model the epidemic of coronvirus (2019-nCoV)disease. The SEIR model has been used to model infectious diseases in Malaysia.Then, the spread and control of the disease is simulated applying a PID controller. The results of this study show that the implementation of strict restrictions such as quarantine, social distancing and closure of gathering centers is effective in controlling the disease. Using the results and analyzing them, it was found that early and strict implementation of strict restrictions such as quarantine, social distance and closure of centers with a high percentage of community is very important to control this disease and prevent irreparable economic losses and depreciation of medical staff


Modelling potential responses to severe acute respiratory syndrome in Japan: the role of initial attack size, precaution, and quarantine.

Abstract: BACKGROUND There has been an outbreak of the severe acute respiratory syndrome (SARS) worldwide. With the use of detailed epidemiological data from other countries, this article describes the possible reason for the SARS epidemic not appearing in Japan, and simulates the impact of different control strategies that can break the transmission cycle of SARS associated coronavirus. METHOD Mathematical modelling is used for predicting the epidemiological outcome and simultaneously for evaluating the effect of interventions on SARS. The study estimates the initial attack size that would result in failed invasion. Three different interventions have been incorporated into the public health response policies; precautionary public health measures, isolation of infected people, and quarantine of exposed humans. RESULTS The maximum number of humans newly infected could be roughly estimated on the basis of the initial attack size, using simple formulas. It is seen that the introduction of only a few cases into certain communities would not lead easily to an epidemic. The possible trajectories of SARS epidemic depend on the levels of public health interventions as quarantine and precautionary public health measures greatly affected the transmissibility of the disease. It is shown that there exist threshold levels of interventions at which the SARS epidemic settles down. CONCLUSION Initial attack size is one of the determinants of whether SARS can successfully invade the community or not. Two of the most effective policy procedures to prevent new infections would be to apply stringent precautionary measures and to impose quicker and more effective quarantine of the exposed populace.


Active and inactive quarantine in epidemic spreading on adaptive activity-driven networks

Abstract: We consider an epidemic process on adaptive activity-driven temporal networks, with adaptive behaviour modelled as a change in activity and attractiveness due to infection. By using a mean-field approach, we derive an analytical estimate of the epidemic threshold for SIS and SIR epidemic models for a general adaptive strategy, which strongly depends on the correlations between activity and attractiveness in the susceptible and infected states. We focus on a strong adaptive behaviour, implementing two types of quarantine inspired by recent real case studies: an active quarantine, in which the population compensates the loss of links rewiring the ineffective connections towards non-quarantining nodes, and an inactive quarantine, in which the links with quarantined nodes are not rewired. Both strategies feature the same epidemic threshold but they strongly differ in the dynamics of active phase. We show that the active quarantine is extremely less effective in reducing the impact of the epidemic in the active phase compared to the inactive one, and that in SIR model a late adoption of measures requires inactive quarantine to reach containment.


Home-based exercise note in Covid-19 quarantine situation for office workers: A commentary


Integrated Hospital Quarantine System against COVID-19


Reducing onward spread of COVID-19 from imported cases: quarantine and 'stay at home' measures for travellers and returning residents to Singapore


Is a COVID19 Quarantine Justified in Chile or USA Right Now?

Abstract: During the current COVID-19 pandemic it is imperative to give early warnings to reduce mortality. However, non-specialist such as authorities and the general population face several problems to understand the real thread of this pandemic, and under/overestimation of its risk are a commonplace in the press and social media. Here we define an index, which we call the COVID-19 Burden Index, that relates the capacities of the healthcare system of a given country to treat severe and critical cases. Its value is 0 if there is no extra strain in the healthcare system, and it reaches 1.0 when the collapse is imminent. As of 23 March 2020, we show that Chile, the USA, UK, among other countries, must reduce the rate of infections right now, otherwise, in less than 7 days they could be in a catastrophic situation such as Italy, Spain and Iran.


Spatio-temporal propagation of COVID-19 pandemics

Abstract: The new coronavirus known as COVID-19 is spread world-wide since December 2019. Without any vaccination or medicine, the means of controlling it are limited to quarantine and social distancing. Here we study the spatio-temporal propagation of the first wave of the COVID-19 virus in China and compare it to other global locations. We provide a comprehensive picture of the spatial propagation from Hubei to other provinces in China in terms of distance, population size, and human mobility and their scaling relations. Since strict quarantine has been usually applied between cities, more insight about the temporal evolution of the disease can be obtained by analyzing the epidemic within cities, especially the time evolution of the infection, death, and recovery rates which affected by policies. We study and compare the infection rate in different cities in China and provinces in Italy and find that the disease spread is characterized by a two-stages process. At early times, at order of few days, the infection rate is close to a constant probably due to the lack of means to detect infected individuals before infection symptoms are observed. Then at later times it decays approximately exponentially due to quarantines. The time evolution of the death and recovery rates also distinguish between these two stages and reflect the health system situation which could be overloaded.


On a quarantine model of coronavirus infection and data analysis

Abstract: Attempts to curb the spread of coronavirus by introducing strict quarantine measures apparently have different effect in different countries: while the number of new cases has reportedly decreased in China and South Korea, it still exhibit significant growth in Italy and other countries across Europe. In this brief note, we endeavour to assess the efficiency of quarantine measures by means of mathematical modelling. Instead of the classical SIR model, we introduce a new model of infection progression under the assumption that all infected individual are isolated after the incubation period in such a way that they cannot infect other people. Disease progression in this model is determined by the basic reproduction number $\mathcal{R}_0$ (the number of newly infected individuals during the incubation period), which is different compared to that for the standard SIR model. If $\mathcal{R}_0>1$, then the number of latently infected individuals exponentially grows. However, if $\mathcal{R}_0<1$ (e.g.~due to quarantine measures and contact restrictions imposed by public authorities), then the number of infected decays exponentially. We then consider the available data on the disease development in different countries to show that there are three possible patterns: growth dynamics, growth-decays dynamics, and patchy dynamics (growth-decay-growth). Analysis of the data in China and Korea shows that the peak of infection (maximum of daily cases) is reached about 10 days after the restricting measures are introduced. During this period of time, the growth rate of the total number of infected was gradually decreasing. However, the growth rate remains exponential in Italy. Arguably, it suggests that the introduced quarantine is not sufficient and stricter measures are needed.


Optimal quarantine strategies for COVID-19 control models

Abstract: Optimal control problems reflecting the finding of effective quarantine strategies are considered for two control SEIR~type models describing the spread of the COVID-19 virus in the human population. The properties of the corresponding optimal controls are established analytically by applying the Pontryagin maximum principle. The optimal solutions are obtained numerically using BOCOP 2.0.5 software. The behavior of the appropriate optimal solutions and their dependence on the basic reproductive ratio and length of quarantine are discussed in detail. Necessary conclusions are made.


Only strict quarantine measures can curb the coronavirus disease (COVID-19) outbreak in Italy, 2020

Abstract: Several Italian towns are under lockdown to contain the COVID-19 outbreak. The level of transmission reduction required for physical distancing interventions to mitigate the epidemic is a crucial question. We show that very high adherence to community quarantine (total stay-home policy) and a small household size is necessary for curbing the outbreak in a locked-down town. The larger the household size and amount of time in the public, the longer the lockdown period needed.


Assessing the Efficiency of Different Control Strategies for the Coronavirus (COVID-19) Epidemic

Abstract: The goal of this work is to analyse the effects of control policies for the coronavirus (COVID-19) epidemic in Brazil. This is done by considering an age-structured SEIR model with a quarantine class and two types of controls. The first one studies the sensitivity with regard to the parameters of the basic reproductive number R0 which is calculated by the next generation method. The second one evaluates different quarantine strategies by comparing their relative total number of deaths.


Recurrent PCR positivity after hospital discharge of people with coronavirus disease 2019 (COVID-19)


Epidemics, quarantine and mental health


Achieving Safe, Effective and Compassionate Quarantine or Isolation of Older Adults with Dementia in Nursing Homes.

Abstract: Abstract Nursing homes are facing the rapid spread of COVID-19 among residents and staff and are at the centre of the public health emergency due to the COVID-19 pandemic. As policy changes and interventions designed to support nursing homes are put into place, there are barriers to implementing a fundamental, highly effective element of infection control, namely the isolation of suspected or confirmed cases. Many nursing home residents have dementia, associated with impairments in memory, language, insight and judgment that impact their ability to understand and appreciate the necessity of isolation and to voluntarily comply with isolation procedures. While there is a clear ethical and legal basis for the involuntary confinement of people with dementia, the potential for unintended harm with these interventions is high, and there is little guidance for nursing homes on how to isolate safely, while maintaining the human dignity and personhood of the individual with dementia. In this commentary, we discuss strategies for effective, safe and compassionate isolation care planning, and present a case vignette of a person with dementia who is placed in quarantine on a dementia unit.


A method for evaluating health care workers’ personal protective equipment technique

Abstract: BACKGROUND: Given the potential for the transfer of infectious diseases among patients in isolation, health care workers (HCWs), and other patients in the hospital environment, the proper use of personal protective equipment (PPE) is paramount. The literature is limited regarding studies of HCWs’ use of PPE in patient care tasks. METHODS: A pilot study was conducted to examine the feasibility of using a simulated health care environment to assess HCWs’ technique when implementing standard airborne and contact isolation precautions. The participants (n = 10) were assigned patient care tasks based on their specific professional roles. The encounters were digitally recorded during donning and doffing of PPE, as well as during interactions with the simulated patient. Powdered fluorescent marker was used as a measure of contamination. RESULTS: The pilot data show various inconsistencies in the HCWs’ PPE technique. Each of the 10 participants committed at least one breach of standard airborne and contact isolation precautions. CONCLUSION: An expanded research study of HCW behaviors is needed to properly examine these contamination and exposure pathways. Training programs should be developed that emphasize the common errors in HCWs’ PPE technique.


Systems modeling in support of evidence-based disaster planning for rural areas

Abstract: Abstract The objective of this communication is to introduce a conceptual framework for a study that applies a rigorous systems approach to rural disaster preparedness and planning. System Dynamics is a well-established computer-based simulation modeling methodology for analyzing complex social systems that are difficult to change and predict. This approach has been applied for decades to a wide variety of issues of healthcare and other types of service capacity and delivery, and more recently, to some issues of disaster planning and mitigation. The study will use the System Dynamics approach to create computer simulation models as “what-if” tools for disaster preparedness planners. We have recently applied the approach to the issue of hospital surge capacity, and have reached some preliminary conclusions – for example, on the question of where in the hospital to place supplementary nursing staff during a severe infectious disease outbreak—some of which we had not expected. Other hospital disaster preparedness issues well suited to System Dynamics analysis include sustaining employee competence and reducing turnover, coordination of medical care and public health resources, and hospital coordination with the wider community to address mass casualties. The approach may also be applied to preparedness issues for agencies other than hospitals, and could help to improve the interactions among all agencies represented in a community's local emergency planning committee. The simulation models will support an evidence-based approach to rural disaster planning, helping to tie empirical data to decision-making. Disaster planners will be able to simulate a wide variety of scenarios, learn responses to each and develop principles or best practices that apply to a broad spectrum of disaster scenarios. These skills and insights would improve public health practice and be of particular use in the promotion of injury and disease prevention programs and practices.


COVID-19 Outbreak and Cancer Radiotherapy Disruption in Lombardy, Northern Italy


“COVID-19 Drive Through Testing: An Effective Strategy for Conserving Personal Protective Equipment”


In states with prominent virus crisis, door wide open for move to telehealth

Abstract: Amid ever‐changing policy developments in response to the COVID‐19 crisis, many states have identified loosening restrictions on telehealth services as a front‐burner item. This has allowed mental health provider agencies, particularly in the states hardest hit so far by the virus that causes COVID‐19, to move more quickly to transition in‐person outpatient services to telehealth.


Recommendations for protecting against and mitigating the COVID-19 pandemic in long-term care facilities

Abstract: Abstract The COVID-19 outbreak has drawn heightened attention from public health scholars researching ways to limit its spread. Much of the research has been focused on minimizing transmission in hospitals and in the general community. However, a particularly vulnerable community that has received relatively little attention is elders residing in long-term care facilities (LTCFs). In this article we address this relative lack of attention, arguing that enhanced traffic control bundling (eTCB) can and should be adopted and implemented as a means of protecting LTCF residents and staff. Enhanced TCB has been widely applied in hospital settings and has proven effective at limiting droplet and fomite transmissions both within hospitals and between hospitals and the general community. By effectively adapting eTCB to LTCF conditions, particularly by incorporating compartmentalization within zones plus active surveillance, COVID-19 transmission into and throughout LTCFs can be minimized, thereby saving numerous lives among an especially vulnerable population.


The 1995 Kikwit Ebola outbreak: lessons hospitals and physicians can apply to future viral epidemics

Abstract: Abstract Objective This article looks at lessons learned from the 1995 Kikwit Ebola outbreak and suggests how modern hospitals should apply these lessons to the next lethal viral epidemic that occurs. Method The 1995 Kikwit Ebola outbreak in the Democratic Republic of the Congo (formally Zaire) is one of the most well studied epidemics to have occurred to date. Many of the lessons learned from identifying, containing and treating that epidemic are applicable to future viral outbreaks, natural disasters and bioterrorist attacks. This is due to Ebola's highly contagious nature and high mortality rate. Results When an outbreak occurs, it often produces fear in the community and causes the basic practice of medicine to be altered. Changes seen at Kikwit included limited physical examinations, hesitance to give intravenous medications and closure of supporting hospital facilities. The Kikwit Ebola outbreak also provided beneficial psychological insight into how patients, staff and the general community respond to a biological crisis and how this will affect physicians working in an epidemic. Conclusions General lessons from the outbreak include the importance of having simple, well-defined triage procedures; staff who are flexible and able to adapt to situations with unknowns; and the need to protect staff physically and emotionally to ensure a sustained effort to provide care.


Contributions and challenges of general practitioners in China fighting against the novel coronavirus crisis


Use of quarantine in the control of SARS in Singapore

Abstract: BACKGROUND: A total of 238 cases of the severe acute respiratory syndrome (SARS) occurred in Singapore between February 25 and May 11, 2003. Control relied on empirical methods to detect early and isolate all cases and quarantine those who were exposed to prevent spread in the community. METHODS: On April 28, 2003, the Infectious Diseases Act was amended in Parliament to strengthen the legal provisions for serving the Home Quarantine Order (HQO). In mounting large-scale quarantine operations, a framework for contact tracing, serving quarantine orders, surveillance, enforcement, health education, transport, and financial support was developed and urgently put in place. RESULTS: A total of 7863 contacts of SARS cases were served with an HQO, giving a ratio of 38 contacts per case. Most of those served complied well with quarantine; 26 (0.03%) who broke quarantine were penalized. CONCLUSION: Singapore's experience underscored the importance of being prepared to respond to challenges with extraordinary measures. With emerging diseases, health authorities need to rethink the value of quarantine to reduce opportunities for spread from potential reservoirs of infection.


Advocates for the homeless seeking funding for COVID‐19

Abstract: Now that the federal $8.3 billion appropriations bill has passed and been signed into law this month to stem the spread of the new coronavirus (COVID‐19), advocates are hoping some of that funding reaches one of this country's most vulnerable populations: the homeless.


Are infection control measures helpful in reducing paediatric ward infections?

Abstract: As the majority of children on paediatric wards, especially in winter, have infections all paediatricians will be involved in infection control and prevention (ICP) without realising it. ICP measures include decisions on isolation of patients, which can be difficult with small numbers of cubicles. Children, who are highly infectious, have potential severe infections and those who are more at risk of developing severe infections (e.g. immunocompromised) should be isolated. Handwashing/decontamination is the central and most essential part of ICP measures. It should be actively encouraged and regularly monitored to ensure adherence. The ward layout will influence how we manage ICP. This includes placement and number of alcohol dispensers, sinks, bathrooms, equipment storage and the number of cubicles. It is also worth reviewing ward cleaning policies to assess whether these can be streamlined, potentially freeing up beds/cubicles earlier and leading to cost improvement without putting patients and staff at risk. We encourage all our staff to be fully vaccinated (including seasonal influenza vaccines and MMR). Paediatricians need to be closely involved in antibiotic stewardship and act as role models for all aspects of infection control, particularly proper handwashing.


Self-contamination during doffing of personal protective equipment by healthcare workers to prevent Ebola transmission

Abstract: BACKGROUND: Healthcare workers (HCWs) use personal protective equipment (PPE) in Ebola virus disease (EVD) situations. However, preventing the contamination of HCWs and the environment during PPE removal crucially requires improved strategies. This study aimed to compare the efficacy of three PPE ensembles, namely, Hospital Authority (HA) Standard Ebola PPE set (PPE1), Dupont Tyvek Model, style 1422A (PPE2), and HA isolation gown for routine patient care and performing aerosol-generating procedures (PPE3) to prevent EVD transmission by measuring the degree of contamination of HCWs and the environment. METHODS: A total of 59 participants randomly performed PPE donning and doffing. The trial consisted of PPE donning, applying fluorescent solution on the PPE surface, PPE doffing of participants, and estimation of the degree of contamination as indicated by the number of fluorescent stains on the working clothes and environment. Protocol deviations during PPE donning and doffing were monitored. RESULTS: PPE2 and PPE3 presented higher contamination risks than PPE1. Environmental contaminations such as those originating from rubbish bin covers, chairs, faucets, and sinks were detected. Procedure deviations were observed during PPE donning and doffing, with PPE1 presenting the lowest overall deviation rate (%) among the three PPE ensembles (p < 0.05). CONCLUSION: Contamination of the subjects’ working clothes and surrounding environment occurred frequently during PPE doffing. Procedure deviations were observed during PPE donning and doffing. Although PPE1 presented a lower contamination risk than PPE2 and PPE3 during doffing and protocol deviations, the design of PPE1 can still be further improved. Future directions should focus on designing a high-coverage-area PPE with simple ergonomic features and on evaluating the doffing procedure to minimise the risk of recontamination. Regular training for users should be emphasised to minimise protocol deviations, and in turn, guarantee the best protection to HCWs. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1186/s13756-018-0433-y) contains supplementary material, which is available to authorized users.


Are We Ready? Evidence of Support Mechanisms for Canadian Health Care Workers in Multi-jurisdictional Emergency Planning

Abstract: BACKGROUND: Federal, provincial and municipal leaders in Canada have adopted a culture of preparedness with the development and update of emergency plans in anticipation of different types of disasters. As evident during the 2003 global outbreak of Severe Acute Respiratory Syndrome (SARS), it is important to provide support for health care workers (HCWs) who are vulnerable during infectious outbreak scenarios. Here we focus on the identification and evaluation of existing support mechanisms incorporated within emergency plans across various jurisdictional levels. METHODS: Qualitative content analysis of 12 emergency plans from national, provincial and municipal levels were conducted using NVIVOTM software. The plans were scanned and coded according to 1) informational, 2) instrumental, and 3) emotional support mechanisms for HCWs and other first responders. RESULTS: Emergency plans were comprised of a predominance of informational and instrumental supports, yet few emotional or social support mechanisms. All the plans lacked gender-based analysis of how infectious disease outbreaks impact male and female HCWs differently. Acknowledgement of the need for emotional supports was evident at higher jurisdictional levels, but recommended for implementation locally. CONCLUSIONS: While support mechanisms for HCWs are included in this sample of emergency plans, content analysis revealed few emotional or social supports planned for critical personnel; particularly for those who will be required to work in extremely stressful conditions under significant personal risk. The implications of transferring responsibilities for support to local and institutional jurisdictions are discussed.


The active role of a blood center in outpacing the transfusion transmission of COVID-19


Review of Literature for Air Medical Evacuation High-Level Containment Transport

Abstract: Abstract Introduction Aeromedical evacuation (AE) is a challenging process, further complicated when a patient has a highly hazardous communicable disease (HHCD). We conducted a review of the literature to evaluate the processes and procedures utilized for safe AE high-level containment transport (AE-HLCT) of patients with HHCDs. Methods A literature search was performed in PubMed/MEDLINE (from 1966 through January 2019). Authors screened abstracts for inclusion criteria and full articles were reviewed if the abstract was deemed to contain information related to the aim. Results Our search criteria yielded 14 publications and were separated based upon publication dates, with the natural break point being the beginning of the 2013-2016 Ebola virus disease epidemic. Best practices and recommendations from identified articles are subdivided into pre-flight preparations, inflight operations, and post-flight procedures. Conclusions Limited peer-reviewed literature exists on AE-HLCT, including important aspects related to healthcare worker fatigue, alertness, shift scheduling, and clinical care performance. This hinders the sharing of best practices to inform evacuations and equip teams for future outbreaks. Despite the successful use of different aircraft and technologies, the unique nature of the mission opens the opportunity for greater coordination and development of consensus standards for AE-HLCT operations.


Addressing the Gaps in Preparation for Quarantine

Abstract: INTRODUCTION: In the event of an outbreak of a communicable respiratory illness, quarantine may become necessary. The New York Institute for All Hazard Preparedness (NYIAHP) of the State University of New York (SUNY) Downstate Medical Center, in cooperation with the New York City Department of Health and Mental Hygiene's Healthcare Emergency Preparedness Program, (NYC DOHMH-HEPP) quarantine working group, has developed a series of clinical protocols to help health care facilities respond to such an event. PROBLEM: Two full-scale exercises (FSEs) were designed and conducted a year apart in the quarantine unit at Kings County Hospital Center (KCHC) to test the efficacy and feasibility of these quarantine protocols. The goal of these exercises was to identify the gaps in preparedness for quarantine and increase hospital readiness for such an event. METHODS: Evaluators monitored for efficient management of critical physical plants, personnel and material resources. Players were expected to integrate and practice emergency response plans and protocols specific to quarantine. In developing the exercise objectives, five activities were selected for evaluation: Activation of the Unit, Staffing, Charting/Admission, Symptom Monitoring and Infection Control, and Client Management. RESULTS: The results of the initial FSE found that there were incomplete critical tasks within all five protocols: These deficiencies were detailed in an After Action Report and an Improvement Plan was presented to the KCHC Disaster Preparedness Committee a month after the initial FSE. In the second FSE a year later, all critical tasks for Activation of the unit, Staffing and Charting/Admission were achieved. Completion of critical tasks related to Symptom Monitoring and Infection Control and Client Management was improved in the second FSE, but some tasks were still not performed appropriately. CONCLUSION: In short, these exercises identified critical needs in disaster preparedness of the KCHC Quarantine Unit. The lessons learned from this logistical exercise enabled the planning group to have a better understanding of leadership needs, communication capabilities, and infection control procedures. Kings County Hospital Center performed well during these exercises. It was clear that performance in the second exercise was improved, and many problems noted in the first exercise were corrected. Staff also felt better prepared the second time. This supports the idea that frequent exercises are vital to maintain disaster readiness. R Nathawad, PM Roblin, D Pruitt, B Arquilla. Addressing the gaps in preparation for quarantine. Prehosp Disaster Med. 2013;28(2):1-7 23158909.


Management of inpatients exposed to an outbreak of severe acute respiratory syndrome (SARS)

Abstract: Abstract This is a prospective observational study of a cohort of inpatients exposed to a severe acute respiratory syndrome (SARS) outbreak. Strict infection control policies were instituted. The 70 patients exposed to the SARS outbreak were isolated from the rest of the hospital. They were triaged, quarantined and cohorted in three open plan wards. Selective isolation was carried out immediately when symptoms and signs suspicious of SARS manifested clinically. The patients' ages ranged from 21 to 90 years and 56% had surgery before the quarantine. Sixteen patients with unexplained fever during the period of quarantine were isolated, seven of whom were eventually diagnosed with probable SARS. The crude incidence of SARS in our cohort was 10%. The SARS case fatality was 14%. No secondary transmission of the SARS virus within the cohort was observed. Strict infection control, together with appropriate triaging, cohorting and selective isolation, is an effective and practical model of intervention in cohorts exposed to a SARS outbreak. Such a management strategy eases the logistic constraints imposed by demands for large numbers of isolation facilities in the face of a massive outbreak.


Preventing the Transmission of COVID-19 Amongst Healthcare Workers


Containing Emerging Epidemics: a Quantitative Comparison of Quarantine and Symptom Monitoring

Abstract: Strategies for containing an emerging infectious disease outbreak must be non-pharmaceutical when drugs or vaccines for the pathogen do not yet exist or are unavailable. The success of these non-pharmaceutical strategies will depend not only on the effectiveness of quarantine or other isolation measures but also on the epidemiological characteristics of the infection. However, there is currently no systematic framework to assess the relationship between different containment strategies and the natural history and epidemiological dynamics of the pathogen. Here, we compare the effectiveness of quarantine and symptom monitoring, implemented via contact tracing, in controlling epidemics using an agent-based branching model. We examine the relationship between epidemic containment and the disease dynamics of symptoms and infectiousness for seven case study diseases with diverse natural histories including Ebola, Influenza A, and Severe Acute Respiratory Syndrome (SARS). We show that the comparative effectiveness of symptom monitoring and quarantine depends critically on the natural history of the infectious disease, its inherent transmissibility, and the intervention feasibility in the particular healthcare setting. The benefit of quarantine over symptom monitoring is generally maximized for fast-course diseases, but we show the conditions under which symptom monitoring alone can control certain outbreaks. This quantitative framework can guide policy-makers on how best to use non-pharmaceutical interventions to contain emerging outbreaks and prioritize research during an outbreak of a novel pathogen. Quarantine and symptom monitoring of contacts with suspected exposure to an infectious disease are key interventions for the control of emerging epidemics; however, there does not yet exist a quantitative framework for comparing the control performance of each. Here, we use a mathematical model of seven case study diseases to show how the choice of intervention is influenced by the natural history of the infectious disease, its inherent transmissibility, and the intervention feasibility in the particular healthcare setting. We use this information to identify the most important characteristics of the disease and setting that need to be characterized for an emerging pathogen in order to make an informed decision between quarantine and symptom monitoring.


Appraisal of recommended respiratory infection control practices in primary care and emergency department settings

Abstract: BACKGROUND: The severe acute respiratory syndrome (SARS) epidemic and concern about pandemic influenza prompted the Centers for Disease Control and Prevention (CDC) to develop guidelines to prevent the transmission of all respiratory infections in health care settings during first contact with a potentially infected person. The extent to which health care workers and institutions use these CDC recommended practices is uncertain. METHODS: The study examined health care worker adherence to CDC recommended respiratory infection control practices in primary care clinics and emergency departments of 5 medical centers in King County, Washington, using a self-administered questionnaire. All clinical, allied, and administrative health care workers in study settings were invited to participate: 653 (53%) responded, and 630 were included. RESULTS: The survey revealed important shortcomings in overall personal and institutional use of CDC recommended practices, including deficiencies in posted alerts, patient masking and separation, hand hygiene, personal protective equipment, staff training, and written procedures. Use of recommended measures was generally higher among nursing staff than medical practitioners. CONCLUSION: This study found significant gaps in adherence to CDC recommendations for the control of respiratory infections in ambulatory care clinical settings. Practical strategies are needed to identify and reduce barriers to implementation of recommended practices for control of respiratory infections.


Changes in population movement make COVID-19 spread differently from SARS.

Abstract: This comment discusses the contribution of population movement to the spread of COVID-19, with a reference to the spread of SARS 17 years ago. We argue that the changing geography of migration, the diversification of jobs taken by migrants, the rapid growth of tourism and business trips, and the longer distance taken by people for family reunion are what make the spread of COVID-19 so differently from that of SARS. These changes in population movement are expected to continue. Hence, new strategies in disease prevention and control should be taken accordingly, which are also proposed in the comment.


A cluster of tertiary transmissions of 2019 novel coronavirus (SARS-CoV-2) in the community from infectors with common cold symptoms.

Abstract: Background/Aims As the global impact of the novel coronavirus disease 2019 (COVID-19) has been severe, many countries have intensified containment activities to eliminate virus transmission, through early detection and isolation strategies. To establish a proper quarantine strategy, it is essential to understand how easily the virus can spread in the communities. Methods In this study, we collected detailed information on the circumstances in which human-to-human transmission occurred in the tertiary transmission cases of COVID-19 in the community. Results On January 26, 2020, an imported case of COVID-19 was confirmed, and by February 10, 2020, one secondary transmission and three tertiary transmissions were identified. Secondary transmission occurred on the first day of illness of the infector, and his symptoms were suggestive of a common cold. The transmission occurred during a 90-minute long meal together in a restaurant. The people were sitting within one meter of each other, and had no direct contact. The tertiary transmission also occurred on the first-day illness of the other infector, and his only symptom was slight chills. The transmission occurred at a church during 2-hour-long worship, and two rows separated them. Conclusions Our findings suggest that mildly symptomatic patients with COVID-19 could transmit the virus from the first day of illness through daily activities in the community. Early detection and isolation of patients with COVID-19 may be challenging.


[Epidemiological analysis on a family cluster of COVID-19].

Abstract: Objective: To understand the possible transmission route of a family cluster of COVID-19 in Zhengzhou and the potential infectivity of COVID-19 in incubation period, and provide scientific evidence for the timely control of infectious source and curb the spread of the epidemic. Methods: Epidemiological investigation was conducted for a family cluster of COVID-19 (8 cases) with descriptive epidemiological method, and respiratory tract samples of the cases were collected for the nucleic acid detection of 2019-nCoV by RT-PCR. Results: Two primary cases, which occurred on 31 January and 1 February, 2020, respectively, had a common exposure history in Wuhan. The other six family members had onsets on 30 January, 31 January, 1 February (three cases) and 3 February, 2020. Conclusions: In this family cluster of COVID-19, six family members were infected through common family exposure to the 2 primary cases. Five secondary cases had onsets earlier than or on the same day as the primary cases, indicating that COVID-19 is contagious in incubation period, and the home isolation in the early phase of the epidemic might lead to the risk of family cluster of COVID-19.


Air pollution and COVID-19: Is the connect worth its weight?

Abstract: Primary route of transmission of SARS-CoV-2 among humans is droplets and direct contact. Airborne transmission of this virus is not established conclusively and so is the role of airborne particulate matter. This commentary examines the existing evidence about the role of particulate matter pollutants in SARS-CoV-2 transmission. PM2.5and other small particulate matter have been shown to carry viable virus particles in the air and incriminated in spread of measles and SARS coronavirus. Empirical evidence has been provided regarding role of air pollution in accelerated transmission of SARS-CoV-2 in Italy as well as Wuhan. Lockdown-related reduction in PM2.5levels in ambient air may have contributed to reduce transmission of SARS-CoV-2. High PM2.5levels in the past might have added to SARS-CoV-2 related mortality due to air pollution relate comorbidities. Post-lockdown increase in PM2.5levels may accelerate covid-19 transmission and can add to the burden of COVID-19 morbidity and mortality.


The Presence of SARS-CoV-2 RNA in Feces of COVID-19 Patients.

Abstract: BACKGROUND In December 2019, Coronavirus Disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), emerged in Wuhan, China, and has spread globally. However, the transmission route of SARS-CoV-2 has not been fully understood. In this study, we aimed to investigate the SARS-CoV-2 shedding in excreta of COVID-19 patients. METHODS Electronical medical records, including demographics, clinical characteristics, laboratory and radiological findings, of enrolled patients were extracted and analyzed. Pharyngeal swab, stool and urine specimens were collected and tested for SARS-CoV-2 RNA by RT-PCR. Viral shedding at multiple time points in specimens was recorded, and analyzed its correlation with clinical manifestations and the severity of illness. RESULTS A total of 42 laboratory-confirmed patients were enrolled, 8 (19.05%) of whom had gastrointestinal symptoms. 28 (66.67%) patients tested positive for SARS-CoV-2 RNA in stool specimens, which was not associated with the presence of gastrointestinal symptoms and the severity of illness. Among them, 18 (64.29%) patients remained positive for viral RNA in feces after pharyngeal swabs turned negative. The duration of viral shedding from feces after negative conversion in pharyngeal swabs was 7 (6-10) days, regardless of COVID-19 severity. The demographics, clinical characteristics, laboratory and radiologic findings did no differ between patients tested positive and negative for SARS-CoV-2 RNA in feces. Viral RNA was not detectable in urine specimens from 10 patients. CONCLUSIONS Our results demonstrated the presence of SARS-CoV-2 RNA in feces of COVID-19 patients, and suggested the possibility of SARS-CoV-2 transmission via the fecal-oral route. This article is protected by copyright. All rights reserved.