COVID-19 Pandemic

COVID-19 Pandemic

Coronaviruses are common animal and human pathogens that cause symptoms like breathing difficulty, pneumonia, fever, lung infection, and sweating. In December 2019, China announced pneumonia-like disease outbreak of unknown cause in Wuhan, Hubei province. Initial cases were associated with the Huanan seafood market in which live animals and aquatic animals were sold (Chowdhury, & Oommen, 2020). It quickly spread leading to an epidemic throughout the country and eventually to other countries in the world. Scientists discovered betacoronavirus from the lower respiratory tract samples of infected patient. The virus had similar characteristics to those viruses in the Coronoviridae family. In terms of phylogenetic, the virus resembled two bat derived coronavirus strains, MERS and SARS (Lu, Zhao, & Li, 2020).

In February 2020, the World Health Organization (WHO) named the disease 2019-novel Coronavirus (COVID-19). After assessing how quickly the disease spread across the globe, WHO declared it as a pandemic. As it is a new virus, a lot is not known about it.

Epidemiology of COVID-19

Since the first report from China, COVID-19 spread rapidly and cases soared exponentially. Thailand reported its first case in January11, 2020 and India January 30, 2020. By mid-March, India reported increased number of infected cases and reported its first COVID-related death in March 12.  In January 20, 2020, the Center for Disease Control confirmed first COVID-19 case in in Snohomish County, Seattle. It was a 35-year old man who had a 3-month trip to Wuhan. Swabs collected from the patient’s oropharyngeal and nasopharyngeal tested positive. the stool also tested positive for COVID. COVID-19 reached Brazil in the late February 2020 after which the country became a hotspot.  At the time of writing this work, there have been 168,535,322 confirmed COVID-19 cases and 3,500,047 deaths globally and 33,947,189 cases and 605,208 deaths in the United States. In Africa, the first case was reported in Egypt on February 2020 (Farrer,2020)

The reported case counts may underestimate the total burden of this pandemic, as only a portion of acute infections are reported. Indeed, seroprevalence surveys in Europe and the US indicate that after controlling potential false negatives or positives, the rate of previous exposure to COVID-19 surpasses the incidence of reported COVID-19 cases ten times or more (Havers et al. 2020; Stringhini et al., 2020).

The COVID-19 infection spectrum ranges from asymptomatic to mild, moderate, severe and critical disease. 5 percent of patients would have critical disease, which is described as the respiratory failure, multi-organ failure, often exacerbated by cytokine storm or any other immune hyper-activation (Wu, & McGoogan, 2020). The prevalent lab findings include increased aminoferases, increased lactate dehydrogenase and increased C reactive protein (Wang et al., 2020).

The COVID-19 case fatality rate averages 2.3 percent (Wu, & McGoogan, 2020). Case fatality rate is the number of confirmed deaths divided by the number of confirmed cases. Case fatality rate for COVID-19 is not constant but keeps changing. Common fatalities are individuals with underlying co-morbidities or advanced age. In addition to that, case fatality varies by region based on population features. As of May 27, 2021, Italy reported a case fatality rate of 3 percent, Brazil 2.78, India 1.1 percent and United States 1.78 percent. The high case fatality rate in Italy is attributed to the fact that the country has more of an older population.  In the US, patients with confirmed COVID-19 is 12-fold higher among those with comorbidities (Wu, & McGoogan, 2020). Severe illness like diabetes mellitus, cardiovascular disease, smoking, obesity, chronic kidney disease and hypertension increase the mortality risk. Data from the US and China show higher ICU admissions, hospitalization rates and mortality rates in older persons (CDC COVID-19 Response Team; Wu, & McGoogan, 2020). Therefor long term facilities are especially vulnerable because of chronic diseases and old age.

Route of Transmission

The disease is caused by the SARS-CoV-2 virus. It spreads between people in many different ways. However, the main mode of COVID-19 transmission is direct person-to-person. The transmission occurs primarily via close-range contact through respiratory particles. These particles include smaller aerosols and large respiratory particles. The virus released in respiratory fluid when an infected individual talks, sneezes or cough can infect another individual if it makes direct contact with mucous membranes (eyes, nose, mouth) or inhaled. Additionally, infection can occur by touching contaminated surfaces and then touching the mucous membrane. However, contaminated surfaces are least route of transmission.

COVID-19 can also spread longer distances via the airborne route. It is thought that exhaled droplets from infected person can stay suspected in air for quite a while. The inhalation of these suspended particles might cause infection. Scattered cases of COVID outbreaks on buses and restaurants highlight the likelihood for longer distance transmission in poorly ventilated spaces (Lu et al., 2020; Shen et al., 2020).

COVID-19 has tested positive in non-respiratory specimens like blood, stool, se men and ocular secretions. Nonetheless the role of such sites in COVID-19 transmission is unclear. Countless reports have detected COVID-19 from stool samples even when the virus is not detected from respiratory samples (Cheung et al. 2020). But WHO report rules out the likelihood of trans mission via the fecal-oral route. Detection of COVID-19 in blood has been rare ruling out the potential for blood-borne transmission.

The exact interval during which a person with COVID-19 can spread the infection to other people is unknown. It is most likely that the potential to spread COVID-19 starts before the symptoms manifests. This means that the transmission is highest early in the illness’ course. Infected patients are more contagious in the initial stages when the levels of viral RNA from upper respiratory samples are the peak (COVID-19 Investigation Team, 2020b).  One study estimated that infectiousness reached the peak two days prior to and one day after the onset of symptoms and decreased within 7 days (He et al.2020). Cheng et al. (2020) evaluated 250 close contacts of hundred COVID-19 patients in Taiwan and found that the 22 secondary cases had their initial exposure to the index case within 6 days of the onset of symptoms.

Transmission risk also depends on duration and type of exposure, individual factors and use of preventive measures. The transmission risk after contact with infected patient increases with contact closeness. The risk is high in prolonged contact in enclosed and poorly ventilated settings. Many infections persons do not spread COVID-19 to anyone else. According to epidemiological data (Laximinarayan et al.2020; Sun et al. 2020), only a minority of index cases lead to majority of secondary infections.

COVID-19 disease spread more easily in crowded and poorly ventilated settings. Indoor settings, particularly locations with poor ventilations are riskier. Activities where more respiratory particles are exhaled from nose or mouth like breathing heavily or singing increase the transmission risk. Thus, it is advisable to avoid crowded places, enclosed spaces and close-contact settings. Madewell et al. (2020) performed a systematic review to assess secondary infection ration among family/household contacts of index individuals with the infection. Among 77,758 family contacts in Europe, Australia, Asia and the US, the reviewers found the pooled family secondary infection rate to be 17 percent. Within families, significant others or spouses have the highest secondary infection rates. Similarly, adolescents and children tend to act as index cases.

The transmission risk is also high in congregated settings such as college dormitories, detention facilities and homeless shelters (Baggett, Keyes, Sporn & Gaeta, 2020; Wilson et al., 2020). Cluster of COVID-19 cases are also often reported after social gatherings. Going to eating establishments, restaurants, bars and hotels are associated with transmission risk. Superspreading events are considered to the main drivers of disease transmission.

Transmission of coronavirus from asymptomatic persons has been documented. This basis has been backed up by a study of COVID-19 outbreak in long term facility whereby samples taken from upper respiratory tract of asymptomatic infected persons and cultured six days to the symptom onset (Arons et al. 2020).  The finding showed that the duration and levels of viral RNA are the same for both asymptomatic and symptomatic patients. however, the transmission risk appears less in asymptomatic situations (Wei et al. 2020). It is worth noting that asymptomatic patient is less likely to isolate from others due to lack of knowing.

Contaminated surfaces also increase the risk of transmission. When people touch such surfaces and then the mucous membranes, they transfer the virus. The frequency of this kind of transmission is not certain, as surfaces are not considered a major transmission source. Contaminated surfaces are likely to be an infection source in locations where viral contamination is heavy. In a Singapore study, (Ong et al., 2020) detected viral RNA on almost all surfaces tested (light switches, handles, bed, windows and interior doors, sink basin and toilet bowl) in an isolation room of a symptomatic COVID-19 patient before routine cleaning. After cleaning, the researchers did not detect the viral RNA.

COVID-19 can affect people of all ages. But older persons, and persons with chronic health conditions are more at risk of exhibiting critical symptoms. As COVID-19 is a new virus, the world is still learning more about which group of people are most at risk. There are few reported cases in children.

Impact in My Community at a Systems Level

COVID-19 outbreak has had great implications on community. It has affected the economy, businesses, livelihoods and burdened society.  Self-isolation, social distancing and travel bans have resulted in reduced workforce and caused loss of many jobs. the need for manufactured products and commodities has reduced. Schools have closed down.

The pandemic has affected education system in profound way. The imposition of nationwide closure of schools affects educational system, right from pre-school to tertiary. Although the intention of this imposition is to curb spread of coronavirus within schools and prevent carriage to vulnerable persons, these closures have resulted in widespread socioeconomic implications. Families with small children who depended on daycare suffered greatly. Families that have not attended work since the outbreak lost income.

At the tertiary institutions, postgraduate research community has been hit harder. Many non-COVID-19 related research has been halted. The National Institute for Health has closed non-critical research so as to free up resources and staff for mission critical research. Universities have stopped research in disciplines like social sciences and humanities

COVID-19 infection has wreaked enormous challenge for healthcare systems. Hospitals have to prepare for an increase in hospitalized people with coronavirus by creating more negative pressure rooms, paying off overtime to staff, hiring a backup workforce, obtaining personal protective equipment, and educating staff (Nicola et al., 2020). All elective and non-emergent procedures and surgeries had to be put on hold to free hospital beds and staff. Social distancing practices have resulted in the cancelation of almost all outpatient appointments.

The risk to healthcare professionals became the greatest vulnerability facing healthcare systems. Given that healthcare practitioners are unable to work from home, their frontline work put them at risk. Shortages of PPE, high healthcare costs, lack of ventilators and shortages of ICU bed have exposed weaknesses in patient care delivery (Nicola et al., 2020). Uninsured individuals working in occupations predisposing them to infection would suffer high costs. Pharmaceutical companies have shifted focus to developing coronavirus at the expense of other pharmaceutical products leading in massive shortages.

Patients in long term facilities become more vulnerable, as these facilities were overwhelmingly affected by COVID-19 infection. By March 2020, 167 confirmed cases had been reported in a nursing home in Washington DC affecting 50 employees, 101 residents and 16 visitors. As a result, 50 percent of the staff and 54 percent of residents were hospitalized. The residents registered 33 percent case fatality rate. 8 out of 10 deaths related to COVID-19 occur in persons 65 years and over (Nicola et al., 2020).

Aviation, hospitality and travel industries have been negatively impacted. The revenues have fallen and some employees laid off. Travel cancellations and decrease in demand has left aviation industry struggling. The ban of foreigners entering the country and implementation of travel suspensions have had devastating impacts (Nicola et al., 2020).

More than 51 percent of Americans have lost employment income since COVID-19 pandemic began. The unemployment rate has escalated to 14.7 percent (Nicola et al., 2020). This loss of employment and wages have left many Americans grappling to make mortgage and rent payments.

Reporting Protocol

Surveillance and monitoring of outbreaks is a central public health function important to control and prevention efforts. In the United States, outbreak investigations and reporting are often initiated by territorial, local and state public health agencies and also by the Center for Disease Control and Prevention. The National Outbreak Reporting System (NORS) backs up outbreak reporting by partners in territorial, local and state health agencies. This web-based platform allows health departments to enter outbreak information. This enables CDC to collect data and reports of outbreaks. NORS has become a valuable tool for gathering outbreak data required to enhance public health. The National Respiratory and Enteric Virus Surveillance System monitors geographic and temporal circulation patterns for human coronavirus and other viruses. Participating US labs voluntarily report on weekly basis to CDC the number of weekly aggregate tests conducted to detect these viruses.

In the US, majority of states have laws requiring reporting of infectious disease cases. Each state requires directs the reporting of selected communicable and infectious disease cases to public health authorities. The federal health professionals depend on voluntary reporting of epidemiological data from individual states to the CDC. CDC depends on various systems to monitor the outbreak, such as hospitalized case reporting, outbreak reports, syndromic surveillance, laboratory testing, and overall mortality.

The Minnesota Department of Health (MDH) mandates reporting of any cases and deaths related to SARS-CoV-2 to MDH within one working day. COVID-19 is reported using the MDH COVID-19 Case Report Form. Under the Minnesota state law, licensed healthcare professionals are mandated to report the outbreak to the MDH (Minnesota Department of Health). Minnesota Rules, Chapter 4605.7050 calls for “Any pattern of cases, suspected cases, or increased incidence of any illness beyond the expected number of cases in a given period, which may indicate a newly recognized infectious agent, an outbreak, epidemic, emerging drug resistance, or public health hazard… be reported immediately by telephone, by the person having knowledge, to the commissioner.”

Prevention strategies

COVID-19 is very infectious and currently there is effective vaccine for the population. But the spread of this disease can be prevented or slowed down by undertaking various public health measures. Communities should take recommended public health measures to prevent contact and airborne transmission. These measures include social distancing, frequent handwashing, isolation for infected persons, vaccination, quarantine of people who have come into contact with infected persons and wearing of masks.

Effective strategies to prevent the transmission of COVID-19 needs a system safety approach considering disinfection practices, viral sensitivities, ventilation controls, human factors, and bioburden reduction. Symptomatic and pre-symptomatic patients shed the viral RNA in different ways of aerosols and droplets. Novel coronavirus is contained in diverse mixtures of bodily fluids and organic material consisting of aerosols and droplets. The density and size of the exhaled droplets influence the distance travelled.

Community transmission can be prevented by practicing social distancing. Community members are urged and encouraged to observe social distancing by maintaining a 2-metter distance from others when in public spaces. Individuals are encouraged to especially avoid overcrowding in order to avoid close contacts. It is important to avoid close contact with patients with COVID-19. Keeping 2-meter distance is particularly essential for persons at higher risk of getting sick or for those with chronic health conditions. It is important to be aware that asymptomatic persons can be able to spread the coronavirus and thus the importance of social distancing from others. Residents should also be encouraged to avoid crowd public places like bars, fitness centers, movie theaters and restaurants that put one at risk. If someone experiences difficulty breathing, fever or cough get tested and help if the test is positive.

Residents should also be encouraged to wear masks in order to minimize the risk of transmission and reduce infective bioburden secretion into work, lavatory and surface environments.  Consistence of mask wearing lowers the degree and volume of predicted release of viral RNA, giving risk reduction to wearers. Masks prevents viral-laden bioburden landing on mucous membranes or unconscious hand movements touching the mouth, eyes or nose (Kaye et al. 2020).

Reference

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