The world today is facing double risk of diseases with epidemiological transition and paradigm shift from communicable to non-communicable diseases. But emerging and re-emerging infectious diseases have been always a challenge to mankind. The emerging and e-emerging infectious diseases are the newly identified and previously unknown infections or those spreading to new geographical areas that cause public health problems either nationally or internationally.
High population growth, unplanned urbanization, poor environmental sanitation, tourism and rapid travel, alteration in the microorganisms, antimicrobial resistance, insecticide resistance, and weak public health system are the major attributable factors in the changing pattern of health and disease leading to the occurrence of these emerging and re-emerging infectious diseases. The majority of them have zoonotic (Transmitted between animals and people) origin from the wildlife, 43% being viral in origin. Investigations have shown SARS- CoV to be transmitted from civet cats to humans and MERS- CoV from camels to humans.MERS (Middle East Respiratory Syndrome) and SARS (Severe Acute Respiratory Syndrome) are types of Coronaviruses. Due to its crown shape, the name Corona has been given. The impact of these emerging diseases can be assessed in terms of morbidity(disease), mortality (death) and loss of productivity. Infectious disease contributes to approximately 30% of 1.4 billion DALY’s ( Disability Adjusted Life Years) every year. DALY is an indicator measuring disability.
In December 2019, a local outbreak of pneumonia of initially unknown cause was detected in Wuhan (Hubei, China), and was quickly determined to be caused by a novel Coronavirus, namely severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2). The outbreak has since spread to every province of mainland China as well as 123 other countries and regions, with more than 1,50,006 confirmed cases,5,614 deaths globally and 87 confirmed cases and 2 deaths in India and 72,587 recovered cases as on March 14, 2020. In early January 2020, the World Health Organization identified a new type of 2019 novel coronavirus (mutant strain) and was given official name as COVID-19 by WHO on 10th Feb 2020. On 30th Jan, due to its rapid spread to other parts of the world, WHO declared it as Public Health Emergency of International Concern (PHEIC).On 11th March, WHO declared the outbreak as Pandemic.
The symptoms of the person infected with Coronavirus include running nose, dry cough, sore throat, fever, difficulty in breathing and nausea, diarrhea and vomiting. It also causes middle ear infections in children. If it spreads to the lower respiratory tract (Windpipes and lungs), it can cause pneumonia, especially in the vulnerable age group of older people, children, and person with a weak immune system. However, these symptoms should be co-related with laboratory investigation. A person who fulfills the WHO case definition of confirmed cases irrespective of clinical signs and symptoms is defined as Index (Primary Case) of Coronavirus. The mode of transmission is through coughing and sneezing and through coming in direct contact with an infected person through skin to skin contact or contact with surfaces, soil or vegetation. Studies have shown that the virus retains its viability for over 5 days at temperatures of 22-25 degrees Celsius and humidity of 40-50%. The biggest cohort study by the Chinese CDC reported 81% cases as mild, 14% require hospitalization and only 5%require ventilator and critical care management. Deaths were reported around 1-2 % mainly among the elderly population and those with co- morbidities like diabetes mellitus, hypertension, and other diseases. Since no vaccination is available now, prevention is the key.
WHO has released Interim Guidance on Infection Prevention and Control during health care where nCoV is suspected and the use of masks in community and health care settings in the context of the novel Coronavirus outbreak. Also standardized household transmission investigation protocol for any country where 2019 n COV infection has been reported and households that are exposed have been framed recently by WHO. Some tailoring can be done in local context based on the availability of resources, lab and clinical systems, capacity and cultural appropriateness. Also, the CDC (Centre for Disease Control and Prevention) clinical criteria for a COVID-19 person under investigation (PUI) have been developed based on what is known about MERS-CoV and SARS-CoVin Healthcare Settings.
Health care workers should follow standard precautions like hand and respiratory hygiene (cough etiquette), use of Hazpack Personal Protective equipment (PPE), prevention of needle stick injury, safe waste management, environmental cleaning and sterilization of patient care equipment and linen. The outbreak preparedness can be done by establishing sustainable infection prevention and control infrastructures like well-ventilated isolated rooms or isolation wards and toilets for cohort (group ) patients with beds at least 1 m apart as per WHO recommendation, availability of logistics like PPE,NIOSH (National Institute of Occupational Safety and Health) Certified N 95 Respirators, NIOSH- approved PAPRS (Powered air-purifying respirators (PAPRs), EU(European Unit )standard FFP2(Filtering Facepiece Respirator) or equivalent and Viral Transport Medium (VTM), Cold chain maintenance through thermocolbox, icebox, hardboard box, etc.
The arrangement has to be made for transport of samples in designated ambulance and samples to be collected, packed and transported to apex laboratory National Institute of Virology (NIV), Pune, Maharashtra or other 65 designated laboratory in India as per the standard operating procedure laid down by Indian Council of Medical Research(ICMR). Hands-on training can be given to health care workers regarding six steps of handwashing, WHO 5 moments for hand hygiene, cough etiquette, method of donning and doffing of PPE and biomedical waste management. Policies for early recognition of acute respiratory infection and treatment protocol can be framed in the local context. Health advisory through Information, Education, and Communication (IEC) material at health care setting, Awareness campaign at the community level and through mass media can be done to educate the general public. Screening of suspected cases can also be done at airports and national highways and managed as per the standard protocol. Healthcare providers should obtain a detailed travel history for patients being evaluated with fever and acute respiratory illness. An optimally functioning epidemiological surveillance along with vector, Serological and Microbiological Surveillance will be able to detect outbreaks of infectious disease early. Rapid Response Team can prevent further spread of the disease in the community. With the present scenario of some positive cases detection in Ladakh, containment, active surveillance of cases, tracking identity, isolating and contact tracing, listing and mapping of both containment and buffer zones is the need of the hour.
Health advisory to the general public includes hand hygiene and other IPC (Infection prevention and control) measure to prevent human to human transmission of 2019- n CoV. Individuals without respiratory symptoms should:
1. Avoid visiting crowded spaces.
2. Maintain a distance of at least 1 meter from any person with n CoV respiratory symptoms like coughing and sneezing.
3. Perform hand hygiene by using Alcohol-Based Hand Rub (Sanitizer) when not visibly soiled and soap and water when soiled.
4. During coughing and sneezing, cover the nose and mouth with the flexed elbow or disposable tissue paper.
5. Refrain from touching mouth, nose, and eyes.
6. Masks not mandatory to the healthy general public.
7. Avoid public gathering and travelling by public transport.
In addition, it is mandatory for individuals with respiratory symptoms and health care workers to wear recommended masks/respirators in accordance with the protocol. Relatives and caregivers of individuals with suspected 2019 nCoVinfection should:
1. Perform hand hygiene frequently using sanitizer and soap and water.
2. Keep a distance of 1 meter from the affected individual
3. Wear a mask in the room with the affected individual
4. Clean hands immediately after contact with respiratory secretions.
5. Improve ventilation in the living space.
To conclude, limited information is available to characterize the spectrum of a clinical illness associated with Coronavirus disease 2019 (COVID-19).
Epidemiologists at WHO and Centre for Disease Control and Prevention(CDC) are closely monitoring the disease since its outbreak and updation done when available. An online interactive dashboard, by WHO and Johns Hopkins University, has been developed to visualize and track reported cases of COVID-19 in real-time. The dashboard illustrates the location and number of confirmed COVID-19 cases, deaths, and recoveries for all affected countries.
Research institutes and companies from many countries are making effort to combat the novel Coronavirus epidemic by pushing for the development of a vaccine, as well as more accurate tests for the virus. Till date, 20 countries including China, London and US are in the pipeline of developing the vaccine. So clearly, the battle has not been won! The only way is to prevent and control it. So, no need to get panic among the general population. The only thing we need to do is to maintain hand hygiene, respiratory etiquette and avoid close contact with the symptomatic person. People are advised not to go by the rumors, avoid panic, myths, and misconceptions and refer to reliable and valid sources.
The information provided in this article is from sources like WHO and CDC and standard guidelines by the Ministry of Health and Family Welfare, GOI.
Dr. Yangchen Dolma is an Assistant Professor, Epidemiologist, and Public Health Scientist, at Govt Medical College, Kathua, Jammu. She can be reached at firstname.lastname@example.org.