- User contributions [en]

Managing Health Care Capacity

2020-04-07T07:30:08Z

79.129.118.174: /* Analysis and interpretation */

This page collects observations, interpretations, and consequences for action about Managing Health Care Capacity during SARS-CoV2 pandemic. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[transmission routes]], please use that page, instead of posting your content here.

=What is already known=

=Italian experience=
==Observations==
* Italian clinicians look back on the first 3 months of the COVID19 epidemic in their country, and conclude that proper preparedness for the next pandemic cannot include investments in health care alone. <ref name="Nacoti2020"/>
*Different recommendations for returning to work for health care workers (7 days after the positive test instead of 14 days as in the rest of the population) due to shortage of staff raises questions

==Analysis and interpretation==
* "What we are painfully learning is that we need experts in public health and epidemics, yet this has not been the focus of decision-makers at the national, regional, and hospital levels. We lack expertise on epidemic conditions, guiding us to adopt special measures to reduce epidemiologically negative behaviors."<ref name="Nacoti2020"/>
* "This outbreak is more than an intensive care phenomenon, rather it is a public health and humanitarian crisis.3 It requires social scientists, epidemiologists, experts in logistics, psychologists, and social workers. We urgently need humanitarian agencies who recognize the importance of local engagement." <ref name="Nacoti2020"/>
* Infection committees of hospitals do not always follow the recommendations and personnel refuses to return to work earlier than 14 days or with symptoms as it is required.

==Consequences for action==
* In a pandemic, patient-centered care is inadequate and must be replaced by community-centered care. Solutions for Covid-19 are required for the entire population, not only for hospitals. Home care and mobile clinics avoid unnecessary movements and release pressure from hospitals. <ref name="Nacoti2020">Nacoti, M., Ciocca, A., Giupponi, A., Brambillasca, P., Lussana, F., Pisano, M., ... & Longhi, L. (2020). At the Epicenter of the Covid-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation. NEJM Catalyst Innovations in Care Delivery, 1(2).</ref>

=References=

Managing Health Care Capacity

2020-04-07T07:28:49Z

79.129.118.174: /* Observations */

This page collects observations, interpretations, and consequences for action about Managing Health Care Capacity during SARS-CoV2 pandemic. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[transmission routes]], please use that page, instead of posting your content here.

=What is already known=

=Italian experience=
==Observations==
* Italian clinicians look back on the first 3 months of the COVID19 epidemic in their country, and conclude that proper preparedness for the next pandemic cannot include investments in health care alone. <ref name="Nacoti2020"/>
*Different recommendations for returning to work for health care workers (7 days after the positive test instead of 14 days as in the rest of the population) due to shortage of staff raises questions

==Analysis and interpretation==
* "What we are painfully learning is that we need experts in public health and epidemics, yet this has not been the focus of decision-makers at the national, regional, and hospital levels. We lack expertise on epidemic conditions, guiding us to adopt special measures to reduce epidemiologically negative behaviors."<ref name="Nacoti2020"/>
* "This outbreak is more than an intensive care phenomenon, rather it is a public health and humanitarian crisis.3 It requires social scientists, epidemiologists, experts in logistics, psychologists, and social workers. We urgently need humanitarian agencies who recognize the importance of local engagement." <ref name="Nacoti2020"/>
==Consequences for action==
* In a pandemic, patient-centered care is inadequate and must be replaced by community-centered care. Solutions for Covid-19 are required for the entire population, not only for hospitals. Home care and mobile clinics avoid unnecessary movements and release pressure from hospitals. <ref name="Nacoti2020">Nacoti, M., Ciocca, A., Giupponi, A., Brambillasca, P., Lussana, F., Pisano, M., ... & Longhi, L. (2020). At the Epicenter of the Covid-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation. NEJM Catalyst Innovations in Care Delivery, 1(2).</ref>

=References=

Translating Lessons learnt from Past Pandemics

2020-03-26T15:28:08Z

79.129.118.174: /* Observations */

This page collects observations, interpretations, and consequences for action about Translating Lessons Learnt of SARS-CoV2. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[Sources]], please use that page, instead of posting your content here.

=What is already known=
* There are not yet formal 'Lessons learned' this early in the Pandemic

=Keeping Track of the Economic Burden=
==Observations==
* From previous Pandemics, we learned gradually what the burden to society has been.
* Currently, we observe reluctance of leaders to take far-reaching decisions, moving very carefully forward, guided day by day by 'how the situation evolves'.
*Apart from the direct cost from illness and mortality that mainly affects the health sector, there is the indirect cost from "aversion" behaviour (measures taken to prevent
infection). A unique situation in developed countries.
*Different approaches between countries - balance between protection of life and protection of the "economy". Critisism towards those that delay the implementation of measures of social distancing and at the same time critisism towards the implementation of measures that lead to a huge economic burden.

==Analysis and interpretation==
* Far-reaching interventions may be necessary, but difficult to take because the '''costs''' of those decisions are more visible to the leaders than the '''benefits''' that interventions may have.
* Creating evidence of economic costs to society of pandemics, especially in comparison of different interventions, will be very helpful in training leaders to be prepared for future challenges

==Consequences for action==
* Collect materials for a case study on economic costs of the pandemic

=References=

Translating Lessons learnt from Past Pandemics

2020-03-26T15:22:31Z

79.129.118.174: /* Analysis and interpretation */

This page collects observations, interpretations, and consequences for action about Translating Lessons Learnt of SARS-CoV2. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[Sources]], please use that page, instead of posting your content here.

=What is already known=
* There are not yet formal 'Lessons learned' this early in the Pandemic

=Keeping Track of the Economic Burden=
==Observations==
* From previous Pandemics, we learned gradually what the burden to society has been.
* Currently, we observe reluctance of leaders to take far-reaching decisions, moving very carefully forward, guided day by day by 'how the situation evolves'.
*Apart from the direct cost from illness and mortality that mainly affects the health sector, there is the indirect cost from "aversion" behaviour (measures taken to prevent
infection). A unique situation in developed countries.

==Analysis and interpretation==
* Far-reaching interventions may be necessary, but difficult to take because the '''costs''' of those decisions are more visible to the leaders than the '''benefits''' that interventions may have.
* Creating evidence of economic costs to society of pandemics, especially in comparison of different interventions, will be very helpful in training leaders to be prepared for future challenges

==Consequences for action==
* Collect materials for a case study on economic costs of the pandemic

=References=

Translating Lessons learnt from Past Pandemics

2020-03-26T15:18:09Z

79.129.118.174: /* Observations */

This page collects observations, interpretations, and consequences for action about Translating Lessons Learnt of SARS-CoV2. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[Sources]], please use that page, instead of posting your content here.

=What is already known=
* There are not yet formal 'Lessons learned' this early in the Pandemic

=Keeping Track of the Economic Burden=
==Observations==
* From previous Pandemics, we learned gradually what the burden to society has been.
* Currently, we observe reluctance of leaders to take far-reaching decisions, moving very carefully forward, guided day by day by 'how the situation evolves'.
*Apart from the direct cost from illness and mortality that mainly affects the health sector, there is the indirect cost from "aversion" behaviour (measures taken to prevent
infection). A unique situation in developed countries.

==Analysis and interpretation==
* Far-reaching interventions may be necessary, but difficult to take because the '''costs''' of those decisions are more visible to the leaders than the '''benefits''' that interventions may have.
* creating evidence of economic costs to society of pandemics, especially in comparison of different interventions, will be very helpful in training leaders to be prepared for future challenges

==Consequences for action==
* Collect materials for a case study on economic costs of the pandemic

=References=

Case Definition issues

2020-03-26T15:03:14Z

79.129.118.174: /* National COVID-19 Case Definitions and/or Criteria for Testing */

This page collects observations, interpretations, and consequences for action about the case definition of SARS-CoV2 in general. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[transmission routes]], please use that page, instead of posting your content here.

=What is already known=

'''WHO Case Definition''' (creation date: 27 February 2020, publishing date: 2 March 2020)

A suspected case is:

A. a patient with acute respiratory illness (that is, fever and at least one sign or symptom of respiratory disease, for example,
cough or shortness of breath) AND with no other etiology that fully explains the clinical presentation AND a history of travel to or
residence in a country, area or territory that has reported local transmission of COVID-19 disease during the 14 days prior to
symptom onset (for updated reporting, see the situation reports at
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/ ;

OR

B. a patient with any acute respiratory illness AND who has been a contact of a confirmed or probable case of COVID-19 disease
during the 14 days prior to the onset of symptoms (see the definition of contact below);

OR

C. a patient with severe acute respiratory infection (that is, fever and at least one sign or symptom of respiratory disease, for
example, cough or shortness breath) AND who requires hospitalization AND who has no other etiology that fully explains the
clinical presentation.

'''ECDC Case Definition''' (creation date: unknown, publishing date: 2 March 2020)

Laboratory testing for COVID-19 should be performed for suspected cases according to the following criteria, based on the updated WHO case definition:

1) a patient with acute respiratory tract infection (sudden onset of at least one of the following: cough, fever, shortness of breath) AND with no other aetiology that fully explains the clinical presentation AND with a history of travel or residence in a country/area reporting local or community transmission* during the 14 days prior to symptom onset;

OR

2) a patient with any acute respiratory illness AND having been in close contact with a confirmed or probable COVID-19 case in the last 14 days prior to onset of symptoms;

OR

3) A patient with severe acute respiratory infection (fever and at least one sign/symptom of respiratory disease (e.g., cough, fever, shortness breath)) AND requiring hospitalisation (SARI) AND with no other aetiology that fully explains the clinical presentation.

*according to WHO classification, see respective daily updated Coronavirus disease (COVID-2019) situation reports at https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/

'''Take note:'''

(1) The two case definitions are similiar, but not the same. Imagine that you have to develop a checklist for physicians to facilitate their case assessment process. For WHO, an acute respiratory infection (ARI) means "fever and at least one sign or symptom of respiratory disease for example, cough or shortness breath)", for ECDC, an ARI means "sudden onset of at least one of the following: cough, fever, shortness of breath". So: What does your ARI checklist look like?

(2) Given that the spread of SARS-CoV-2 has resulted in a massive public health emergency worldwide, it is not self-explanatory why physicians are recommended to exclude other causes/pathogens first, according to WHO and ECDC (see "with no other aetiology that fully explains the clinical presentation" clause in the case definitions).

=Implementing case definition changes (2 March 2020)=
==Observations==
WHO (and ECDC) published their new recommendation on COVID case definition on March 2: this contained a significant shift from the previous approach.

* Countries were not aware that this new WHO/ECDC approach was coming out on March 2.
* The new approach created anxiety. Experts were surprised that WHO did not distinguish between countries with "local transmission". De facto, the majority of returning travelers now came from Corona-Risk areas, regardless of the extent of transmission.
* The new approach had a significant impact on testing demand, generating discussions on how to deal with that. In addition, it impacted on case identification among the hospitalized SARI cases, which might have received less attention due to focus on the widely extended travel criteria. Much time was spent (and lost?) on discussing priorities for testing.
* Some countries were seeing in their epidemiological data that the case definition did not work well before March 2. They were confused on whether they should wait for the change definition at a European level or proceed with a change by their own. This delay led to critisism from the public and the Media towards the public health authorities.

==Analysis and interpretation==
* This led to some countries still having no updated policy several days or even two weeks after the new case definitions were published, and as a consequence, most of the medical staff was still focussing on suspected cases coming from high-risk areas with obvious, widespread community transmission of SARS-CoV-2 (such as Italy, China, Iran, South-Korea) or on suspected cases having had contact with a confirmed case only. As a consequence, many new COVID-19 cases could have remained undetected and unreported.
* Some experts strongly disagree with WHO/ECDC about the need to exclude other etiology first. The recommendation is probably aimed to decrease the need for COVID-19 testing, but the fact that this leads to a significant delay in the COVID-19 diagnosis (and thus increased exposure of healthcare workers to undetected COVID-19) some experts find hard to accept.
* The above analysis reflects the situation that had arisen shortly after 2 March. Circumstances and case numbers have rapidly changed since then in many countries, furthermore extremely strict travel restrictions have been implemented by many governments rendering the travel criteria less and less relevant.

==Consequences for and considerations about action==
* Countries should be prepared to rapidly shift gear when international case guidelines change. During pandemics, it is unrealistic to expect that coordinating organizations such as WHO and ECDC can predict when they will change guidelines, so one cannot expect timetables for this. However, since both WHO and ECDC have formally nominated contact points in national public health bodies, it is still sensible and possible to inform countries at least one or two days in advance about major changes planned. Note that the WHO case definition was created on 27 February and published on 2 March only.
* Communication channels from national public health bodies to health care professionals should ideally allow for such rapid changes, and a platform of rapid exchange of information and advice would be beneficial. However, it is unrealistic to expect that national laboratory capacity, health care staff (primary, secondary, tertiary) and public health authorities have the chance to follow and implement changes immediately.
* Health care providers on their term should be prepared to receive rapidly changing guidelines during international infectious disease crises. What is considered a constant among all large pandemics, is that gaps in knowledge are rapidly filled; therefore new insights have to be translated to an improvement of prevention and control in a timely and efficient way. However, when health care providers are increasingly overwhelmed with the management of new suspected and confirmed COVID-19 cases, the focus may inevitably shift to imminent treatment efforts.
* One of the possible ways for countries to prepare for this is to have regular simulation exercises that take these issues into account. It is particularly important for countries to design their own national simulation exercises as health care systems (including infrastructure, staffing, organisation of laboratory services and other relevant factors), health care seeking behaviour, and cultural determinants differ significantly.

=National COVID-19 Case Definitions and/or Criteria for Testing=

[https://www.health.nsw.gov.au/Infectious/diseases/Pages/2019-ncov-case-definition.aspx Australia]

[https://thl.fi/fi/web/infektiotaudit-ja-rokotukset/taudit-ja-torjunta/taudit-ja-taudinaiheuttajat-a-o/koronavirus-covid-19/toimenpideohje-epailtaessa-koronaviruksen-covid-19-aiheuttamaa-infektiota Finland]

[https://www.santepubliquefrance.fr/maladies-et-traumatismes/maladies-et-infections-respiratoires/infection-a-coronavirus/articles/infection-au-nouveau-coronavirus-sars-cov-2-covid-19-france-et-monde France]
See "Definition de cas"

[https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/nCoV.html Germany]
See "Falldefinition Coronavirus Disease 2019"

[https://www.fhi.no/nettpub/coronavirus/helsepersonell/testing-og-diagnostikk-for-nytt-koronavirus-coronavirus/ Norway]

[https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases/investigation-and-initial-clinical-management-of-possible-cases-of-wuhan-novel-coronavirus-wn-cov-infection United Kingdom]

[https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html United States]

[https://www.folkhalsomyndigheten.se/smittskydd-beredskap/utbrott/aktuella-utbrott/covid-19/information-till-varden/ Sweden] See "Falldefinitioner vid anmälan enligt smittskyddslagen av infektion med covid-19"

[https://eody.gov.gr/neos-koronoios-covid-19-kritiria-gia-ergastiriako-elegcho/ Greece] See "Λοίμωξη από νέος κορωνοϊό Covid-19 – Κριτήρια για εργαστηριακό έλεγχο"
==Observations==

==Analysis and interpretation==

==Consequences for action==

=References=

Epidemiology

2020-03-25T19:38:23Z

79.129.118.174: /* What is already known */

This page collects observations, interpretations, and consequences for action about the epidemiology of SARS-CoV2 in general. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[transmission routes]], please use that page, instead of posting your content here.

=What is already known=
* Coronavirus disease (COVID-19) is caused by SARS-COV2 and is a potentially fatal disease <ref name="Rothan2020">Rothan, Hussin A., and Siddappa N. Byrareddy. "The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak." Journal of Autoimmunity (2020): 102433.</ref> that is designated a PHEIC by WHO <Ref name="WHO-PHEIC">Emergency committee regarding the outbreak of novel coronavirus(2019-ncov) https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)</ref>.
===Symptoms===
* The predominant symptoms in laboratory-confirmed cases is fever (88%) and dry cough (68%), followed by fatigue (38%), sputum production (33%), dyspnoea (19%), sore throat (14%), headache (14%) and myalgia or arthralgia (15%). Less common symptoms are diarrhoea (4%) and vomiting (5%).<Ref name="ECDCRRA12032020">ECDC Rapid risk assessment: Novel coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK – [https://www.ecdc.europa.eu/sites/default/files/documents/RRA-sixth-update-Outbreak-of-novel-coronavirus-disease-2019-COVID-19.pdf sixth update]. </ref>
* A loss of a sense of smell or taste may be a symptom of COVID-19 according to recent statements. Further evidence is needed.
* About 80% of reported cases in China had mild to moderate disease (including non-pneumonia and pneumonia cases), 13.8% had severe disease and 6.1% were critical (respiratory failure, septic shock, and/or multiple organ dysfunction/failure). Current estimates suggest a median incubation period from five to six days for COVID-19, with a range from one to up to 14 days. <Ref name="ECDCRRA12032020"/>
* Italy reports consistently between 9% and 11% of the symptomatic cases to require intensive care treatment.<Ref name="Remuzzi">COVID19 and Italy: what next? Remuzzi. Lancet, March 13 2020</ref>
===Case fatality===
* Reliable estimates for case fatality for COVID-19 are still lacking and biased. Based on a large dataset from cases in China, the overall case-fatality risk (CFR) among laboratory-confirmed cases was higher in the early stages of the outbreak (17.3% for cases with symptom onset from 1-10 January) and has reduced over time to 0.7% for patients with symptom onset after 1 February. In data on diagnosed COVID-19 cases in China, Italy and South Korea, overall CFR was 2.3%, 2.8% and 0.5%, respectively, and increased with age in all settings, with the highest CFR among people over 80 years of age (14.8%, 8.2% and 3.7%, respectively).<Ref name="ECDCRRA12032020"/>

===Viral shedding===
* Over the course of the infection, the virus has been identified in respiratory tract specimens 1-2 days before the onset of symptoms and it can persist for 7-12 days in moderate cases and up to 2 weeks in severe cases. <Ref name="ECDCRRA12032020"/>
* In faeces, viral RNA has been detected from day 5 after onset and up to 4 to 5 weeks in moderate cases. <Ref name="ECDCRRA12032020"/>
* SARS-CoV2 has been detected also in whole blood, serum, saliva and urine. <Ref name="ECDCRRA12032020"/>
* Prolonged viral RNA shedding has been reported from nasopharyngeal swabs, up to 37 days among adult patients and in faeces, for more than one month after infection in paediatric patients. <Ref name="ECDCRRA12032020"/>
===Basic reproduction number (R0)===
* The current estimates of the basic reproductive number R0 are between 2 and 3 in settings from China and during the early stage of an outbreak on a cruise ship. <Ref name="ECDCRRA12032020"/>
===Asymptomatic Infections===
* Based on Chinese data, the international WHO mission report indicates that up to 75% of initially asymptomatic cases will progress to clinical disease, making the true asymptomatic infection rather rare (estimated at 1-3%). <Ref name="ECDCRRA12032020"/>
** The virus has been detected in asymptomatic persons. On a rapidly evolving cruise ship outbreak, where most of the passengers and staff were tested irrespective of symptoms, 51% of the laboratory-confirmed cases were asymptomatic at the time of confirmation. In Italy, 44% of the laboratory-confirmed cases have been asymptomatic. In Japan, 0.06% of reported cases have been asymptomatic. These proportions based on nationally notified cases likely reflect laboratory testing algorithms rather than true estimates of asymptomatic infections. <Ref name="ECDCRRA12032020"/>
** Both viral RNA and infectious virus particles were detected in throat swabs from two German citizens evacuated from Hubei province on 1 February 2020, who remained well and afebrile seven days after admission to a hospital in Frankfurt. Both a mother and a child in a family cluster remained asymptomatic (including normal chest CT images during the observation period) with qRT-PCR positive nasopharyngeal swab samples. Similar viral load in asymptomatic versus symptomatic cases was reported in a study including 18 patients. Persistent positivity of viral RNA in throat and anal swabs were reported in an asymptomatic female patient after 17 days of clinical observation and treatment. <Ref name="ECDCRRA12032020"/>
* Potential transmission from an asymptomatic person has been reported in a familial cluster of five COVID-19 patients hospitalised with fever and respiratory symptoms that had contact before their onset of symptoms with an asymptomatic family member, a young 20-year-old woman, upon her return from Wuhan. She remained asymptomatic for the whole duration of laboratory and clinical monitoring (19 days).
* Transmission in a pre-symptomatic stage of infection: In addition to case reports, the pre-symptomatic transmission has been inferred through modelling, and the proportion of pre-symptomatic transmission was estimated to be around 48% and 62%. The pre-symptomatic transmission was deemed likely based on a shorter serial interval of COVID-19 (4.0 to 4.6 days) than the mean incubation period (five days) with the authors indicating that many secondary transmissions would have already occurred at the time when symptomatic cases are detected and isolated. Major uncertainties remain in assessing the influence of pre-symptomatic transmission on the overall transmission dynamics of the pandemic.

===Vulnerable groups===
* Population groups that have been more frequently reported having severe disease and death include people above 60 years of age, males, people with underlying conditions such as hypertension, diabetes, cardiovascular disease, chronic respiratory disease and cancer.
* The proportion of most of the reported chronic diseases and health conditions is similar to the prevalence of these conditions in the elderly age groups in China, therefore they might be surrogates of increasing age only. Higher ACE (angiotensin-converting enzyme II) gene expression may be linked to higher susceptibility to SARS-CoV-2.
* It has been shown that ACE 2 expression in lung tissues increases with age, tobacco use and with some hypertensive treatment. These observations might explain the vulnerability of older people, tobacco users/smokers and those with hypertension; they also highlight the importance of identifying smokers as a potential vulnerable group for COVID-19. <Ref name="ECDCRRA12032020"/>
* There is '''limited''' scientific evidence on the severity of illness among pregnant women with COVID-19. Pregnant women appear to experience similar clinical manifestations as non-pregnant adult patients with COVID-19 pneumonia. There is no evidence of severe adverse outcomes in neonates due to maternal COVID-19 pneumonia, and the virus has not been found in breastmilk. <Ref name="ECDCRRA12032020"/>
* Currently available information indicates that children are as likely to be infected as adults, however they experience mild clinical manifestations. About 2.4% of the total reported cases in China (as of 20 February 2020) were individuals under 19 years of age. A very small proportion of those aged under 19 years have developed severe (2.5%) or critical disease (0.2%). <Ref name="ECDCRRA12032020"/>
===Reservoir and sources===
* The three first reported cases were hospitalized on 27 December 2019 in Wuhan; one patient was a retailer on the seafood market in Wuhan, another was a frequent visitor of the same market. The third patients was not reported to be associated to the market. <Ref name="Zhu2020"> Zhu, Na, et al. "A novel coronavirus from patients with pneumonia in China, 2019." New England Journal of Medicine (2020).</ref>
* COVID19 is likely of animal origin. <ref name="Rothan2020"/> The virus has 85% similarity to a strain that was isolated from bats in East China. <Ref name="Zhu2020"/>
===Transmission Routes===
* Person-to-person transmission of COVID-19 infection is the predominant way in which this virus spreads among the human population. <ref name="Rothan2020"/>. Transmission occurs through close contact (droplets, hands) and fomites. Therefore handwashing and social distancing are effective control measures, in the absence of a vaccine.
* Extensive measures to reduce person-to-person transmission of COVID-19 have been implemented to control the current outbreak. <ref name="Rothan2020"/>
* Special attention and efforts to protect or reduce transmission should be applied in susceptible populations including children, health care providers, and elderly people.<ref name="Rothan2020"/>

=Detailed pages=
For the following specific epidemiological topics, please use the subpages to document your observations:
** [[Reservoirs]]
*** [[Sources]]
** [[Transmission routes|Transmission Routes]]
** [[Transmission Barriers]]
** [[Immune Response]]
** [[Pathogenesis]]
*** [[Risk factors for severe disease]]
** [[Contagiousness]]

For other epidemiological topics, please use this page.

=Proportion asymptomatic=
==Observations==
* A study of the COVID19 outbreak on the Pacific Princess cruise ship found proportions of asymptomatic infections up to 50% <Ref name=“Mizmuto2020”> Mizumoto, Kenji, et al. "Estimating the asymptomatic ratio of 2019 novel coronavirus onboard the princess cruises ship, 2020." medRxiv (2020). </ref>
* Based on Chinese data, the international WHO mission report indicates that up to 75% of initially asymptomatic cases will progress to clinical disease, making the true asymptomatic infection rather rare (estimated at 1-3%). <Ref name="ECDCRRA12032020"/>

==Analysis and interpretation==
* The observations by Mizumoto and the International WHO Mission seem to contradict on the issue of proportion asymptomatic infections. Though cruise ship populations are hardly representative of national populations, they can be considered reliable environments to study the natural history of infectious disease, when observing large groups of exposed susceptibles.
* Having reliable estimates of the proportion asymptomatics is relevant for modelling the disease at the population level and making predictions about group immunity and transmission coefficients.

==Consequences for action==
* Ideally, cohorts of exposed individuals need to be identified and followed up to establish the proportion asymptomatic more reliably.

=Anosmia=
==Observations==
* An increasing number of reports occur on the sudden loss of smell and taste among a proportion of the COVID19 patients. <Ref name="Business Insider">If you’ve lost your sense of smell or taste, you could be a ‘hidden carrier’ of the coronavirus. [https://www.businessinsider.nl/coronavirus-symptoms-loss-of-smell-taste-covid-19-anosmia-hyposmia-2020-3?international=true&r=US Brianna Moné. Business Insider 22 Mar 2020] </ref>
==Analysis and Interpretation==
* This observation requires a systematic clinical follow up of COVID19 patients, including pathognomonic studies
==Consequences for Action==
* If the relation COVID19 and Anosmia is confirmed, then clusters of sudden anosmia could be considered a clinical indicator of COVID19 in the population when testing is unavailable.

=References=

Case Definition issues

2020-03-25T19:30:42Z

79.129.118.174: /* Observations */

This page collects observations, interpretations, and consequences for action about the case definition of SARS-CoV2 in general. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[transmission routes]], please use that page, instead of posting your content here.

=What is already known=

'''WHO Case Definition''' (creation date: 27 February 2020, publishing date: 2 March 2020)

A suspected case is:

A. a patient with acute respiratory illness (that is, fever and at least one sign or symptom of respiratory disease, for example,
cough or shortness of breath) AND with no other etiology that fully explains the clinical presentation AND a history of travel to or
residence in a country, area or territory that has reported local transmission of COVID-19 disease during the 14 days prior to
symptom onset (for updated reporting, see the situation reports at
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/ ;

OR

B. a patient with any acute respiratory illness AND who has been a contact of a confirmed or probable case of COVID-19 disease
during the 14 days prior to the onset of symptoms (see the definition of contact below);

OR

C. a patient with severe acute respiratory infection (that is, fever and at least one sign or symptom of respiratory disease, for
example, cough or shortness breath) AND who requires hospitalization AND who has no other etiology that fully explains the
clinical presentation.

'''ECDC Case Definition''' (creation date: unknown, publishing date: 2 March 2020)

Laboratory testing for COVID-19 should be performed for suspected cases according to the following criteria, based on the updated WHO case definition:

1) a patient with acute respiratory tract infection (sudden onset of at least one of the following: cough, fever, shortness of breath) AND with no other aetiology that fully explains the clinical presentation AND with a history of travel or residence in a country/area reporting local or community transmission* during the 14 days prior to symptom onset;

OR

2) a patient with any acute respiratory illness AND having been in close contact with a confirmed or probable COVID-19 case in the last 14 days prior to onset of symptoms;

OR

3) A patient with severe acute respiratory infection (fever and at least one sign/symptom of respiratory disease (e.g., cough, fever, shortness breath)) AND requiring hospitalisation (SARI) AND with no other aetiology that fully explains the clinical presentation.

*according to WHO classification, see respective daily updated Coronavirus disease (COVID-2019) situation reports at https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/

'''Take note:'''

(1) The two case definitions are similiar, but not the same. Imagine that you have to develop a checklist for physicians to facilitate their case assessment process. For WHO, an acute respiratory infection (ARI) means "fever and at least one sign or symptom of respiratory disease for example, cough or shortness breath)", for ECDC, an ARI means "sudden onset of at least one of the following: cough, fever, shortness of breath". So: What does your ARI checklist look like?

(2) Given that the spread of SARS-CoV-2 has resulted in a massive public health emergency worldwide, it is not self-explanatory why physicians are recommended to exclude other causes/pathogens first, according to WHO and ECDC (see "with no other aetiology that fully explains the clinical presentation" clause in the case definitions).

=Implementing case definition changes (2 March 2020)=
==Observations==
WHO (and ECDC) published their new recommendation on COVID case definition on March 2: this contained a significant shift from the previous approach.

* Countries were not aware that this new WHO/ECDC approach was coming out on March 2.
* The new approach created anxiety. Experts were surprised that WHO did not distinguish between countries with "local transmission". De facto, the majority of returning travelers now came from Corona-Risk areas, regardless of the extent of transmission.
* The new approach had a significant impact on testing demand, generating discussions on how to deal with that. In addition, it impacted on case identification among the hospitalized SARI cases, which might have received less attention due to focus on the widely extended travel criteria. Much time was spent (and lost?) on discussing priorities for testing.
* Some countries were seeing in their epidemiological data that the case definition did not work well before March 2. They were confused on whether they should wait for the change definition at a European level or proceed with a change by their own. This delay led to critisism from the public and the Media towards the public health authorities.

==Analysis and interpretation==
* This led to some countries still having no updated policy several days or even two weeks after the new case definitions were published, and as a consequence, most of the medical staff was still focussing on suspected cases coming from high-risk areas with obvious, widespread community transmission of SARS-CoV-2 (such as Italy, China, Iran, South-Korea) or on suspected cases having had contact with a confirmed case only. As a consequence, many new COVID-19 cases could have remained undetected and unreported.
* Some experts strongly disagree with WHO/ECDC about the need to exclude other etiology first. The recommendation is probably aimed to decrease the need for COVID-19 testing, but the fact that this leads to a significant delay in the COVID-19 diagnosis (and thus increased exposure of healthcare workers to undetected COVID-19) some experts find hard to accept.
* The above analysis reflects the situation that had arisen shortly after 2 March. Circumstances and case numbers have rapidly changed since then in many countries, furthermore extremely strict travel restrictions have been implemented by many governments rendering the travel criteria less and less relevant.

==Consequences for and considerations about action==
* Countries should be prepared to rapidly shift gear when international case guidelines change. During pandemics, it is unrealistic to expect that coordinating organizations such as WHO and ECDC can predict when they will change guidelines, so one cannot expect timetables for this. However, since both WHO and ECDC have formally nominated contact points in national public health bodies, it is still sensible and possible to inform countries at least one or two days in advance about major changes planned. Note that the WHO case definition was created on 27 February and published on 2 March only.
* Communication channels from national public health bodies to health care professionals should ideally allow for such rapid changes, and a platform of rapid exchange of information and advice would be beneficial. However, it is unrealistic to expect that national laboratory capacity, health care staff (primary, secondary, tertiary) and public health authorities have the chance to follow and implement changes immediately.
* Health care providers on their term should be prepared to receive rapidly changing guidelines during international infectious disease crises. What is considered a constant among all large pandemics, is that gaps in knowledge are rapidly filled; therefore new insights have to be translated to an improvement of prevention and control in a timely and efficient way. However, when health care providers are increasingly overwhelmed with the management of new suspected and confirmed COVID-19 cases, the focus may inevitably shift to imminent treatment efforts.
* One of the possible ways for countries to prepare for this is to have regular simulation exercises that take these issues into account. It is particularly important for countries to design their own national simulation exercises as health care systems (including infrastructure, staffing, organisation of laboratory services and other relevant factors), health care seeking behaviour, and cultural determinants differ significantly.

=National COVID-19 Case Definitions and/or Criteria for Testing=

[https://www.health.nsw.gov.au/Infectious/diseases/Pages/2019-ncov-case-definition.aspx Australia]

[https://thl.fi/fi/web/infektiotaudit-ja-rokotukset/taudit-ja-torjunta/taudit-ja-taudinaiheuttajat-a-o/koronavirus-covid-19/toimenpideohje-epailtaessa-koronaviruksen-covid-19-aiheuttamaa-infektiota Finland]

[https://www.santepubliquefrance.fr/maladies-et-traumatismes/maladies-et-infections-respiratoires/infection-a-coronavirus/articles/infection-au-nouveau-coronavirus-sars-cov-2-covid-19-france-et-monde France]
See "Definition de cas"

[https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/nCoV.html Germany]
See "Falldefinition Coronavirus Disease 2019"

[https://www.fhi.no/nettpub/coronavirus/helsepersonell/testing-og-diagnostikk-for-nytt-koronavirus-coronavirus/ Norway]

[https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases/investigation-and-initial-clinical-management-of-possible-cases-of-wuhan-novel-coronavirus-wn-cov-infection United Kingdom]

[https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html United States]

[https://www.folkhalsomyndigheten.se/smittskydd-beredskap/utbrott/aktuella-utbrott/covid-19/information-till-varden/ Sweden] See "Falldefinitioner vid anmälan enligt smittskyddslagen av infektion med covid-19"

==Observations==

==Analysis and interpretation==

==Consequences for action==

=References=

Case management in Community

2020-03-25T19:14:38Z

79.129.118.174: /* 3. Recommendation of cases with mild symptoms to stay home. */

=1. Quarantine of laboratory confirmed cases.=
Question: For how long?
* for 14 days after the onset of symptoms
* for 14 days after the positive test
* if someone becomes symptomatic during the 14 days? after 5-7 days that the case is asymptomatic?

Question: Do we need testing after quarantine? One test or two tests?
Question: how you assure compliance?

=2. Quarantine of close contacts.=
Question: For how long?
* for 14 days after the onset of symptoms
* for 14 days after the positive test
* if someone becomes symptomatic during the 14 days? when does quarantine end? after 5-7 days that the case is asymptomatic?

Question: how you assure compliance?

=3. Recommendation of cases with mild symptoms to stay home.=
Question: How we define mild symtoms?

NEED for protocols - algorithms based on different scenarios regarding the available resources.
The optimal is not always possible however the decision on a strategy which is not the optimal should be based on evidence.
how referral to the hospital will be done? by whom?

Risk factors for severe disease

2020-03-18T18:40:29Z

79.129.118.174: /* What is already known */

This page collects observations, interpretations, and consequences for action about Risk Factors of SARS-CoV2. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[Sources]], please use that page, instead of posting your content here.

=What is already known=
* Recent studies suggest that ACE2 expression is increased in diabetes and treatment with ACE inhibitors and ARBs increases ACE2 expression. Consequently, the increased expression of ACE2 would facilitate infection with COVID-19. This observation makes some researchers hypothesize that diabetes and hypertension treatment with ACE2-stimulating drugs increases the risk of developing severe and fatal COVID-19. <ref name="Fang2020">Fang, Lei, George Karakiulakis, and Michael Roth. "Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection?." The Lancet Respiratory Medicine (2020).</ref>

=Rumours about interaction with medicines=
==Observations==
* The publication by Fang et al. suggests that ACE-inhibitors may increase the risk of Coronavirus infection and severe outcomes. <Ref name="Fang2020"/>. This is so far, the only publication that we know of.
* In the Netherlands, rumours circulate (and are even discussed at National Television) that Ibuprofen and NSAID in general increase the rik of severe COVID19 disease outcome.
* In Greece, the same rumours have lead to a shortage of paracetamol in the pharmacies. The representative of the Ministry of Health said that there is not enough evidence thus it would be good when people have symoptoms to prefer paracetamol.

==Analysis and interpretation==
* The study of Fang et al. is relevant and credible. However, the study alone does not (yet) constitute convincing evidence that ACE2-inhibitors are risk factors for COVID19 and severe outcome. The association is plausible, yet requires more study to generate supporting evidence.
* Notwithstanding the above, it is important to take note of the study of Fang et al. The observation deserves consideration, especially by clinicians treating patients who are in known risk groups for severe COVID19
* Rumours on NSAID are currently unsubstantiated.

==Consequences for action==
* Additional studies to find supporting evidence (or refuting) are needed
* Clinicians should take note of the study of Fang et al., and make decisions on a case by case basis
* In absence of evidence supporting NSAID as risk factor, experts need to very clearly explain that such rumours are unsubstantiated

=References=

Risk factors for severe disease

2020-03-18T18:38:39Z

79.129.118.174: /* References */

This page collects observations, interpretations, and consequences for action about Risk Factors of SARS-CoV2. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[Sources]], please use that page, instead of posting your content here.

=What is already known=
* Recent studies suggest that ACE2 expression is increased in diabetes and treatment with ACE inhibitors and ARBs increases ACE2 expression. Consequently, the increased expression of ACE2 would facilitate infection with COVID-19. This observation makes some researchers hypothesize that diabetes and hypertension treatment with ACE2-stimulating drugs increases the risk of developing severe and fatal COVID-19. <ref name="Fang2020">Fang, Lei, George Karakiulakis, and Michael Roth. "Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection?." The Lancet Respiratory Medicine (2020).</ref>
*No evidence of vertical transmission of coronavirus disease 2019 (COVID-19). COVID-19 has not been detected in the maternal milk. Concern whether infected mother can transmit the virus through respiratory droplets during breastfeeding REF. COVID-19 in pregnant women Manuel B Schmid,Jehudith Fontijn,Nicole Ochsenbein-Kölble,Christoph Berger,Dirk Bassler<

=Rumours about interaction with medicines=
==Observations==
* The publication by Fang et al. suggests that ACE-inhibitors may increase the risk of Coronavirus infection and severe outcomes. <Ref name="Fang2020"/>. This is so far, the only publication that we know of.
* In the Netherlands, rumours circulate (and are even discussed at National Television) that Ibuprofen and NSAID in general increase the rik of severe COVID19 disease outcome.
* In Greece, the same rumours have lead to a shortage of paracetamol in the pharmacies. The representative of the Ministry of Health said that there is not enough evidence thus it would be good when people have symoptoms to prefer paracetamol.

==Analysis and interpretation==
* The study of Fang et al. is relevant and credible. However, the study alone does not (yet) constitute convincing evidence that ACE2-inhibitors are risk factors for COVID19 and severe outcome. The association is plausible, yet requires more study to generate supporting evidence.
* Notwithstanding the above, it is important to take note of the study of Fang et al. The observation deserves consideration, especially by clinicians treating patients who are in known risk groups for severe COVID19
* Rumours on NSAID are currently unsubstantiated.

==Consequences for action==
* Additional studies to find supporting evidence (or refuting) are needed
* Clinicians should take note of the study of Fang et al., and make decisions on a case by case basis
* In absence of evidence supporting NSAID as risk factor, experts need to very clearly explain that such rumours are unsubstantiated

=References=

Risk factors for severe disease

2020-03-18T18:38:22Z

79.129.118.174: /* What is already known */

This page collects observations, interpretations, and consequences for action about Risk Factors of SARS-CoV2. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[Sources]], please use that page, instead of posting your content here.

=What is already known=
* Recent studies suggest that ACE2 expression is increased in diabetes and treatment with ACE inhibitors and ARBs increases ACE2 expression. Consequently, the increased expression of ACE2 would facilitate infection with COVID-19. This observation makes some researchers hypothesize that diabetes and hypertension treatment with ACE2-stimulating drugs increases the risk of developing severe and fatal COVID-19. <ref name="Fang2020">Fang, Lei, George Karakiulakis, and Michael Roth. "Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection?." The Lancet Respiratory Medicine (2020).</ref>
*No evidence of vertical transmission of coronavirus disease 2019 (COVID-19). COVID-19 has not been detected in the maternal milk. Concern whether infected mother can transmit the virus through respiratory droplets during breastfeeding REF. COVID-19 in pregnant women Manuel B Schmid,Jehudith Fontijn,Nicole Ochsenbein-Kölble,Christoph Berger,Dirk Bassler<

=Rumours about interaction with medicines=
==Observations==
* The publication by Fang et al. suggests that ACE-inhibitors may increase the risk of Coronavirus infection and severe outcomes. <Ref name="Fang2020"/>. This is so far, the only publication that we know of.
* In the Netherlands, rumours circulate (and are even discussed at National Television) that Ibuprofen and NSAID in general increase the rik of severe COVID19 disease outcome.
* In Greece, the same rumours have lead to a shortage of paracetamol in the pharmacies. The representative of the Ministry of Health said that there is not enough evidence thus it would be good when people have symoptoms to prefer paracetamol.

==Analysis and interpretation==
* The study of Fang et al. is relevant and credible. However, the study alone does not (yet) constitute convincing evidence that ACE2-inhibitors are risk factors for COVID19 and severe outcome. The association is plausible, yet requires more study to generate supporting evidence.
* Notwithstanding the above, it is important to take note of the study of Fang et al. The observation deserves consideration, especially by clinicians treating patients who are in known risk groups for severe COVID19
* Rumours on NSAID are currently unsubstantiated.

==Consequences for action==
* Additional studies to find supporting evidence (or refuting) are needed
* Clinicians should take note of the study of Fang et al., and make decisions on a case by case basis
* In absence of evidence supporting NSAID as risk factor, experts need to very clearly explain that such rumours are unsubstantiated

=References=
Manuel B Schmid,Jehudith Fontijn,Nicole Ochsenbein-Kölble,Christoph Berger,Dirk Bassler. COVID-19 in pregnant women – Authors' reply
Published:March 17, 2020DOI:https://doi.org/10.1016/S1473-3099(20)30192-4

Risk factors for severe disease

2020-03-18T18:36:04Z

79.129.118.174: /* References */

This page collects observations, interpretations, and consequences for action about Risk Factors of SARS-CoV2. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[Sources]], please use that page, instead of posting your content here.

=What is already known=
* Recent studies suggest that ACE2 expression is increased in diabetes and treatment with ACE inhibitors and ARBs increases ACE2 expression. Consequently, the increased expression of ACE2 would facilitate infection with COVID-19. This observation makes some researchers hypothesize that diabetes and hypertension treatment with ACE2-stimulating drugs increases the risk of developing severe and fatal COVID-19. <ref name="Fang2020">Fang, Lei, George Karakiulakis, and Michael Roth. "Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection?." The Lancet Respiratory Medicine (2020).</ref>
*no evidence of vertical transmission of coronavirus disease 2019 (COVID-19) based on two small clinical series </ref>
COVID-19 was not detected in the maternal milk of six patients. </ref>
concern whether an infected mother can transmit the virus through respiratory droplets during breastfeeding </ref>

=Rumours about interaction with medicines=
==Observations==
* The publication by Fang et al. suggests that ACE-inhibitors may increase the risk of Coronavirus infection and severe outcomes. <Ref name="Fang2020"/>. This is so far, the only publication that we know of.
* In the Netherlands, rumours circulate (and are even discussed at National Television) that Ibuprofen and NSAID in general increase the rik of severe COVID19 disease outcome.
* In Greece, the same rumours have lead to a shortage of paracetamol in the pharmacies. The representative of the Ministry of Health said that there is not enough evidence thus it would be good when people have symoptoms to prefer paracetamol.

==Analysis and interpretation==
* The study of Fang et al. is relevant and credible. However, the study alone does not (yet) constitute convincing evidence that ACE2-inhibitors are risk factors for COVID19 and severe outcome. The association is plausible, yet requires more study to generate supporting evidence.
* Notwithstanding the above, it is important to take note of the study of Fang et al. The observation deserves consideration, especially by clinicians treating patients who are in known risk groups for severe COVID19
* Rumours on NSAID are currently unsubstantiated.

==Consequences for action==
* Additional studies to find supporting evidence (or refuting) are needed
* Clinicians should take note of the study of Fang et al., and make decisions on a case by case basis
* In absence of evidence supporting NSAID as risk factor, experts need to very clearly explain that such rumours are unsubstantiated

=References=
Manuel B Schmid,Jehudith Fontijn,Nicole Ochsenbein-Kölble,Christoph Berger,Dirk Bassler. COVID-19 in pregnant women – Authors' reply
Published:March 17, 2020DOI:https://doi.org/10.1016/S1473-3099(20)30192-4

Risk factors for severe disease

2020-03-18T18:32:20Z

79.129.118.174: /* What is already known */

This page collects observations, interpretations, and consequences for action about Risk Factors of SARS-CoV2. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[Sources]], please use that page, instead of posting your content here.

=What is already known=
* Recent studies suggest that ACE2 expression is increased in diabetes and treatment with ACE inhibitors and ARBs increases ACE2 expression. Consequently, the increased expression of ACE2 would facilitate infection with COVID-19. This observation makes some researchers hypothesize that diabetes and hypertension treatment with ACE2-stimulating drugs increases the risk of developing severe and fatal COVID-19. <ref name="Fang2020">Fang, Lei, George Karakiulakis, and Michael Roth. "Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection?." The Lancet Respiratory Medicine (2020).</ref>
*no evidence of vertical transmission of coronavirus disease 2019 (COVID-19) based on two small clinical series </ref>
COVID-19 was not detected in the maternal milk of six patients. </ref>
concern whether an infected mother can transmit the virus through respiratory droplets during breastfeeding </ref>

=Rumours about interaction with medicines=
==Observations==
* The publication by Fang et al. suggests that ACE-inhibitors may increase the risk of Coronavirus infection and severe outcomes. <Ref name="Fang2020"/>. This is so far, the only publication that we know of.
* In the Netherlands, rumours circulate (and are even discussed at National Television) that Ibuprofen and NSAID in general increase the rik of severe COVID19 disease outcome.
* In Greece, the same rumours have lead to a shortage of paracetamol in the pharmacies. The representative of the Ministry of Health said that there is not enough evidence thus it would be good when people have symoptoms to prefer paracetamol.

==Analysis and interpretation==
* The study of Fang et al. is relevant and credible. However, the study alone does not (yet) constitute convincing evidence that ACE2-inhibitors are risk factors for COVID19 and severe outcome. The association is plausible, yet requires more study to generate supporting evidence.
* Notwithstanding the above, it is important to take note of the study of Fang et al. The observation deserves consideration, especially by clinicians treating patients who are in known risk groups for severe COVID19
* Rumours on NSAID are currently unsubstantiated.

==Consequences for action==
* Additional studies to find supporting evidence (or refuting) are needed
* Clinicians should take note of the study of Fang et al., and make decisions on a case by case basis
* In absence of evidence supporting NSAID as risk factor, experts need to very clearly explain that such rumours are unsubstantiated

=References=