China coronavirus: cases surge as official admits human to human transmission
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m236 (Published 20 January 2020) Cite this as: BMJ 2020;368:m236Read our latest coverage of the Coronavirus outbreak
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Dynamics on Transmission of COVID-19 - Take home message for Health Care providers and Policy Makers
Currently there is no known cure identified for clinical management of COVID-19; in this condition the next ultimate goal of health care providers (HCP) is to focus on preventive measures. The scientific outcome elaborates that human coronaviruses can survive up to nine days in the pathogenic form after expulsion. The average expected reproductive number of virus spread by individual was considered to be 2.2, which indicates that each infected case has a high possibility of transmission to another two people [1].
Regulatory authorities emphasize more the use of N95 respirator masks in preventing droplet infection but the efficiency (300nm as recommended) [2] of such masks is under potential threat due to its limitation in filtering aerosol viral particles between 80-120 nm [3]. Masks for toddlers and children below 5 years old have not been approved. On the other hand, proper education on personal protective equipment (PPE) has to be imparted to the general public, including the geriatric population who are at high risk of exposure and infection.
Contaminated N95 mask is considered to be potential medical waste hence a proper biomedical waste management program has to be adopted to prevent the recurrent spread of virus through surface contamination. Engagement of dedicated resources in the process of knowledge sharing on safe usage and disposal of N-95 masks in clinics will in turn reduce the incidence of new infection. Policy makers may think of placing exclusive mask disposable hoods fitted with HEPA filters, which can logically perform well in reducing the contamination.
Fecal oral contamination - Apart from aerosol droplet infection, viral transmission is also achieved effectively through fecal oral contamination [4]. Studies indicate a paradigm shift of swab viral load from oral positive (earlier phase) to anal positive (later phase) in infected patients. In this context, contamination may be controlled by maintaining a proper level of sanitation and with disinfection procedures. Research has proven that a combination of ethanol and hydrogen peroxide or sodium hypochlorite can effectively degrade the viral proteins.
Temperature and humidity favors the life span of atmospheric virons. Studies have proven that a decrease in air temperature increases spreadability [5]. Demography data issued by the WHO between 22 January to 20 February 2020 indicates that total infected cases have shown a huge marginal increase from 278 to 74,675 in China and 314 to 75,748 globally [6]. It might also be one of the reasons that the temperature in the severely affected regions helped in transmission between Jan to Feb 2020. Hospitals may think of propagating hot water hand sanitation programs along with conventional sterilization. Warm air blowers and heaters in rooms may also considerably reduce the viral load.
Doctor’ stress – A potential risk factor
Managing the stress level of health care workers is equally import in providing the quality of care to patients. Nurses priorities top the stress level scale among other health care providers: it seems like 39% of those in intensive care exhibit posttraumatic stress disorder [7]. Extended work hours, continuous clinical interventions, restlessness, inadequate quality time with family members make clinicians and professionals of healthcare sectors more prone to the condition called burnout--a kind of emotional exhaustion with reduced interest and attention towards work. Deep breath meditation and periodic counselling led by a psychologist may help to manage the stress related burnouts and also minimize the chances of medication and decision making errors [8,9].
Take home message for Clinicians and other HCPs
1. Impart knowledge to the public on proper usage and safe disposal of face masks
2. Implementation of programs that regulate good biomedical waste management practice
3. Effective management of professional stress related burnout for dynamic decision making
4. Fruitful coordination with other health care professionals in providing quality care to infected patients
5. CME discussion among medical team to enrich the recent updated on therapeutic management of COVID-19
6. Sharing success stories with other clinicians to boost confidence level
Take home message for Policy Makers (health monitoring authorities)
It's highly appreciated if health monitoring authorities frame specific guidelines on emergency basis to address the following:
1. Facilitating mobile medicare units for handling the patients resident in homes
2. Installation of HEPA cabinet protected waste bins for mask and medical waste disposal
3. High standard on sanitation programs to avoid other possible routes of viral transmission (fecal oral)
4. Educating people on seeking medical care at earlier stage of disease
5. Promotion of medical textile policies in designing and manufacturing masks exclusively for toddlers and children of age less than 5 years
6. Development of a unique strategy to control infection rate and mortality index
In conclusion, services offered by clinicians and other health care professionals in managing historic crisis like COVID-19 seem remarkable as they risking their life in saving thousands of infected individuals. Hence at this stage a helping hand from paramedical staff, allied health professionals, general public, researchers and policy makers is likely to widen the scope of disease control and prevention.
Acknowledgements
The authors would like to thank the Indian Council of Medical Research (ICMR), Government of India, New Delhi, India.
Competing interests: The authors declare no competing interests.
References
1. Qun Li, M.Med., Xuhua Guan et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia. NEJM. 2020. Published January 29, 2020.DOI: http://doi:10.1056/NEJMoa2001316
2. U.S.Food and Drug administration. Masks and N95 Respirators. Personal protective equipment for infection and control 2020. https://www.fda.gov/medical-devices/personal-protective-equipment-infect...
3. I-Mei Yu, Michael L. Oldham. Crystal Structure of the Severe Acute Respiratory Syndrome (SARS) Coronavirus Nucleocapsid Protein Dimerization Domain Reveals Evolutionary Linkage between Corona- and Arteriviridae. The Journal of Biological Chemistry.2006;281: 17134 –17139.
4. David L Heymann, Nahoko Shindo. COVID-19: what is next for public health?. The Lancet 2020;395:542-545. Published February 13, 2020. DOI: https://doi.org/10.1016/S0140-6736(20)30374-3.
5. Kampf G et al., Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents, Journal of Hospital Infection 2020, DOI:https: //doi.org /10.1016 /j.jhin. 2020.01.022
6. WHO Coronavirus disease (COVID-2019) situation reports 2020 https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situatio...
7. Seaman JB, Cohen TR, White DB. Reducing the Stress on Clinicians Working in the ICU. JAMA. 2018;320(19):1981–1982.DOI: http://doi:10.1001/jama.2018.14285
8. Gunasingam N, Burns K, Edwards J, et alReducing stress and burnout in junior doctors: the impact of debriefing sessions. BMJ.Postgraduate Medical Journal 2015;91:182-187.DOI: http://dx.doi.org/10.1136/postgradmedj-2014-132847
9. Persaud R. Reducing the stress in medicine. BMJ. Postgraduate Medical Journal 2002;78:1-3.DOI: http://dx.doi.org/10.1136/pmj.78.915.1
Competing interests: No competing interests
Re: China coronavirus: cases surge as official admits human to human transmission
Dear Editor
At the beginning, in January 2020, there was suspicion of the transmission of the new coronavirus from person to person, but more evidence was required to support this hypothesis. Another important aspect would also be defined to the extent that covid-19 spread and was related to the ease in which the virus was transmitted, an aspect in which airborne transmission, contact with contaminated surfaces and objects and their permanence for long periods of time on various surfaces, which would contribute to the spread of the germ.
Another aspect that would be relevant is the role of asymptomatic patients in the transmission of covid-19. Asymptomatic patients were initially thought not to transmit the disease. Confirmation would come from a study developed by a group of researchers in Germany in February 2020; study that was published in March 2020 and in which the transmission between officials of a German company was described, in which several of its members developed mild to moderate symptoms from a contact with a Chinese businesswoman who visited the German company. The Chinese patient in question who had traveled symptom-free to Germany would begin to show signs of covid-19 back in China. The mistake was made by the German and even French authorities who did not give credit to the results published by this working group, which caused the loss of important time to stop the spread of the disease.
Then other dilemmas would arise such as the use or not of masks and their role in containing the transmissibility of covid-19.
It is noteworthy that it was a mistake to expect that all the evidence or all the quality evidence that some groups required for decision-making was available, when common sense and prudence indicated that it was important to adopt norms that would contribute to cut the transmissibility of the new coronavirus. Undoubtedly, low-cost measures could be taken, but they could have a great impact in slowing the spread of the pandemic.
There are several factors that decisively contribute to the transmissibility of the new coronavirus, but we consider that the great mobility of individuals, which allows them to travel long distances in a short time, the contagiousness of the virus and the existence of many asymptomatic patients contributed to the development of the covid-19 pandemic. To or before was added the slowness in the adoption of containment measures.
There is still a long way to go until the control of the covid-19 pandemic and many lessons to be learned from this disease, but it has become clear that prudence and common sense remain a very powerful weapon for epidemiology, which cannot be abandoned. in the absence of evidence that supports or denies the taking of a prudently prophylactic behavior in situations not fully understood and that would have prevented thousands of deaths or have slowed the progression of covid-19.
The world and researchers must bear in mind the lessons learned at such a high cost in the future.
Competing interests: No competing interests