Responding to the COVID-19 pandemic in complex humanitarian crises

Purinergic signaling in the battlefield of viral infections

Purinergic signaling has been associated with immune defenses against pathogens such as bacteria, protozoa, fungi, and viruses, acting as a sentinel system that signals to the cells when a threat is present. This review focuses on the roles of purinergic signaling and its therapeutic potential for viral infections. In this context, the purinergic system may play potent antiviral roles by boosting interferon signaling. In other cases, though, it can contribute to a hyperinflammatory response and disease severity, resulting in poor outcomes, such as during flu and potentially COVID-19. Lastly, a third situation may occur since viruses are obligatory intracellular parasites that hijack the host cell machinery for their infection and replication. Viruses such as HIV-1 use the purinergic system to favor their infection and persistence within the host cell. Therefore, understanding the particular nuances of purinergic signaling in each viral infection may contribute to designing proper therapeutic strategies to treat viral diseases.

Equity and extent of financial risk protection indicators during COVID-19 pandemic in rural part of Tamil Nadu, India

Catastrophic health expenditure [CHE] in India is on a rise. This situation would worsen even further when resources are disproportionately distributed across various socioeconomic classes. Hence, we conducted this study to determine the equity and extent of out-of-pocket [OOP] payments, Catastrophic health expenditure and impoverishment among rural households during COVID-19 pandemic in Tamil Nadu, India. A cross-sectional survey covering 2409 households was conducted during November 2021 across six districts in rural part of Tamil Nadu. Information on out-of-pocket payments, Catastrophic health expenditure (based on 40% capacity-to-pay [CTP] method) and impoverishment was obtained through World Health Organization standard criteria. Point estimates were reported as proportions with 95% Confidence Interval [CI]. Our results showed that the proportion of households with out-of-pocket payments on health and Catastrophic health expenditure in the month preceding the survey was 82.8% (95%CI: 81.2%-84.3%) and 26.9% (95%CI: 25.1%-28.7%) respectively. Nuclear (couple with dependent children only) and joint family type (extended family), presence of under-five children and lower socioeconomic status were significant determinants of Catastrophic health expenditure. The prevalence of impoverishment was 6.4% (95%CI: 5.4%-7.5%). To conclude, more than three fourth of the rural households in Tamil Nadu has out-of-pocket payments for health with one-fourth having Catastrophic health expenditure. Almost one in fourteen non-poor households faced impoverishment during the COVID-19 pandemic. This shows the disproportionate distribution of health expenses especially in the rural areas. Hence, appropriate financial risk protection measures should be taken in order to progress towards universal healthcare in our country.

Key ethical issues encountered during COVID-19 research: a thematic analysis of perspectives from South African research ethics committees

BACKGROUND

The COVID-19 pandemic presents significant challenges to research ethics committees (RECs) in balancing urgency of review of COVID-19 research with careful consideration of risks and benefits. In the African context, RECs are further challenged by historical mistrust of research and potential impacts on COVID-19 related research participation, as well as the need to facilitate equitable access to effective treatments or vaccines for COVID-19. In South Africa, an absent National Health Research Ethics Council (NHREC) also left RECs without national guidance for a significant duration of the COVID-19 pandemic. We conducted a qualitative descriptive study that explored the perspectives and experiences of RECs regarding the ethical challenges of COVID-19 research in South Africa.

METHODS

We conducted in-depth interviews with 21 REC chairpersons or members from seven RECs at large academic health institutions across South Africa that were actively involved in the review of COVID-19 related research from January to April 2021. In-depth interviews were conducted remotely via Zoom. Interviews (60-125 min) were conducted in English using an in-depth interview guide, until data saturation was achieved. Audio-recordings were transcribed verbatim and field notes were converted into data documents. Line-by-line coding of transcripts was performed, and data were organised into themes and sub-themes. An inductive approach to thematic analysis was used to analyse data.

RESULTS

Five main themes were identified, namely: rapidly evolving research ethics landscape, extreme vulnerability of research participants, unique challenges to informed consent, challenges to community engagement during COVID-19, and overlapping research ethics and public health equity issues. Sub-themes were identified for each main theme.

CONCLUSIONS

Numerous, significant ethical complexities and challenges were identified by South African REC members in the review of COVID-19 related research. While RECs are resilient and adaptable, reviewer and REC member fatigue were major concerns. The numerous ethical issues identified also highlight the need for research ethics teaching and training, especially in informed consent, as well as the urgent requirement for the development of national guidelines for research ethics during public health emergencies. Further, comparative analysis between different countries is needed to develop the discourse around African RECs and COVID-19 research ethics issues.

Early Determination of Case Fatality Rate of Covid-19 Pandemic During the Ongoing Yemeni Armed Conflict

OBJECTIVES

To determine the case-fatality rate (CFR) of coronavirus disease 2019 (Covid-19) and its associated determinants in order to understand the true magnitude of the problem during the ongoing conflict in Yemen.

METHODS

The CFR among the confirmed Covid-19 cases in Yemen was calculated. The data was retrieved from national Covid-19 surveillance between April 10, when the first COVID-19 case reported, and May 31, 2020.

RESULTS

A total of 419 confirmed Covid-19 cases were reported. There were 14.1% and 5.7% of cases who required intensive care and mechanical ventilators, respectively. Out of the total cases, 95 deaths were reported, giving a CFR of 22.6% which is much higher compared to other countries. CFR was significantly higher among elderly people compared to young adults and varied between governorates. Mortality was associated with pre-existing hypertension (OR: 2.30; 95% CI: 1.58, 3.54) and diabetes (OR: 1.68; 95% CI: 1.08, 2.61).

CONCLUSIONS

The elderly and those with comorbidities, in particular hypertension and diabetes, have higher risk for poor outcomes and therefore should receive more attention in the clinical setting. Preventive measures should also be prioritized to protect those groups in order to reduce the severe cases and deaths-associated COVID-19 in armed-conflict.

Building resilient hospitals in the Eastern Mediterranean Region: lessons from the COVID-19 pandemic

Since the COVID-19 pandemic began, hospitals in the Eastern Mediterranean Region (EMR) have faced significant challenges in providing essential services, while simultaneously combatting this pandemic and responding to new and ongoing shocks and emergencies. Despite these challenges, policy-makers and hospital managers adapted their hospital responses to maintain operations and continue providing essential health services in resource-restraint and fragile and conflict affected, offering valuable insights to others in similar contexts. The aim of this paper is to share the lessons learnt from hospital responses to COVID-19 from the EMR. To do this, we triangulated findings from literature review, open-ended online surveys and 46 in-depth key informant interviews from 18 EMR countries. Qualitative findings from semistructured key informant interviews along with the open-ended survey responses resulted in nine major themes for lessons learnt in the EMR. These themes include Preparedness, Leadership and Coordination, Communication, Human Resources, Supplies and Logistics, Surge Capacity and Essential Services, Clinical Management (including Rapid Identification, Diagnosis and Isolation), Infection Prevention and Control, and Information and Research. Each of the nine themes (domains) included 4-6 major subthemes offering key insights into the regional hospital response to health emergencies. Resilient hospitals are those that can provide holistic, adaptable, primary-care-based health systems to deliver high-quality, effective and people-centred health services and respond to future outbreaks. Both bottom-up and top-down approaches are needed to strengthen collaboration between policy-makers, hospitals, front-line workers and communities to mitigate the continued spread of SARS CoV2, build resilient hospital systems and improve public health preparedness and emergency response.

Equity at a time of pandemic

Health promotion has long aspired for a world where all people can live to their full potential. Yet, COVID-19 illuminates dramatically different consequences for populations bearing heavy burdens of systemic disadvantage within countries and between the Global South and Global North. Many months of pandemic is entrenching inequities that reveal themselves in the vastly differential distribution of hospitalization and mortality, for example, among racialized groups in the USA. Amplified awareness of the intimate relationship between health, social structures, and economy opens a window of opportunity to act on decades of global commitments to prioritize health equity. Choices to act (or not act) are likely to accelerate already vast inequities within and between countries as rapidly as the COVID-19 pandemic itself. Recognizing the inherently global nature of this pandemic, this article explores how determinants of equity are embedded in global responses to it, arguing that these determinants will critically shape our global futures. This article aims to stimulate dialogue about equity-centered health promoting action during a pandemic, using the Canadian Coalition for Global Health Research (CCGHR) Principles for Global Health Research to examine equity considerations at a time of pandemic. Attentiveness to power and the relationship between political economy and health are argued as central to identifying and examining issues of equity. This article invites dialogue about how equity-centered planning, decision-making and action could leverage this massive disruption to society to spark a more hopeful, just, and humane collective future.

Measuring the impact of donations at the Bottom of the Pyramid (BoP) amid the COVID-19 pandemic

The governments' isolation measures to contain the transmission of COVID-19 imposed a dilemma for the people at the bottom of the pyramid. Since these people have very unreliable sources of income, a dilemma arises: they must either work under risky conditions or refrain from work and suffer from income cuts. Emergency donations of food and cleaning supplies in a pandemic context might be overlooked by government and civil society actors. This paper aims to model the effects of donations on mitigating the negative effects of COVID-19 on vulnerable communities. Applying the system dynamics method, we simulated the behaviour of the pandemic in Rio de Janeiro (Brazil) communities and the impacts that donations of food and cleaning supplies have in these settings. We administered surveys to the beneficiaries and local organisations responsible for the final distribution of donations to gather information from the field operations. The results show that increasing access to cleaning supplies in communities through donations can significantly reduce coronavirus transmission, particularly in high-density and low-resource areas, such as slums in urban settings. In addition, we also show that food donations can increase the vulnerable population's ability to afford necessities, alleviating the stress caused by the pandemic on this portion of the population. Therefore, this work helps decision-makers (such as government and non-governmental organisations) understand the impacts of donations on controlling outbreaks, especially under COVID-19 conditions, in a low-resource environment and, thus, aid these hard-to-reach populations in a pandemic setting.

Recent advances and applications of polymeric materials in healthcare sector and COVID-19 management

The coronavirus disease pandemic is considered at its worst and all nations are collectively fighting to improve global public health. In this outlook, polymers and their related materials (including plastics) are the primary sources in the manufacturing of medical and personal protective equipment. Plastics can be mass-produced, economical, and sterilized, which makes them an inevitable material in the medical and healthcare sector. Along with plastics, antibacterial and antiviral coatings, polymeric nanomaterials and nanocomposites, and functional polymers have become excellent materials for COIVD-19. This review centres on the applications of polymer materials in managing the COVID-19 outbreak. Moreover, the utilization of plastics with its healthcare applications are reviewed. Apart from this, major challenges and future directions of these materials have also been discussed. This review will help aspiring researchers to develop the basic understanding of polymeric materials currently employed in medical sector.

Challenges of Providing Health Care in Complex Emergencies: A Systematic Review

Providing health care in times of complex emergencies (CEs) is one of the most vital needs of people. CEs are situations in which a large part of the population is affected by social unrest, wars, and food shortages. This systematic review study was conducted to identify the challenges of health-care delivery in CEs. We searched terms related to health-care delivery and CEs in PubMed, Web of Sciences, Science Direct, and Google scholar databases, as well as Persian databases SID and Magiran. The searching keywords included: "Health Care, Complex Crises, War, Humanitarian, Refugees, Displaced Persons, Health Services, and Challenges." Of 409 records, we selected 6 articles based on the Preferred Reporting Items for Systematic Reviews (PRISMA) checklist. Studies were analyzed through qualitative content analysis. The results show that CEs affect health-care delivery in 4 primary areas: the workforce, infrastructure, information access, and organization of health services. These areas can pose potential threats for health-care providers and planners at times of emergencies. Thus, they should be informed about these challenges to strengthen the health-care system.

Knowledge, Attitudes, and Practices Regarding COVID-19 Among Health Care Workers in Public Health Facilities in Eastern Ethiopia: Cross-sectional Survey Study

Background

On March 13, 2020, Ethiopia reported the first confirmed case of COVID-19 in Addis Ababa. COVID-19 is likely to overwhelm an already-fragile health care delivery system and reduce the availability of essential health services. This analysis of data from the Somali Region of Eastern Ethiopia on health care workers’ (HCWs) knowledge, attitudes, and practices regarding the prevention and control of COVID-19 may be used in planning health education programs about the emerging viral disease.

Objective

This study aimed to investigate the knowledge, attitudes, and practices of HCWs regarding COVID-19 infection.

Methods

This cross-sectional study was conducted among HCWs in three public health facilities in the Somali Region, Eastern Ethiopia. A self-administered questionnaire was shared with all HCWs working at the public health facilities. A total of 15 knowledge questions were scored as 1 or 0 for correct or incorrect responses, respectively. A total of 14 practice questions were scored on a 3-point scale from 1 (“always”) to 3 (“never”). A total of six attitude questions were rated on a 5-point Likert scale, in a negative dimension, as follows: 1 (“strongly agree”), 2 (“agree”), 3 (“neutral”), 4 (“disagree”), and 5 (“strongly disagree”). Mean scores were calculated and used as a cut point to dichotomize the outcome variables (>13.7 indicated good knowledge, <18.8 indicated good practices, and ≤10.5 indicated favorable attitudes). We used t tests and analyses of variance (ie, F tests) to analyze the mean score differences of knowledge, attitudes, and practices between the independent variables. Spearman correlation was used to assess the relationship between mean knowledge and attitude scores.

Results

Of the 686 HCWs approached, a total of 434 HCWs responded (63.3% response rate). The mean age of the participants was 27.6 (SD 5.3) years, and the majority of the participants were male (293/434, 67.5%). The mean knowledge score was 13.7 (SD 2.6), and 73.3% (318/434) of participants had sufficient knowledge. The mean attitude score was 10.5 (SD 4.1), and 54.8% (238/434) of the participants had a good attitude toward COVID-19. The mean practice score was 18.8 (SD 5.8), and 61.5% (267/434) of the participants practiced precautionary measures to prevent COVID-19. There was a negative correlation between knowledge and attitude scores (r=–0.295, P<.001) and between knowledge and practice scores (r=–0.298, P<.001).

Conclusions

The overall levels of knowledge and practice were relatively better than the attitude level. This highlights the need to implement strategies that enhance the positive attitudes and safe practices of the HCWs for better containment of the pandemic and supporting of essential health care services.

The Roots of Structural Racism in the United States and their Manifestations During the COVID-19 Pandemic

During the COVID-19 pandemic, the disproportionate morbidity and mortality borne by racial minorities, patients of lower socioeconomic status, and patients lacking health insurance reflect pre-existing structural inequities. Structural racism is racial discrimination rooted in history, perpetuated through policies, and manifested in disparities in healthcare, housing, education, employment, and wealth. Although these disparities exert greater impacts on health outcomes than do genetics or behavior, scientists, and policy makers are only beginning to name structural racism as a key determinant of population health and take the necessary steps to dismantle it. In radiology, structural racism impacts how imaging services are utilized. Here we review the history and policies that contribute to structural racism and predispose minority and disadvantaged communities to inferior outcomes during the COVID-19 pandemic in order to identify policy changes that could promote more equitable access to radiologic services.

Sexual and reproductive health self-care in humanitarian and fragile settings: where should we start?

Recent crises have accelerated global interest in self-care interventions. This debate paper aims to raise the issue of sexual and reproductive health (SRH) self-care and invites members of the global community operating in crisis-affected settings to look at potential avenues in mainstreaming SRH self-care interventions. We start by exploring self-care interventions that could align with well-established humanitarian standards, such as the Minimum Initial Service Package (MISP) for Sexual and Reproductive Health in Crises, point to the potential of digital health support for SRH self-care in crisis-affected settings, and discuss related policy, programmatic, and research considerations. These considerations underscore the importance of self-care as part of the care continuum and within a whole-system approach. Equally critical is the need for self-care in crisis-affected settings to complement other live-saving SRH interventions-it does not eliminate the need for provider-led services in health facilities. Further research on SRH self-care interventions focusing distinctively on humanitarian and fragile settings is needed to inform context-specific policies and practice guidance.

Examining the spatial and temporal relationship between social vulnerability and stay-at-home behaviors in New York City during the COVID-19 pandemic

Social distancing and particularly staying at home are effective public health responses to the COVID-19 pandemic. The sheer scale of behavior changes across a mass population scale is unprecedented and will undoubtedly cause disproportionate hardships for certain vulnerable groups of population and marginalized communities during different periods of the pandemic. However, at the community level, few studies have considered the spatial and temporal variations in such public health behavior changes during this pandemic. We applied a geographically and temporally weighted regression (GTWR) to analyze the spatiotemporal pattern of community stay-at-home behaviors against social vulnerability indicators at the census tract level in New York City from March to August 2020. Our findings are generally supporting the conventional wisdom of social vulnerability yet they also offer new insights. Despite the spatial variations in the effects of social vulnerability on stay-at-home behaviors, people from different vulnerable groups are also exhibiting varying reactions to the pandemic over the duration of this study, thereby highlighting the importance of understanding the spatiotemporal pattern of public health behaviors to develop an effective policy response to avoid the risk of deepening inequalities and to promote a just and sustainable urban future.

Medical students as the volunteer workforce during the COVID-19 pandemic: Polish experience

In response to the COVID-19 pandemic medical students in different countries were mobilized to support healthcare systems during the emergency. This study presents the experience of 580 students of a single medical university in Poland who served as volunteers at different healthcare units during the first six months of the first case being recorded in the country (March-September 2020). The mean ± SD hours and days spent on volunteering in the studied group were 52 ± 36 h and 144 ± 126 d, respectively, the collective number of worked hours amounted to 83,460 h. Compared to other fields of study students of medicine engaged in volunteering for more hours and for more days. The main tasks performed by the surveyed group included triage, servicing call-centers for patients and working at the admission ward, hospital clinics, emergency departments and diagnostic labs. The level of fear at the beginning of volunteering was relatively low in the studied group and did not increase over the course. The majority of students received positive feedback from families, friends, patients and healthcare workers, revealed a high level of satisfaction from volunteering (also when experiencing COVID-19-related prejudice), while gaining professional experience and a sense of giving real aid were among the most frequently indicated benefits. The results of the present study demonstrate that although medical students are not essential workers in response to the COVID-19 pandemic, they can be of real assistance to healthcare systems during times of emergency, and should be considered as such in the future in case such a need arises again.

Complex emergencies: overcoming barriers to health care

BACKGROUND

At the intersection of the Sustainable Development Goals, humanitarian assistance and health, the umbrella term 'health in the last mile' has gained traction. In August 2019, the Norwegian Red Cross commissioned a global report to conceptualise and assess what 'health in the last mile' refers to, in terms of access, needs and structural and geographical barriers and vulnerabilities, and describe how these vulnerabilities overlap in different humanitarian settings and regions.

AIMS

The purpose of this commentary article is to highlight the report's most important findings for an academic audience, from the perspective of the Norwegian Red Cross.

DISCUSSION

The aim of the report was to propose a definition and create a methodology to help identify people and populations living in the last mile of healthcare; acknowledging that these go far beyond those affected by armed conflicts and sudden onset disasters. As the report reveals, last-mile populations are not adequately reached by current universal health coverage strategies. The report highlights the key role played by local humanitarian actors in reducing barriers to access to healthcare. Local stakeholders have first-hand knowledge of the needs of populations in the last mile and on how they navigate the barriers to healthcare access. The report also addresses questions such as: Who are the people with least access to healthcare? What are their health needs and what barriers do they face? Not least, when many live without access to healthcare services, how do we determine where the last mile begins? The report proposes a definition of 'the last mile' involving converging factors that exacerbate barriers to healthcare and identifies 18 groups that are considered potential last-mile populations. Global epidemics, such as the latest COVID-19, have shown that the concept of vulnerability is continually changing. These situations can bring new vulnerable populations to the edge of the last mile which were already vulnerable and ignored before the outset of the outbreak.

CONCLUSIONS

Millions of people do not and will not benefit from the global progress in universal health coverage under current health systems. To reach the Sustainable Development Goals 3 and 16, we need solutions to overcome the barriers they face to access basic healthcare.

Novel Case-Based Reasoning System for Public Health Emergencies

Purpose

Several threatening infectious diseases, including influenza, Ebola, SARS, and COVID-19, have affected human society over the past decades. These disease outbreaks naturally inspire a demand for sustained and advanced safety and suppression measures. To protect public health and safety, further research developments on emergency analysis methods and approaches for effective emergency treatment generation are urgently needed to mitigate the severity of the pandemic and save lives.

Methods

To address these issues, a novel case-based reasoning (CBR) system is proposed using three phases. In the first phase, the similarity between the current case and the historical cases is calculated under a variety of heterogeneous information. In the second phase, a filter approach based on grey clustering analysis is created to retrieve relevant cases. In the third phase, the cases retrieved are taken as initial host nests in a cuckoo search (CS) algorithm, and our system searches an optimal solution through iteration of this algorithm.

Results

The proposed model is compared with a CBR method improved by particle swarm optimization (PSO) and a CBR method improved by a differential evolution algorithm (DE), to confirm the efficiency of our CS algorithm in adapting solutions for public health emergencies. The results show that the proposed model is better than the existing algorithms.

Conclusion

The proposed model improves the speed of case retrieval using grey clustering and increases solution accuracy with CS algorithms. The present research can contribute to government, CDC, and infectious disease emergency management fields with regard to the implementation of fast and accurate public biohazard prevention and control measures based on a variety of heterogeneous information.

Access to and Quality of Healthcare for Pregnant and Postpartum Women During the COVID-19 Pandemic

Introduction: During the COVID-19 pandemic, obstetric care has adopted new precautions to ensure services can be maintained for pregnant women. The aim of this study was to describe access to and quality of obstetric care for pregnant and postpartum women during the COVID-19 pandemic and to identify factors that predict quality of care at this time. Methods: Between May 3 and June 28, 2020, we recruited women who were pregnant or within the first 6 months after delivery to participate in an online survey. This included questions on access to obstetric healthcare (type and place of health care provider, changes to obstetric appointments/services, appointment preferences) and the Quality of Prenatal Care Questionnaire (QPCQ). Results: Of the 917 eligible women, 612 (67%) were pregnant and 305 (33%) were in the first 6 months after delivery. Sixty-two percent (n = 571) reported that COVID-19 had affected their healthcare; appointments were rearranged, canceled or occurred via virtual means for 29% (n = 166), 29% (n = 167), and 31% (n = 175) of women, respectively. The majority preferred to physically attend appointments (74%; n = 676) and perceived the accompaniment of birth partners as important (77%; n = 471). Sixty-two percent (n = 380) were permitted a birth partner at delivery, 18% (n = 111) were unsure of the rules while 4% (n = 26) were not permitted accompaniment. During pregnancy, QPCQ was negatively associated with disruption to obstetric services including exclusion or uncertainty regarding birth partner permissions [F (7, 433) = 11.5, p < 0.001, R 2 = 0.16] while QPCQ was negatively associated with inadequate breastfeeding support postpartum [F (1, 147) = 12.05, p = 0.001, R 2 = 0.08]. Conclusion: Pregnant and postpartum have experienced disruption in their access to obstetric healthcare. Perceived quality of obstetric care was negatively influenced by cancellation of appointment(s), suspension of services and exclusion of birth partners at delivery. During this time, continuity of care can be fulfilled via virtual and/or phone appointments and women should receive clear guidance on changes to services including birth partner permissions to attend delivery.

Sustaining quality education and practice learning in a pandemic and beyond: 'I have never learnt as much in my life, as quickly, ever'

The context of healthcare and of healthcare education has radically changed as a result of the Covid-19 pandemic. To identify positive strategies for midwifery education in this context, five case studies from the UK and beyond were conducted using an appreciative enquiry approach, from the perspectives of students, the maternity services, cross-university collaboration, and digital learning. A health system analysis was used to identify strategies to cope, adapt, and transform for the future, at the levels of individuals, teams, and the whole system. Findings showed that the implementation of effective responses was possible. Responding effectively and rapidly to a shock as profound as this pandemic requires courageous, respectful, evidence-based, innovative, collaborative, cross-sectoral working and leadership across education institutions, practice settings, the regulator, government, and with students themselves. Pre-existing trusting relationships and collaborative systems supported rapid responses. Effective digital learning requires a pro-active, student-centred approach, and addressing the problems of inequitable access to equipment and space. Joint problem-solving and focussing on the key outcomes that matter contribute to developing successful strategies and robust processes. The pandemic provides an opportunity for student midwives to be re-imagined as essential members of midwifery teams and not 'just students'. Transformative actions identified include whole-system working, tackling longstanding problems including racism, poverty, prejudice, and systemic discrimination, and keeping students at the heart of the education system.

Shedding of SARS-CoV-2 in feces and urine and its potential role in person-to-person transmission and the environment-based spread of COVID-19

The recent detection of SARS-CoV-2 RNA in feces has led to speculation that it can be transmitted via the fecal-oral/ocular route. This review aims to critically evaluate the incidence of gastrointestinal (GI) symptoms, the quantity and infectivity of SARS-CoV-2 in feces and urine, and whether these pose an infection risk in sanitary settings, sewage networks, wastewater treatment plants, and the wider environment (e.g. rivers, lakes and marine waters). A review of 48 independent studies revealed that severe GI dysfunction is only evident in a small number of COVID-19 cases, with 11 ± 2% exhibiting diarrhea and 12 ± 3% exhibiting vomiting and nausea. In addition to these cases, SARS-CoV-2 RNA can be detected in feces from some asymptomatic, mildly- and pre-symptomatic individuals. Fecal shedding of the virus peaks in the symptomatic period and can persist for several weeks, but with declining abundances in the post-symptomatic phase. SARS-CoV-2 RNA is occasionally detected in urine, but reports in fecal samples are more frequent. The abundance of the virus genetic material in both urine (ca. 102-105 gc/ml) and feces (ca. 102-107 gc/ml) is much lower than in nasopharyngeal fluids (ca. 105-1011 gc/ml). There is strong evidence of multiplication of SARS-CoV-2 in the gut and infectious virus has occasionally been recovered from both urine and stool samples. The level and infectious capability of SARS-CoV-2 in vomit remain unknown. In comparison to enteric viruses transmitted via the fecal-oral route (e.g. norovirus, adenovirus), the likelihood of SARS-CoV-2 being transmitted via feces or urine appears much lower due to the lower relative amounts of virus present in feces/urine. The biggest risk of transmission will occur in clinical and care home settings where secondary handling of people and urine/fecal matter occurs. In addition, while SARS-CoV-2 RNA genetic material can be detected by in wastewater, this signal is greatly reduced by conventional treatment. Our analysis also suggests the likelihood of infection due to contact with sewage-contaminated water (e.g. swimming, surfing, angling) or food (e.g. salads, shellfish) is extremely low or negligible based on very low predicted abundances and limited environmental survival of SARS-CoV-2. These conclusions are corroborated by the fact that tens of million cases of COVID-19 have occurred globally, but exposure to feces or wastewater has never been implicated as a transmission vector.

Shedding of SARS-CoV-2 in feces and urine and its potential role in person-to-person transmission and the environment-based spread of COVID-19

The recent detection of SARS-CoV-2 RNA in feces has led to speculation that it can be transmitted via the fecal-oral/ocular route. This review aims to critically evaluate the incidence of gastrointestinal (GI) symptoms, the quantity and infectivity of SARS-CoV-2 in feces and urine, and whether these pose an infection risk in sanitary settings, sewage networks, wastewater treatment plants, and the wider environment (e.g. rivers, lakes and marine waters). A review of 48 independent studies revealed that severe GI dysfunction is only evident in a small number of COVID-19 cases, with 11 ± 2% exhibiting diarrhea and 12 ± 3% exhibiting vomiting and nausea. In addition to these cases, SARS-CoV-2 RNA can be detected in feces from some asymptomatic, mildly- and pre-symptomatic individuals. Fecal shedding of the virus peaks in the symptomatic period and can persist for several weeks, but with declining abundances in the post-symptomatic phase. SARS-CoV-2 RNA is occasionally detected in urine, but reports in fecal samples are more frequent. The abundance of the virus genetic material in both urine (ca. 10²-10⁵ gc/ml) and feces (ca. 10²-10⁷ gc/ml) is much lower than in nasopharyngeal fluids (ca. 10⁵-10¹¹ gc/ml). There is strong evidence of multiplication of SARS-CoV-2 in the gut and infectious virus has occasionally been recovered from both urine and stool samples. The level and infectious capability of SARS-CoV-2 in vomit remain unknown. In comparison to enteric viruses transmitted via the fecal-oral route (e.g. norovirus, adenovirus), the likelihood of SARS-CoV-2 being transmitted via feces or urine appears much lower due to the lower relative amounts of virus present in feces/urine. The biggest risk of transmission will occur in clinical and care home settings where secondary handling of people and urine/fecal matter occurs. In addition, while SARS-CoV-2 RNA genetic material can be detected by in wastewater, this signal is greatly reduced by conventional treatment. Our analysis also suggests the likelihood of infection due to contact with sewage-contaminated water (e.g. swimming, surfing, angling) or food (e.g. salads, shellfish) is extremely low or negligible based on very low predicted abundances and limited environmental survival of SARS-CoV-2. These conclusions are corroborated by the fact that tens of million cases of COVID-19 have occurred globally, but exposure to feces or wastewater has never been implicated as a transmission vector.

Shedding of SARS-CoV-2 in feces and urine and its potential role in person-to-person transmission and the environment-based spread of COVID-19

The recent detection of SARS-CoV-2 RNA in feces has led to speculation that it can be transmitted via the fecal-oral/ocular route. This review aims to critically evaluate the incidence of gastrointestinal (GI) symptoms, the quantity and infectivity of SARS-CoV-2 in feces and urine, and whether these pose an infection risk in sanitary settings, sewage networks, wastewater treatment plants, and the wider environment (e.g. rivers, lakes and marine waters). A review of 48 independent studies revealed that severe GI dysfunction is only evident in a small number of COVID-19 cases, with 11 ± 2% exhibiting diarrhea and 12 ± 3% exhibiting vomiting and nausea. In addition to these cases, SARS-CoV-2 RNA can be detected in feces from some asymptomatic, mildly- and pre-symptomatic individuals. Fecal shedding of the virus peaks in the symptomatic period and can persist for several weeks, but with declining abundances in the post-symptomatic phase. SARS-CoV-2 RNA is occasionally detected in urine, but reports in fecal samples are more frequent. The abundance of the virus genetic material in both urine (ca. 10²-10⁵ gc/ml) and feces (ca. 10²-10⁷ gc/ml) is much lower than in nasopharyngeal fluids (ca. 10⁵-10¹¹ gc/ml). There is strong evidence of multiplication of SARS-CoV-2 in the gut and infectious virus has occasionally been recovered from both urine and stool samples. The level and infectious capability of SARS-CoV-2 in vomit remain unknown. In comparison to enteric viruses transmitted via the fecal-oral route (e.g. norovirus, adenovirus), the likelihood of SARS-CoV-2 being transmitted via feces or urine appears much lower due to the lower relative amounts of virus present in feces/urine. The biggest risk of transmission will occur in clinical and care home settings where secondary handling of people and urine/fecal matter occurs. In addition, while SARS-CoV-2 RNA genetic material can be detected by in wastewater, this signal is greatly reduced by conventional treatment. Our analysis also suggests the likelihood of infection due to contact with sewage-contaminated water (e.g. swimming, surfing, angling) or food (e.g. salads, shellfish) is extremely low or negligible based on very low predicted abundances and limited environmental survival of SARS-CoV-2. These conclusions are corroborated by the fact that tens of million cases of COVID-19 have occurred globally, but exposure to feces or wastewater has never been implicated as a transmission vector.

People with Disabilities and Other Forms of Vulnerability to the COVID-19 Pandemic: Study Protocol for a Scoping Review and Thematic Analysis

OBJECTIVES

To develop a protocol for a scoping review mapping as well as thematically analyzing the literature on the effect of, and responses to, the coronavirus disease 2019 (COVID-19) pandemic, focused on people with disabilities with other layers of individual vulnerability or social disadvantage.

METHODS

We will search scientific databases (Medline/PubMed, Web of Science, Scopus, AgeLine, PsycINFO, CINAHL, ERIC) and preprint servers (MedRxiv, SocArXiv, PsyArXiv). Google searches, snowballing, and key-informant strategies were also used, including a focus on the gray literature (eg, official reports). Peer-reviewed and preprint publications will be covered in 6 languages, and the gray literature in English. Publications will be included if they address individuals with disabilities; the COVID-19 pandemic or subsequent socioeconomic or occupational effects; and individual or social vulnerabilities, including any form of discrimination, marginalization, or social disadvantage. Two independent reviewers will perform eligibility decisions and key data extractions. Beyond mapping the literature, the results will thematically analyze any disproportionate risks people with disabilities and other forms of vulnerability experience in terms of being infected by COVID-19, having severe health consequences, and facing negative socioeconomic effects. Actions taken or recommended to reduce identified inequalities will also be synthesized. Our entire research team, with diverse backgrounds, will be involved in the synthesis.

CONCLUSIONS

This review, which we plan to expedite, aims to inform policy makers, health authorities, disability advocates, and other stakeholders regarding the needs and ways to promote equity and disability-inclusive responses to the COVID-19 pandemic and the resultant socioeconomic shockwaves.

The first 2 months of the SARS-CoV-2 epidemic in Yemen: Analysis of the surveillance data

INTRODUCTION

Yemen was one of the last countries in the world to declare the first case of the pandemic, on 10 April 2020. Fear and concerns of catastrophic outcomes of the epidemic in Yemen were immediately raised, as the country is facing a complex humanitarian crisis. The purpose of this report is to describe the epidemiological situation in Yemen during the first 2 months of the SARS-CoV-2 epidemic.

METHODS

We analyzed the epidemiological data from 18 February to 05 June 2020, including the 2 months before the confirmation of the first case. We included in our analysis the data from 10 out of 23 governorates of Yemen, located in southern and eastern part of the country.

RESULTS

A total of 469 laboratory confirmed, 552 probable and 55 suspected cases with onset of symptoms between 18 February and 5 June 2020 were reported through the surveillance system. The median age among confirmed cases was 46 years (range: 1-90 years), and 75% of the confirmed cases were male. A total of 111 deaths were reported among those with confirmed infection. The mean age among those who died was 53 years (range: 14-88 years), with 63% of deaths (n = 70) occurring in individuals under the age 60 years. A total of 268 individuals with confirmed SARS-CoV-2 infection were hospitalized (57%), among whom there were 95 in-hospital deaths.

CONCLUSIONS

The surveillance strategy implemented in the first 2 months of the SARS CoV 2 in the southern and eastern governorates of Yemen, captured mainly severe cases. The mild and moderate cases were not self-reported to the health facilities and surveillance system due to limited resources, stigma, and other barriers. The mortality appeared to be higher in individuals aged under 60 years, and most fatalities occurred in individuals who were in critical condition when they reached the health facilities. It is unclear whether the presence of other acute comorbidities contributed to the high death rate among SARS-CoV-2 cases. The findings only include the southern and eastern part of the country, which is home to 31% of the total population of Yemen, as the data from the northern part of the country was inaccessible for analysis. This makes our results not generalizable to the rest of the country.

'Most at risk' for COVID19? The imperative to expand the definition from biological to social factors for equity

First recognized in December 2019, the Coronavirus Disease 2019 (COVID19) was declared a global pandemic by the World Health Organization on March 11, 2020. To date, the most utilized definition of 'most at risk' for COVID19 morbidity and mortality has focused on biological susceptibility to the virus. This paper argues that this dominant biomedical definition has neglected the 'fundamental social causes' of disease, constraining the effectiveness of prevention and mitigation measures; and exacerbating COVID19 morbidity and mortality for population groups living in marginalizing circumstances. It is clear - even at this early stage of the pandemic - that inequitable social conditions lead to both more infections and worse outcomes. Expanding the definition of 'most at risk' to include social factors is critical to implementing equitable interventions and saving lives. Prioritizing populations with social conditions is necessary for more effective control of the epidemic in its next phase; and should become standard in the planning for, and prevention and mitigation of all health conditions. Reversing disparities and health inequities is only possible through an expansion of our 'most-at-risk' definition to also include social factors.

A brief outline of respiratory viral disease outbreaks: 1889-till date on the public health perspectives

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is currently causing the respiratory illness termed as the coronavirus disease 2019 or the COVID-19 pandemic. Indeed, the significant increase in deaths in the current days due to influenza around the world started in 1889 is a continued public health threat because of its intermittent style of pandemic outbreaks. An array of research on the influenza viruses has been conducted especially pointing on (1) the development of the anti-viral drugs and the design of probable vaccines on trial basis, (2) the biochemical and genetic aspects underlying the viral pathogenicity, (3) the viral epidemiology, and on (4) the protective immunity against the influenza viruses. Current review briefly discussed the epidemic/ pandemic history of influenza and correlated with the current epidemiology, the possible preventive measures that may be taken by the public health professionals as well as to increase the protective awareness among the general people. The viral reassortments during the initiation of pandemics have also been focused based on the previous literatures.

All Hands on Deck: A synchronized whole-of-world approach for COVID-19 mitigation

The COVID-19 pandemic can no longer be mitigated by a nationwide approach of individual nations alone. Given its scale and accelerating expansion, COVID-19 requires a coordinated and simultaneous Whole- of-World approach that galvanizes clear global leadership and solidarity from all governments of the world. Considering an 'all hands-on deck' concept, we present a comprehensive list of tools and entities responsible for enabling them, as well a conceptual framework to achieve the maximum impact. The list is drawn from pandemic mitigation tools developed in response to past outbreaks including influenza, coronaviruses, and Ebola, and includes tools to minimize transmission in various settings including person-to-person, crowd, funerals, travel, workplace, and events and gatherings including business, social and religious venues. Included are the roles of individuals, communities, government and other sectors such as school systems, health, institutions, and business. While individuals and communities have significant responsibilities to prevent person-to-person transmission, other entities can play a significant role to enable individuals and communities to make use of the tools. Historic and current data indicate the role of political will, whole-of-government approach, and the role of early introduction of mitigation measures. There is also an urgent need to further elucidate the immunologic mechanisms underlying the epidemiological characteristics such as the low disease burden among women, and the role of COVID-19 in inducing Kawasaki-like syndromes in children. Understanding the role of and development of anti-inflammatory strategies based on our understanding of pro-inflammatory cytokines (IL1, IL-6) is also critical. Similarly, the role of oxygen therapy as an anti-inflammatory strategy is evident and access to oxygen therapy should be prioritized to avoid the aggravation of COVID-19 infection. We highlight the need for global solidarity to share both mitigation commodities and infrastructure between countries. Given the global reach of COVID-19 and potential for repeat waves of outbreaks, we call on all countries and communities to act synergistically and emphasize the need for synchronized pan-global mitigation efforts to minimize everyone's risk, to maximize collaboration, and to commit to shared progress.

Predictors of coronavirus disease 19 (COVID-19) pneumonitis outcome based on computed tomography (CT) imaging obtained prior to hospitalization: a retrospective study

PURPOSE

Computed tomography (CT) has been utilized as a diagnostic modality in the coronavirus disease 19 (COVID-19), while some studies have also suggested a prognostic role for it. This study aimed to assess the diagnostic and prognostic value of computed tomography (CT) imaging in COVID-19 patients.

METHODS

This was a retrospective study of fifty patients with COVID-19 pneumonia. Twenty-seven patients survived, while 23 passed away. CT imaging was performed in all of the patients on the day of admission. Imaging findings were interpreted based on current guidelines by two expert radiologists. Imaging findings were compared between surviving and deceased patients. Lung scores were assigned to patients based on CT chest findings. Then, the receiver operating characteristic curve was used to determine cutoff values for lung scores.

RESULTS

The common radiologic findings were ground-glass opacities (82%) and airspace consolidation (42%), respectively. Air bronchogram was more commonly seen in deceased patients (p = 0.04). Bilateral and multilobar involvement was more frequently found in deceased patients (p = 0.049 and 0.014, respectively). The mean number of involved lobes was 3.46 ± 1.80 lobes in surviving patients and 4.57 ± 0.60 lobes in the deceased patients (p = 0.009). The difference was statistically significant. The area under the curve for a lung score cutoff of 12 was 0.790.

CONCLUSION

Air bronchogram and bilateral and multilobar involvement were more frequently seen in deceased patients and may suggest a poor outcome for COVID-19 pneumonia.

Why lockdown? Why national unity? Why global solidarity? Simplified arithmetic tools for decision-makers, health professionals, journalists and the general public to explore containment options for the 2019 novel coronavirus

As every country in the world struggles with the ongoing COVID-19 pandemic, it is essential that as many people as possible understand the epidemic containment, elimination and exclusion strategies required to tackle it. Simplified arithmetic models of COVID-19 transmission, control and elimination are presented in user-friendly Shiny and Excel formats that allow non-specialists to explore, query, critique and understand the containment decisions facing their country and the world at large. Although the predictive model is broadly applicable, the simulations presented are based on parameter values representative of the United Republic of Tanzania, which is still early enough in its epidemic cycle and response to avert a national catastrophe. The predictions of these models illustrate (1) why ambitious lock-down interventions to crush the curve represent the only realistic way for individual countries to contain their national-level epidemics before they turn into outright catastrophes, (2) why these need to be implemented so early, so stringently and for such extended periods, (3) why high prevalence of other pathogens causing similar symptoms to mild COVID-19 precludes the use of contact tracing as a substitute for lock down interventions to contain and eliminate epidemics, (4) why partial containment strategies intended to merely flatten the curve, by maintaining epidemics at manageably low levels, are grossly unrealistic, and (5) why local elimination may only be sustained after lock down ends if imported cases are comprehensively excluded, so international co-operation to conditionally re-open trade and travel between countries certified as free of COVID-19 represents the best strategy for motivating progress towards pandemic eradication at global level. The three sequential goals that every country needs to emphatically embrace are contain, eliminate and exclude. As recently emphasized by the World Health Organization, success will require widespread genuine national unity and unprecedented global solidarity.

Health equity and COVID-19: global perspectives

The COVID-19 is disproportionally affecting the poor, minorities and a broad range of vulnerable populations, due to its inequitable spread in areas of dense population and limited mitigation capacity due to high prevalence of chronic conditions or poor access to high quality public health and medical care. Moreover, the collateral effects of the pandemic due to the global economic downturn, and social isolation and movement restriction measures, are unequally affecting those in the lowest power strata of societies. To address the challenges to health equity and describe some of the approaches taken by governments and local organizations, we have compiled 13 country case studies from various regions around the world: China, Brazil, Thailand, Sub Saharan Africa, Nicaragua, Armenia, India, Guatemala, United States of America (USA), Israel, Australia, Colombia, and Belgium. This compilation is by no-means representative or all inclusive, and we encourage researchers to continue advancing global knowledge on COVID-19 health equity related issues, through rigorous research and generation of a strong evidence base of new empirical studies in this field.

Critical medical ecology and SARS-COV-2 in the urban environment: a pragmatic, dynamic approach to explaining and planning for research and practice

BACKGROUND

Practitioners and researchers in the midst of overwhelming coronavirus disease 2019 (COVID-19) outbreaks are calling for new ways of looking at such pandemics, with an emphasis on human behavior and holistic considerations. Viral outbreaks are characterized by socio-behaviorally-oriented public health efforts aimed at reducing exposure and prevention of morbidity/mortality once infected. These efforts involve different points-of-view, generally, than do those aimed to understand the virus' natural history. Rampant spread of SARS-CoV-2 infection in cities clearly signals that urban areas contain conditions favorable for rapid transmission of the virus.

MAIN TEXT

The Critical Medical Ecology model is a multidimensional, multilevel way of viewing pandemics comprehensively, rooted simultaneously in microbiology and in anthropology, with shared priority for evolution, context, stressors, homeostasis, adaptation, and power relationships. Viewing COVID-19 with a Critical Medical Ecological lens suggests three important interpretations: 1) COVID-19 is equally - if not more - a socially-driven disease as much as a biomedical disease, 2) the present interventions available for primary prevention of transmission are social and behavioral interventions, and 3) wide variation in COVID-19 hospitalization/death rates is not expected to significantly be attributable to a more virulent and rapidly-evolving virus, but rather to differences in social and behavioral factors - and power dynamics - rather than (solely) biological and clinical factors. Cities especially are challenged due to logistics and volume of patients, and lack of access to sustaining products and services for many residents living in isolation.

CONCLUSIONS

In the end, SARS-CoV-2 is acting upon dynamic social human beings, entangled within structures and relationships that include but extend far beyond their cells, and in fact beyond their own individual behavior. As a comprehensive way of thinking, the Critical Medical Ecology model helps identify these elements and dynamics in the context of ecological processes that create, shape, and sustain people in their multidimensional, intersecting environments.

Is Nigeria prepared and ready to respond to the COVID-19 pandemic in its conflict-affected northeastern states?

Northeastern Nigeria has over the decade suffered from the Boko Haram insurgency and is still in the process of recovery from the complex humanitarian crisis that has displaced and subjected millions of vulnerable children, women and elderly population to poverty, disease outbreaks, hunger and malnutrition. Yet, the conflict-affected states in Northeastern Nigeria is not far away from being the worse-hit by the COVID-19 pandemic if urgent public health preventive measures are not taken to contain the spread of the deadly and highly infectious virus. The question arises, “what is Nigeria doing to tackle the burden of a COVID-19 spread and an ongoing humanitarian crisis?

MSC Therapies for COVID-19: Importance of Patient Coagulopathy, Thromboprophylaxis, Cell Product Quality and Mode of Delivery for Treatment Safety and Efficacy

Numerous clinical trials of mesenchymal stromal/stem cells (MSCs) as a new treatment for coronavirus-induced disease (COVID-19) have been registered recently, most of them based on intravenous (IV) infusion. There is no approved effective therapy for COVID-19, but MSC therapies have shown first promise in the treatment of acute respiratory distress syndrome (ARDS) pneumonia, inflammation, and sepsis, which are among the leading causes of mortality in COVID-19 patients. Many of the critically ill COVID-19 patients are in a hypercoagulable procoagulant state and at high risk for disseminated intravascular coagulation, thromboembolism, and thrombotic multi-organ failure, another cause of high fatality. It is not yet clear whether IV infusion is a safe and effective route of MSC delivery in COVID-19, since MSC-based products express variable levels of highly procoagulant tissue factor (TF/CD142), compromising the cells' hemocompatibility and safety profile. Of concern, IV infusions of poorly characterized MSC products with unchecked (high) TF/CD142 expression could trigger blood clotting in COVID-19 and other vulnerable patient populations and further promote the risk for thromboembolism. In contrast, well-characterized products with robust manufacturing procedures and optimized modes of clinical delivery hold great promise for ameliorating COVID-19 by exerting their beneficial immunomodulatory effects, inducing tissue repair and organ protection. While the need for MSC therapy in COVID-19 is apparent, integrating both innate and adaptive immune compatibility testing into the current guidelines for cell, tissue, and organ transplantation is critical for safe and effective therapies. It is paramount to only use well-characterized, safe MSCs even in the most urgent and experimental treatments. We here propose three steps to mitigate the risk for these vulnerable patients: (1) updated clinical guidelines for cell and tissue transplantation, (2) updated minimal criteria for characterization of cellular therapeutics, and (3) updated cell therapy routines reflecting specific patient needs.

Combating COVID-19 Pandemic in Nepal: Ethical Challenges in an Outbreak

Pandemic outbreak of COVID-19 is the largest of its kind of this century. All countries throughout the globe are trying their best to contain the disease and eliminate at the earliest. Efforts are continuing to improve the outcome of the infection in terms of minimizing the morbidity and mortality. As a public health strategy every state has the responsibility of protecting the health of the community and such measures includes the preventive measures like social distancing or even lockdown of the state as a whole restricting the movement of the people, diagnostic measures like testing the suspects, contact tracing and isolation of the patients. Treatment of the infected requires decisions in resource constraint situation particularly ICU beds and ventilators. In the meantime, protecting doctors, nurses, other health workers as well as frontline workers need personal protective equipment (PPE) which is a scarce commodity. While doing so there might be a compromise in the individual autonomy, privacy, confidentiality, and social justice for the beneficence for the larger community. This is an attempt to explore the ethical quandaries in relation to combating COVID-19 in Nepal by relating the issues with the principles of biomedical ethics.

Proteção da saúde dos trabalhadores da saúde em tempos de COVID-19 e respostas à pandemia

Resumo Objetivo: discutir desafios para a elaboração e implementação de planos de resposta e prontidão estratégica contra a COVID-19. Métodos: partindo de recomendações da Organização Mundial da Saúde, que enfatiza três grupos de objetivos a serem buscados nesses planos, defende-se a inclusão do tema da proteção à saúde dos trabalhadores da Saúde no âmbito de seu terceiro objetivo: “Minimizar o impacto da epidemia sobre sistemas de saúde”. Discussão: a ênfase dada ao uso de EPI, medidas de etiqueta social e higiene é discutida como potencialmente minimizadora da importância de medidas de controle de engenharia e de controles administrativos para a prevenção da doença. Destaque é dado à necessidade de treinamentos que formem trabalhadores para o reconhecimento de situações de risco associadas às dificuldades das novas atividades surgidas na pandemia, com ênfase em novas interações entre colegas e entre trabalhadores, assim como em novos instrumentos e contextos dela decorrentes. Os custos a serem pagos na forma de impactos na saúde dos trabalhadores tendem a crescer em contextos de degradação de situações de trabalho associados à rápida evolução da doença. Um dos desafios dos programas de resposta é o de reconhecer e responder com rapidez às mudanças que criam novos riscos.