SARS in healthcare facilities, Toronto and Taiwan

The duty of care and the right to be cared for: is there a duty to treat the unvaccinated?

Vaccine hesitancy or refusal has been one of the major obstacles to herd immunity against Covid-19 in high-income countries and one of the causes for the emergence of variants. The refusal of people who are eligible for vaccination to receive vaccination creates an ethical dilemma between the duty of healthcare professionals (HCPs) to care for patients and their right to be taken care of. This paper argues for an extended social contract between patients and society wherein vaccination against Covid-19 is conceived as essential for the protection of the right of healthcare providers to be taken care of. Thus, a duty of care is only valid when those who can receive vaccination actually receive it. Whenever that is not the case, the continuing functioning of HCPs can only be perceived as supererogatory and not obligatory.

The necessity of healthcare supply chain resilience for crisis preparedness

Prior to and during the COVID-19 pandemic, Canadian provincial health systems and governments did not sufficiently consider healthcare supply chain in their crisis preparedness plans, leading to an exposed and vulnerable healthcare system. There have been many opportunities to learn from past Canadian and global crises, which have emphasized the importance of healthcare supply chain resilience in providing essential care to patients; however, considerations of healthcare supply chain resilience remain a significant gap in preparedness planning. Illustrated through the Canadian response to COVID-19 pandemic, this article will explore how healthcare supply chain resilience should be a necessary consideration in any crisis preparedness plans. Further, without this consideration of healthcare supply chain resilience, it is the person (the patient and healthcare worker), and especially vulnerable populations, that are most put at risk in the event of a future crisis.

Estimating the Epidemic Size of Superspreading Coronavirus Outbreaks in Real Time: Quantitative Study

BACKGROUND

Novel coronaviruses have emerged and caused major epidemics and pandemics in the past 2 decades, including SARS-CoV-1, MERS-CoV, and SARS-CoV-2, which led to the current COVID-19 pandemic. These coronaviruses are marked by their potential to produce disproportionally large transmission clusters from superspreading events (SSEs). As prompt action is crucial to contain and mitigate SSEs, real-time epidemic size estimation could characterize the transmission heterogeneity and inform timely implementation of control measures.

OBJECTIVE

This study aimed to estimate the epidemic size of SSEs to inform effective surveillance and rapid mitigation responses.

METHODS

We developed a statistical framework based on back-calculation to estimate the epidemic size of ongoing coronavirus SSEs. We first validated the framework in simulated scenarios with the epidemiological characteristics of SARS, MERS, and COVID-19 SSEs. As case studies, we retrospectively applied the framework to the Amoy Gardens SARS outbreak in Hong Kong in 2003, a series of nosocomial MERS outbreaks in South Korea in 2015, and 2 COVID-19 outbreaks originating from restaurants in Hong Kong in 2020.

RESULTS

The accuracy and precision of the estimation of epidemic size of SSEs improved with longer observation time; larger SSE size; and more accurate prior information about the epidemiological characteristics, such as the distribution of the incubation period and the distribution of the onset-to-confirmation delay. By retrospectively applying the framework, we found that the 95% credible interval of the estimates contained the true epidemic size after 37% of cases were reported in the Amoy Garden SARS SSE in Hong Kong, 41% to 62% of cases were observed in the 3 nosocomial MERS SSEs in South Korea, and 76% to 86% of cases were confirmed in the 2 COVID-19 SSEs in Hong Kong.

CONCLUSIONS

Our framework can be readily integrated into coronavirus surveillance systems to enhance situation awareness of ongoing SSEs.

Cohort profile: recruitment and retention in a prospective cohort of Canadian healthcare workers during the COVID-19 pandemic

PURPOSE

Healthcare workers were recruited early in 2020 to chart effects on their health as the COVID-19 pandemic evolved. The aim was to identify modifiable workplace risk factors for infection and mental ill health.

PARTICIPANTS

Participants were recruited from four Canadian provinces, physicians (medical doctors, MDs) in Alberta, British Columbia, Ontario and Quebec, registered nurses (RNs), licensed practical nurses (LPNs) and healthcare aides (HCAs) in Alberta and personal support workers (PSWs) in Ontario. Volunteers gave blood for serology testing before and after vaccination. Cases with COVID-19 were matched with up to four referents in a nested case-referent study.

FINDINGS TO DATE

Overall, 4964/5130 (97%) of those recruited joined the longitudinal cohort: 1442 MDs, 3136 RNs, 71 LPNs, 235 PSWs, 80 HCAs. Overall, 3812 (77%) were from Alberta. Prepandemic risk factors for mental ill health and respiratory illness differed markedly by occupation. Participants completed questionnaires at recruitment, fall 2020, spring 2021, spring 2022. By 2022, 4837 remained in the cohort (127 had retired, moved away or died), for a response rate of 89% (4299/4837). 4567/4964 (92%) received at least one vaccine shot: 2752/4567 (60%) gave postvaccine blood samples. Ease of accessing blood collection sites was a strong determinant of participation. Among 533 cases and 1697 referents recruited to the nested case-referent study, risk of infection at work decreased with widespread vaccination.

FUTURE PLANS

Serology results (concentration of IgG) together with demographic data will be entered into the publicly accessible database compiled by the Canadian Immunology Task Force. Linkage with provincial administrative health databases will permit case validation, investigation of longer-term sequelae of infection and comparison with community controls. Analysis of the existing dataset will concentrate on effects on IgG of medical condition, medications and stage of pregnancy, and the role of occupational exposures and supports on mental health during the pandemic.

The evolution of workplace risk for Covid-19 in Canadian healthcare workers and its relation to vaccination: A nested case-referent study

BACKGROUND

During the early months of the Covid-19 pandemic, studies demonstrated that healthcare workers (HCWs) were at increased risk of infection. Few modifiable risks were identified. It is largely unknown how these evolved over time.

METHODS

A prospective case-referent study was established and nested within a cohort study of Canadian HCWs. Cases of Covid-19, confirmed by polymerase chain reaction, were matched with up to four referents on job, province, gender, and date of first vaccination. Cases and referents completed a questionnaire reporting exposures and experiences in the 21 days before case date. Participants were recruited from October 2020 to March 2022. Workplace factors were examined by mixed-effects logistic regression allowing for competing exposures. A sensitivity analysis was limited to those for whom family/community transmission seemed unlikely.

RESULTS

533 cases were matched with 1697 referents. Among unvaccinated HCWs, the risk of infection was increased if they worked hands-on with patients with Covid-19, on a ward designated for care of infected patients, or handled objects used by infected patients. Sensitivity analysis identified work in residential institutions and geriatric wards as high risk for unvaccinated HCWs. Later, with almost universal HCW vaccination, risk from working with infected patients was much reduced but cases were more likely than referents to report being unable to access an N95 mask or that decontaminated N95 masks were reused.

CONCLUSIONS

These results suggest that, after a rocky start, the risks of Covid-19 infection from work in health care are now largely contained in Canada but with need for continued vigilance.

Current SARS-CoV-2 Protective Strategies for Healthcare Professionals

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is responsible for the Coronavirus disease 2019 (COVID-19). COVID-19 was first reported in China in December 2019. SARS-CoV-2 is highly contagious and spread primarily via an airborne route. Hand hygiene, surgical masks, vaccinations and boosters, air filtration, environmental sanitization, instrument sterilization, mouth rinses, and social distancing are essential infection control measures against the transmission of SARS-CoV-2. This paper aims to provide healthcare professionals with evidence-based protective strategies.

Bacterial-Viral Interactions: A Factor That Facilitates Transmission Heterogeneities

The transmission of infectious diseases is characterized by heterogeneities that are shaped by the host, the pathogen, and the environment. Extreme forms of these heterogeneities are called super-spreading events. Transmission heterogeneities are usually identified retrospectively, but their contribution to the dynamics of outbreaks makes the ability to predict them valuable for science, medicine, and public health. Previous studies identified several factors that facilitate super-spreading; one of them is the interaction between bacteria and viruses within a host. The heightened dispersal of bacteria colonizing the nasal cavity during an upper respiratory viral infection, and the increased shedding of HIV-1 from the urogenital tract during a sexually transmitted bacterial infection, are among the most extensively studied examples of transmission heterogeneities that result from bacterial-viral interactions. Interrogating these transmission heterogeneities, and elucidating the underlying cellular and molecular mechanisms, are part of much-needed efforts to guide public health interventions, in areas that range from predicting or controlling the population transmission of respiratory pathogens, to limiting the spread of sexually transmitted infections, and tailoring vaccination initiatives with live attenuated vaccines.

Healthcare workers, epidemic biological risks - recommendations based on the experience with COVID-19 and Ebolavirus

Infectious disease outbreaks frequently cause illness and death among Healthcare Workers (HCWs). We compare strategies from recent, past and ongoing outbreak measures used to protect HCWs, including those facing additional challenges such as racial disparities, violence and stigmatization. Outbreaks and pandemics superimposed on countries with preexisting crises have also affected emergency response to these viral outbreaks. Strategies to protect HCWs include adherence to recommended infection prevention and control measures; new technology such as rapid point-of-care tests and remote monitoring; adopting national public health preparedness plans to ensure the supply and allocation of PPE, staff, and testing supplies; occupational health and mental health support services. Lessons learned from recent pandemics should be used by Infection Prevention and Control and Occupational Health staff to refine preparedness plans to protect HCWs better.

The development and psychometric evaluation of COVID-19 staff questionnaire for infectious disease outbreak readiness and preparedness (SQIDORP)

Background

The COVID-19 pandemic has inundated the capacity of hospitals across the globe, exhausting resources, and placing extreme burden on health care workers (HCWs). Hospital preparedness during infectious disease outbreak involves development and implementation of appropriate strategies, procedures, and adequate training for HCWs. Reliable and valid tools to evaluate the perception of HCWs on the effectiveness of hospital preparedness strategies are imperative and literature is yet to fill that gap.

Methods

Items for ‘The Staff Questionnaire for Infectious Disease Outbreak Readiness and Preparedness (SQIDORP)’ were selected from literature that addressed hospital preparedness during novel pandemic outbreaks. The SQIDORP was distributed within a regional hospital in Victoria, Australia. Psychometric evaluation included estimates of reliability and factor analysis while factors associated with the questionnaire were explored using regression analysis.

Results

Omega coefficient of 0.89, Cronbach’s alpha coefficient of 0.88 and item-total correlations (> 0.3) indicated adequate reliability of the SQIDORP. Factor Analysis yielded three meaningful latent factors that are effectiveness of training (Factor 1), self-confidence (Factor 2) and risk to self and stress (Factor 3). Demographic factors did not influence the correlation with SQIDORP. However, rating ‘the current plan for management of COVID-19 in your ward’ and ‘personal knowledge/skills in caring for patients with COVID-19’ had significant positive correlation and accounted for 33% of the variance in readiness and preparedness using SQIDORP (R2 = 0.33, F = 10.227, P < 0.001).

Conclusion

Most of the items of SQIDORP questionnaire achieved adequate internal consistence reliability. This is a valuable tool that can be utilized by hospitals to explore aspects of preparedness and give insights to the knowledge, skills, and mental health of HCWs, as perceived by the HCW themselves.

Protective Measures Practices Among Hospitals' Professionals Working in a Fragile Health System

OBJECTIVE

This study aimed to assess the protective measures among health-care workers (HCWs) in a war-torn area during coronavirus disease 2019 (COVID-19) pandemic.

METHODS

An online cross-sectional questionnaire was administrated to HCWs in Syria between April 1 and May 21, 2020. The questions aimed to assess the HCWs' application of safety, hygiene, and necessary protection considerations while attending to suspected or proven COVID-19 cases. Unpaired t-test and 1-way analysis of variance (ANOVA) were used for statistical analysis.

RESULTS

Of the 290 participants included in the statistical analysis, 250 were medical doctors. Low scores of protective practices were noticed among the participants, as only 12% of doctors had a score above 6/15 points, and only 37.5% of nurses had a score of more than 4/12 points. Medical doctors who were not on the frontlines scored significantly higher than those who were on the frontlines (4.69 vs 3.80 points, respectively; P < 0.001).

CONCLUSIONS

More courses and training sessions should be implemented to improve the practice of protective measures among HCWs (frontliners in particular) in areas with fragile health systems, such as Syria, during the COVID-19 pandemic, especially those on the frontlines. Moreover, specific COVID-19 protection measures guidelines to low-income countries are needed.

Phospholipids dock SARS-CoV-2 spike protein via hydrophobic interactions: a minimal in-silico study of lecithin nasal spray therapy

Understanding the physical and chemical properties of viral infections at molecular scales is a major challenge for the scientific community more so with the outbreak of global pandemics. There is currently a lot of effort being placed in identifying molecules that could act as putative drugs or blockers of viral molecules. In this work, we computationally explore the importance in antiviral activity of a less studied class of molecules, namely surfactants. We employ all-atoms molecular dynamics simulations to study the interaction between the receptor-binding domain of the SARS-CoV-2 spike protein and the phospholipid lecithin (POPC), in water. Our microsecond simulations show a preferential binding of lecithin to the receptor-binding motif of SARS-CoV-2 with binding free energies significantly larger than [Formula: see text]. Furthermore, hydrophobic interactions involving lecithin non-polar tails dominate these binding events, which are also accompanied by dewetting of the receptor binding motif. Through an analysis of fluctuations in the radius of gyration of the receptor-binding domain, its contact maps with lecithin molecules, and distributions of water molecules near the binding region, we elucidate molecular interactions that may play an important role in interactions involving surfactant-type molecules and viruses. We discuss our minimal computational model in the context of lecithin-based liposomal nasal sprays as putative mitigating therapies for COVID-19.

Symptom and Age Homophilies in SARS-CoV-2 Transmission Networks during the Early Phase of the Pandemic in Japan

Kanagawa and Hokkaido were affected by COVID-19 in the early stage of the pandemic. Japan's initial response included contact tracing and PCR analysis on anyone who was suspected of having been exposed to SARS-CoV-2. In this retrospective study, we analyzed publicly available COVID-19 registry data from Kanagawa and Hokkaido (n = 4392). Exponential random graph model (ERGM) network analysis was performed to examine demographic and symptomological homophilies. Age, symptomatic, and asymptomatic status homophilies were seen in both prefectures. Symptom homophilies suggest that nuanced genetic differences in the virus may affect its epithelial cell type range and can result in the diversity of symptoms seen in individuals infected by SARS-CoV-2. Environmental variables such as temperature and humidity may also play a role in the overall pathogenesis of the virus. A higher level of asymptomatic transmission was observed in Kanagawa. Moreover, patients who contracted the virus through secondary or tertiary contacts were shown to be asymptomatic more frequently than those who contracted it from primary cases. Additionally, most of the transmissions stopped at the primary and secondary levels. As expected, significant viral transmission was seen in healthcare settings.

Effectiveness of thermal screening in detection of COVID-19 among truck drivers at Mutukula Land Point of Entry, Uganda

Introduction

Despite the limited evidence for its effectiveness, thermal screening at points of entry has increasingly become a standard protocol in numerous parts of the globe in response to the COVID-19 pandemic. We sought to determine the effectiveness of thermal screening as a key step in diagnosing COVID-19 in a resource-limited setting.

Materials and methods

This was a retrospective cross-sectional study based on a review of body temperature and Xpert Xpress SARS CoV-2 test results records for truck drivers entering Uganda through Mutukula between 15^th May and 30^th July 2020. All records missing information for body temperature, age, gender, and Xpert Xpress SARS CoV-2 status were excluded from the data set. A data set of 7,181 entries was used to compare thermal screening and Xpert Xpress SARS CoV-2 assay test results using the diagnostic statistical test in STATAv15 software. The prevalence of COVID-19 amongst the truck drivers based on Xpert Xpress SARS CoV-2 assay results was determined. The sensitivity, specificity, positive predictive value, negative predictive value, positive and negative Likelihood ratios were obtained using Xpert Xpress SARS CoV-2 assay as the gold standard.

Results

Based on our gold standard test, the proportion of persons that tested positive for COVID-19 was 6.7% (95% CI: 6.1–7.3). Of the 7,181 persons that were thermally screened, 6,844 (95.3%) were male. The sample median age was 38 years (interquartile range, IQR: 31–45 years). The median body temperature was 36.5°C (IQR: 36.3–36.7) and only n (1.2%) had a body temperature above 37.5°C. The sensitivity and specificity of thermal screening were 9.9% (95% CI: 7.4–13.0) and 99.5% (95% CI: 99.3–99.6) respectively. The positive and negative predictive values were 57.8 (95% CI: 46.5–68.6) and 93.9 (95% CI: 93.3–94.4) respectively. The positive and negative Likelihood Ratios (LRs) were 19 (95% CI: 12.4–29.1) and 0.9 (95% CI: 0.88–0.93) respectively.

Conclusion

In this study population, the use of Thermal screening alone is ineffective in the detection of potential COVID-19 cases at point of entry. We recommend a combination of screening tests or additional testing using highly sensitive molecular diagnostics such as Polymerase Chain Reaction.

Factors affecting the risk of SARS-CoV-2 transmission to anesthesiologists performing endotracheal intubation in patients with SARS-CoV-2

BACKGROUND

In this study, we estimated the predictive factors of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission in anesthesiologists performing endotracheal intubation in patients with confirmed SARS-CoV-2.

METHOD

We analyzed data from a survey conducted by the Chinese Society of Anesthesiology Task Force on Airway Management on endotracheal intubation in 98 patients with SARS-CoV-2 confirmed through nucleic acid testing and chest computed tomography. The multivariate logistic model with stepwise selection was used for selecting the predictive factors significantly associated with SARS-CoV-2 infection in the corresponding anesthesiologists.

RESULTS

SARS-CoV-2 prevalence in the corresponding anesthesiologists was 20.41% after intubation in patients with SARS-CoV-2. Univariate analysis indicated that intubation for elective treatment, intubation in an operating room or isolation ward, and routine rapid induction with continuous positive-pressure ventilation (PPV) for intubation were associated with a lower SARS-CoV-2 risk in the anesthesiologists. Multivariate analysis revealed that intubation for elective treatment was associated with a significantly decreased SARS-CoV-2 risk (adjusted odds ratio [aOR] = 0.28, 95% confidence interval [CI]: 0.14-0.68, P < 0.0001), and coughing by patients during endotracheal intubation was associated with a significantly increased SARS-CoV-2 risk (aOR = 1.70, 95% CI: 1.39-2.97, P = 0.0404) in the anesthesiologists.

CONCLUSION

Endotracheal intubation for elective treatments, intubation in an operating room or isolation ward, and routine rapid induction with continuous PPV for patients with confirmed SARS-CoV-2 are associated with a lower risk of SARS-CoV-2 transmission in practicing anesthesiologists, and coughing by patients during intubation increases the risk.

From lionizing to protecting health care workers during and after COVID-19-systems solutions for human tragedies

During the COVID‐19 pandemic, health care workers (HCWs) have been lauded as heroes, yet both before and during the pandemic, they lacked the protections needed to keep them safe. We summarize data on HCW infections and deaths during previous epidemics, the costs of the failure to protect them, and provide recommendations for strengthening HCW protections by investments in and implementation of infection prevention and control and water, sanitation, and hygiene programs, training and career development, and national and global monitoring of HCW infections. We must move from placing individuals at undue risk to accepting collective responsibility and accountability for the well‐being of our HCWs and take concrete actions to protect HCWs who risk their lives to protect patients and populations.

Protected code blue: using in situ simulation to develop a protected code blue and modify staff training protocol-experience in a large community teaching hospital during the COVID-19 pandemic

The surge in clinical demand, shortage in personal protective equipment and high-exposure risk for healthcare workers during the COVID-19 pandemic has challenged hospital common practices and forced a reassessment of care delivery models. Code blue teams are highly specialised units that partake in life-saving situations that can jeopardise the safety of team members. There is a paucity of guidance in regards to proper infection control measures to protect the responders.This study describes a methodical approach to assessing vulnerabilities to transmission of SARS-CoV-2 within existing code blue practices, modalities to limit the number of code blue team responders and modifications to the protocol at a large community teaching hospital. The effort undertaken faced challenges due to the nature of the pandemic and the increased demand on healthcare workers. Quality improvement methods facilitated our protocol design and implementation. To this date, there has been no identified COVID-19 disease in any protected code blue (PCB) team members. We recommend that similar practices be considered and adopted widely and practised periodically.

Pragmatic Recommendations for Infection Prevention and Control Practices for Healthcare Facilities in Low- and Middle-Income Countries during the COVID-19 Pandemic

Infection prevention and control (IPC) strategies are key in preventing nosocomial transmission of COVID-19. Several commonly used IPC practices are resource-intensive and may be challenging to implement in resource-constrained settings. An international group of healthcare professionals from or with experience in low- and middle-income countries (LMICs) searched the literature for relevant evidence. We report on a set of pragmatic recommendations for hospital-based IPC practices in resource-constrained settings of LMICs. For cases of confirmed or suspected COVID-19, we suggest that patients be placed in a single isolation room, whenever possible. When single isolation rooms are unavailable or limited, we recommend cohorting patients with COVID-19 on dedicated wards or in dedicated hospitals. We also recommend that cases of suspected COVID-19 be cohorted separately from those with confirmed disease, whenever possible, to minimize the risk of patient-to-patient transmission in settings where confirmatory testing may be limited. We suggest that healthcare workers be designated to care exclusively for patients with COVID-19, whenever possible, as another approach to minimize nosocomial spread. This approach may also be beneficial in conserving limited supplies of reusable personal protective equipment (PPE). We recommend that visitors be restricted for patients with COVID-19. In settings where family members or visitors are necessary for caregiving, we recommend that the appropriate PPE be used by visitors. We also recommend that education regarding hand hygiene and donning/doffing procedures for PPE be provided. Last, we suggest that all visitors be screened for symptoms before visitation and that visitor logs be maintained.

The Management and Outcomes of Coronavirus Disease 2019 Infection in a Series of Neurosurgical Patients

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has impacted neurosurgical practice worldwide. In Iran, hospitals have halted their routine activities, and most hospital beds have been assigned to COVID-19 patients. Here, we share our experience with 10 neurosurgical cases with confirmed COVID-19.

MATERIALS AND METHODS

From February 24, 2020 to April 20, 2020, we were able to obtain clinical data on ten neurosurgical patients with COVID-19 through a predefined electronic form.

RESULTS

Of the 10 patients with COVID-19 on neurosurgical units, eight underwent surgical interventions. The age of the patients ranged from 21 to 75 years and 70% were males. The diagnosis of COVID-19 was based on chest imaging findings and reverse transcriptase-polymerase chain reaction for coronavirus and an infectious disease specialist and a pulmonologist confirmed the diagnoses. In two cases, there was a significant decrease in O2 saturation intraoperatively. Three patients in this series died during the assessment period. One death was due to respiratory failure induced by the coronavirus infection. The cause of death in other two patients was cardiovascular failure not related to COVID-19.

CONCLUSIONS

We hope we can provide a reference for future studies and help develop a clearer understanding of neurosurgical practice and outcomes in patients with COVID-19. In the time of COVID-19 pandemic when dealing with neurosurgical emergencies, a conservative approach is recommended. Using committed personal protective equipment, short-time operating procedures or minimally invasive surgery must be considered in the management of emergent patients. Resuming elective surgeries need defining measures needed to ensure patients and health-care providers' safety. Reorganizing the health-care system for telemonitoring released patients can lessen hospital visits.

Oxygen Therapy and Risk of Infection for Health Care Workers Caring for Patients With Viral Severe Acute Respiratory Infection: A Systematic Review and Meta-analysis

STUDY OBJECTIVE

To synthesize the evidence regarding the infection risk associated with different modalities of oxygen therapy used in treating patients with severe acute respiratory infection. Health care workers face significant risk of infection when treating patients with a viral severe acute respiratory infection. To ensure health care worker safety and limit nosocomial transmission of such infection, it is crucial to synthesize the evidence regarding the infection risk associated with different modalities of oxygen therapy used in treating patients with severe acute respiratory infection.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2000, to April 1, 2020, for studies describing the risk of infection associated with the modalities of oxygen therapy used for patients with severe acute respiratory infection. The study selection, data extraction, and quality assessment were performed by independent reviewers. The primary outcome measure was the infection of health care workers with a severe acute respiratory infection. Random-effect models were used to synthesize the extracted data.

RESULTS

Of 22,123 citations, 50 studies were eligible for qualitative synthesis and 16 for meta-analysis. Globally, the quality of the included studies provided a very low certainty of evidence. Being exposed or performing an intubation (odds ratio 6.48; 95% confidence interval 2.90 to 14.44), bag-valve-mask ventilation (odds ratio 2.70; 95% confidence interval 1.31 to 5.36), and noninvasive ventilation (odds ratio 3.96; 95% confidence interval 2.12 to 7.40) were associated with an increased risk of infection. All modalities of oxygen therapy generate air dispersion.

CONCLUSION

Most modalities of oxygen therapy are associated with an increased risk of infection and none have been demonstrated as safe. The lowest flow of oxygen should be used to maintain an adequate oxygen saturation for patients with severe acute respiratory infection, and manipulation of oxygen delivery equipment should be minimized.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Febrile Infants Without Respiratory Distress

We report two cases of SARS-CoV-2 infection (COVID-19) in infants presenting with fever in the absence of respiratory distress who required hospitalization for evaluation of possible invasive bacterial infections. The diagnoses resulted from routine isolation and real-time RT-PCR-based testing for SARS-CoV-2 for febrile infants in an outbreak setting.

Challenge and strategies of infection control in psychiatric hospitals during biological disasters-From SARS to COVID-19 in Taiwan

Psychiatric hospitals play an important role in supporting patients with mental illness to relieve symptoms and improve functioning in a physically and psychologically safe environment. However, these hospitals are also vulnerable to emerging infectious diseases. In early 2020, a psychiatric hospital and a psychiatric unit were reported to have nosocomial coronavirus disease 2019 (COVID-19) infection. A large number of patients and staff were severely impacted. This type of nosocomial infection threatens patient safety and quality of care. By learning from previous experiences of severe acute respiratory syndrome (SARS) and previous studies, psychiatric hospitals can provide safeguards to prevent nosocomial infection among patients and staff during an epidemic or biological disaster. These strategies include a series of actions such as following national guidelines for infection control, reserving adequate support for disinfection equipment, providing relevant and sufficient pro-service and in-service education and training, establishing regular surveillance of hand hygiene habits, proper communication and health education, and providing opportunities for vaccination if possible. Based on the harm reduction concept, staff division of office breaks and ward classification and shunting are recommended and should be further implemented.

Healthcare worker attendance during the early stages of the COVID-19 pandemic: A longitudinal analysis of fingerprint-verified data from all public-sector secondary and tertiary care facilities in Bangladesh

Background

The COVID-19 pandemic has overwhelmed hospitals in several areas in high-income countries. An effective response to this pandemic requires health care workers (HCWs) to be present at work, particularly in low- and middle-income countries (LMICs) where they are already in critically low supply. To inform whether and to what degree policymakers in Bangladesh, and LMICs more broadly, should expect a drop in HCW attendance as COVID-19 continues to spread, this study aims to determine how HCW attendance has changed during the early stages of the COVID-19 pandemic in Bangladesh.

Methods

This study analyzed daily fingerprint-verified attendance data from all 527 public-sector secondary and tertiary care facilities in Bangladesh to describe HCW attendance from January 26, 2019 to March 22, 2020, by cadre, hospital type, and geographic division. We then regressed HCW attendance onto fixed effects for day-of-week, month, and hospital, as well as indicators for each of three pandemic periods: a China-focused period (January 11, 2020 (first confirmed COVID-19 death in China) until January 29, 2020), international-spread period (January 30, 2020 (World Health Organization’s declaration of a global emergency) until March 6, 2020), and local-spread period (March 7, 2020 (first confirmed COVID-19 case in Bangladesh) until the end of the study period).

Findings

On average between January 26, 2019 and March 22, 2020, 34.1% of doctors, 64.6% of nurses, and 70.6% of other health care staff were present for their scheduled shift. HCWs’ attendance rate increased with time in 2019 among all cadres. Nurses’ attendance level dropped by 2.5% points (95% confidence interval (CI) = -3.2% to -1.8%) and 3.5% points (95% CI = -4.5% to -2.5%) during the international-spread and the local-spread periods of the COVID-19 pandemic, relative to the China-focused period. Similarly, the attendance level of other health care staff declined by 0.3% points (95% CI = -0.8% to 0.2%) and 2.3% points (95% CI = -3.0% to -1.6%) during the international-spread and local-spread periods, respectively. Among doctors, however, the international-spread and local-spread periods were associated with a statistically significant increase in attendance by 3.7% points (95% CI = 2.5% to 4.8%) and 4.9% points (95% CI = 3.5% to 6.4%), respectively. The reduction in attendance levels across all HCWs during the local-spread period was much greater at large hospitals, where the majority of COVID-19 testing and treatment took place, than that at small hospitals.

Conclusions

After a year of significant improvements, HCWs’ attendance levels among nurses and other health care staff (who form the majority of Bangladesh’s health care workforce) have declined during the early stages of the COVID-19 pandemic. This finding may portend an even greater decrease in attendance if COVID-19 continues to spread in Bangladesh. Policymakers in Bangladesh and similar LMICs should undertake major efforts to achieve high attendance levels among HCWs, particularly nurses, such as by providing sufficient personal protective equipment as well as monetary and non-monetary incentives.

Current knowledge of COVID-19 and infection prevention and control strategies in healthcare settings: A global analysis

OBJECTIVE

In the current absence of a vaccine for COVID-19, public health responses aim to break the chain of infection by focusing on the mode of transmission. We reviewed the current evidence on the transmission dynamics and on pathogenic and clinical features of COVID-19 to critically identify any gaps in the current infection prevention and control (IPC) guidelines.

METHODS

In this study, we reviewed global COVID-19 IPC guidelines by organizations such as the World Health Organization (WHO), the US Centers for Disease Control and Prevention (CDC), and the European Centre for Disease Prevention and Control (ECDC). Guidelines from 2 high-income countries (Australia and United Kingdom) and from 1 middle-income country (China) were also reviewed. We searched publications in English on 'PubMed' and Google Scholar. We extracted information related to COVID-19 transmission dynamics, clinical presentations, and exposures that may facilitate transmission. We then compared these findings with the recommended IPC measures.

RESULTS

Nosocomial transmission of SARS-CoV-2 in healthcare settings occurs through droplets, aerosols, and the oral-fecal or fecal-droplet route. However, the IPC guidelines fail to cover all transmission modes, and the recommendations also conflict with each other. Most guidelines recommend surgical masks for healthcare providers during routine care and N95 respirators for aerosol-generating procedures. However, recommendations regarding the type of face mask varied, and the CDC recommends cloth masks when surgical masks are unavailable.

CONCLUSION

IPC strategies should consider all the possible routes of transmission and should target all patient care activities involving risk of person-to-person transmission. This review may assist international health agencies in updating their guidelines.

Preparedness, Adaptation, and Innovation: Approach to the COVID-19 Pandemic at a Decentralized, Quaternary Care Department of Emergency Medicine

The COVID-19 pandemic has required healthcare systems to be creative and adaptable in response to an unprecedented crisis. Below we describe how we prepared for and adapted to this pandemic at our decentralized, quaternary-care department of emergency medicine, with specific recommendations from our experience. We discuss our longstanding history of institutional preparedness, as well as adaptations in triage, staffing, workflow, and communications. We also discuss innovation through working with industry on solutions in personal protective equipment, as well as telemedicine and methods for improving morale. These preparedness and response solutions and recommendations may be useful moving forward as we transition between response and recovery in this pandemic as well as future pandemics.

Comparative Review of SARS-CoV-2, SARS-CoV, MERS-CoV, and Influenza A Respiratory Viruses

The 2019 novel coronavirus (SARS-CoV-2) pandemic has caused a global health emergency. The outbreak of this virus has raised a number of questions: What is SARS-CoV-2? How transmissible is SARS-CoV-2? How severely affected are patients infected with SARS-CoV-2? What are the risk factors for viral infection? What are the differences between this novel coronavirus and other coronaviruses? To answer these questions, we performed a comparative study of four pathogenic viruses that primarily attack the respiratory system and may cause death, namely, SARS-CoV-2, severe acute respiratory syndrome (SARS-CoV), Middle East respiratory syndrome (MERS-CoV), and influenza A viruses (H1N1 and H3N2 strains). This comparative study provides a critical evaluation of the origin, genomic features, transmission, and pathogenicity of these viruses. Because the coronavirus disease 2019 (COVID-19) pandemic caused by SARS-CoV-2 is ongoing, this evaluation may inform public health administrators and medical experts to aid in curbing the pandemic's progression.

COVID-19: Recovery Models for Radiology Departments

The coronavirus disease 2019 (COVID-19) pandemic has greatly affected demand for imaging services, with marked reductions in demand for elective imaging and image-guided interventional procedures. To guide radiology planning and recovery from this unprecedented impact, three recovery models were developed to predict imaging volume over the course of the COVID-19 pandemic: (1) a long-term volume model with three scenarios based on prior disease outbreaks and other historical analogues, to aid in long-term planning when the pandemic was just beginning; (2) a short-term volume model based on the supply-demand approach, leveraging increasingly available COVID-19 data points to predict examination volume on a week-to-week basis; and (3) a next-wave model to estimate the impact from future COVID-19 surges. The authors present these models as techniques that can be used at any stage in an unpredictable pandemic timeline.

Healthcare Worker Attendance During the Early Stages of the COVID-19 Pandemic: A Longitudinal Analysis of Daily Fingerprint-Verified Data from All Public-Sector Secondary and Tertiary Care Facilities in Bangladesh

BACKGROUND

The COVID-19 pandemic has overwhelmed hospitals in several areas in high-income countries. An effective response to this pandemic requires healthcare workers (HCWs) to be present at work, particularly in low- and middle-income countries (LMICs) where they are already in critically low supply. To inform whether and to what degree policymakers in Bangladesh, and LMICs more broadly, should expect a drop in HCW attendance as COVID-19 continues to spread, this study aims to determine how HCW attendance has changed during the early stages of the COVID-19 pandemic in Bangladesh.

METHODS

This study analyzed daily fingerprint-verified attendance data from all 527 public-sector secondary and tertiary care facilities in Bangladesh to describe HCW attendance from January 26, 2019 to March 22, 2020, by cadre, hospital type, and geographic division. We then regressed HCW attendance onto fixed effects for day-of-week, month, and hospital, as well as indicators for each of three pandemic periods: a China-focused period (January 11, 2020 [first confirmed COVID-19 death in China] until January 29, 2020), international-spread period (January 30, 2020 [World Health Organization declared a global emergency] until March 6, 2020), and local-spread period (March 7, 2020 [first confirmed COVID-19 case in Bangladesh] until the end of the study period).

FINDINGS

On average between January 26, 2019 and March 22, 2020, 34.1% of doctors, 64.6% of nurses, and 70.6% of other healthcare staff were present for their scheduled shift. Attendance rate increased with time in 2019 among all cadres. Attendance level of nurses dropped by 2.5% points (95% CI; -3.2% to -1.8%) and 3.5% points (95% CI; -4.5% to -2.5%) during the international-spread and the local-spread periods of the COVID-19 pandemic, relative to the China-focused period. Similarly, the attendance level of other healthcare staff declined by 0.3% points (95% CI; -0.8% to 0.2%) and 2.3% points (95% CI; -3.0% to -1.6%) during the international-spread and local-spread periods, respectively. Among doctors, however, the international-spread and local-spread periods were associated with a statistically significant increase in attendance by 3.7% points (95% CI; 2.5% to 4.8%) and 4.9% points (95% CI; 3.5% to 6.4%), respectively. The reduction in attendance levels across all HCWs during the local-spread period was much greater at large hospitals, where the majority of COVID-19 testing and treatment took place, than that at small hospitals.

CONCLUSIONS

After a year of significant improvements, attendance levels among nurses and other healthcare staff (who form the majority of the healthcare workforce in Bangladesh) have declined during the early stages of the COVID-19 pandemic. This finding may portend an even greater decrease in attendance if COVID-19 continues to spread in Bangladesh. Policymakers in Bangladesh and similar LMICs should undertake major efforts to achieve high attendance levels among HCWs, particularly nurses, such as by providing sufficient personal protective equipment as well as monetary and non-monetary incentives.

Frontline Health-Care Workers in Combating the COVID-19: Respect and Reflect

The ongoing coronavirus disease has heightened enormous concern in the global community. China implemented extraordinary public health measures to take the major transmission hotspots under control at great socioeconomic cost. Frontline health-care workers have shown their commitment and accountability in the fight against the epidemic outbreak. This commentary acknowledges their contribution and offers important insights for devising future strategies in enhancing preparedness and response competencies among the health-care workforce to manage future epidemic events.

Do superspreaders generate new superspreaders? A hypothesis to explain the propagation pattern of COVID-19

The current global propagation of COVID-19 is heterogeneous, with slow transmission continuing in many countries and exponential propagation in others, where the time that it took for the explosive spread to begin varied greatly. It is proposed that this could be explained by cascading superspreading events, in which new infections caused by a superspreader are more likely to be highly infectious. The mechanism suggested for this is related to viral loads. Exposure to high viral loads may result in high-intensity infection, which exposes new cases to high viral loads. This notion is supported by experimental veterinary research.

COVID-19: a primer for healthcare providers

According to the World Health Organization (WHO) the China office was first notified of cases of atypical pneumonia in Wuhan City on 31 December 2019. A viral genome sequence of a novel coronavirus, currently termed SARS-CoV‑2, with a disease process called COVID-19 was released 1 week later via online resources to obtain public health support in control of spread. Since then, the virus rapidly evolved into a global pandemic. Therefore, healthcare providers need to be familiar with the clinical presentation of infected patients and measures to quickly isolate them. The prevention of nosocomial spread is paramount to proper control of COVID-19 and is reviewed. Currently, treatment is supportive. Researchers are working to develop vaccines and identify effective antiviral interventions. Those recently discussed in the literature are briefly reviewed.

A Double Triage and Telemedicine Protocol to Optimize Infection Control in an Emergency Department in Taiwan During the COVID-19 Pandemic: Retrospective Feasibility Study

Background

Frontline health care workers, including physicians, are at high risk of contracting coronavirus disease (COVID-19) owing to their exposure to patients suspected of having COVID-19.

Objective

The aim of this study was to evaluate the benefits and feasibility of a double triage and telemedicine protocol in improving infection control in the emergency department (ED).

Methods

In this retrospective study, we recruited patients aged ≥20 years referred to the ED of the National Taiwan University Hospital between March 1 and April 30, 2020. A double triage and telemedicine protocol was developed to triage suggested COVID-19 cases and minimize health workers’ exposure to this disease. We categorized patients attending video interviews into a telemedicine group and patients experiencing face-to-face interviews into a conventional group. A questionnaire was used to assess how patients perceived the quality of the interviews and their communication with physicians as well as perceptions of stress, discrimination, and privacy. Each question was evaluated using a 5-point Likert scale. Physicians’ total exposure time and total evaluation time were treated as primary outcomes, and the mean scores of the questions were treated as secondary outcomes.

Results

The final sample included 198 patients, including 93 cases (47.0%) in the telemedicine group and 105 cases (53.0%) in the conventional group. The total exposure time in the telemedicine group was significantly shorter than that in the conventional group (4.7 minutes vs 8.9 minutes, P<.001), whereas the total evaluation time in the telemedicine group was significantly longer than that in the conventional group (12.2 minutes vs 8.9 minutes, P<.001). After controlling for potential confounders, the total exposure time in the telemedicine group was 4.6 minutes shorter than that in the conventional group (95% CI −5.7 to −3.5, P<.001), whereas the total evaluation time in the telemedicine group was 2.8 minutes longer than that in the conventional group (95% CI −1.6 to −4.0, P<.001). The mean scores of the patient questionnaire were high in both groups (4.5/5 to 4.7/5 points).

Conclusions

The implementation of the double triage and telemedicine protocol in the ED during the COVID-19 pandemic has high potential to improve infection control.

Social, Psychological, and Philosophical Reflections on Pandemics and Beyond

This conceptual paper presents social, psychological and philosophical (ethical and epistemological) reflections regarding the current (COVID-19) pandemic and beyond, using an analytic and comparative approach. For example, Taiwan and Canada are compared, addressing Taiwan’s learning from SARS. Suggestions are made in relation to current and future relevant practice, policy, research and education. For example, highly exposed individuals and particularly vulnerable populations, such as health care providers and socially disadvantaged (homeless and other) people, respectively, are addressed as requiring special attention. In conclusion, more reflection on and study of social and psychological challenges as well as underlying philosophical issues related to the current pandemic and more generally to global crises is needed.

SARS, MERS and COVID-19 among healthcare workers: A narrative review

In the recent two decades, three global viral infectious diseases, severe acute respiratory syndrome (SARS), middle east respiratory syndrome (MERS), and coronavirus disease (COVID-19), have occurred worldwide. SARS occurred in November 2002, causing 8096 infected cases, as well as 774 deaths. MERS occurred in June, 2012, causing 2519 confirmed cases, along with 866 associated deaths. COVID-19 occurred in December 2019, as of 30 April 2020, a total of 3,024,059 clinical cases have been reported, including 208,112 deaths. Healthcare workers (HCWs) need to be in close contact with these virus-infected patients and their contaminated environments at work, thus leading to be infected in some of them, even a few of them are died in line of duty. In this review, we summarized the infection status of HCWs during the outbreak of SARS, MERS and COVID-19, with in-depth discussion, hoping to provoke sufficient attention to the HCWs infection status by more people.

Initial experiences of US neurologists in practice during the COVID-19 pandemic via survey

OBJECTIVE

To test the hypothesis that US neurologists were experiencing significant challenges with lack of personal protective equipment (PPE), rapid changes in practice, and varying institutional protocols, we conducted this survey study. The current coronavirus disease of 2019 (COVID-19) pandemic has caused widespread disease and death. Rapid increases in patient volumes have exposed weaknesses in health care systems and challenged our ability to provide optimal patient care and adequate safety measures to health care workers (HCWs).

METHODS

A 36-item survey was distributed to neurologists around the United States through various media platforms.

RESULTS

Over a 1-week period, 567 responses were received. Of these, 56% practiced in academia. A total of 87% had access to PPE, with 45% being asked to reuse PPE due to shortages. The pandemic caused rapid changes in practice, most notably a shift toward providing care by teleneurology, although a third experienced challenges in transitioning to this model. Wide variations were noted both in testing and in the guidance provided for the exposed, sick, or vulnerable HCWs. Notably, 59% of respondents felt that their practices were doing what they could, although 56% did not feel safe taking care of patients.

CONCLUSIONS

Results from our survey demonstrate significant variability in preparedness and responsiveness to the COVID-19 pandemic in neurology, affected by region, health care setting, and practice model. Practice guidelines from professional societies and other national entities are needed to improve protection for physicians and their patients, promote recommended practice changes during a pandemic, and optimize future preparedness for public health emergencies.

Occupational health and safety hazards faced by healthcare professionals in Taiwan: A systematic review of risk factors and control strategies

Background

Healthcare professionals in Taiwan are exposed to a myriad of occupational health and safety hazards, including physical, biological, chemical, ergonomic, and psychosocial hazards. Healthcare professionals working in hospitals and healthcare facilities are more likely to be subjected to these hazards than their counterparts working in other areas.

Objectives

This review aims to assess current research literature regarding this situation with a view to informing policy makers and practitioners about the risks of exposure and offer evidence-based recommendations on how to eliminate or reduce such risks.

Methods

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses review strategy, we conducted a systematic review of studies related to occupational health and safety conducted between January 2000 and January 2019 using MEDLINE (Ovid), PubMed, PMC, TOXLINE, CINAHL, PLOS One, and Access Pharmacy databases.

Results

The review detected 490 studies addressing the issue of occupational health and safety hazards; of these, 30 articles were included in this systematic review. These articles reported a variety of exposures faced by healthcare professionals. This review also revealed a number of strategies that can be adopted to control, eliminate, or reduce hazards to healthcare professionals in Taiwan.

Conclusion

Hospitals and healthcare facilities have many unique occupational health and safety hazards that can potentially affect the health and performance of healthcare professionals. The impact of such hazards on healthcare professionals poses a serious public health issue in Taiwan; therefore, controlling, eliminating, or reducing exposure can contribute to a stronger healthcare workforce with great potential to improve patient care and the healthcare system in Taiwan. Eliminating or reducing hazards can best be achieved through engineering measures, administrative policy, and the use of personal protective equipment.

Implications

This review has research, policy, and practice implications and provides future students and researchers with information on systematic review methodologies based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses strategy. It also identifies occupational health and safety risks and provides insights and strategies to address them.

Health-care preparedness and health-care worker protection in COVID-19 pandemic

The COVID-19 pandemic has ravaged the nations and has created the institution of unprecedented measures globally toward its containment. Extraordinary measures may be needed for health-care preparedness, to reduce morbidity and mortality. Health-care workers who are at the frontlines in such pandemics are the most vulnerable. These issues are addressed in this article.

Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients

A global health emergency has been declared by the World Health Organization as the 2019-nCoV outbreak spreads across the world, with confirmed patients in Canada. Patients infected with 2019-nCoV are at risk for developing respiratory failure and requiring admission to critical care units. While providing optimal treatment for these patients, careful execution of infection control measures is necessary to prevent nosocomial transmission to other patients and to healthcare workers providing care. Although the exact mechanisms of transmission are currently unclear, human-to-human transmission can occur, and the risk of airborne spread during aerosol-generating medical procedures remains a concern in specific circumstances. This paper summarizes important considerations regarding patient screening, environmental controls, personal protective equipment, resuscitation measures (including intubation), and critical care unit operations planning as we prepare for the possibility of new imported cases or local outbreaks of 2019-nCoV. Although understanding of the 2019-nCoV virus is evolving, lessons learned from prior infectious disease challenges such as Severe Acute Respiratory Syndrome will hopefully improve our state of readiness regardless of the number of cases we eventually manage in Canada.

Can we contain the COVID-19 outbreak with the same measures as for SARS?

The severe acute respiratory syndrome (SARS) outbreak in 2003 resulted in more than 8000 cases and 800 deaths. SARS was eventually contained by means of syndromic surveillance, prompt isolation of patients, strict enforcement of quarantine of all contacts, and in some areas top-down enforcement of community quarantine. By interrupting all human-to-human transmission, SARS was effectively eradicated. By contrast, by Feb 28, 2020, within a matter of 2 months since the beginning of the outbreak of coronavirus disease 2019 (COVID-19), more than 82 000 confirmed cases of COVID-19 have been reported with more than 2800 deaths. Although there are striking similarities between SARS and COVID-19, the differences in the virus characteristics will ultimately determine whether the same measures for SARS will also be successful for COVID-19. COVID-19 differs from SARS in terms of infectious period, transmissibility, clinical severity, and extent of community spread. Even if traditional public health measures are not able to fully contain the outbreak of COVID-19, they will still be effective in reducing peak incidence and global deaths. Exportations to other countries need not result in rapid large-scale outbreaks, if countries have the political will to rapidly implement countermeasures.

Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, China: a modelling study

BACKGROUND

Since Dec 31, 2019, the Chinese city of Wuhan has reported an outbreak of atypical pneumonia caused by the 2019 novel coronavirus (2019-nCoV). Cases have been exported to other Chinese cities, as well as internationally, threatening to trigger a global outbreak. Here, we provide an estimate of the size of the epidemic in Wuhan on the basis of the number of cases exported from Wuhan to cities outside mainland China and forecast the extent of the domestic and global public health risks of epidemics, accounting for social and non-pharmaceutical prevention interventions.

METHODS

We used data from Dec 31, 2019, to Jan 28, 2020, on the number of cases exported from Wuhan internationally (known days of symptom onset from Dec 25, 2019, to Jan 19, 2020) to infer the number of infections in Wuhan from Dec 1, 2019, to Jan 25, 2020. Cases exported domestically were then estimated. We forecasted the national and global spread of 2019-nCoV, accounting for the effect of the metropolitan-wide quarantine of Wuhan and surrounding cities, which began Jan 23-24, 2020. We used data on monthly flight bookings from the Official Aviation Guide and data on human mobility across more than 300 prefecture-level cities in mainland China from the Tencent database. Data on confirmed cases were obtained from the reports published by the Chinese Center for Disease Control and Prevention. Serial interval estimates were based on previous studies of severe acute respiratory syndrome coronavirus (SARS-CoV). A susceptible-exposed-infectious-recovered metapopulation model was used to simulate the epidemics across all major cities in China. The basic reproductive number was estimated using Markov Chain Monte Carlo methods and presented using the resulting posterior mean and 95% credibile interval (CrI).

FINDINGS

In our baseline scenario, we estimated that the basic reproductive number for 2019-nCoV was 2·68 (95% CrI 2·47-2·86) and that 75 815 individuals (95% CrI 37 304-130 330) have been infected in Wuhan as of Jan 25, 2020. The epidemic doubling time was 6·4 days (95% CrI 5·8-7·1). We estimated that in the baseline scenario, Chongqing, Beijing, Shanghai, Guangzhou, and Shenzhen had imported 461 (95% CrI 227-805), 113 (57-193), 98 (49-168), 111 (56-191), and 80 (40-139) infections from Wuhan, respectively. If the transmissibility of 2019-nCoV were similar everywhere domestically and over time, we inferred that epidemics are already growing exponentially in multiple major cities of China with a lag time behind the Wuhan outbreak of about 1-2 weeks.

INTERPRETATION

Given that 2019-nCoV is no longer contained within Wuhan, other major Chinese cities are probably sustaining localised outbreaks. Large cities overseas with close transport links to China could also become outbreak epicentres, unless substantial public health interventions at both the population and personal levels are implemented immediately. Independent self-sustaining outbreaks in major cities globally could become inevitable because of substantial exportation of presymptomatic cases and in the absence of large-scale public health interventions. Preparedness plans and mitigation interventions should be readied for quick deployment globally.

FUNDING

Health and Medical Research Fund (Hong Kong, China).