key: cord-0989054-rhfafy70 authors: Greene, Christopher J.; Burleson, Samuel L.; Crosby, James C.; Heimann, Matthew A.; Pigott, David C. title: Coronavirus disease 2019: International public health considerations date: 2020-02-27 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12040 sha: d6d04fe8e640c9961f08ad7c7f8e19fae6a42fdd doc_id: 989054 cord_uid: rhfafy70 On December 31, 2019, the Chinese government announced an outbreak of a novel coronavirus, recently named COVID‐19. During the following weeks the international medical community has witnessed with unprecedented coverage the public health response both domestically by the Chinese government, and on an international scale as cases have spread to dozens of countries. While much regarding the virus and the Chinese public health response is still unknown, national and public health institutions globally are preparing for a pandemic. As cases and spread of the virus grow, emergency and other front‐line providers may become more anxious about the possibility of encountering a potential case. This review describes the tenets of a public health response to an infectious outbreak by using recent historical examples and also by characterizing what is known about the ongoing response to the COVID‐19 outbreak. The intent of the review is to empower the practitioner to monitor and evaluate the local, national and global public health response to an emerging infectious disease. This review is intended to parse through the ever-evolving details of the COVID-19 crisis and explain the expected evolution of the international public health response. We look back at past pandemics, their economic and societal impacts, the players in a public health response to address such a crisis, and how those tools are being utilized in the COVID-19 outbreak. To better understand the current novel coronavirus outbreak as well as the robust Chinese public health response, it is useful to examine During the initial period of outbreak, health care resources are often diverted away from providing routine care and shifted to outbreak management. During the 2014-2015 Ebola crisis in West Africa, the health care systems of Liberia, Sierra Leone, and Guinea resulted in a reduction in the ability to provide routine care for HIV/AIDS, malaria, and tuberculosis. 7 One author estimated this reduction in services cost >10,600 additional lives, rivaling the total death toll due to Ebola of the 3 countries combined. 8, 9 Although some of this increased mortality is likely due to the limitations of health care in that region, an issue not shared by China, developed There is a large penumbra of social capital at risk during the COVID-19 outbreak. Public health emergencies splash constantly across news headlines and social media platforms. In a positive sense, researchers have demonstrated the ability to harness this open source information and created an entire field called "digital epidemiology." Twitter data has been used to track surveillance for outbreaks and responses to interventions. 14 Alternatively, misinformation, perceived versus actual risk and fear-based communication strategies can become normative. The recent Zika emergency revealed that repetitive exposures to media messages can demonstrably augment fear. 15 This fear may lead to palpable changes in behavior patterns. Retrospective analysis of prior outbreaks shows both over-and under-reaction to health information. In response to alarm-based messaging the populace has both mass-exited and not complied with quarantines, burdened and underutilized health systems, and ignored and demanded extraordinary precautionary measures. Locations and people groups that are low risk for being threats experience fallout and social ostracism. 16 The COVID-19 has followed suit with accounts of uninformed acts of racism against French Asians, detainments of 6000 cruise ship passengers, airline route suspensions, and country border closures. [17] [18] [19] On February 2nd, the WHO released a situation report stating they are in a fight against an "infodemic" (overabundance of information of varying accuracy) and will utilize multiple media platforms to inform the public. 20 The global public health response is less a structured hierarchy than a complex web of organizations with specific roles working together to address specific issues. 21 Table 1 and Figure 1 detail the primary roles of some key stakeholders, and illustrate their interactions. The WHO, an agency of the United Nations and empowered by the National public health institutes (NPHI) perform many of the practical functions of surveillance and containment in public health and function independently of any international organization, but NPHIs communicate voluntarily with the WHO for the purpose of monitoring and surveillance. 30 In the case of COVID-19, the Chinese CDC has functioned as the NPHI involved in the crisis. Local providers identify initial cases of concern. Provide front-line data to regional health officials Regional officials report an increase in amount or virulence of a known agent or introduction of new agent Coordinate with health departments to develop case definition and identification protocols for persons under investigation NPHIs report outbreak to WHO and international community Release first case definitions of the infection Facilitate genotyping and development of a diagnostic test Promote communication between NPHIs and provide technical guidance for individual country readiness. Engage and educate health care systems aproviders The process of establishing the existence of an outbreak begins with the report of a cluster of cases that is unusual in incidence, location, or in relation to each other. 34 The report is followed by implementation of a plan. Outcomes improve when countries have a pandemic plan and move quickly to establish protocols that limit the spread of an outbreak. 35 These include establishing case definitions, designating persons under investigation (PUI), pursuit of diagnostic tests, continuing incidence surveillance, and characterization of morbidity and case fatality rate (CFR). These key characteristics for COVID-19 are listed in Table 2 . Determining the criteria for a PUI is a particular concern for emergency and other frontline medical providers. A patient who meets criteria for a PUI should initiate hospital protocols for infection con- Containment of past outbreaks such as SARS and Ebola has relied on the traditional public health strategies of evaluation of persons under investigation (those suspected but not confirmed of having the disease), exposure mapping or contact tracing, isolating and treating affected patients, and potentially quarantining those exposed but not symptomatic. 35, 40 The unusually long incubation period (median 5.2 days, IQR 4.1-7, with 95th percentile at 12.5 days) has led to the WHO and CDC recommendation to quarantine certain individuals exposed to asymptomatic persons with potential COVID-19 for up to 14 days after exposure. 36 The recommendations have informed the decisions by multiple NPHIs to quarantine returned travelers in government facilities and to quarantine cruise ship passengers onboard multiple vessels. 41 Table 3 for further discussion of public health interventions. On January 30, 2020 the World Health Organization (WHO) took the "last resort" step of declaring a PHEIC, only the 6th time the WHO has been galvanized to take such an action. 57 The announcement came amid reports of evacuation, lockdown, quarantine, travel restrictions and international border closures. The COVID-19 has demonstrated the challenges and successes when applying these public health principles to an ongoing crisis. Shortcomings often emerge in the first few weeks of an outbreak and have emerged in COVID-19 pandemic. 58 Incomplete or poorly communicated preliminary data may hamper the national and international response. For example, the relatively low CFR rate (∼2% compared to >60% in Ebola Virus cases, >30% in MERS-CoV cases, and >9% in SARS-CoV cases) raises concerns for subclinical and unreported infections. 59 This restricts public health officials' ability to determine whether this ongoing Chinese epidemic (widespread disease transmission within a nation) has yet made the jump to a pandemic (widespread disease transmission occurring in multiple nations). Similarly, the competence of the Chinese CDC in identifying the outbreak and implementing rapid control measures is threatened by reports of "narrative controlling" preventing effective communication between frontline practitioners and the global outbreak response. 60 In an outbreak that seems to change hourly, a delay of days or weeks diminishes the responders' ability to truly assess the impact, transmissibility, extent of spread, and virulence of the disease. As such, much of the characterizations of COVID-19 should be understood as preliminary and subject to change as data becomes more readily available. These persistent knowledge gaps regarding the outbreak remain concerning. The European Center for Disease Prevention and Control (ECDC) rapid risk assessment publication on January 22, 2020 points out that "in the absence of detailed information from the ongoing outbreak investigations in China, it is not possible to quantify the extent of human-to-human transmission." A similar concern exists regarding the Chinese algorithm for testing, case definitions, means of identifying PUIs, or surveillance of contacts. 61 Without this information it remains difficult for NPHIs to determine specific risk of transmission, quantify virulence, or estimate CFR with any certainty. Some of the more extreme policies enacted by individual governments may stem from this deficit in effective communication and transparency. In addition to a lack of transparency, some experts have also called into question the specific measures employed by the Chinese government. A recent review of the efficacy of travel checkpoint temperature screening during the Ebola Virus and SARS outbreaks revealed that no cases were identified by these measures. 62 The complete lockdown of the city of Wuhan is an unprecedented intervention, and its efficacy will be of great interest to the public health community. There are some improvements in the Chinese response to the crisis as compared to prior public health events. In contrast to the decisions made by Chinese health authorities and government officials during the 2003 SARS outbreak, the existence of the initial patient cluster was rapidly reported to the WHO China Office in December 2019, with a novel coronavirus being identified by early January 2020. The speed of cluster identification and pathogen isolation is likely due to additional investment in public health resources and infrastructure by China's CDC. 8 The Chinese government has demonstrated commitment to controlling spread of the virus, including closure of the seafood market in Wuhan, cessation of public transport, screening at travel checkpoints, travel restrictions, closure of cultural landmarks and businesses, and cancellation of the Lunar New Year celebrations. 61, 63 Media sources and inhabitants of Wuhan have described the situation as "complete lockdown" in a city of >11 million people, representing an "unprecedented public health intervention." 61 As hospital systems and emergency departments monitor and prepare for the COVID-19 outbreak, there are still many unanswered questions. The situation is dynamic with cases identified nearly hourly. The stakes are high, as the CFR and morbidity of the virus appears to be higher than influenza. 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