A Novel Coronavirus Outbreak: A Teaching Case-Study Student’s Guide Haitham Bashier, Yousef Khader,

A Novel Coronavirus Outbreak: A Teaching Case-Study Student’s Guide Haitham Bashier, Yousef Khader, Ruba Al-Souri, Ilham Abu-Khader Affiliations: The Eastern Mediterranean Public Health Network (EMPHNET) Corresponding author: Dr. Haitham Bashier, MBB, MSc. Ph, PhD The Eastern Mediterranean Public Health Network (EMPHNET) Introduction The People’s Republic of China (PRC), in East Asia is the world’s most populous country, with a population of around 1.428 billion in 2017. China covers approximately 9,600,000 square kilometers with population density of 149.93 people per square kilometer [1]. About 17% of the population were 14 years old or younger, 70% were between 15 and 59 years old, and 13% were over 60 years old. The population growth rate for 2018 is estimated to be 0.46% [1]. By 2015, less than 3.1% of the Chinese population lived below the international poverty line of US$1.9 per day [2]. The People’s Republic of China is divided into 22 provinces, five autonomous regions (each with a designated minority group), and four municipalities—collectively referred to as “mainland China”—as well as the special administrative regions (SARs) of Hong Kong and Macau. Geographically, all 31 provincial divisions of mainland China are grouped into six regions: North China, Northeast China, East China, South Central China, Southwest China, and Northwest China. Since the late 1990s, China’s national road network has been significantly expanded through the creation of a network of national highways and expressways. In 2018, China’s highways had reached a total length of 142,500 km (88,500 mi), making it the longest highway system in the world; and China’s railways reached a total length of 127,000 km by 2017. By the end of 2018, China’s high-speed railway network reached a length of 29,000 km, representing more than 60% of the world’s total. By October 2014, there were 81 such bridges and tunnels. The railways strain to meet enormous demand particularly during the Chinese New Year holiday, when the world’s largest annual human migration takes place. In 2013, Chinese railways delivered 2.106 billion passenger trips, generating 1,059.56 billion passenger-kilometers and carried 3.967 billion tons of freight, generating 2,917.4 billion cargo tons-kilometers. There were approximately 229 airports in 2017, with around 240 planned by 2020. With rapid expansion in civil aviation, the largest airports in China have also joined the ranks of the busiest in the world. In 2018, Beijing’s Capital Airport ranked second in the world by passenger traffic. Since 2010, the Hong Kong International Airport and Shanghai Pudong International Airport have ranked first and third in air cargo tonnage. China has over 2,000 river and seaports, about 130 of which are open to foreign shipping. In 2017, the Ports of Shanghai, Hong Kong, 7 Shenzhen, Ningbo-Zhoushan, Guangzhou, Qingdao and Tianjin ranked in the Top 10 in the world in container traffic and cargo tonnage. Water supply and sanitation infrastructure in China face challenges due to rapid urbanization, as well as water scarcity, contamination, and pollution. About 36% of the rural population in China still did not have access to improved sanitation. There are around 1,944 municipal wastewater treatment plants across China’s city/urban regions and 1,599 municipal wastewater treatment plants across China’s counties, accounting for daily processing capacities of 140 and 29 million cubic meters respectively. The National Health and Family Planning Commission, together with its counterparts in the local commissions, oversees the health needs of the Chinese population. An emphasis on public 8 health and preventive medicine has characterized Chinese health policy since the early 1950s. Diseases such as cholera, typhoid and scarlet fever, which were previously rife in China, were nearly eradicated by the Patriotic Health Campaign. After economic reforms in 1978, the health of the Chinese public improved rapidly. Healthcare in China became mostly privatized and experienced a significant rise in quality. In 2009, the government began a 3-year large-scale healthcare provision initiative, the campaign resulted in 95% of China’s population having basic health insurance coverage. In 2011, China was estimated to be the world’s third-largest supplier of pharmaceuticals, but its population has suffered from the development and distribution of counterfeit medications. China has several emerging public health problems, such as respiratory illnesses caused by widespread air pollution, hundreds of millions of cigarette smokers, and large population and densely populated cities. In recent years, China was challenged by 2003 outbreak of SARS, and in 2010, air pollution caused 1.2 million premature deaths in China. Part 1: The Story On 31 December 2019, the WHO China Country Office was informed of cases of pneumonia of unknown etiology (unknown cause) detected in Wuhan City, Hubei Province of China. From 31 December 2019 through 3 January 2020, a total of 44 case-patients with pneumonia of unknown etiology were reported to WHO by the national authorities in China. During this reported period, the causal agent was not identified. On 11 and 12 January 2020, WHO received further detailed information from the National Health Commission China that the disease was associated with exposures in one seafood market in Wuhan City. Public health authorities in China decided to implement case-based surveillance to enhance the surveillance system. Part 2: Methods As news of the outbreak spread globally, neighboring countries and elsewhere heightened their surveillance to quickly detect potential new cases of the virus. More people infected with COVID-19 were identified in China, and cases were exported to other countries. This was not entirely unexpected given the volume of travel between Wuhan and other countries. Given the initial link between cases and a live animal market, as well as other coronaviruses that have animal reservoirs, an animal source seems the most likely primary source of the outbreak, with some human to human transmission occurring. The Emergency Committee convened on 22 and 23 January 2020 under the International Health Regulations (IHR 2005), and decided that it was not appropriate to declare the COVID-19 outbreak in China a public health emergency of international concern (PHEIC) given the disease’s spread and the control efforts undertaken by the PRC.. The WHO Director General accepted this advice. “Make no mistake,” commented Dr Tedros, “This is an emergency in China, but it has not yet become a global health emergency. It may yet become one”. The Emergency Committee on the novel coronavirus (COVID-19) under the International Health Regulations In May 2005 the World Health Assembly adopted the revised International Health Regulations (IHR). On June 15, 2007, IHR entered into force and are binding on 194 States Parties. The purpose and scope of IHR is to prevent, protect against, control and provide a public health response to the international spread of disease and to establish a single code of procedures and practices for routine public health measures. The benefits to the Member States include; improved surveillance system, effective detection and quick response to public health risks, use of modern communication tools and have access to global resources. The IHR has identified core capacity requirements that countries must have to detect, report and respond to risks in general, and to those at international ports, airports and land crossings. “Public Health Emergency of International Concern” (PHEIC ) means an extraordinary event which constitutes a public health risk to other States through the international spread of disease, and potentially requires a coordinated international response. If two or more of the four basic criteria are identified, the IHR Focal Point is obliged to report the event to WHO as a PHEIC. *more details in the readings annexes Fact sheet 2 11 (IHR 2005) was reconvened on 30 January. WHO declared the outbreak to be a public health emergency of international concern. Part 3: Results A small study of 99 cases observed at Wuhan Jinyintan Hospital, 49 had been exposed to the seafood and animal market believed to be at the center of the outbreak. The average age was 55.5 years and most (67) were men. Fever and cough were the most common symptoms. Seventeen patients developed acute respiratory distress syndrome and 11 of them died of multiple organ failure; 31 of the 99 had been released from the hospital by 25 January. Question 23. What’s the case fatality rate in Wuhan Jinyintan hospital? What does it tell? By January 31, China has reported 15,238 suspected cases and 9,720 cases were confirmed. The reported deaths due to the outbreak is 213 deaths and 1,527 severe cases. 106 cases were confirmed outside of China in 19 countries in 4 contents. Table 1. Countries with reported confirmed cases of COVID-19 , Jan 21 to Feb 1, 2020 1/21 1/22 1/23 1/24 1/25 1/26 1/27 1/28 1/29 1/30 1/31 2/1 China 446 579 581 846 1300 2000 2800 4600 6100 7800 9800 12000 Thailand 0 0 4 4 4 5 5 14 14 14 19 19 Japan 0 0 1 1 3 3 4 6 7 11 15 17 Singapore 0 0 0 1 3 4 4 7 7 10 16 16 Australia 0 0 0 0 3 4 4 5 7 7 9 12 Republic of Korea 0 0 1 2 2 2 3 4 4 4 11 12 Malaysia 0 0 0 0 0 3 4 4 4 7 8 8 Germany 0 0 0 0 0 0 0 1 4 4 6 7 USA 0 0 1 1 2 2 5 5 5 5 6 7 Viet Nam 0 0 0 2 2 2 2 2 2 2 2 5 France 0 0 0 0 3 3 3 3 4 5 6 6 Canada 0 0 0 0 0 0 1 2 3 3 3 4 UAE 0 0 0 0 0 0 0 0 4 4 4 4 Italy 0 0 0 0 0 0 0 0 0 0 2 2 Russia 0 0 0 0 0 0 0 0 0 0 2 2 UK 0 0 0 0 0 0 0 0 0 0 2 2 Spain 0 0 0 0 0 0 0 0 0 0 0 1 Sweden 0 0 0 0 0 0 0 0 0 0 1 1 Sri Lanka 0 0 0 0 0 0 0 1 1 1 1 1 Nepal 0 0 0 0 1 1 1 1 1 1 1 1 Philippines 0 0 0 0 0 0 0 0 0 1 1 1 India 0 0 0 0 0 0 0 0 0 1 1 1 Cambodia 0 0 0 0 0 0 0 0 0 1 1 1 Finland 0 0 0 0 0 0 0 0 0 1 1 1 Till February 1st, all deaths due to the corona outbreak were reported in China. The summary of deaths is shown in Table 2 Table 2: Summary of total deaths from COVID-19 worldwide Date Deaths 21-Jan 9 22-Jan 17 23-Jan 25 24-Jan 41 25-Jan 56 26-Jan 80 27-Jan 106 28-Jan 132 29-Jan 170 30-Jan 213 31-Jan 259 Population: In this report section, you will summarize key elements of the population in the research study and analyze the population impacted by the health issue. Summarize the people, places, and times represented in the research study to provide context for your report. Describe three social and behavioral determinants strongly associated with the public health issue in the research study. Cite specific examples from the research study to support your description. Describe three known disparities associated with the health of the specific population. Cite specific examples from the research study to support your description. Explain how the identified social and behavioral determinants relate to the disparities you identified and explain your reasoning. Health Issue: In this section of your final project, you will analyze the health issue that is the focus of the research study. You will draw conclusions about the health issue by reviewing the research study, the coronavirus case study data tables, and your own research on the topic. Describe the risk factors associated with the public health issue. Support your description with evidence from the research study and your independent research. Describe the mode of transmission of the public health issue. Support your description with evidence from the research study and your independent research. Determine the incidence and prevalence of the health issue. Use the data from the Coronavirus Case Study Data Tables resource to perform the appropriate calculations. Table 1 displays the number of confirmed COVID-19 cases by country that were reported daily between January 21, 2020, and February 1, 2020. Calculate the incidence of COVID-19 in China on January 21, 2020. Assume the population of China at the beginning of the coronavirus pandemic was 1.4 billion, or 1,400,000,000. Calculate the prevalence of COVID-19 worldwide during the entire period from January 21, 2020, to February 1, 2020. Assume that the global population of China at the beginning of the coronavirus pandemic was 7.821 billion or 7,821,000,000. Determine the mortality rate of the health issue. Use the data from the Coronavirus Case Study Data Tables resource to perform the appropriate calculations. Table 2 displays the total number of deaths from COVID-19 in all countries each day between January 21, 2020, and January 31, 2020. To calculate mortality, use the total number of deaths from Table 2 and the total number of confirmed cases from Table 1. Interpret the odds ratios in the Coronavirus Case Study Data Tables resource to determine the strength of association between baseline characteristics and the disease mortality. Use the odds ratios in Table 3 for your interpretation. Draw connections between the population and public health issue using your research and analysis. Consider where you identified common elements, what you learned about the public health issue by studying the population, and what you learned about the population by studying the public health issue. Consider the study’s suggestion of the most likely primary source of the outbreak. Levels of Prevention: In this section, you will describe the prevention strategies epidemiologists use to address the health issue. You will identify a strategy for each level of prevention and then differentiate between the strategies. Review the Module Four overview and resources for a refresher on levels of prevention. Describe a primary prevention strategy. Explain how the strategy addresses key factors impacting the health issue of the specific population. Provide one example of a primary prevention strategy from the case study or your independent research. Describe a secondary prevention strategy. Explain how the strategy addresses key factors impacting the health issue of the specific population. Provide one example of a secondary prevention strategy from the case study or your independent research. Describe a tertiary prevention strategy. Explain how the strategy addresses key factors impacting the health issue of the specific population. Provide one example of a tertiary prevention strategy from the case study or your independent research. Explain how the primary, secondary, and tertiary prevention strategies differ in how they address the key factors impacting the health issue in the research study. Conclusion: Now that you have analyzed the research study, you will develop a research question to further investigate the specific health issue and population. You will also select an appropriate research design and explain why the research is important to the field of public health. Review the Module Five overview and resources for a refresher on key points of developing a research question. Develop a research question to further investigate the specific public health issue and impacted population based on your analysis of the research study. Determine whether an observational or experimental research design would be more appropriate to investigate your research question. Justify your determination. Explain the importance of further research for improving the quality of health from a global perspective. What is the potential benefit?

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