countries like developing for approach based cases: community suspected A Rapid assessment of COVID-19 Naeem Shahzad 2 1 www.jogh.org JoGH ©2020ISGH © 2020TheAuthor(s) RawalpindiInstituteofCardiology, ,Pakistan NationalUniversityofSciencesandTechnology, RisalpurCampus,Pakistan • doi:10.7189/jogh.10.010353 Spanish flu in early 20 early in flu Spanish after times recent the in front global the on diseases spreading largest the of one become has COVID-19 rus toitstrack[2 12,2020,andthengraduallydecreasedgle-day eventonFebruary tillChinawasabletocontainthisvi- case, the epidemic reached its first peak on January 24-26, 2020, and an unusually high incidence of reported sin- first the after days 30 from municipalities) / regions (autonomous provinces 31 affecting idly transmission iscriticaltodevelopingandimplementingeffective control strategies.Thisvirusspread rap- (2019-nCoV) Virus Corona of characteristics epidemiological the Understanding epidemic. the stop to der lockdown and the Chinese made government the highest-level commitment to mobilize effortevery un- went Council. State the approvalof the on China Commission Health and Health National the uary, thenewcoronavirus pneumoniawasincludedinthemanagementofClassBinfectiousdiseasesby by geneticsequenceanalysisandthedevelopmentofadetectionmethod[1 subsequently,and 2020 coronavirus followed new (2019-nCoV), a as identified was agent causative the T and management of the biological disasters including the most developed nations of the world. Despite and managementofthebiologicaldisastersincluding mostdevelopednationsoftheworld.Despite level preparedness in gaps inherent the highlighted has VirusCorona Novel of outbreak global Current of 14 days inactivity of the virus, which may lead to a wrong diagnostic, resulting into spread of the disease. period a is spread the for flag red raising factor important Another treatment. and testing for attention ical cially in the under developed world. This required a scientific approach to shortlist the case requiring med- on the global front coupled with thecapacity of available healthfacilitiesto test and treat the patients, espe - kits testing of deficiency a also is There halt. a to world broughtthe has rate transfer rapid and disease the helped spreading this virus atan enormous rate, which is unprecedented. The non-availability of cure for developed nationsofthe world. paredness levelandmanagement ofthebiologicaldisastersnotwithstanding themost Current globaloutbreakof NovelCoronavirushashighlightedtheinherent gaps inpre 1 , Irfan Abid , Irfan The Chinese government notified the WHO of the epidemic situation in the first week of January monia occurred inWuhan, oftheresponsible healthdepartmentoftheCity. Chinaraisingconcern he Coronavirus pandemicstartedinlateDecember2019,when anunexplainedcaseofmasspneu- ]. th 1 century. Current globalized environment and rapid modes of transportation have have transportation of modes century.rapid and environment globalized Current , Wajahat JavedMirza 1 2 , MuhammadMazharIqbal June 2020 •Vol. 10 No. 1•010353 ]. In the second week of Jan- 1 -

VIEWPOINTS VIEWPOINTS June 2020 •Vol. 10 No. 1•010353 permission). emergency control room (from thecollectionofDrNaeemShahzad,usedwith score card from asuspectedpatientforinitialscreening andtriageatthe Photo: Nursewearinglocallyproduced lowcostCOVID-19kitandfillingthe Based on different research findings [7 findings researchdifferent on Based ing capabilities[6 tries like Pakistan where the suspected cases of COVID-19 are likely to be under-detected due to low test- COVID-19 cases at community level. This will be quite beneficial for rapid triage especially for the coun- community level which will help the low-incomeand developing countries toascertain the suspected study hasmadean effort to design a rapid assessment score card usingbottom up approach starting from this Therefore, kits. testing COVID-19 of absence the in cumbersome and tiring becomes individuals quarantine ofthesuspectedcasestocircumvent healthcare systemoverload[5 and isolation tracing, contact testing, excessive to resorting by facilities care health weak already its of stretching avoid to Pakistan like countries developing moreof is case This the COVID-19. in the critical [ of citiestoisolation cases, in order toprevent thenumberofcaseshavingsevere illnessrequiring ICU Different strategies for suppression of the COVID-19 are being practiced globally ranging from lockdown transmission. COVID-19 the stop and contain to unrealistic be will GDPs low with countries in systems care health [3 COVID-19 of spread rapid to countries these of abilities tries isonhighersideascompared tomiddleandhigh-incomecountriesthereby highlightingthevulner be entirely different as compared to US, China and Europe. The average household in low-income coun- will economies poor with countries in COVID-19 by posed risks that infer to imperative Therefore,is it healthcarenumber offactorsincludingoverwhelmed systemsanddifferent underlyingco-morbidities. sort tothisscore card atcommunityleveltotriagethesuspectedpatientsandmayadopttestingofonly no or limited testing capabilities of COVID-19 tests. It is perceived that countries like Pakistan, could re- tients has been taken into consideration. This score card has been designed for low income countries with el history, isolation period, appearance of the symptoms and contact with the suspected or confirmed pa- in covering numerous effective parameters for rapid assessment of the probable COIVD-19 cases, as shown control overthespread ofthediseaseandpreventive measures, aneffective score card hasbeendeveloped patient screening withoutoverburdening the healthcare infrastructure whilestillnotcompromising the possible/ probable causes of COVID-19 suspicion among the community. To develop an effective tool for 4 ]. Different countries are resorting to massive lock down and social distancing to manage and contain contain and manage to distancing social and down lock Differentmassive ]. areresortingto countries total scoreofthesuspect tofilterhim/herforaprobabletestcaseorotherwise. score card,wheretheparameters discussedhavebeengivendueweightto assessthe trolled with a systematic filtering and triage of the suspect cases using the proposed Basing onthediscussed factors, theoverburdeningofhealthsystem can becon Figure 1.Forthispurposethetrends andeffects ofspread rate,agefactor, previous health history, trav- ].

- 12], ascore card has been developed encompassingmaximum 2 with low GDPs are already over burdened due to due burdened over already are GDPs low with this healthemergency. Itiscontingentthatcountries nomic infrastructure willnotbeabletocopeupwith developing countries and countries with poor eco - the that apparent is it COVID-19, to countries pean Euromost - and US the of response the observing By considerable fatalities. with patients of number huge managing is US while effectively controlled thespread ofthispandemic countries like China, South Korea and Singapore have worth mentioningthatnotwithstandingallodds, nential increase passingday. incaseswithevery Itis health care byexpo - systemshavebeenoverwhelmed tries are struggling to respond and manage, as their break hasexposedtheloopholeswhichmanycoun- out- VirusCorona the conventions, and frameworks related other and 2015) (UNISDR, Reduction Risk logical hazards by the Sendai Framework for Disaster inclusion ofepidemicsandpandemicsamongstbio- ]. Forthisreason dependingontheexisting www.jogh.org ]. Aggressive testingofthe • doi:10.7189/jogh.10.010353 - - www.jogh.org • doi:10.7189/jogh.10.010353 technique toreduce the burden ontheirtesting facilities.Itispertinent tomentionthatthisisnot anide- tests whichaccountsfor3% only. Low-incomecountrieswithlimitedhealthfacilities mayresort tothis uals who reported to the control room for suspicion of COVID-19, only 35 persons required COVID-19 isolated and quarantined for 14 days. It can be easily inferred that instead of testing all the 1166 individ - patients ie, 35 were sent to Islamabad and and all tested negative. However, these patients were much at the health facility available in the area, which is Class ‘C’ hospital, so tests of all the suspected be tested on priority, while 14 others were immediately hospitalized. Since the burden of patients was not These results show that 21 persons were suspectedand their scores suggested that they were required to til April3,2020,1166personswere screened at thecontrol room. COVID-19 was first screened at this centre and was then further referred to the Hospital if required. Un- of symptoms probable expecting or complaining individual any Besides, suspicion. COVID-19 for ual manned 24/7 and any person entering Risalpur Cantonment was sent here in order is roomto screenThis the situation. individ- COVID-19 the with deal to community the in developed been has room trol since March 23, 2020 and limited entrance and exit was allowed to this community. An emergency con- Cantonment. This score card was tested for its effectiveness after the area was under complete lock down demographic distribution of this community cannot be shared due tosecurity issues as itis housed in a 71.99276 longitude) which is an enclosed community consisting of a population of around 30 latitude, (34.06048 Cantonment Risalpur of community small a on tested been has card score The ing andoverburdening theWHOefforts tofightthispandemic. due totheirin-capacitydetectCOVID-19patientsandavailabilityofthetestingkitsisbadlyhamper arewhich outbreaketc., exponential Chad to virus Bangladesh, vulnerable this , of like tries testing facilities available in the country.oratory The method will also be helpful for low-income coun- those patients who have higher scores (ie, Figure 1. The proposed score card forrapidCOVID-19diagnosis. ˃ 3 100). This will help lessen the burden of already limited lab- June 2020 •Vol. 10 No. 1•010353 000. The 000. The -

VIEWPOINTS VIEWPOINTS June 2020 •Vol. 10 No. 1•010353 REFERENCES 4 3 2 1    Qiu Geneva: WHO;2020. World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). Zhang 2020;9:221-36. Medline:31987001 Infect. Wuhan.MicrobesEmerg visiting after pneumonia atypical with patient a from isolated coronavirus pathogenic human- novel 2019 the of characterization ToGenomic KK-W,H, al. Chu et Z, YuanJF-W,S, Zhu Chan K-H, Kok doi:10.1016/S1473-3099(20)30198-5 study.cohort observational an China: Zhejiang, in (COVID-19) 2019 disease total score ofthesuspecttofilterhim/herforaprobable testcaseorotherwise. tering ofthesuspectcases,where theparametersdiscussedhavebeengivendueweightagetoassess above mentioned factors, the over burdening of the health system can be controlled with a systematic fil- testing facilities for management, treatment and care of the suspected COVID-19 patients. Basing on the beneficial in small villages and towns to adopt a bottom up approach and ease the already over stretched card based assessment, to reduce the loadon the testingcenters all across the country. Thiswillbevery enhancing the country’s testing capabilities by importing to test addition kits, In it wagers. is daily imperative and to businesses adopt small suggested for score especially crisis economic to lead will down lock to limited testing capabilities. Similarly, owing to the poor economic conditions of the country, complete rea [13, controland contain to Coronastrategies Ko- successful and two China VirusThe by adopted been have CONCLUSIONS statistics. Besides findingshighlightedabove,followingdeductionshavebeenmadefortheobserved minimal orlowtestingcapacities. to Testingdue No all to at alternative an be can but patients suspected COVID-19 the tracing of way al H the corresponding author)anddeclare noconflictofinterests. Competing interests: The authors completed the ICMJE Competing Interests form (available upon request from score card and assistingindatagathering.MMIreviewed thefinaldraft. preparing part of the paper and reviewing and improving the initial draft. WJM was involved in developing the Authorship contributions: NS was involved in data gathering and preparing of initial draft. IA was involved in Funding: Nofundingwasavailableforthisstudy. regarding personsreporting thecontrol room. Acknowledgements: The authors hereby acknowledge the Risalpur Cantonment authorities for sharing the data , Y Wu . 5. 4.  3. 2. 1. Analysis ofepidemiologicalcharacteristics ofnewcoronavirus pneumonia.

in alocalityorregion. pearance ofthesymptomsdisease.Thisishelpfulineliminatingdiseaseanditsspread spread, prevention, and cure of this disease has shown the efficacy of the isolation period and ap- the with deal to weeks few last of experience the over evolved mechanism exiting already An tient countdramatically(bothforconfirmedandnon-confirmedcases). pa- affectthe still can affectedregion or country the within mobility local and days 14 of period started toexercise thetravelbaninternationally, buttheghostphenomenonofdiseasefora have countries the of most parameter. Although significant a also is history travel Nevertheless, ease adaptabilityandseriousness. extent geographical location. This also contributes significantly to the potential proneness for dis- Previous health history is associated to age, health infrastructure, trends in the society, and to some ple withageover70yearsintheunderdevelopedworld. same also results in a less average age due to a fatigued life, there by having significantly less peo- the but illness the against fight to people the of immunity better in result facilities health Poor lockdown ofthesocietywasalready inferred basingontheinitialdevastationofdisease. been lowerwhilestillbeingontheexponentialscale,aspreventive modelofisolationand where 20, 2020,the rate of spreadFor a country thediseasehasbeen imported afterFebruary has ]. For countries like Pakistan, Korea’sPakistan, like countries For 14]. Trace,to strategy Test Treatand due difficult adopt is to J , Hong L ,

Luo Y , Song Q , Chen D . Clinical and epidemiological features of 36 children with coronavirus with children 36 of features epidemiological and Clinical 4 Lancet InfectDis. www.jogh.org Chin JEpidemiol. • doi:10.7189/jogh.10.010353 Medline:32220650 2020; 41: 1 2020. - 7 . www.jogh.org REFERENCES • doi:10.7189/jogh.10.010353 12  13  14  11  5 10  9 6 7 8      Colbourn Organization 15. potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. ciehus R, De Salazar PM, Taylor AR, Lipsitch M. 2667(20)30072-4. Onlineaheadofprint. prevalence estimatesinWuhan, China. coronavirus (COVID-19)pneumonia. Pan Xu Medline:32081636 challenges. the and epidemic the (COVID-19): disease-2019 virus corona Chen respiratory distress syndrome. Zu Dawoong Chung China. 2020. blogs.worldbank.org/eastasiapacific/koreas-response-covid-19-early-lessons-tackling-pandemic. Lai Medline:32139904 Zheng Medline:32151335 ZY C-C, Z, F , , H Ye Shi Y-Y Radiology Jiang ,

Shih T Guo , , T. L, Sun Ma

COVID-19: extending or relaxing distancing control measures. control distancing relaxing or extending COVID-19: MD, Wang WH. Coronavirus disease2019(COVID-19):situationreport, 59.2020. T-P J , Y-T P . , Wang , . Korea’sHSS. pandemic. the tackling in responselessons Early COVID-19: to Gui 2020; Ko Xu , Y Zhang , W-C PP S Zhang C , 200490. , Liang , Chen , Luo J-Y Tang J, , Lancet RespirMed. B F Xie W , , Huang Online aheadofprint. H-J, Li Yu , Ni X L

X , . Hsueh Radiology QQ, , et al. COVID-19 and the cardiovascular system. cardiovascular the and COVID-19 Lancet InfectDis. Zhang L, Medline:32220654 Zhang Lu Time courseoflungchangesonchestCTduringrecovery from 2019novel P-R. GM, W Using observational data to quantify bias of traveller-derived COVID-19 . , 2020; Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)2 coronavirussyndrome respiratory acute Severeand C, 2020; et al. 5 et al. et al. 200370. Medline:32083985 8 Clinical characteristics and intrauterine vertical transmission Clinical characteristicsandintrauterineverticaltransmission 2020; pii:S1473-3099(20)30229-2.Medline:32246905 : Coronavirus Disease 2019 (COVID-19): A Perspective from Perspective A (COVID-19): 2019 Disease Coronavirus 420- Pathological findings of COVID-19 associated with acute with associated COVID-19 of findings Pathological 2 Online aheadofprint. . Medline:32085846 Dr. NaeemShahzad Correspondence to: [email protected] Pakistan Risalpur (KPK),24080 (NUST) RisalpurCampus National UniversityofSciencesandTechnology Head ofDepartmentDisasterManagement Int J Antimicrob Agents. Antimicrob J Int

Lancet Public Health. Public Lancet June 2020 •Vol. 10 No. 1•010353 Nat Rev Cardiol. Rev Nat Medline:32053470

2020. Available:

Lancet. Accessed: 30 March ; pii: S2468- pii: 2020; 2020; 2020; 2020 55: 17: ; 395: 105924. 259-

https:// 809- 60.

VIEWPOINTS