Coronavirus 2019: Scope of Community Medicine to contain the Outbreak

The corona virus was first discovered in 1937, named as, avian infectious bronchitis virus. In 1967, June Almeida and David Tyrrell performed electron microscopy on specimens from cultures of viruses causing cold in humans and identified particles that resembled avian infectious bronchitis virus. Almeida coined the term “corona virus,” from the Latin corona (“crown”) because the glycoprotein spikes of the isolated viruses appeared to look like a solar corona. These strains that occasionally infected humans generally caused mild symptoms. However, in more recent past, animal corona viruses’ outbreaks caused outbreaks of severe respiratory disease in humans, including severe acute respiratory syndrome (SARS) 2002, Middle East respiratory syndrome (MERS) 2012, and corona virus disease (COVID-19) 2019.

The virus that is currently causing so much fear globally is commonly referred to as, the novel coronavirus & the disease it causes has been termed as COVID-19. Novel here refers to ‘new’ because the corona virus disease, or COVID-19, is just the latest mutant of a virus that has been around humans probably for a longer period, but infection in Humans was observed to have occurred for the first time. Corona viruses most typically cause disease in animals, specifically mammals and birds like pigs and bats. Occasionally, the virus mutates so that it can also infect humans. There are many reports that the current virus may have spread from bats or pangolins that inhabit China. But experts are not yet sure of the origins of this coronavirus disease. It has also been called SARS-CoV-2 because it is similar to the one that caused the outbreak of SARS, or severe acute respiratory syndrome, from 2002 to 2004.

The diameter of the SARS CoV-2 is approximately 50-200 nanometers (about 125 nanometers). This makes the virus most likely too heavy to be aerosolized and requires the inhalation of respiratory droplets that contain the virus or transmission through infected surfaces. It is thought that COVID-19 spreads mainly through close contact from person-to-person in respiratory droplets from someone who is already infected. Infected people often have symptoms of illness. Some people without the symptoms may also spread the virus. In addition to the respiratory secretions, SARS-CoV-2 has also been detected in blood, urine, and feces. In specific circumstances and settings, the airborne transmission may be possible in which procedures or support treatments that generate aerosols are performed. The Virus has the capability for remaining viable for between a few hours and a few days depending on the surface. Studies showed that the virus can survive on hard surfaces such as plastic and stainless steel for up to 72 hours and on cardboard for up to 24 hours. Some surfaces are less hospitable to SARS-CoV-2, interestingly, for instance, the virus remained viable on copper for only about four hours. Corona virus can live on surfaces for 2 to 3 days. As this is a new disease, we are still learning about how it spreads and the severity of illness it causes.

People with COVID-19 have had a wide range of symptoms which reports from mild symptoms to severe illness. These symptoms may appear 2-14 days (incubation period has been found to be as long as 24 days also) after exposure to the virus – Fever, Cough, Shortness of breath or difficulty breathing, Headache, Sore throat, New loss of taste or smell, Chills, Repeated shaking with chills, muscle pain. Adults who are older with severe underlying medical conditions like diabetes or heart or lung disease are at a higher risk of developing serious complications from the illness of COVID-19.

The outbreak of the 2019 novel coronavirus disease (COVID-19) was firstly reported in Wuhan, China on December 31, 2019. Within a few weeks, the virus had spread rapidly throughout China and within 1 month to several other countries through human-human transmission among close contacts. Currently COVID-19 is affecting 210 countries & territories around the world leading to 25,57,213 cases & 1,77,641 deaths as on 21st April 2020. The doubling rate of the infection was calculated to be 7.4 days. The World Health Organization declared a Public Health Emergency of International Concern on 30th January 2020, and Pandemic due to COVID-19 was declared on 11th March.

The first case in India was reported on 30th January 2020 from Thrissur, Kerala, a young woman studying medicine at Wuhan, China the epicenter of the nCoV-19 outbreak. Currently there are 20,080 cases spread throughout the country and a total of 645 deaths due to COVID19 as on 21st April 2020. With the proactive commitment by Honorable PM Shri Narendra Modi ji, early intervention like countrywide lockdown & social distancing, the doubling rate of the cases has risen to 7.4 days from 3.4 days before lockdown. 

 In India the number of cases are constantly rising, but so far, we have been able to successfully slow down the ongoing Pandemic from entering into Stage – III transmission. A lot of groundwork, insight, and brainstorming are involved in drafting the health policy and guidelines in such a situation. Though all the health workforce is involved at multiple levels, the role of a community medicine expert is maximum in controlling the spread in the community and managing the situation. The ongoing COVID19 Pandemic is one of the greatest disasters the globe has faced with the widespread transmission of infection leading to high mortality. The expertise of Community Medicine specialists has a major role in planning & implementation of guidelines & to interrupt the current Pandemic which may otherwise result with high proportions of mortality & morbidity. 

Scope and role of Community Medicine in such a situation can be understood & described in a step by step manner as enumerated below:

  1. Reporting of cases from Wuhan province of China – clustering of cases in multiple provinces of China – leading to activation of a surveillance program for the cases and identifying that it’s an epidemic of a new disease (investigation of an epidemic - an aspect of Community Medicine).
  2. World Health Organization coming into action and declaring it as a Public Health Emergency of International Concern – suggesting evidence-based preventive measures to contain its spread to other countries. (WHO which is the highest agency of International Health drafting the International Guidelines on Travel, Social distancing, Quarantine, Contact tracing, etc., – again a part of Community Medicine).
  3. Surveillance units established at all entry & exit points or ports of different countries (again a subject of Community Medicine).
  4. Right now, India is at the verge of entering stage 3 of the Epidemic - The dynamics of an epidemic can only be understood thoroughly through Community Medicine by applying the principles of epidemiology – Study the natural history of Disease – describing the susceptible population – measures to prevent transmission – guidelines & policies to be practiced. Eminent Community Medicine experts all over the country are in close communication with the respective district/state administrations to arrest the epidemic in stage 3 itself.
  5.  Formulation of Standard Operating Procedures for all healthcare personnel can be done adequately only if you possess deep knowledge about transmission and control of diseases (another aspect of Community Medicine)
  6.  Organizing and providing training to trainers who would further train the other health care workers in SOPs (done by Community Medicine experts in collaboration with WHO and District Administration)
  7.  Drafting modules for training of grass root level workers in the rural and urban areas and training them.
  8. Drafting public awareness campaigns to prevent the spread of infection.
  9. Spearheading public health research into various aspects of the epidemic (cause, spread, treatment, control, and prevention)
  10. Exploring the various alternatives for possible control and prevention.
  11. Establishing efficacy through sensitivity and specificity studies of different options of diagnostic methods and then demarking them as a screening tool or diagnostic tool (again a very important aspect of Community Medicine)
  12. Establishing which PPE kits are suitable for which level of health care workers
  13. Training the staff in resource management in a disaster like situations.
  14. Establishment of isolation and quarantine facilities on the principles of disease transmission (an important part of the subject)
  15. Doing field trials of vaccines under study for use in the community (should have adequate efficacy and safety)  
  16. Administrative skills to – manage man force, resources & finances.
  17. Documentation & records keeping.
  18. Data analysis, statistical evaluation & generate SOPs.
  19. Be a part of the Epidemic Task Force.

At each of these steps, the guidance of a community medicine expert is required. This branch gives an in-depth knowledge of all aspects related to an epidemic like the stages of an epidemic, the different control strategies for each stage, and the prevention of progression to the next stage. Although individual cases are managed by other specialities but community management at large scale is essentially the task of a community medicine expert. 

To conclude, Community Medicine is the only speciality which provides a wide array of all the required skills to manage any health-related emergency situation like, Disaster management, outbreak interruption, food poisoning, establishing standards of health care delivery & most importantly in an ethical way.