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      COVID-19 and Middle East Respiratory Syndrome Infections in Health-Care Workers in Korea

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          Abstract

          Outside of China, Korea was the first country to face a peak explosion of the COVID-19 global pandemic situation. On January 20, 2020, a Chinese who arrived from Wuhan, China, was detected for the first case of COVID-19 in Korea [1], and the outbreak started from the 31st case in Daegu Province in the third week of February. The Korea Centers for Disease Control and Prevention have tracked all cases [2]. All possible case contact people were identified, and polymerase chain reaction (PCR) tests for COVID-19 were performed to confirm cases of infection. The positive cases were admitted to a special room equipped with negative pressure ventilation. The case contacts who were shown to be negative for the COVID-19 PCR test were requested to be in isolation for 14 days; thereafter, they were retested for COVID-19. The Korean prevention strategy was strengthened when the 31st case was reported and several hundred cases were identified in an orthodox church located in Daegu, in the south of the Republic of Korea. The many possible cases were church congregants, who then spread the COVID-19 infection throughout the country. As of April 5, 2020, the Korea Centers for Disease Control and Prevention reported that there were 241 COVID-19 cases (2.4%) in health-care workers (HCWs), among a total of 10,062 positive COVID-19 cases. Of the 241 cases in HCWs, 101 had been infected at work. No one was infected during treatment. (Table 1 ). There were 11 doctors, 82 nurses, and 8 other HCW categories. The proportions of HCWs and HCWs who were occupationally infected among all cases of COVID-19 were 2.4 and 1.0%, respectively. This proportion is substantially lower when compared with the cases reported for the Middle East respiratory syndrome (MERS) outbreak in 2015 [3]. During the MERS outbreak, the percentage of HCWs who were infected at work was 21.0% (39 cases) of all MERS cases (186) in Korea. The HCW categories were physicians (8), nurses (15), caregivers (8), radiographers (2), and other HCWs (6). They were infected in outpatient clinics, emergency rooms, intensive care units, wards, radiographic chambers, and even in ambulances. Table 1 The status of COVID-19 infection in health-care workers in Korea as of April 5, 2020 Table 1 Cases Physicians Nurses Other HCWs Occupational infection Treatment for confirmed cases 0 0.0% 0 0 0 Screening tests 3 1.2% 1 2 0 General treatment 66 27.4% 6 57 3 Outbreak in hospitals 32 13.3% 4 23 5 Subtotal 101 41.9% 11 82 8 Nonoccupational infection Community infection 101 41.9% 7 76 18 Unknown source 26 10.8% 5 21 Subtotal 127 52.7% 12 97 18 Still under investigation 13 5.4% 2 11 Total 241 100.0% 25 190 26 HCWs, health-care workers. The basic reproduction number (R0) of COVID-19 ranges 2 to 5.7, which is higher than that of the severe adult respiratory syndrome (<2) and MERS (<1) [4]. The relatively lower rate of COVID-19 in HCWs is quite significant in occupational health, in view of the fact that COVID-19 is known to be more contagious than MERS. This observed lower rate of infection can be attributed to prevention actions and protocol designed for HCWs, based on the experience and lessons learned from the MERS outbreak. First, during the MERS outbreak in 2015, respiratory patients with fever, who possibly had a highly contagious disease, were treated with other patients at outpatient clinics and emergency rooms on arrival at hospitals or clinics. At that time, HCWs did not have any information on the possible infection and they did not know with whom their patients had had contact. Second, when confirmed cases were found, there was no way of knowing who the case contacts were unless the patients were honest in their descriptions of possible contacts and if they did not have a recall bias. At that time, the tracking of possibly infected contacts was impossible due to the enforcement of the Personal Information Protection Act. After the MERS outbreak, the act was amended so that the epidemiological team is now able to track and trace the route of confirmed cases to let people know whether they may have had contact with a possible source of infection [5]. Lastly, HCWs were not well versed or trained in good practices and the proper use of personal protective equipment. HCWs were in direct contact with patients without wearing the adequate personal protective equipment, such as masks, until well after the MERS infection was already widely spread. A health mask, KF94, which is equivalent to the N95 mask in the USA, was used only when seeing patients presenting at the infectious diseases departments. A national action plan for preventing endemic diseases was established only after the MERS outbreak. In hospitals, virtual training exercises had been periodically carried out using a scenario of a highly contagious patient referred or identified during a diagnostic process. Although the number of COVID-19 cases has been steadily decreasing, there is no way of knowing if the pandemic in Korea is nearing the end. However, many prevention actions and protocols have been established and implemented, based on the experience of COVID-19 since the first case was reported in January, followed by the massive outbreak in February. We can anticipate that the protection measures implemented for HCWs during this outbreak situation have been successful, even though there may be other reasons for the low rate of COVID-19 infections observed in HCWs in Korea. The important points in terms of the observed low rates of COVID-19 infection in HCWs are (1) segregation of potentially infected patients by operating a separate screening area for those patients who present with fever or respiratory symptoms. Patients suspected of having COVID-19 infection are submitted to PCR testing and sent to a dedicated room equipped with negative pressure ventilation if they have pneumonia or pneumonia symptoms, until confirmation can be obtained from the PCR test results. Separating the infected patients can prevent infection of HCWs and other patients, and it can reduce the burden of the workload experienced by HCWs. (2) Identification of infected patients through a massive, proactive case-finding and testing exercise for COVID-19 infection (test, trace, and treat) [6]. Identifying infected persons through a rapid test is very effective in preventing further transmission to people with whom the infected patients may have had close contact. (3) The good practice of wearing a mask, by HCWs and patients alike. The practice of patients wearing a mask may prevent HCWs from becoming infected by their patients during medical procedures. (4) All hospital staff and visitors are required to have their body temperature checked every day when entering the hospital premises. (5) Hand sanitizers have been provided throughout hospitals and other clinical settings. Other infection prevention actions have been taken in combination with the aforementioned good practices; these include frequent hand washing, social distancing in the seating arrangements in canteens and after work, temporary closure of public rooms such as change rooms and common meeting areas, postponement or cancellation of face-to-face meetings or conversion of these meetings to web-based communication events, and so on. Preventing infection of HCWs is a critical aspect of national response and very important for the duration of any pandemic [7]. Infection of HCWs will lead to reduced medical manpower and inadequate medical care of patients. Korea can ensure the efficiency and sustainability of its health-care system during the COVID-19 pandemic first and foremost by keeping its HCWs safe and healthy. Conflicts of interest The author declares that there is no conflict of interest.

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          Most cited references6

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          High Contagiousness and Rapid Spread of Severe Acute Respiratory Syndrome Coronavirus 2

          Severe acute respiratory syndrome coronavirus 2 is the causative agent of the ongoing coronavirus disease pandemic. Initial estimates of the early dynamics of the outbreak in Wuhan, China, suggested a doubling time of the number of infected persons of 6–7 days and a basic reproductive number (R0) of 2.2–2.7. We collected extensive individual case reports across China and estimated key epidemiologic parameters, including the incubation period (4.2 days). We then designed 2 mathematical modeling approaches to infer the outbreak dynamics in Wuhan by using high-resolution domestic travel and infection data. Results show that the doubling time early in the epidemic in Wuhan was 2.3–3.3 days. Assuming a serial interval of 6–9 days, we calculated a median R0 value of 5.7 (95% CI 3.8–8.9). We further show that active surveillance, contact tracing, quarantine, and early strong social distancing efforts are needed to stop transmission of the virus.
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            The First Case of 2019 Novel Coronavirus Pneumonia Imported into Korea from Wuhan, China: Implication for Infection Prevention and Control Measures

            In December 2019, a viral pneumonia outbreak caused by a novel betacoronavirus, the 2019 novel coronavirus (2019-nCoV), began in Wuhan, China. We report the epidemiological and clinical features of the first patient with 2019-nCoV pneumonia imported into Korea from Wuhan. This report suggests that in the early phase of 2019-nCoV pneumonia, chest radiography would miss patients with pneumonia and highlights taking travel history is of paramount importance for early detection and isolation of 2019-nCoV cases.
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              Contact Transmission of COVID-19 in South Korea: Novel Investigation Techniques for Tracing Contacts

              (2020)
              In the epidemiological investigation of an infectious disease, investigating, classifying, tracking, and managing contacts by identifying the patient’s route are important for preventing further transmission of the disease. However, omissions and errors in previous activities can occur when the investigation is performed through only a proxy interview with the patient. To overcome these limitations, methods that can objectively verify the patient’s claims (medical facility records, Global Positioning System, card transactions, and closed-circuit television) were used for the recent ongoing coronavirus disease 2019 contact investigations in South Korea.
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                Author and article information

                Contributors
                Journal
                Saf Health Work
                Saf Health Work
                Safety and Health at Work
                Occupational Safety and Health Research Institute, Published by Elsevier Korea LLC.
                2093-7911
                2093-7997
                7 May 2020
                7 May 2020
                Affiliations
                [1]Gachon University College of Medicine, Gil Medical Center, 21 Namdongdae-ro 774-beon Gil, Namdong-gu, Incheon, 21565, Republic of Korea
                Article
                S2093-7911(20)30273-0
                10.1016/j.shaw.2020.04.007
                7204702
                32382448
                69b25699-8ae9-4c43-9873-d19178c9e589
                © 2020 Occupational Safety and Health Research Institute, Published by Elsevier Korea LLC.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                : 20 April 2020
                : 22 April 2020
                : 23 April 2020
                Categories
                Article

                Occupational & Environmental medicine
                covid-19,hcws,health care workers,mers,middle east respiratory syndrome

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