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      Epidemic preparedness in urban settings: new challenges and opportunities

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          Abstract

          In recent decades, many emerging infectious diseases have been occurring at an increasing scale and frequency—i.e. Ebola virus disease, severe acute respiratory syndrome (SARS), avian and pandemic influenza, Middle-East respiratory syndrome (MERS), and the recently emerged coronavirus disease 2019 (COVID-19). The outbreaks of these diseases resulted in wide ranging socioeconomic consequences, including loss of lives and disruption to trade and travel. Preparedness is a crucial investment because its cost is small compared with the unmitigated impact of a health emergency. The financing gap for preparedness, estimated at US$4·5 billion per year, is miniscule compared with estimated pandemic costs of $570 billion per year.1, 2 Within urban settings, preparedness activities have the added challenge of navigating a host of disruptive determinants that demand innovative solutions, especially the way in which diseases and their human hosts behave. 3 Ensuring that urban settings are prepared for emerging infectious diseases is crucially important. In 2018, 55% of the world's population (4·2 billion people) resided in urban areas, and this proportion might increase to 68% by 2050. 4 Emerging infectious diseases also either originate in urban settings, such as the emergence of COVID-19 in Wuhan, China, or rapidly propagate because of urbanisation once they are established, such as outbreaks of SARS in 2003 and Zika virus disease in the Americas.5, 6, 7 Many cities are important hubs of travel and trade; hence an uncontained outbreak would result in severe economic consequences beyond lives lost. More importantly, these urban centres risk becoming conduits of transmission to the world. As seen from the spread of COVID-19, diseases now follow major patterns of travel connections both domestically (with major cities in China connected by high speed rail) and internationally through flights. 8 For example, as of Feb 17, 2020, there were 172 exported cases of COVID-19 from China to 25 countries, with 156 secondary cases in 14 countries, and these were mostly in major cities with travel connections to China. 9 Urban settings have some common characteristics, many of which are disruptive factors that need to be addressed for effective preparedness. 3 For example, the density of people in housing, during commutes using public transportation, and in work environments is high. Inequalities, exacerbated by the rapid influx of people from rural areas, often results in poor housing, insufficient supply of fresh water, poor sanitation facilities, and ineffective ventilation systems, all of which increase outbreak risks. Rapid urbanisation might lead to encroachment into natural habitats and closer encounters with wildlife and zoonoses, and increased proximity to animals in backyard farms and food markets also provides opportunities for zoonotic infections. Both SARS and COVID-19 might have originated from food markets, and of the 335 emerging infectious diseases recognised between 1940 and 2004, more than 60% were of zoonotic origin. 10 Ensuring better preparedness in urban settings will require a fresh emphasis on strengthening capacities to deal with outbreaks and other health emergencies. Many of these efforts are applicable across all settings, urban or otherwise, such as having a good understanding of the local socioeconomic and cultural milieu and an active involvement of communities and local leaders in both planning and implementation. However, urban settings also offer new opportunities (table ), such as securing the commitment of local leaders and strengthening public health networks to prevent, detect, and respond to disease threats early. Businesses can be appropriately engaged to manage employees in an emergency, and risk communication can be pushed through prevalent social media networks. Many lessons will also be learned from the city-wide community containment measures in Wuhan—the largest community quarantine exercise in history—and other containment measures rolled out in other Chinese cities and in Singapore. Table Challenges, and opportunities for epidemic preparedness associated with characteristics of urban settings Challenges Opportunities High population density and high volume of public transportation A larger population to be managed; ease of disease spread between humans in congested areas; difficulties in contact tracing, especially causal contact in public areas; inequalities resulting in poor housing environments that might hinder outbreak prevention and control efforts; closer encounters with wildlife via food markets or because of expansion into previously untouched ecosystems Urban planners can consider epidemic preparedness in their designs and implementation; transport networks can be used to rapidly move supplies to outbreak epicentres; harnessing advancement in technologies for more effective contact tracing Interface between animals and humans Areas of poor sanitation with rodents and other animal vectors; live domestic and wild animal markets; animals raised in backyard farms or industrial agricultural facilities in close proximity to humans Improved sanitation and rodent control around humans and animal communities; vaccination of domestic animals for common zoonotic infections; precautions at slaughter to prevent contact with blood; regulating live animal markets to phase out sale of live animals or to ensure that those for sale are raised on commercial farms and have been verified to be disease free Governance by local authorities Competing interests within a finite local budget; insufficient authority to institute response measures promptly; insufficient epidemic preparedness capabilities or capacities at a subnational and local level; difficulties in accessing national capacities Leaders in cities would be better placed to develop and implement effective and contextually appropriate solutions; consolidated local surveillance data can improve sense-making at the national level; local leaders can be engaged to advocate for greater investments in local systems Heterogeneous subpopulations A wide range of cultural factors, including modes of social interactions and acceptable control measures; some subpopulations might be difficult to reach Community leaders can be mobilised for targeted approaches to preparedness and response; innovative solutions can be shared and adapted across cultures High connectivity to other urban centres (domestic and international) High likelihood of multiple importation events; risk of rapid export of disease to other parts of the country or to other countries; fear might lead to restrictions on travel and trade Evidence-based points of entry measures and exit screening measures can be implemented; trust can be built through strong diplomatic relations to allow for better collaboration Centres of commerce Greater disruption to economic activity, stability, and growth Businesses and corporations can be engaged in business continuity plans that also prevent further spread, as part of a whole-of-society approach Unconventional communications and interactions Multiple information sources leading to misinformation; false information might spread quickly Unconventional but reliable information channels and social media can be used for risk communication Many urban settings now have substantial expertise and experience in preparing for and dealing with health emergencies. Having had large outbreaks of infectious diseases, authorities in some urban areas have developed purpose-built surveillance systems that make use of digital and web-based information. 11 Other local authorities have established surge capacity and contingency plans, including strong links with health-care facilities and national coordination bodies. 12 In some urban settings, complex simulation exercises have been run and disease spread has been modelled to determine the most effective public health actions to control the spread of infectious diseases. 13 There is room for sharing of best practices and measures in urban settings. Having an assessment and evaluation tool that is tailored for urban settings might also be useful for preparedness planning. The ongoing pandemic of COVID-19 is a strong reminder that urbanisation has changed the way that people and communities live, work, and interact, and the need to strengthen systems and local capacities to prevent the spread of infectious diseases is urgent. As a global community, we must collectively invest in and build strong preparedness systems that are better adapted to increasingly urbanised settings.

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          Most cited references6

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          Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia

          Abstract Background The initial cases of novel coronavirus (2019-nCoV)–infected pneumonia (NCIP) occurred in Wuhan, Hubei Province, China, in December 2019 and January 2020. We analyzed data on the first 425 confirmed cases in Wuhan to determine the epidemiologic characteristics of NCIP. Methods We collected information on demographic characteristics, exposure history, and illness timelines of laboratory-confirmed cases of NCIP that had been reported by January 22, 2020. We described characteristics of the cases and estimated the key epidemiologic time-delay distributions. In the early period of exponential growth, we estimated the epidemic doubling time and the basic reproductive number. Results Among the first 425 patients with confirmed NCIP, the median age was 59 years and 56% were male. The majority of cases (55%) with onset before January 1, 2020, were linked to the Huanan Seafood Wholesale Market, as compared with 8.6% of the subsequent cases. The mean incubation period was 5.2 days (95% confidence interval [CI], 4.1 to 7.0), with the 95th percentile of the distribution at 12.5 days. In its early stages, the epidemic doubled in size every 7.4 days. With a mean serial interval of 7.5 days (95% CI, 5.3 to 19), the basic reproductive number was estimated to be 2.2 (95% CI, 1.4 to 3.9). Conclusions On the basis of this information, there is evidence that human-to-human transmission has occurred among close contacts since the middle of December 2019. Considerable efforts to reduce transmission will be required to control outbreaks if similar dynamics apply elsewhere. Measures to prevent or reduce transmission should be implemented in populations at risk. (Funded by the Ministry of Science and Technology of China and others.)
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            MERS-CoV outbreak following a single patient exposure in an emergency room in South Korea: an epidemiological outbreak study

            Summary Background In 2015, a large outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) infection occurred following a single patient exposure in an emergency room at the Samsung Medical Center, a tertiary-care hospital in Seoul, South Korea. We aimed to investigate the epidemiology of MERS-CoV outbreak in our hospital. Methods We identified all patients and health-care workers who had been in the emergency room with the index case between May 27 and May 29, 2015. Patients were categorised on the basis of their exposure in the emergency room: in the same zone as the index case (group A), in different zones except for overlap at the registration area or the radiology suite (group B), and in different zones (group C). We documented cases of MERS-CoV infection, confirmed by real-time PCR testing of sputum samples. We analysed attack rates, incubation periods of the virus, and risk factors for transmission. Findings 675 patients and 218 health-care workers were identified as contacts. MERS-CoV infection was confirmed in 82 individuals (33 patients, eight health-care workers, and 41 visitors). The attack rate was highest in group A (20% [23/117] vs 5% [3/58] in group B vs 1% [4/500] in group C; p<0·0001), and was 2% (5/218) in health-care workers. After excluding nine cases (because of inability to determine the date of symptom onset in six cases and lack of data from three visitors), the median incubation period was 7 days (range 2–17, IQR 5–10). The median incubation period was significantly shorter in group A than in group C (5 days [IQR 4–8] vs 11 days [6–12]; p<0·0001). There were no confirmed cases in patients and visitors who visited the emergency room on May 29 and who were exposed only to potentially contaminated environment without direct contact with the index case. The main risk factor for transmission of MERS-CoV was the location of exposure. Interpretation Our results showed increased transmission potential of MERS-CoV from a single patient in an overcrowded emergency room and provide compelling evidence that health-care facilities worldwide need to be prepared for emerging infectious diseases. Funding None.
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              Is Open Access

              Potential for global spread of a novel coronavirus from China

              An epidemic of a novel coronavirus emerged from Wuhan, China, in late December 2019 and has since spread to several large Chinese cities. Should a scenario arise where this coronavirus spreads more broadly across China, we evaluate how patterns of international disease transmission could change.
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                Author and article information

                Contributors
                Journal
                Lancet Infect Dis
                Lancet Infect Dis
                The Lancet. Infectious Diseases
                Elsevier Ltd.
                1473-3099
                1474-4457
                27 March 2020
                May 2020
                27 March 2020
                : 20
                : 5
                : 527-529
                Affiliations
                [a ]Saw Swee Hock School of Public Health, National University of Singapore, Singapore
                [b ]Ministry of Health, Singapore 169854
                [c ]London Universidad del Desarrollo, Saniago, Chile
                [d ]London School of Hygiene & Tropical Medicine, London, UK
                [e ]Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
                Article
                S1473-3099(20)30249-8
                10.1016/S1473-3099(20)30249-8
                7270736
                32224312
                7d8f127b-d8c6-4a8a-8f94-0f994fa58a5a
                © 2020 Elsevier Ltd. All rights reserved.

                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.

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                Infectious disease & Microbiology
                Infectious disease & Microbiology

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