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      Earthquake in the time of COVID-19: The story from Croatia (CroVID-20)

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          Abstract

          On the hundredth day since days since the WHO was notified of the first cases of “pneumonia with unknown cause” in China, the COVID-19 pandemic, caused by SARS-CoV-2, has spread throughout the world to 195 countries with over 1.5 million cases and more than 85 000 deaths [1]. In early January, when we had just learned that a newly discovered disease was spreading in faraway China, only a few thought it would soon be coming to Croatia. Nevertheless, by February, when the epidemic was rapidly spreading in northern Italy, it was already quite likely that it would not bypass Croatia, and on 25 February 2020 the first case of COVID-19 was registered in our country [2]. The Government of the Republic of Croatia has established the National Civil Defense Headquarters in order to raise the level of preparedness of all the competent authorities, protect the health of Croatian citizens and coordinate all the services in the battle against SARS-CoV-2 in Croatia. The Deputy Prime Minister and Minister of the Interior was chosen to lead the headquarters, whose members are the Director of the Croatian Institute of Public Health, the Director of the Croatian Institute of Emergency Medicine, and the Director of the Dr Fran Mihaljević University Hospital for Infectious Diseases (UHID), who is also the President of the Croatian Society for Biosafety and Biosecurity. After the daily meetings, the headquarters issues press releases. Together with other public services, all the health care institutions were quickly mobilized in preparation for the battle against the COVID-19 epidemic, with the UHID taking the leading role, from the establishment of quarantine to being declared the National Hospital for COVID-19. The Minister of Health issued the decision to proclaim the threat of a COVID-19 epidemic as an administrative measure, which does not indicate the degree of the threat but permits the Minister to mobilize all the resources in the health care system, redeploying ID physicians, other health care workers (HCWs) and equipment, in order to improve the administration of the health care system. Unfortunately, what few had thought possible has come to pass. An infectious disease has transformed social and economic relations, as well as humanity as a whole, entering and altering every pore of society. Colleges and schools have closed their doors, students are attending classes from home, via television and computers, the majority of the public sector employees are working from home, while some, regrettably, have lost their jobs. The churches have also closed their doors. At the end of the fourth week of the epidemic in Croatia, a total of 206 cases had been confirmed, with 49 newly diagnosed on 21 March 2020. When we thought that nothing worse could happen, on 22 March 2020, the citizens of Zagreb, the capital of Croatia, home to a quarter of the total Croatian population, were awakened at 6:24 am by an earthquake of 5.5 magnitude on the Richter scale, followed in the next 24 hours by 57 aftershocks. Due to extensive property damage, several hospitals had to be evacuated, including the UHID, where there were 86 patients at the moment, including 22 COVID-19 patients, 15 of whom were in the ICU. This additional misfortune has jeopardized the safety of us all, especially the most vulnerable members of our society: children, the elderly and the sick. A total of 27 persons were injured during the earthquake, of whom one, sadly a 15-year-old girl, died of her injuries. We as HCWs were expected to remain clear-headed, gather all our strength, knowledge and skills, and provide our patients with the best of what was possible, and sometimes even the impossible. But we also remember the scene around our hospital buildings, where the old and young, staff and patients, corona-positive and negative, were scattered on the grass and the parking lot, shivering from the cold and fear. Nevertheless, we survived that, too, and we will continue to survive, even when faced with greater challenges. We have demonstrated and proven that we cannot do without one another: physicians without nurses, patients without HCWs, HCWs without non-medical and support staff, parents without children, and children without parents. Photo: During the earthquake in Zagreb on 22 March 2020, 86 patients, including 22 COVID-19 patients, were evacuated from the extensively damaged hospital buildings (authors’ photo archive, used with permission). In addition to property damage, we were quite apprehensive that the earthquake would accelerate the spread of the COVID-19 epidemic in Croatia since the earthquake, which left many homeless and fearful of earthquakes to come, triggered migrations to other parts of the country. However, six weeks since the first COVID-19 case and three weeks after the earthquake, only 1650 cases have been registered in Croatia ( Figure 1 ), with 25 deaths (CFR of 1.5%) [3], making Croatia a country with one of the lowest rates of COVID-19 infection in Europe: 343 cases and 5 deaths per million inhabitants [4]. Figure 1 The number of confirmed COVID-19 cases in Croatia and the city of Zagreb six weeks after the first COVID-19 case and three weeks after the earthquake. The subtitle of the previously cited article by Čivljak et al. [2], What's next?, warns of the looming danger from infectious diseases and the need for ongoing surveillance, because respiratory infections such as coronavirus diseases (SARS, MERS and COVID-19) are major threats to humanity. Nevertheless, no one expected that a second misfortune, the earthquake, would occur during this pandemic in our little country. All HCWs, including physicians, nurses, technicians, laboratory personnel, caregivers and other staff who come into contact with patients, are being directly or indirectly exposed to the infected and sick, which places them at risk. At the UHID, among 691 employees, only two have acquired SARC-CoV-2 infection in the post-earthquake period: one nurse and one ancillary worker. On the national level, no increase in the incidence of COVID-19 was experienced in the post-earthquake period, as shown in Figure 1 . Moreover, owing to the chronic shortage of medical personnel throughout the entire health care system, particularly now when the demands are increasing, we are being expected to make great sacrifices in order to provide the best possible care to all citizens. An additional burden is that 216 HCWs in Croatia have COVID-19, while another 562 are in self-isolation at the moment. All of them are currently unable to perform their regular professional duties and the number may soon increase. The Minister of Health has stated that the health care system is not in jeopardy for now and the ministry is redeploying HCWs in order to fill the most crucial positions. This third coronavirus epidemic underscores the need for the ongoing surveillance of infectious disease trends throughout the world. However, in combination with a natural disaster, such as earthquake, the risk for increasing the number of the infected, as well as outbreaks of other infectious diseases, is higher. As shown in the systematic review by Suk et al., cascading effects of post-disaster outbreaks are possible after earthquakes, such as outbreaks of Salmonella, chickenpox, or other infectious diseases in general [5]. By now, due to a well-organized public health system and coordinated outbreak response, Croatia has overcome the current challenges, including extensive damage to hospitals, shortage of hospital personnel, and disruption of supply chains. We hope that everything done so far will provide the basis for stopping this epidemic in Croatia and mitigating the damage done from the COVID-19 epidemic and the recent earthquake.

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          Natural disasters and infectious disease in Europe: a literature review to identify cascading risk pathways

          Abstract Background Natural disasters are increasing in their frequency and complexity. Understanding how their cascading effects can lead to infectious disease outbreaks is important for developing cross-sectoral preparedness strategies. The review focussed on earthquakes and floods because of their importance in Europe and their potential to elucidate the pathways through which natural disasters can lead to infectious disease outbreaks. Methods A systematic literature review complemented by a call for evidence was conducted to identify earthquake or flooding events in Europe associated with potential infectious disease events. Results This review included 17 peer-reviewed papers that reported on suspected and confirmed infectious disease outbreaks following earthquakes (4 reports) or flooding (13 reports) in Europe. The majority of reports related to food- and water-borne disease. Eleven studies described the cascading effect of post-disaster outbreaks. The most reported driver of disease outbreaks was heavy rainfall, which led to cross-connections between water and other environmental systems, leading to the contamination of rivers, lakes, springs and water supplies. Exposure to contaminated surface water or floodwater following flooding, exposure to animal excreta and post-disaster living conditions were among other reported drivers of outbreaks. Conclusions The cascade effects of natural disasters, such as earthquakes and floods, include outbreaks of infectious disease. The projection that climate change-related extreme weather events will increase in Europe in the coming century highlights the importance of strengthening preparedness planning and measures to mitigate and control outbreaks in post-disaster settings.
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            The third coronavirus epidemic in the third millennium: what’s next?

            The current epidemic of a new coronavirus disease (COVID-19), caused by a novel coronavirus (2019-nCoV), recently officially named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has reopened the issue of the role and importance of coronaviruses in human pathology (1-5). This epidemic definitively confirms that this heretofore relatively harmless family of viruses, Coronaviridae, includes major pathogens of epidemic potential. The COVID-19 epidemic has clearly demonstrated the power of infectious diseases, which have been responsible for many devastating epidemics throughout history. The epidemiological potential of emerging infectious diseases, especially zoonoses, is affected by numerous environmental, epidemiological, social, and economic factors (6,7). Emerging zoonoses pose both epidemiological and clinical challenges to health care professionals. Since the 1960s, coronaviruses have caused a wide variety of human and animal diseases. In humans, they cause up to a third of all community-acquired upper respiratory tract infections, such as the common cold, pharyngitis, and otitis media. However, more severe forms of bronchiolitis, exacerbations of asthma, and pneumonia in children and adults have also been described, sometimes with fatal outcomes in infants, the elderly, and the immunocompromised. Some coronaviruses are associated with gastrointestinal disease in children. Sporadic infections of the central nervous system have also been reported, although the role of coronaviruses in infections outside the respiratory tract has not been completely clarified (8). Previous epidemics caused by coronaviruses Most coronaviruses are adapted to their hosts, whether animal or human, although cases of possible animal-to-human transmission and adaptation have been described in the past two decades, causing two epidemics. The first such outbreak originated in Guangdong, a southern province of the People’s Republic of China, in mid-November of 2002. The disease was named severe acute respiratory syndrome (SARS). The cause was shown to be a novel coronavirus (SARS-CoV), an animal virus that had crossed the species barrier and infected humans. The most likely reservoir were bats, with evidence that the virus was transmitted to a human through an intermediate host, probably a palm civet or raccoon dog (8,9). In less than a year, SARS-CoV infected 8098 people in 26 countries, of whom 774 died (10,11). Approximately 25% of the patients developed organ failure, most often acute respiratory distress syndrome (ARDS), requiring admission to an intensive care unit (ICU), while the case fatality rate (CFR) was 9.6%. However, in elderly patients (>60 years), the CFR was over 40%. Poor outcomes were seen in patients with certain comorbidities (diabetes mellitus and hepatitis B virus infection), patients with atypical symptoms, and those with elevated lactic acid dehydrogenase (LDH) values on admission. Interestingly, the course of the disease was biphasic in 80% of the cases, especially those with severe clinical profiles, suggesting that immunological mechanisms, rather than only the direct action of SARS-CoV, are responsible for some of the complications and fatal outcomes (8,9). Approximately 20% of the reported cases during this epidemic were health care workers. Therefore, in addition to persons exposed to animal sources and infected family members, health care workers were among the most heavily exposed and vulnerable individuals (9,10). During 2004, three minor outbreaks were described among laboratory personnel engaged in coronavirus research. Although several secondary cases, owing to close personal contact with infected patients, were described, there was no further spread of the epidemic. It is not clear how the SARS-CoV eventually disappeared and if it still circulates in nature among animal reservoirs. Despite ongoing surveillance, there have been no reports of SARS in humans worldwide since mid-2004 (11). In the summer of 2012, another epidemic caused by a novel coronavirus broke out in the Middle East. The disease, often complicated with respiratory and renal failure, was called Middle East respiratory syndrome (MERS), while the novel coronavirus causing it was called Middle East respiratory syndrome coronavirus (MERS-CoV). Although a coronavirus, it is not related to the coronaviruses previously described as human pathogens. However, it is closely related to a coronavirus isolated from dromedary camels and bats, which are considered the primary reservoirs, albeit not the only ones (8,12). From 2012 to the end of January 2020, over 2500 laboratory-confirmed MERS cases, including 866 associated deaths, were reported worldwide in 27 countries (13). The largest number of such cases has been reported among the elderly, diabetics, and patients with chronic diseases of the heart, lungs, and kidneys. Over 80% of the patients required admission to the ICU, most often due to the development of ARDS, respiratory insufficiency requiring mechanical ventilation, acute kidney injury, or shock. The CFR is around 35%, and even 75% in patients >60 years of age. However, MERS-CoV, unlike its predecessor SARS-CoV, did not disappear, but still circulates among animal and human populations, occasionally causing outbreaks, either in connection with exposure to camels or infected persons (12). Overall, 19.1% of all MERS cases have been among health care workers, and more than half of all laboratory-confirmed secondary cases were transmitted from human to human in health care settings, at least in part due to shortcomings in infection prevention and control (12,13). Post-exposure prophylaxis with ribavirin and lopinavir/ritonavir decreased the MERS-CoV risk in health care workers by 40% (14). The emergence of COVID-19 caused by SARS-CoV-2 In mid-December of 2019, a pneumonia outbreak erupted once again in China, in the city of Wuhan, the province of Hubei (1). The outbreak spread during the next two months throughout the country, with currently over 80 000 cases and more than 2400 fatal outcomes (CFR 2.5%), according to official reports. Exported cases have been reported in 30 countries throughout the world, with over 2400 registered cases, of which 276 are in Europe. On February 25, the first case of COVID-19 was confirmed in Zagreb, Croatia, and was linked to the current outbreak in the Lombardy and Veneto regions of northern Italy (15). The case definition was first established on January 10 and modified over time, taking into account both the virus epidemiology and clinical presentation. The clinical criteria were expanded on February 4 to include any lower acute respiratory diseases, and the epidemiological criterion was extended to the whole of China, with the possibility of expansion to some surrounding countries (16,17). At the early stage of the outbreak, patients’ full-length genome sequences were identified, showing that the virus shares 79.5% sequence identity with SARS-CoV. Furthermore, 96% of its whole genome is identical to bat coronavirus. It was also shown that this virus uses the same cell entry receptor, ACE2, as SARS-CoV (18). The full clinical spectrum of COVID-19 ranges from asymptomatic cases, mild cases that do not require hospitalization, to severe cases that require hospitalization and ICU treatment, and those with fatal outcomes. Most cases were classified as mild (81%), 14% as severe, and 5% as critical (ie, respiratory failure, septic shock, and/or multiple organ dysfunction or failure). The overall CFR was 2.3%, while the rate in patients with comorbidities was considerably higher – 10.5% for cardiovascular disease, 7.3% for diabetes, 6.3% for chronic respiratory diseases, 6.0% for hypertension, and 5.6% for cancer. The CFR in critical patients was as high as 49.0% (4). It is still not clear which factors contribute to the risk of transmitting the infection, especially by persons who are in the incubation stage or asymptomatic, as well as which factors contribute to the severity of the disease and fatal outcome. Evidence from various types of additional studies is needed to control the epidemic (19). However, it is certain that the binding of the virus to the ACE 2 receptor can induce certain immunoreactions, and the receptor diversity between humans and animal species designated as SARS-CoV-2 reservoirs further increases the complexity of COVID-19 immunopathogenicity (20). Recently, a diagnostic RT-PCR assay for the detection of SARS-CoV-19 has been developed using synthetic nucleic acid technology, despite the lack of virus isolates and clinical samples, owing to its close relation to SARS. Additional diagnostic tests are in the pipeline, some of which are likely to become commercially available soon (21). Currently, randomized controlled trials have not shown any specific antiviral treatment to be effective for COVID-19. Therefore, treatment is based on symptomatic and supportive care, with intensive care measures for the most severe cases (22). However, many forms of specific treatment are being tried, with various results, such as with remdesivir, lopinavir/ritonavir, chloroquine phosphate, convalescent plasma from patients who have recovered from COVID-19, and others (23-26). No vaccine is currently available, but researchers and vaccine manufacturers have been attempting to develop the best option for COVID-19 prevention. So far, the basic target molecule for the production of a vaccine, as well as therapeutic antibodies, is the CoV spike (S) glycoprotein (27,28). The spread of the epidemic can be only contained, and SARS-CoV-2 transmission in hospitals reduced, by strict compliance with infection prevention and control measures (contact, droplet, and airborne precautions) (22,29). During the current epidemic, health care workers have been at an increased risk of contracting the disease and consequent fatal outcome owing to direct exposure to patients. Early reports from the beginning of the epidemic indicated that a large proportion of the patients had contracted the infection in a health care facility (as high as 41%), and that health care workers constituted a large proportion of these cases (as high as 29%). However, the largest study to date on more than 72 000 patients from China has shown that health care workers make up 3.8% of the patients. In this study, although the overall CFR was 2.3%, among health care workers it was only 0.3%. In China, the number of severe or critical cases among health care workers has declined overall, from 45.0% in early January to 8.7% in early February (4). This poses numerous psychological and ethical questions about health care workers’ role in the spread, eventual arrest, and possible consequences of epidemics. For example, during the 2014-2016 Ebola virus disease epidemic in Africa, health care workers risked their lives in order to perform life-saving invasive procedures (intravenous indwelling, hemodialysis, reanimation, mechanical ventilation), and suffered high stress and fatigue levels, which may have prevented them from practicing optimal safety measures, sometimes with dire consequences (30). A lesson for the future This third coronavirus epidemic, caused by the highly pathogenic SARS-CoV-2, underscores the need for the ongoing surveillance of infectious disease trends throughout the world. The examples of pandemic influenza, avian influenza, but also the three epidemics caused by the novel coronaviruses, indicate that respiratory infections are a major threat to humanity. Although Ebola virus disease and avian influenza are far more contagious and influenza currently has a greater epidemic potential, each of the three novel coronaviruses require urgent epidemiologic surveillance. Many infectious diseases, such as diphtheria, measles, and whooping cough, have been largely or completely eradicated or controlled through the use of vaccines. It is hoped that developments in vaccinology and antiviral treatment, as well as new preventive measures, will ultimately vanquish this and other potential threats from infectious diseases in the future.
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              Author and article information

              Journal
              J Glob Health
              J Glob Health
              JGH
              Journal of Global Health
              International Society of Global Health
              2047-2978
              2047-2986
              June 2020
              02 May 2020
              : 10
              : 1
              : 010349
              Affiliations
              [1 ]Dr Fran Mihaljević University Hospital for Infectious Diseases, Zagreb, Croatia
              [2 ]University of Zagreb School of Medicine, Zagreb, Croatia
              [3 ]Catholic University of Croatia, Zagreb, Croatia
              [4 ]Faculty of Medicine of the University of Rijeka, Rijeka, Croatia
              [5 ]Croatian Institute of Public Health, Zagreb, Croatia
              Author notes
              Correspondence to:
Assist. Prof. Rok Čivljak, MD, PhD
Dr. Fran Mihaljevic University Hospital for Infectious Diseases
Mirogojska 8
10000 Zagreb, Croatia
 rok.civljak@ 123456bfm.hr
              Article
              jogh-10-010349
              10.7189/jogh.10.010349
              7211414
              32426118
              bd30a96e-1af1-4bd4-90d6-f28514a3e86b
              Copyright © 2020 by the Journal of Global Health. All rights reserved.

              This work is licensed under a Creative Commons Attribution 4.0 International License.

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