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      Big data integration and analytics to prevent a potential hospital outbreak of COVID-19 in Taiwan

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          To Editor: Big data integration and analytics play the key role to successfully prevent COVID-19 hospital outbreaks in Taiwan. A 30 year-old lady came to our outdoor quarantine station in front of our hospital and planned to visit the clinic inside our hospital due to cough and diarrhea for 3 days. However, her travel history of abroad to a COVID-19 epidemic country one week ago was identified automatically outside the hospital via Taiwan National Health Insurance (NHI) identification card data by a card reader. The infection control personnel referred the patient to our emergent department for a throat swab of SARS-CoV-2 immediately without entering the hospital building. Later, she was confirmed with COVID-19 infection and transferred to a negative-pressure isolation room in a medical center. Kaohsiung Municipal Ta-Tung hospital (KMTTH) is a 428-bed community hospital in Kaohsiung, Taiwan. Currently, a “limited community transmission” of COVID-19 was announced in Taiwan Centers for Disease Control (CDC). The policy of our hospital is to explore any person with suspected COVID-19 infection as soon as possible in outdoor quarantine station and transferred to a negative-pressure isolated room in medical centers to avoid hospital infection and outbreak. Healthcare system collapse has been the major damage of COVID-19 pandemic in many countries worldwide because the hospitals were overwhelmed by huge number of COVID-19 patients. One of the leading factors is hospital outbreak, which resulting in consecutive infection and illness of healthcare workers and patients in the hospital and community.1, 2, 3 To find and isolate any infected patient with all-out effort to prevent in-hospital infection could reserve the healthcare capacities. Although cross-border control is very important to prevent pandemic in many countries, the accurate personal travel and contact history for every visitor or patient before entering the hospital might not be accessible if the person does not inform it honestly. 4 False TOCC (travel, occupation, contact and cluster) history by verbal or written questionnaire lead to a high risk of hospital infection. In fact, more than 99% residents in Taiwan were covered by the National Health Insurance System. Taiwan government integrated and analyzed several big data, especially from National Health Insurance Administration, National Immigration Agency and Taiwan Centers for Disease Control, and provided real time and accurate immigration and contact information for outdoor quarantine station of each clinic and hospital in Taiwan. It would let all hospital staffs can easily access the travel abroad history via personal NHI identification card for all visitors who will enter the hospital. 5 Before entering the building, any suspected person would be transferred to emergent department for further examination. A comprehensive public health system that covered almost all residents can offer appropriate medical service for all residents and the effective and efficient national big data integration and analysis presented a valuable contribution on preventing further hospital outbreak to reserve the healthcare system and public health. Funding sources None. Declaration of Competing Interest None declared.

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          Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing

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            Reasons for healthcare workers becoming infected with novel coronavirus disease 2019 (COVID-19) in China

            Sir, The outbreak of novel coronavirus disease 2019 (COVID-19) in mainland China has been declared as a public health emergency (PHE) by the World Health Organization (WHO) [1]. Globally, until February 28th, 2020, there have been reported 83,774 confirmed cases and 2867 deaths [2]. During the periods of outbreak of COVID-19 or other infectious diseases, implementation of infection prevention and control (IPC) is of great importance in healthcare settings, especially regarding personal protection of healthcare workers [3,4]. In order to contain the outbreak of COVID-19 in mainland China, the National Health Commission of the People's Republic of China (NHCPRC) has so far dispatched medical support teams (41,600 healthcare workers from 30 provinces and municipalities) to assist with medical treatment in Wuhan and Hubei provinces [5]. A survey by the Health Commission of Guangdong Province released information on the distribution of 2431 healthcare workers in the Guangdong medical support teams [6]. Nurses (∼60%) were the predominant healthcare workers in the teams, followed by clinicians (∼30%). Half of clinicians with job titles were deputy chief physician, and 25% specialized in respiratory and critical medicine [6]. It is worth mentioning that 5.8% (140/2431) healthcare workers worked on the outbreak of severe acute respiratory syndrome in 2003 [6]. Recently, Wu et al. have reported the problems relating to COVID-19 IPC in healthcare settings, highlighting the personal protection of healthcare workers [7]. However, at a press conference of the WHO–China Joint Mission on COVID-19, NHCPRC reported that up until February 24th 2055 healthcare workers (community/hospital-acquired not to be defined) had been confirmed infected with COVID-19, with 22 (1.1%) deaths [8]. Ninety percent of infected healthcare workers were from Hubei province, and most cases happened in late January. It is worth mentioning that the proportion of healthcare workers infected by COVID-19 (2.7%, 95% CI: 2.6–2.8) was significantly lower compared with healthcare workers infected by SARS (21.1%, 95% CI: 20.2–22.0). Therefore, the director of the National Hospital Infection Management and Quality Control Centre summarized some reasons for such a high number of infected healthcare workers during the beginning of the emergency outbreak [9]. First, inadequate personal protection of healthcare workers at the beginning of the epidemic was a central issue. In fact, they did not understand the pathogen well; and their awareness of personal protection was not strong enough. Therefore, the front-line healthcare workers did not implement the effective personal protection before conducting the treatment. Second, long-time exposure to large numbers of infected patients directly increased the risk of infection for healthcare workers. Also, pressure of treatment, work intensity, and lack of rest indirectly increased the probability of infection for healthcare workers. Third, shortage of personal protective equipment (PPE) was also a serious problem. First-level emergency responses have been initiated in various parts of the country, which has led to a rapid increase in the demand for PPE. This circumstance increased the risk of infection for healthcare workers due to lack of sufficient PPE. Fourth, the front-line healthcare workers (except infectious disease physicians) received inadequate training for IPC, leaving them with a lack of knowledge of IPC for respiratory-borne infectious diseases. After initiation of emergency responses, healthcare workers have not had enough time for systematic training and practice. Professional supervision and guidance, as well as monitoring mechanisms, were lacking. This situation further amplified the risk of infection for healthcare workers. Finally, international communities, especially in other low- and middle-income countries with potential COVID-19 outbreaks, should learn early how to protect their healthcare workers. Furthermore, the COVID-19 confirmed cases have been reported to have surged in South Korea, Japan, Italy, and Iran in the past few days [2]. The increase in awareness of personal protection, sufficient PPE, and proper preparedness and response would play an important role in lowering the risk of infection for healthcare workers. Conflict of interest statement None declared. Funding sources None.
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              Emerging threats from zoonotic coronaviruses-from SARS and MERS to 2019-nCoV

              Coronaviruses are enveloped RNA viruses that are widely detected in mammals and birds, and commonly denoted in etiologies of upper respiratory tract infections in humans.1, 2, 3 Two potentially dangerous zoonotic coronaviruses have emerged in the past two decades. The severe acute respiratory syndrome coronavirus (SARS-CoV), originating from China, was responsible for the first outbreak that extended from 2002 to 2003. The second outbreak occurred in 2012 in the Middle East and was caused by the Middle East respiratory syndrome coronavirus (MERS-CoV).1, 2, 3, 4 A new strain of coronavirus, designated as the 2019 novel coronavirus (2019-nCoV), emerged during the third outbreak in Wuhan, China, at the end of 2019. 5 Symptoms of pneumonia with unknown etiology were reported in several patients. The infection was epidemiologically linked to the Huanan seafood market in Wuhan. 6 Similar to the SARS-CoV and the MERS-CoV, bats have been denoted as the likely primary reservoirs of the 2019-nCoV based on its similarity to bat coronaviruses. 7 The intermediary reservoir is yet to be denoted. The pertinent and critical factor for an emerging virus is its pandemic potential. Efficient human-to-human transmission is a requirement for large-scale spread of a new virus. The proportion of patients with mild symptoms of illness is another important factor that determines our ability to identify infected individuals and to prevent the spread of virus. Identification of transmission chains and subsequent contact tracing are further complicated when several infected individuals remain asymptomatic or mildly symptomatic. 5 A key factor for efficient human-to-human transmission is the ability of the virus to attach to human cells. Coronaviruses use a spike protein for attachment to host cells. 8 Apparently, the 2019-nCoV uses the same human angiotensin-converting enzyme 2 receptor as the SARS-CoV, 5 whereas the MERS-CoV used dipeptidyl peptidase 4 (also known as CD26). 9 An efficient human-to-human transmission involves multiples routes of transmission, including droplet transfer, direct contact, and indirect contact. A limited human-to-human transmission may require a high infective dose and a significantly close contact with an infected person as prerequisites (Table 1 ). Table 1 Efficiency of animal virus-associated human-to-human transmission. Table 1 Efficiency Infective dose Pandemic potential Example Efficient Low High SARS-CoV, probably 2019-nCoV Limited High Low MERS-CoV Very limited Very high Very low Avian influenza virus No None None Japanese encephalitis virus SARS-CoV, severe acute respiratory syndrome coronavirus; 2019-nCoV, 2019 novel coronavirus; MERS-CoV, Middle East respiratory syndrome coronavirus. All three zoonotic coronavirus outbreaks in recent decades are associated with pneumonia in patients with severe illness. Available data suggest that the 2019-nCoV may be less pathogenic than the MERS-CoV and SARS-CoV (Table 2 ). However, the severity of the disease is not necessarily linked to its transmission efficiency and pandemic potential. 5 A rapidly increasing number of 2019-nCoV-infected cases suggests that this virus may be transmitted effectively among humans, and mild illness may be quite common in infected individuals. 1 , 2 , 5 , 6 These two features confer a high pandemic potential to the 2019-nCoV (Table 2). Table 2 Epidemiological and clinical characteristics of zoonotic coronaviruses. Table 2 Coronavirus SARS-CoV MERS-CoV 2019-nCoV Years of outbreak 2002–2003 2012–present 2019–present Primary reservoir Bat Bat Bat Intermediary reservoir Civet cat Camel Unknown Human-to-human transmission Efficient Limited Possibly efficient Pandemic potential Yes No Yes Contained Yes No No, efforts ongoing Incubation period 2–10 days 2–14 days 1–14 days Pneumonia Very common Common Common Fatality rate 9.5% 34.4% 2–4% in confirmed cases to date SARS-CoV, severe acute respiratory syndrome coronavirus; MERS-CoV, Middle East respiratory syndrome coronavirus; 2019-nCoV, 2019 novel coronavirus. The next important factor to consider for the 2019-nCoV outbreak is our ability to contain the spread of this new virus. There was a lag of three months between the commencement of the SARS epidemic and the initiation of investigation by healthcare officials in 2003 in China. 10 Consequently, the infection spread to approximately 8100 people in 29 countries and resulted in 774 deaths. 10 Since mild illness is uncommon in SARS infection and infected individuals are easily identifiable, SARS could be contained effectively and eradicated without vaccination or effective antiviral therapy. 10 Currently, there are a limited number of studies from China that investigate the efficacy and potential of lopinavir/ritonavir (Kaletra), a combination of protease inhibitors used to treat and prevent HIV/AIDS, in the treatment of 2019-nCoV infection. 11 Other agents, including nucleoside analogues, neuraminidase inhibitors, remdesivir, umifenovir (arbidol), tenofovir disoproxil (TDF), and lamivudine (3TC), along with several Chinese traditional medicines, are reported as viable options for antiviral treatment of human pathogenic coronavirus. 11 Clinical efficacy of remdesivir for the treatment of the first US case of pneumonia caused by 2019-nCoV was recently reported. 12 However, these data are derived from preliminary stages of studies and are insufficient to support the implementation for clinical use in treatment of 2019-nCoV infection. 11 , 12 The severe lack of information during the initial stage of the 2019-nCoV outbreak posed challenges to and complicated the containment of the infection in specific limited areas. A higher proportion of mild 2019-nCoV infections facilitates rapid spreading of the virus. Present efforts for containment may not be completely effective. However, we can hope that these efforts may delay the spread of 2019-nCoV, and provide us with sufficient time to develop effective vaccines and antiviral agents against the virus. Declaration of Competing Interest The authors declares no conflicts of interest.
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                Author and article information

                Contributors
                Journal
                J Microbiol Immunol Infect
                J Microbiol Immunol Infect
                Journal of Microbiology, Immunology, and Infection
                Taiwan Society of Microbiology. Published by Elsevier Taiwan LLC.
                1684-1182
                1995-9133
                20 April 2020
                20 April 2020
                Affiliations
                [1]Department of Surgery, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
                [2]Department of Nursing, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
                [3]Department of Internal Medicine Surgery, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
                [4]School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
                [5]Department of Internal Medicine Surgery, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
                [6]Department of Internal Medicine Surgery, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
                [7]School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
                [8]Institute of Graduate Medicine, Center of Sepsis, Center of Tropical Medicine and Infectious Diseases, Kaohsiung Medical University, Kaohsiung, Taiwan
                [9]Department of Biological Science and Technology, College of Biological Science and Technology, National Chiao Tung University, Hsin-Chu, Taiwan
                Author notes
                []Corresponding author. Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, No. 68, Chunghwa 3rd Road, Kaohsiung City, Taiwan. Fax: +886 7 316 1210. infchen@ 123456gmail.com
                Article
                S1684-1182(20)30104-3
                10.1016/j.jmii.2020.04.010
                7167582
                32327328
                0d538998-4b0d-4b04-b88b-2f9ac2a006fa
                © 2020 Taiwan Society of Microbiology. Published by Elsevier Taiwan 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
                : 10 April 2020
                : 14 April 2020
                Categories
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                covid-19,prevention strategies,big data integration and analytics

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