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Lessons learned from a global perspective of COVID-19

Published:November 23, 2022DOI:https://doi.org/10.1016/j.ccm.2022.11.020

      Keywords

      Key Points:

      • Non-pharmacological measures (NPM) are effective in containing the spread of the SARS-CoV-2 virus
      • Telehealth has seen a significant and beneficial increase in both high- and low-middle income countries allowing healthcare to be delivered when in-person consultations were suspended
      • Robust peer-reviewed research played an integral role in responding to the COVID-19 pandemic, from studying the role of NPM to treatments and vaccines
      • Collaboration of regional, national, and international public health organizations and social media or mass communication platforms is vital to decrease the spread of misinformation
      • COVID-19 vaccines were the central element in reducing the morbidity and mortality of the COVID-19 pandemic. Vaccine equity is a top priority to ensure the most vulnerable are also protected
      • Access to appropriate healthcare and preventative measures reduced morbidity and mortality from COVID-19

      INTRODUCTION

      On March 11, 2020, the World Health Organization (WHO) declared the spread of SARS-CoV-2 infection (COVID-19), a pandemic.

      WHO Director-General’s opening remarks at the media briefing on COVID-19 - 11 March 2020. Accessed April 5, 2022. https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020

      A few months before this declaration, a cluster of severe pneumonia cases was reported in Wuhan, China. As of September 30, 2022, the WHO recorded 614,385,693 cases worldwide of COVID-19 with 6,522,600 cumulative deaths.

      WHO Coronavirus (COVID-19) Dashboard. Accessed October 3, 2022. https://covid19.who.int

      The Wuhan seafood wholesale market was shut down with the hopes of local mitigation. China’s Viral Pneumonia of Unknown Etiology system, which was created after the SARS epidemic, was activated by January 3, 2020, followed by limitation of travel in and out of the region by January 23, 2020.
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      Dissecting the early COVID-19 cases in Wuhan.

      A national fight against COVID‐19: lessons and experiences from China - Wang - 2020 - Australian and New Zealand Journal of Public Health - Wiley Online Library. Accessed April 29, 2022. https://onlinelibrary.wiley.com/doi/full/10.1111/1753-6405.13042

      Around the same time, patients with symptoms of the virus were asked to quarantine. These measures required the individual to stay isolated for up to 14 days to curb the spread of the virus.
      On January 13, 2020, a case of SARS-CoV-2 infection was reported in Thailand. This was the first report of a case outside of China. Without a known vaccine or cure available, stricter measures were implemented including holiday extensions, city-wide lockdowns, and quarantine of suspected patients.
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      On February 20, 2020, a young patient in Codogno hospital (Lombardy, Italy) with no known risk factors for SARS-CoV-2 infection tested positive for the virus. By February 21, 2020, there was a rapid rise in the number of cases of COVID-19 in the Northern part of Italy. ICUs had to double their pre-pandemic capacity in less than 6 weeks to accommodate the large number of patients arriving to hospital with severe COVID-19.
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      Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency Response.
      ,

      Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy | Critical Care Medicine | JAMA | JAMA Network. Accessed July 20, 2022. https://jamanetwork.com/journals/jama/fullarticle/2764365

      By March 17,2020, there were 31,506 positive cases despite the entire country of Italy having been placed under lockdown by March 9, 2020.
      • Marca A.L.
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      • Nelson S.M.
      COVID-19: lessons from the Italian reproductive medical experience.
      Lockdowns were similarly instituted by numerous countries. By March 25, 2020, a third of countries in the world were in lockdown.

      UPDATED: Timeline of the Coronavirus | Think Global Health. Council on Foreign Relations. Accessed June 22, 2022. https://www.thinkglobalhealth.org/article/updated-timeline-coronavirus

      The virus was spreading unabated by now. Thailand declared a State of Emergency Decree on March 26, 2020. Additional measures included a stay-at-home policy, canceled national holidays, imposed school closures, and suspended international flights.
      • Rajatanavin N.
      • Tuangratananon T.
      • Suphanchaimat R.
      • Tangcharoensathien V.
      Responding to the COVID-19 second wave in Thailand by diversifying and adapting lessons from the first wave.
      Nevertheless, COVID-19 continued to spread.

      NON-PHARMACOLOGICAL MEASURES (NPM)

      Containment of SARS-CoV-2 spread was necessary to reduce morbidity and mortality from COVID-19 and to reduce the pressure on the healthcare system. Non-pharmacological measures (NPMs) aimed at transmission mitigation were implemented including quarantines, mobility restrictions, socioeconomic restrictions, physical distancing measures, face masking, and hygiene measures. Many countries used travel restrictions to varied degrees throughout the pandemic, ranging from complete isolation as implemented by the Australian and New Zealand Governments to temporary border closures implemented by countries like France, the United Kingdom, and the United States of America. A study model showed that sustained 90% travel restrictions to and from mainland China, for example, were only modestly effective unless they were also associated with behavioral changes, likely due to the ability of the virus to be transmitted by asymptomatic and oligosymptomatic individuals in an airborne route.
      • Bruinen de Bruin Y.
      • Lequarre A.S.
      • McCourt J.
      • et al.
      Initial impacts of global risk mitigation measures taken during the combatting of the COVID-19 pandemic.
      ,

      The effect of travel restrictions on the spread of the 2019 novel coronavirus (COVID-19) outbreak. Accessed May 13, 2022. https://www.science.org/doi/full/10.1126/science.aba9757

      Travel restrictions applied reactively to countries which were reporting variants and ignoring countries with little or no reported surveillance data worsened the inequity of the global response.

      Preiser W, Engelbrecht S, Maponga T. No point in travel bans if countries with poor surveillance are ignored. The Lancet. 2022;399(10331):1224. doi:10.1016/S0140-6736(22)00363-4

      Based on the now accumulated data on the transmissibility of the SARS-CoV-2, it is now known that travel restriction measures in isolation failed to halt the spread of the pandemic. Rather, demanding mask use during travelling, a proof of a negative COVID-19 test shortly before airline boarding, and more recently - demanding a complete vaccination status - seem to be more reasonable measures to help reduce transmissibility without unreasonably compromising travel mobility.

      Contact tracing

      Contact tracing was another measure adopted by some countries with varying levels of strictness to identify probable or confirmed cases. Individuals in contact with those diagnosed with or exposed to COVID-19 were instructed to quarantine. Accessibility to testing and rapid turnaround times were crucial to the success of contact tracing and proved to be a challenge. It took many months for countries committed to contact tracing to be able to effectively implement it. The disparity in availability of testing highlighted the known biases in global health.
      • Thornton J.
      Covid-19: Lack of testing in Brazil is a “major failure,” says MSF.

      Donors bet on a US firm to fix testing in Africa. Then COVID-19 hit. Reuters. https://www.reuters.com/investigates/special-report/health-coronavirus-africa-cepheid/. Accessed May 13, 2022.

      • Praharaj I.
      • Jain A.
      • Singh M.
      • et al.
      Pooled testing for COVID-19 diagnosis by real-time RT-PCR: A multi-site comparative evaluation of 5- & 10-sample pooling.

      Mobility restrictions

      Mobility is a variable associated with the spread of the virus spread. Mobility restrictions included limitations on public transportation use, air traffic travel, and indoor as well as outdoor activities.
      • Caruso P.F.
      • Angelotti G.
      • Greco M.
      • et al.
      Early prediction of SARS-CoV-2 reproductive number from environmental, atmospheric and mobility data: A supervised machine learning approach.
      Although these measures appeared to be effective initially at limiting the spread outside of the Wuhan region, there has been evidence of SARS-CoV-2 present in the USA since at least January 20, 2020. The impact of the pandemic on mobility was either determined by governments or by the population themselves perceiving the risk, which varied significantly throughout the world.
      Brazil, for example, saw a natural decline in mobility in March 2020, when the first official death was reported in the country. This had a direct impact on slowing the increase in the number of cases during the first wave of the pandemic in the country, when vaccines didn’t exist.
      The United Kingdom also saw a significant impact on its mobility; however the population changed its behavior at each lockdown. The first lockdown came into effect on March 26, 2020; gradual reopening started on June 1 of the same year. The second and third national lockdowns were enforced on May 5, 2021 and August 3, 2021. Mobility during those lockdowns was 47% higher than in the first lockdown, where the mobility dropped to 73% lower than in the pre-pandemic period (Figure 1).
      Figure thumbnail gr1
      Figure 1Mobility in the United Kingdom over time. The zero mark in the y-axis refers to pre-pandemic mobility levels. Note an attenuated reduction in mobility from the first, second, and third lockdowns.From Rede Análise Available at: http://bit.ly/Rede_MobilitySymptoms. Accessed Jun 22 2022.
      The Delta variant surge in India offered another example where cases started to rise exponentially in the second week of March 2021. As a result, deaths began to rise at the beginning of April 2021, while the mobility dropped only in the second week of April 2021 – after deaths increased exponentially by more than a week (Figure 2).
      Figure thumbnail gr2
      Figure 2The relationship between new daily cases of COVID-19 in India (upper panel), daily deaths (middle panel) and mobility (lower panel). Note the mobility reduction following an exponential rise in deaths after one week. The zero mark in the mobility graph refers to pre-pandemic mobility levels.
      Mobility reductions have had a clear impact in reducing the transmission of COVID-19. When informed by changes in trends in COVID-19 case monitoring, mobility restrictions were useful in controlling the effective reproduction number (Rt) and preventing deaths, especially before widespread use of vaccination.

      Socioeconomic restrictions

      Socioeconomic restrictions refer to the placement of limitations on or closure of community gatherings such as schools, workplaces, daycares, elderly housing, swimming pools, bars/restaurants, banks, grocery stores, etc. Complete lockdowns had large effects in controlling COVID-19 community transmission, however these measures come with significant impacts in the economy and in the mental health of the population, disproportionately affecting resource poor areas
      • Atalan A.
      Is the lockdown important to prevent the COVID-19 pandemic? Effects on psychology, environment and economy-perspective.
      ,
      • Butterworth P.
      • Schurer S.
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      • Wooden M.
      Effect of lockdown on mental health in Australia: evidence from a natural experiment analysing a longitudinal probability sample survey.
      Restrictions lighter than a complete lockdown proved effective for control of community transmission in 2020 (to drive the reproduction number – Rt – below 1).
      • Denis F.
      • Septans A.L.
      • Le Goff F.
      • Jeanneau S.
      • Lescure F.X.
      Analysis of COVID-19 Transmission Sources in France by Self-Assessment Before and After the Partial Lockdown: Observational Study.
      Based on data from Reuters, Italy and Spain had a 94% decrease in retail and recreational trips during the pandemic. A reduction of over 60% was noted in physical presence in workplaces. It is evident that these measures contributed to decreased transmission but at high socioeconomic costs which led countries to implement these changes in different degrees.
      • Bruinen de Bruin Y.
      • Lequarre A.S.
      • McCourt J.
      • et al.
      Initial impacts of global risk mitigation measures taken during the combatting of the COVID-19 pandemic.

      Physical distancing

      Physical distancing, also known as social distancing, is a regulation of the distance and number of people per square meter in a location. Based on studies published during the SARS outbreak, six feet was determined to be potentially effective in the reduction of transmission.

      CDC. COVID-19 and Your Health. Centers for Disease Control and Prevention. Published July 14, 2021. Accessed June 28, 2022. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html

      A significant focus was placed on reducing mass gatherings, closing of workplaces, and isolating households, towns, and cities. A combination of these measures has been reported to have a nearly 60% reduction in transmission.
      • Anderson R.M.
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      How will country-based mitigation measures influence the course of the COVID-19 epidemic?.
      Similarly, personal hygiene measures were implemented and aimed to reduce other routes of SARS-CoV-2 transmission, such as fomites. These measures included hand washing, avoidance of contact with contaminated surfaces, appropriate utilization of personal protective equipment (PPE) such as eye and hand protection with the use of face shields/goggles with gloves, protective glass, and temperature checks upon entrance.

      Facemasks

      Facemasks played a notable role in shaping the course of the pandemic. The utility of universal face masks was gradually learned leading to various mask mandates across the globe.
      • Mitze T.
      • Kosfeld R.
      • Rode J.
      • Wälde K.
      Face masks considerably reduce COVID-19 cases in Germany.
      At the beginning of the pandemic, with a lack of in-depth knowledge about how transmission occurred (whether by aerosols or direct/indirect contact, or both) and with concern about the scarcity of masks for health professionals, the World Health Organization (WHO) delayed recommending the use of masks to the general population. On April 3, 2020, the Centers for Disease Control (CDC) recommended wearing a face covering to reduce the spread in the community.

      Recommendation regarding the use of cloth face coverings, especially in areas of significant community-based transmission. Accessed May 13, 2022. https://stacks.cdc.gov/view/cdc/86440

      This recommendation was followed by similar advice from the WHO on April 6, 2020.

      World Health Organization. Advice on the Use of Masks in the Context of COVID-19: Interim Guidance, 6 April 2020. World Health Organization; 2020. Accessed May 13, 2022. https://apps.who.int/iris/handle/10665/331693

      However, these initial recommendations encouraged the use of masks that could be manufactured by hand, even with the folding of cotton cloths, and used with elastics, albeit without clarification on the issue of adjustment and filtration efficiency. On June 5, WHO published an updated guide, including placing a table with the filtration efficiencies of masks made with different fabrics (ranging from 0.7 to 26%).

      World Health Organization. Advice on the Use of Masks in the Context of COVID-19: Interim Guidance, 6 April 2020. World Health Organization; 2020. Accessed May 13, 2022. https://apps.who.int/iris/handle/10665/331693

      In 2020, the number of fabric masks made by the textile industry increased, mainly in developing countries.

      Produção de máscaras cria alternativa para negócios. Agência Brasil. Published May 4, 2020. Accessed June 22, 2022. https://agenciabrasil.ebc.com.br/economia/noticia/2020-05/producao-de-mascaras-cria-alternativa-para-negocios

      A systematic review and meta-analysis published by Sharma et al. in 2020 noted that the effectiveness of cloth masks was very low for the prevention of COVID-19, but that they could be used in outdoor public spaces to reduce transmission.

      Sharma SK, Mishra M, Mudgal SK. Efficacy of cloth face mask in prevention of novel coronavirus infection transmission: A systematic review and meta-analysis. J Educ Health Promot. 2020;9:192. doi:10.4103/jehp.jehp_533_20

      However, a portion of the population with greater purchasing power chose to use professional masks (surgical or FFP2/N95). The most penetrating particle size (MPPS) for N95s ranges from 30 – 100 nm while that for surgical masks ranges from 200 – 500 nm. The MPPS for cloth masks is similar as surgical masks. The particle filtration efficiency (PFE) for various masks however depends on several factors including type of the mask, condition of the mask, and mask fit.
      • Ju J.T.J.
      • Boisvert L.N.
      • Zuo Y.Y.
      Face masks against COVID-19: Standards, efficacy, testing and decontamination methods.
      A study in patients with seasonal coronaviruses showed that the surgical face masks significantly reduced the detection of viral RNA in both respiratory droplets and aerosols in the air. Those who did not use masks were found to have a 40% rate of aerosol detection, compared to zero detection rate in those who used face masks.
      • Leung N.H.
      • Chu D.K.
      • Shiu E.Y.
      • et al.
      Respiratory Virus Shedding in Exhaled Breath and Efficacy of Face Masks.
      Since the pandemic, many studies evaluated the efficiency of masks. Experiments performed using particle counters and probes coupled to different models of masks to simulate coughing, speech, sneezing, or breathing
      • Clapp P.W.
      • Sickbert-Bennett E.E.
      • Samet J.M.
      • et al.
      Evaluation of Cloth Masks and Modified Procedure Masks as Personal Protective Equipment for the Public During the COVID-19 Pandemic.
      showed that the filtration efficiencies of masks/respirators FFP2/N95 were much higher (92 to 98%) than those obtained with the use of surgical masks (around 70%) or cloth masks (between 0.7 and 30%).
      • Konda A.
      • Prakash A.
      • Moss G.A.
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      Aerosol Filtration Efficiency of Common Fabrics Used in Respiratory Cloth Masks.
      These studies helped the scientific community to claim that FFP2/N95 respirators, previously only used by health professionals, would be the most protective against an airborne disease such as COVID-19.
      • Asadi S.
      • Cappa C.D.
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      • Ristenpart W.D.
      Efficacy of masks and face coverings in controlling outward aerosol particle emission from expiratory activities.
      A study from Bangladesh compared the use and non-use of cloth and surgical masks in more than 340,000 people, and a randomized clinical study in health professionals published for influenza in 2019

      N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel: A Randomized Clinical Trial | Infectious Diseases | JAMA | JAMA Network. Accessed June 22, 2022. https://jamanetwork.com/journals/jama/fullarticle/2749214

      comparing surgical masks and N95 in health professionals, demonstrated the efficacy of mask use in reducing SARS-CoV-2 transmission. Importantly, masks should not be regarded as single measures or with 100% efficiency. Proof-of-concept studies, experimental laboratory projections, and mathematical and physical models, have shown that the effectiveness of masks is related not only to their filtration efficacy, but to proper fitting, the viral load of infectious sources, environment aeration, and the reproduction rate of the predominant viral variant.

      Face masks effectively limit the probability of SARS-CoV-2 transmission. Accessed June 22, 2022. https://www.science.org/doi/10.1126/science.abg6296

      For this reason, it is challenging to make projections regarding the "percentage" of generalized protection, as different combinations of the above mentioned factors yield different risks. Nevertheless, well aerated outdoor environments, even with many infected sources, provide less transmission risk, which allows the use of masks of lower efficacy but with relative safety. On the other hand, indoor environments, such as public transport and medical centers that treat COVID-19 patients, require more efficient masks. Finally, as SARS-CoV-2 is highly dispersed through aerosol droplets, in general terms, the more efficient the mask is (in terms of filtration), the better the protection.

      Two metres or one: what is the evidence for physical distancing in covid-19? | The BMJ. Accessed June 22, 2022. https://www.bmj.com/content/370/bmj.m3223

      Surveillance

      Surveillance was pivotal for understanding the pandemic and giving early warnings to the population, so that risk management could be more effective. Several initiatives were launched, like the Covid Trends and Impacts Survey (CTIS), developed by the University of Maryland and Facebook Health.

      UMD Global CTIS. Accessed June 22, 2022. https://covidmap.umd.edu/

      This survey inquired Facebook users on the presence of COVID-like symptoms. COVID-like symptoms were a sum of fever, cough, and shortness of breath. A rise in COVID-like symptoms anticipated official data by approximately 15 days The CTIS survey demonstrated that using masks lowered the incidence of COVID-19 symptoms as questions on the use of masks were also part of the survey.
      • Nguyen M.
      Mask Mandates and COVID-19 Related Symptoms in the US.
      The data from Brazil’s Rio Grande do Sul state showed the impact of mask mandates on the incidence of symptoms (Figure 3).
      Figure thumbnail gr3
      Figure 3Impact of mask mandates on mask wearing reports on CTIS survey. On the state of Rio Grande do Sul, Brazil. The graph shows patients with COVID-like symptoms and the dark blue line depicts persons reporting mask usage outside of their homes. On the wave depicted in May 2022, a rise in symptoms is noted when the mask usage reporting is the lowest.From Rede Análise Available at: http://bit.ly/Rede_MobilitySymptoms. Accessed Jun 22 2022.
      During the COVID-19 pandemic, we have learned about the colossal impact of contact tracing, mobility and socioeconomic restrictions, physical distancing, face masking, and surveillance. These NPMs to control disease transmission came with their own difficulties, such as real and perceived limitations in personal freedom. Public dissatisfaction also stemmed from the impacts of social isolation on the economy, behavioral and mental health.
      • Hanna K.
      • Giebel C.
      • Tetlow H.
      • et al.
      Emotional and Mental Wellbeing Following COVID-19 Public Health Measures on People Living With Dementia and Carers.
      Wide ranging debates on ideal long term strategies to limit transmission while maintaining sustainable social, financial, and mental health are ongoing.

      IMPACT ON HEALTHCARE AND RESOURCE ALLOCATION

      Temporal heterogeneity marked the pandemic worldwide, which meant that there were regions experiencing a spike in cases, weeks or months before others (as was the case for China followed by Europe and then the Americas). Rising cases led to a rise in emergency room visits followed by hospitalizations, including utilization of the intensive care units. During the “surges'' the wise use of rapid and generously shared information by countries helped some regions to prepare for these acute burdens on healthcare. Allocation of scarce resources such as the supply of oxygen and ventilators were great challenges and in some highly burdened areas led to catastrophic system collapse such as in Brazil, India, or in Iran.

      Coronavirus COVID-19 collapses health system in Manaus, Brazil | MSF. Médecins Sans Frontières (MSF) International. Accessed June 28, 2022. https://www.msf.org/coronavirus-covid-19-collapses-health-system-manaus-brazil

      ,

      Fassihi F. Iran’s Health System ‘Beyond Disastrous’ From Covid Surge. The New York Times. https://www.nytimes.com/2021/08/13/world/middleeast/iran-virus-delta-variant.html. Published August 13, 2021. Accessed June 28, 2022.

      As the pandemic progressed, and the medical systems were overwhelmed on a wider scale, countries going through periods of increased transmission and case burden struggled to keep up with the needs of the patients.
      During the initial wave, the lack of PPE and medical devices such as ventilators was an important limiting factor. The lack of resources was less stark during subsequent waves compared to the deficit of trained personnel.
      • Schaller S.J.
      • Mellinghoff J.
      • Cecconi M.
      Education to save lives: C19SPACE, the COVID19 Skills PrepAration CoursE.
      Regional and wide scale redeployment of personnel from non-critical care areas was necessary. These redeployments led to physical, mental, emotional, and financial strain on healthcare personnel, with an increased rate of burnout. These challenges highlighted the importance of proactive personnel management during future pandemics.
      The lack of evidence-based strategies for resource allocation and the most appropriate models for local, regional, national, and international resource sharing was starkly evident.
      • Hempel S.
      • Burke R.
      • Hochman M.
      • et al.
      Allocation of scarce resources in a pandemic: rapid systematic review update of strategies for policymakers.
      ,
      • Ramachandran P.
      • Swamy L.
      • Kaul V.
      • Agrawal A.
      A National Strategy for Ventilator and ICU Resource Allocation During the Coronavirus Disease 2019 Pandemic.
      The sparse existing guidelines for resource allocation were revisited.

      Zucker HA, Adler KP, Berens DP. Current Members of the New York State Task Force on Life and the Law. :272.

      What stood out was the variation in guidelines across various states even within one country.

      Variation in Ventilator Allocation Guidelines by US State During the Coronavirus Disease 2019 Pandemic: A Systematic Review | Critical Care Medicine | JAMA Network Open | JAMA Network. Accessed May 13, 2022. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2767360

      Evidence abounds on the overburdening of health system posed by COVID-19. Lack of appropriate public health measures to control disease transmission and the ICU bed occupancy in Sao Paulo state in Brazil illustrates that after the ICU bed occupancy reached near 100%, there was a rapid increase in new deaths despite the added ICU beds. These newly available ICU beds could not provide high-standard ICU care as critical care health professionals were not available to staff them. This shortage of healthcare workers resulted from a significant burden of stress and negative socioeconomic, psychological, and physical impacts across the spectrum of healthcare workers with successive waves during the pandemic.
      • Kolié D.
      • Semaan A.
      • Day L.T.
      • Delvaux T.
      • Delamou A.
      • Benova L.
      Maternal and newborn healthcare providers’ work-related experiences during the COVID-19 pandemic, and their physical, psychological, and economic impacts: Findings from a global online survey.
      Studies reported a significant increase in the turnover intention in nurses, which was also noted amongst rest of the healthcare workers.
      • Falatah R.
      The Impact of the Coronavirus Disease (COVID-19) Pandemic on Nurses’ Turnover Intention: An Integrative Review.
      By spring of 2020, Canadian healthcare workers reported more than 30% prevalence of severe burnout.

      Burnout in Hospital-Based Healthcare Workers during COVID-19. Ontario COVID-19 Science Advisory Table. doi:10.47326/ocsat.2021.02.46.1.0

      Half of the healthcare workers reported decreased likelihood of maintaining their current occupation due to the pandemic in the United States while a study found that only 4.8% of nurses at a hospital in Egypt reported no intent to leave their current job.
      • Hendrickson R.C.
      • Slevin R.A.
      • Hoerster K.D.
      • et al.
      The Impact of the COVID-19 Pandemic on Mental Health, Occupational Functioning, and Professional Retention Among Health Care Workers and First Responders.
      ,
      • Said R.M.
      • El-Shafei D.A.
      Occupational stress, job satisfaction, and intent to leave: nurses working on front lines during COVID-19 pandemic in Zagazig City, Egypt.
      As institutions recover in the aftermath of the pandemic, workforce retention and wellbeing will prove to be an uphill battle while providing quality care to the community making workforce satisfaction and wellbeing a top priority at all levels of policy making in healthcare.
      In the out-of-hospital setting, outpatient clinics pivoted to providing telehealth services to allow social distancing measures that in turn limited in-person health care. A retrospective study noted an 80% reduction of utilization in outpatient resources compared to pre-pandemic years with a four-fold increase in telehealth resources.

      Journal of Medical Internet Research - Impact of the COVID-19 Pandemic on Health Care Utilization in a Large Integrated Health Care System: Retrospective Cohort Study. Accessed May 13, 2022. https://www.jmir.org/2021/4/e26558/

      A large review of countries implementing telehealth during the pandemic had a positive sentiment about its use going forward – an enormous 84.9%. This was based on data from high-income countries: 43.6% of the articles reviewed originated in the USA. On the other hand, the feasibility of telehealth in countries that are low- and middle-income or resource-scarce may continue to be an issue.
      • Doraiswamy S.
      • Abraham A.
      • Mamtani R.
      • Cheema S.
      Use of Telehealth During the COVID-19 Pandemic: Scoping Review.
      Governments took unprecedented measures to address resource shortages. In the United States, the Defense Production Act was invoked to allow robust public-private partnerships to accelerate the development and testing of therapeutics, ventilators, vaccines, and time-sensitive release of funds for the same.

      Defense Production Act | FEMA.gov. Accessed May 13, 2022. https://www.fema.gov/disaster/defense-production-act

      In the United Kingdom, companies produced 14,000 ventilators in 3 months as part of the “Ventilator Challenge”, one part of the government’s three-pronged approach to increase ventilator production in a short period of time.

      Ventilator Challenge hailed a success as UK production finishes. GOV.UK. Accessed May 13, 2022. https://www.gov.uk/government/news/ventilator-challenge-hailed-a-success-as-uk-production-finishes

      The international healthcare supply chain is a dynamic multi-tiered process. It involves manufacturers, vendors, purchasers, storage, distribution, and providers. As the chain requires constant flow without disruption, the consequences of the pandemic were felt worldwide due to the multifactorial impact on every single step of the supply chain across various countries. A shortage of personal protective equipment due to a drastic uptick in use and limited global supplies was the hallmark of resource limitation at the beginning of the pandemic. With China as the primary producer, as well as the pandemic epicenter, international efforts shifted towards reclaiming, reusing, and repurposing the existing supply. Manufacturing infrastructure was repurposed to bolster supply and fulfill the deficits.
      • Livingston E.
      • Desai A.
      • Berkwits M.
      Sourcing Personal Protective Equipment During the COVID-19 Pandemic.
      As an example, India stopped the export of 26 active pharmaceutical ingredients due to the fear of shortages for use within the country.

      Impact of the coronavirus pandemic on the supply chain in healthcare | British Journal of Healthcare Management. Accessed May 13, 2022. https://www.magonlinelibrary.com/doi/full/10.12968/bjhc.2020.0047

      With the unsettling rise in cases globally, many lessons were learned from the direct and indirect impact on healthcare delivery. Information sharing between countries is vital and constant evaluation of local and national resource allocation plans is important to stay prepared for future pandemics. Telehealth visits rose as resource shortages were observed. The importance of public-private partnership to address shortages will serve as benchmarks for future crises.

      LITERATURE IN COVID AND RESEARCH EFFORTS

      The COVID-19 pandemic, with its unprecedented needs, led to an acceleration in research on COVID-19 and concomitant rise in the number of scientific articles. The rapid spread of COVID-19 was paralleled by the speed of literature being published. The first publication on COVID-19 was on January 2nd, 2020 and the rate of published articles related to COVID-19 hit an all-time high of 2,276 in a week by the 22nd week of 2020. Between January 2nd, 2020 and July 21, 2020 the mean number of publications per week was 990.
      • Abd-Alrazaq A.
      • Schneider J.
      • Mifsud B.
      • et al.
      A Comprehensive Overview of the COVID-19 Literature: Machine Learning–Based Bibliometric Analysis.
      Both researchers and journals were overstretched by COVID-19. The use of preprint online platforms to speed up the release of information was another consequence of the pandemic that had its own pros and cons. Publishing on preprint platforms allowed for rapid dissemination of data by overcoming that limitation of traditional publishing processes including slow timelines of peer-review, time to publication, and challenges with formatting per different journals’ guidelines. However, the importance of robust peer-review became evident as incomplete, fabricated, or improperly analyzed data led to spread of information that eventually was proven to be incorrect.
      • Kaul V.
      • Gallo de Moraes A.
      • Khateeb D.
      • et al.
      Medical Education During the COVID-19 Pandemic.
      While open to public comment which serves as form of peer-review, about 5% of pre-print articles were commented on, usually with only one comment per article.
      • Kodvanj I.
      • Homolak J.
      • Virag D.
      • Trkulja V.
      Publishing of COVID-19 preprints in peer-reviewed journals, preprinting trends, public discussion and quality issues.
      Traditional publications also suffered from the challenges of need of rapid publication such as the retracted article regarding use of hydroxycholoroquine in COVID-19.
      • Mehra M.R.
      • Ruschitzka F.
      • Patel A.N.
      Retraction—Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis.
      Impressive robust scientific initiatives were also launched. A highlight was the implementation of adaptive platforms to run multiple research questions in COVID-19 simultaneously, such as RECOVERY

      RECOVERY Trial - Using adaptive designs to help identify treatments for COVID-19. MRC Biostatistics Unit. Published June 18, 2020. Accessed May 13, 2022. https://www.mrc-bsu.cam.ac.uk/blog/recovery-trial-using-adaptive-designs-to-help-identify-treatments-for-covid-19/

      ,
      Dexamethasone in Hospitalized Patients with Covid-19.
      , REMAP-CAP

      Response to COVID-19 pandemic. REMAP-CAP Trial. Accessed May 13, 2022. https://www.remapcap.org/coronavirus

      and the ACTT

      National Institute of Allergy and Infectious Diseases (NIAID). A Multicenter, Adaptive, Randomized Blinded Controlled Trial of the Safety and Efficacy of Investigational Therapeutics for the Treatment of COVID-19 in Hospitalized Adults. clinicaltrials.gov; 2022. Accessed May 12, 2022. https://clinicaltrials.gov/ct2/show/NCT04280705

      . Adaptive trials such as these allowed rapid reaction to changing knowledge and therapeutics while evaluating different target candidates for the treatments. These trials subsequently provided guidance and clarity on the role of multiple therapeutics such as the role of antivirals, systemic steroids, and other immunomodulators, amongst others.
      Another critical achievement of the global medical research community was the creation and maintenance of the “living” guidelines on therapeutics for COVID-19 published by the WHO.

      Therapeutics and COVID-19: living guideline. Accessed May 13, 2022. https://www.who.int/publications-detail-redirect/WHO-2019-nCoV-therapeutics-2022.3

      The first version of these guidelines was published in September, 2020 and most recently the twelfth iteration of the guidelines was released on September 26, 2022. Curated by a review committee with global representation, these guidelines provided front-line clinicians with the ability to deliver evidence-based care that was in keeping with the most recent high-quality literature.

      Misinformation

      COVID-19 is the first pandemic in history during which technology and social media were used on a large scale to keep people safe, informed, productive, and connected. At the same time, the technology we rely on to keep us connected and informed enabled and amplified a deluge of inaccurate information that undermined the global response and jeopardized the measures to control the pandemic due to conflicting messaging.
      With the deluge of data and information came a similarly impressive amount of confusion and misinformation.
      • Abd-Alrazaq A.
      • Schneider J.
      • Mifsud B.
      • et al.
      A Comprehensive Overview of the COVID-19 Literature: Machine Learning–Based Bibliometric Analysis.
      While the discordance in statements from official sources was based on available literature, the interpretation and implementation of the information was often askew by the populace leading to confusion in the community. From vital information on the origin and therapies of a pandemic to ongoing published literature, we saw the emergence of an “infodemic”.
      • Naeem S.B.
      • Bhatti R.
      The Covid-19 ‘infodemic’: a new front for information professionals.
      In a rapidly changing situation, with millions of individuals in isolation, social media became a frontrunner source for major updates. Research conducted in Italy showed that in March of 2020, an average of daily 46,000 Twitter posts were linked to misinformation.

      Mostrous A, Cummings B, Hollowood E. the infodemic fake news coronavirus. Tortoise. Published March 23, 2020. Accessed May 13, 2022. https://www.tortoisemedia.com/2020/03/23/the-infodemic-fake-news-coronavirus/

      A survey published in the UK indicated that 46% of adults had seen misleading information about the pandemic; 40% reported finding it hard to know what is true or false.

      Covid-19 news and information: consumption and attitudes. :5.

      Over a quarter of the most-viewed 75 videos regarding COVID-19 in March 2020 on Youtube contained misinformation.
      • Li H.O.Y.
      • Bailey A.
      • Huynh D.
      • Chan J.
      YouTube as a source of information on COVID-19: a pandemic of misinformation?.
      Misinformation also stemmed from poor conduct of research; examples include studies published by researchers in both pre-print and traditional publications who claimed passionately that hydroxychloroquine or proxalutamide were effective.
      • Gautret P.
      • Lagier J.C.
      • Parola P.
      • et al.
      Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial.
      ,
      • Taylor L.
      Covid-19: Trial of experimental “covid cure” is among worst medical ethics violations in Brazil’s history, says regulator.
      Medical journals faced a herculean task of processing submitted manuscripts while ensuring standards.
      • Eisen M.B.
      • Akhmanova A.
      • Behrens T.E.
      • Weigel D.
      Publishing in the time of COVID-19.
      ,

      COVID-19 research: pandemic versus “paperdemic”, integrity, values and risks of the “speed science.” Accessed May 13, 2022. https://www.tandfonline.com/doi/epub/10.1080/20961790.2020.1767754?needAccess=true

      This pandemic highlighted the importance of rapid development and sharing of research findings while ensuring consistent messaging. The role of social media was significant and provided impetus for healthcare personnel to actively participate in ensuring accurate information dissemination.
      • Topf J.M.
      • Williams P.N.
      COVID-19, Social Media, and the Role of the Public Physician.
      Healthcare agencies recognized the importance of cohesive messaging as noted by increased connectivity of messaging between different stakeholder agencies on Twitter as the pandemic progressed.
      • Wang Y.
      • Hao H.
      • Platt L.S.
      Examining risk and crisis communications of government agencies and stakeholders during early-stages of COVID-19 on Twitter.

      VACCINATION

      The development of vaccines required unprecedented efforts to bring resources, manpower, and intellectual strengths together. As discussed earlier, the public-private partnerships fostered across the globe were critical for this endeavor. In December 2020, two mRNA vaccines were approved for administration in the United States.

      CDC. CDC Museum COVID-19 Timeline. Centers for Disease Control and Prevention. Published January 5, 2022. Accessed May 13, 2022. https://www.cdc.gov/museum/timeline/covid19.html

      Since then several types of vaccines against COVID-19 have been developed and deployed across the globe including nucleic acid vaccines, viral vector vaccines, inactivated vaccines, and protein-based vaccines.

      COVID-19 Clinical Resources | COVID-19 Resource Center. American College of Chest Physicians. Accessed May 13, 2022. https://www.chestnet.org/topic-collections/covid-19/clinical-resources

      The WHO COVAX initiative declared that “no one is safe, unless everyone is safe'', in a bid to ensure equitable distribution of vaccines globally. The goal was to fundraise capital to ensure vaccine access for 100 low-to-middle income countries.

      Deployment of COVID-19 vaccines. In: Wikipedia. ; 2022. Accessed May 13, 2022. https://en.wikipedia.org/w/index.php?title=Deployment_of_COVID-19_vaccines&oldid=1084870211

      By mid-December 2020, nearly half of the expected production of 5.3 billion doses of vaccines for 2021 had been pre-ordered by the 27 countries of the European Union, the United States, the United Kingdom, Canada, Australia, and Japan. Cumulatively these high-income countries represented only 13% of the global population.
      • Mullard A.
      How COVID vaccines are being divvied up around the world.
      In contrast, the COVAX facility had only reserved a few hundred million doses.

      Deployment of COVID-19 vaccines. In: Wikipedia. ; 2022. Accessed May 13, 2022. https://en.wikipedia.org/w/index.php?title=Deployment_of_COVID-19_vaccines&oldid=1084870211

      Several countries developed vaccines indigenously and provided a robust vaccine program for their population, demonstrating the importance of engaging all shareholders internationally. India launched its vaccine program in January of 2021 and as of April 2, 2022 reported 91% of the entire population was at least partially vaccinated.

      Deployment of COVID-19 vaccines. In: Wikipedia. ; 2022. Accessed May 13, 2022. https://en.wikipedia.org/w/index.php?title=Deployment_of_COVID-19_vaccines&oldid=1084870211

      By the end of 2021, Latin America was one of the leaders in vaccination numbers globally, where existing resources for vaccine deployment were crucial for the success of vaccination campaigns.
      • Lotta G.
      • Fernandez M.
      • Kuhlmann E.
      • Wenham C.
      COVID-19 vaccination challenge: what have we learned from the Brazilian process?.
      The global vaccination efforts have been hindered by hesitancy, among other reasons, with misinformation playing a significant role.

      Sharma K, Zhang Y, Liu Y. COVID-19 Vaccine Misinformation Campaigns and Social Media Narratives. arXiv; 2022. doi:10.48550/arXiv.2106.08423

      As of April 2022, vaccination efforts across the globe have reached a plateau, with many countries such as the USA reporting only 67% of the population as being completely immunized. Countries such as Nigeria and Ethiopia at the same time reported 10 - 20% vaccination rates, starkly bringing into focus the impact of resource limitation, imbalance of sharing these resources, and factors such as hesitancy causing a dent in acceptance.

      Ritchie H, Mathieu E, Rodés-Guirao L, et al. Coronavirus Pandemic (COVID-19). Our World Data. Published online March 5, 2020. Accessed May 13, 2022. https://ourworldindata.org/covid-vaccinations

      The vaccine coverage in some countries revealed these inequities. In May of 2022, the African continent had 17% of its population vaccinated with two doses and 1.65% of its population vaccinated with three doses. In Brazil, a low-middle income country (LMIC), with significant socioeconomic disparities, vaccine inequity has been clearly demonstrated. The southeast and south regions had the most robust coverage: Sao Paulo State was the most vaccinated state, with 84% of its total population vaccinated with two doses. The north region had the lowest coverage, with less than 50% of the population in states like Amapá and Roraima vaccinated with two doses. When the third dose coverage was analyzed, the northern states in Brazil had less than 15% of their total population covered, which was directly associated with worse socioeconomic status in the north and northeast of Brazil. Lower-income regions, like the north, reported an average of 55% of two doses of vaccinal coverage, and the higher-income regions, like south and southeast, reported an average of 75% of two doses (Figure 4).
      Figure thumbnail gr4
      Figure 4Vaccine inequality in Brazil. The graph shows the northern region of Brazil had a lower vaccine coverage than the southeast (mainly São Paulo, the richest state of the country).From Rede Análise Available at: https://redeanalise.com.br/. Accessed Jun 22 2022.
      As we have learned from the pandemic, age-based vaccine distribution strategies were crucial for mortality reduction.

      Bubar KM, Reinholt K, Kissler SM, et al. Model-informed COVID-19 vaccine prioritization strategies by age and serostatus. Science. 2021;371(6532):916-921. doi:10.1126/science.abe6959

      ,
      • Fitzpatrick M.C.
      • Galvani A.P.
      Optimizing age-specific vaccination.
      Countries globally adopted this recommendation prioritizing older-age individuals and healthcare workers.

      Bubar KM, Reinholt K, Kissler SM, et al. Model-informed COVID-19 vaccine prioritization strategies by age and serostatus. Science. 2021;371(6532):916-921. doi:10.1126/science.abe6959

      ,
      • Fitzpatrick M.C.
      • Galvani A.P.
      Optimizing age-specific vaccination.
      As the vaccine supply is currently plentiful, nations with low vaccine supplies have become the focal point for vaccination efforts. Models have shown that dose sharing between countries with high and low vaccine availability is beneficial from a global perspective as vaccine sharing lessens the costs of surveillance such as from border testing and genomic surveillance as well as decreases the risk of evolution of the virus.

      Vaccine nationalism and the dynamics and control of SARS-CoV-2. Accessed May 13, 2022. https://www.science.org/doi/10.1126/science.abj7364

      In certain populations, specific targeting such as social media campaigns, slogans, and trusted messengers proved beneficial. Vaccine uncertainty was eased by involving communities hit the hardest by the pandemic.
      • AuYoung M.
      • Rodriguez Espinosa P.
      • ting Chen W.
      • et al.
      Addressing racial/ethnic inequities in vaccine hesitancy and uptake: lessons learned from the California alliance against COVID-19.
      Africa, a continent that has experience vaccinating large numbers of its population, had systems in place to effectively implement vaccinations. Such efforts include storing vaccines at cold temperatures, a requirement for the Ebola vaccine, and establishing vaccine sites such as churches, mosques, banks, and markets.

      Key lessons from Africa’s COVID-19 vaccine rollout. WHO | Regional Office for Africa. Accessed May 13, 2022. https://www.afro.who.int/news/key-lessons-africas-covid-19-vaccine-rollout

      Vaccination efforts continue to heighten. Access to vaccines plagued the initial rollout, but governments quickly combated the issue. During future pandemics, ensuring equitable access to vaccines will be key to address the global spread of agents.

      SOCIOECONOMIC IMPACT

      The socioeconomic impact of this pandemic was evident early in the pandemic. In Brazil, for example, regional health disparities played a massive role in disease burden and mortality. In low-income areas, the mortality rates in the young were similar to the rates seen in the elderly, in contrast to regions with a high-income status and greater availability of higher quality of care. The need for high-quality care in these disadvantaged regions of critically ill patients was highlighted. These findings can be extrapolated to other low-income and middle-income countries with similar socioeconomic status.
      • Ranzani O.T.
      • Bastos L.S.L.
      • Gelli J.G.M.
      • et al.
      Characterisation of the first 250,000 hospital admissions for COVID-19 in Brazil: a retrospective analysis of nationwide data.
      Brazil had remarkable differences between the first (March-October 2020) and second (January-May 2021) waves. During the second wave, Brazil faced the Gamma variant of SARS-CoV-2 and an increase in mobility likely due to pandemic fatigue while the vaccine coverage was still very low. This led to an increase in admissions for invasive and non-invasive ventilation by 192%. However, the admissions to the intensive care unit were similar, suggesting a limitation in access to critical care. Also noted was a decrease in admissions in the state capitals, which again pointed towards socioeconomic challenges in specific regions.
      • Bastos L.S.
      • Ranzani O.T.
      • Souza T.M.L.
      • Hamacher S.
      • Bozza F.A.
      COVID-19 hospital admissions: Brazil’s first and second waves compared.
      The second wave proved to be more devastating with an increased burden of severe cases resulting in a higher mortality. Similar situations were seen in both the UK and Africa.93In Africa, despite the first wave, many countries had not instituted similar degrees of public health measures, and those that had instituted them, experienced fatigue in adherence to the measures which contributed in part to the subsequent waves.
      • Salyer S.J.
      • Maeda J.
      • Sembuche S.
      • et al.
      The first and second waves of the COVID-19 pandemic in Africa: a cross-sectional study.
      In South Africa, women experienced increased vulnerability to domestic trauma.
      • Piquero A.R.
      • Jennings W.G.
      • Jemison E.
      • Kaukinen C.
      • Knaul F.M.
      Domestic violence during the COVID-19 pandemic - Evidence from a systematic review and meta-analysis.
      Police reported 87,000 cases of violence during the first week of lockdown. This further suggested an increased need for mental health professionals during these stressful times
      • Nguse S.
      • Wassenaar D.
      Mental health and COVID-19 in South Africa.
      while a significant decrease in motor vehicle accidents, pedestrian-vehicle accidents, and assaults was seen. In particular, assaults involving a knife decreased dramatically.
      • Zsilavecz A.
      • Wain H.
      • Bruce J.L.
      • et al.
      Trauma patterns during the COVID-19 lockdown in South Africa expose vulnerability of women.
      The unemployment rate was a striking 30.1% during the lockdown. Measures such as social distancing, mask-wearing, and avoiding close contact were more consistently implemented by individuals of educated and higher socioeconomic status, as opposed to those of lower socioeconomic status.
      • Kollamparambil U.
      • Oyenubi A.
      Behavioural response to the Covid-19 pandemic in South Africa.
      The profound socioeconomic impact of the pandemic is a major lesson learned. High-income regions have access to high-quality care which in turn decreases mortality rates as highlighted. To reiterate: addressing inequities is as important to delivery of healthcare as innovation in therapies and preventative strategies.

      THE PATH FORWARD

      Progress in technology, diagnostics, networks, and preparedness for pandemics must continue. Following the 2009 influenza pandemic, the Member States of the WHO adopted the Pandemic Influenza Preparedness (PIP) Framework, which supports fair access to measures to alleviate threats and financing. Each country has a different risk profile. Going forward, attention needs to be placed on an immediate response plan to implement national strategies similar to the WHO-adopted method, keeping existing inequities in mind so as not to exacerbate them during a pandemic situation.

      Strategic preparedness, readiness and response plan to end the global COVID-19 emergency in 2022. Accessed May 13, 2022. https://www.who.int/publications-detail-redirect/WHO-WHE-SPP-2022.1

      Continued research on public health and mitigation measures will accelerate the positive impact we have noted and minimize harm going forward. The mistrust in science and healthcare will likely be restored as vaccines and effective COVID-19 treatments become established. Reliance on inter-organizational consistency, trusted leaders, and accessible, evidence-based guidelines will pave the way towards rebuilding public trust. Lastly, ongoing efforts are needed to protect the health and safety of healthcare workers who experienced the burdens of burn-out, discrimination, risk of occupational exposure, and illness from COVID-19.

      Strategic preparedness, readiness and response plan to end the global COVID-19 emergency in 2022. Accessed May 13, 2022. https://www.who.int/publications-detail-redirect/WHO-WHE-SPP-2022.1

      The use of facemasks, indoor aeration, and distancing can mitigate the airborne transmission of virus. Early implementation of quarantine and contact tracing in conjunction with common-sense public health measures are effective in controlling transmission. A global effort to keep resources, knowledge, and implementation equitably distributed and available at all levels is critical for success.
      Many possible scenarios exist going forward. Endemicity similar to influenza and other human coronaviruses is entirely possible.

      After the pandemic: perspectives on the future trajectory of COVID-19 | Nature. Accessed May 13, 2022. https://www.nature.com/articles/s41586-021-03792-w

      Vaccinations and previous infections may achieve herd immunity. However, a broad application of vaccines worldwide and accurate and available diagnostic testing is needed for accurate monitoring and local mitigation.
      • Aschwanden C.
      Five reasons why COVID herd immunity is probably impossible.
      As for now, COVID-19 will continue to circulate for the foreseeable future.
      Table 1
      Table 1Lessons learned from COVID-19: summary of considerations for future respiratory virus pandemics
      GLOBAL SPREAD•Non-pharmacological measures are effective in containing the spread of the virus

      •Contact tracing can help limit the spread

      •Face masks, in conjunction with other public health measures can tangibly reduce transmission
      IMPACT ON HEALTHCARE•Rapid and generous sharing of information between researchers, clinicians, agencies, and countries is instrumental in planning, preparation, treatment, and prevention

      •Resource allocation strategies should be considered at all levels to prepare for equitable distribution of resources between areas suffering varying degrees of impact

      •Supply chain challenges can be effective addressed by robust deployment of public-private collaborations

      •Telehealth can be effectively used to provide care

      •Attention needs to be paid to the mental and physical well-being of healthcare workers

      •Evaluation of healthcare worker needs, provision of meaningful incentives, and infusing effort into training future generation of healthcare workers should be prioritized to ensure long term retention
      DISSSEMINATION OF KNOWLEDGE•Preprint articles provide rapid dissemination of information but the need for rapidity must be balanced with robust peer-review to avoid inaccurate publications

      •Peer-reviewed research plays an integral role to ensure accurate science is shared between stakeholders

      •Living guidelines promote unity and availability of timely evidence-based guidance

      •Collaboration of regional, national, international public health organizations along with mass media channels is vital to decrease the spread of misinformation
      VACCINATION•Equitable sharing of vaccines and other resources among countries is a top priority

      •Misinformation hinders vaccination efforts globally

      •Low- and middle-income areas can have lower vaccinations rates than the high-income areas, further exacerbating the socioeconomic disparity
      SOCIOECONOMIC IMPACT•Disparity in access to robust health care in areas of low socioeconomic status can lead to worse outcomes

      •Despite increases in hospital beds, good quality care is limited by availability of trained personnel and appropriate resources

      •Pandemics can have significant impact on the financial well-being of society and balancing mitigation strategies with socio-economic feasibility remains an ongoing learning curve
      Clinics Care Points

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