Contact Tracing Policies Research Articles

COVID-19 contact tracing and quarantine policies in the Indo-Pacific Region: A mixed-methods study of experiences of public health professionals.

Contact tracing and quarantine are valuable public health tools to prevent the transmission of SARS-CoV-2 and control the epidemic. Many low-and middle-income countries (LMICs) adopted global contact tracing and quarantine guidelines but were unable to contextualise the guidance into policies and practices that were relevant to their setting. Therefore, we examine contact tracing policies and practices in the Indo-Pacific region and the need to design context-specific policies. We conducted a mixed-methods study, including a cross-sectional online survey followed by key-informant interviews (KIIs). Using convenience snowball sampling, we invited public health professionals primarily involved in COVID-19 pandemic response from the Indo-Pacific region. We undertook descriptive analyses using counts and percentages for survey data and framework analysis for qualitative data. Seventy-seven public health professionals participated in the survey, of whom ten also participated in the KIIs. The study identified significant gaps between policies and the local contexts. Factors that broaden the gaps were limited knowledge of the changing dynamics of COVID-19 transmission, poor leadership, and coordination, little or no formal training on contact tracing, poor understanding of the guideline recommendations, limited resources, community resistance and mistrust, social stigmatisation and fear of being ostracised, and discrimination. This study revealed substantial disparities between policies and local contexts, significantly influencing policy implementation at national, provincial, and district levels across the studied countries. To bridge these gaps, we advocate for national contact tracing and quarantine guidelines explicitly addressing the quarantine needs of specific demographics, including children, pregnant women, prisoners, and individuals affected by social exclusion issues. Furthermore, we propose strengthening contact tracing training programs, urging revised guidelines to account for social, cultural, and infrastructural nuances influencing contact tracing and quarantine implementation. We also recommend engaging local NGOs, faith-based organisations, and local administrations to reinforce community connections and strengthen contact tracing.

The Impact of the COVID-19 Epidemic on Hospital Admissions for Alcohol-related Liver Disease and Pancreatitis in Western Sydney.

The Impact of the COVID-19 Epidemic on Hospital Admissions for Alcohol-related Liver Disease and Pancreatitis in Western Sydney.

Visual Analytics of Contact Tracing Policy Simulations During an Emergency Response

AbstractEpidemiologists use individual‐based models to (a) simulate disease spread over dynamic contact networks and (b) to investigate strategies to control the outbreak. These model simulations generate complex ‘infection maps’ of time‐varying transmission trees and patterns of spread. Conventional statistical analysis of outputs offers only limited interpretation. This paper presents a novel visual analytics approach for the inspection of infection maps along with their associated metadata, developed collaboratively over 16 months in an evolving emergency response situation. We introduce the concept of representative trees that summarize the many components of a time‐varying infection map while preserving the epidemiological characteristics of each individual transmission tree. We also present interactive visualization techniques for the quick assessment of different control policies. Through a series of case studies and a qualitative evaluation by epidemiologists, we demonstrate how our visualizations can help improve the development of epidemiological models and help interpret complex transmission patterns.

Expert insights on digital contact tracing: interviews with contact tracing policy professionals in New Zealand.

Digital contact tracing (DCT) is the application of digital tools to assist with identifying and informing close contacts of a COVID-19 case. DCT is a potential solution to capacity constraints of current manual contact tracing processes. Expert opinion from contact tracing professionals rarely informs public discourse on the benefits and limitations of DCT solutions. Three focus groups were undertaken in New Zealand to understand benefits and limitations of DCT solutions from contact tracing professionals. One was with the National Investigation and Tracing Centre (NITC) and two were with Public Health Units (PHUs). Participants highlighted four key themes including: (i) equity, (ii) privacy, (iii) communication and public perception and (iv) the operational model. Participants were concerned DCT solutions could exacerbate existing health inequities due to lack of access to, or familiarity with, technology. Poor communication and public understanding of DCT were seen as a major threat to both the efficacy of DCT solutions and the wider COVID-19 response. Most importantly, end-users were cautious of the operational model for DCT data that might: (i) attempt to replace manual processes that cannot or should not be automated by technology (case investigations, follow-ups); (ii) place undue burden on citizens and (iii) increase the workload for the current system beyond its capacity, for unproven or limited benefit. To be effective, contact tracing professionals believed DCT technologies must have strong privacy safeguards, a clear and simple communication strategy, interoperability with the existing contact tracing system and a foundation of health equity.

Mathematical modeling and stability analysis of the COVID-19 with quarantine and isolation

The present paper focuses on the modeling of the COVID-19 infection with the use of hospitalization, isolation and quarantine. Initially, we construct the model by spliting the entire population into different groups. We then rigorously analyze the model by presenting the necessary basic mathematical features including the feasible region and positivity of the problem solution. Further, we evaluate the model possible equilibria. The theoretical expression of the most important mathematical quantity of major public health interest called the basic reproduction number is presented. We are taking into account to study the disease free equilibrium by studying its local and global asymptotical analysis. We considering the cases of the COVID-19 infection of Pakistan population and find the parameters using the estimation with the help of nonlinear least square and have R0≈1.95. Further, to determine the influence of the model parameters on disease dynamics we perform the sensitivity analysis. Simulations of the model are presented using estimated parameters and the impact of various non-pharmaceutical interventions on disease dynamics is shown with the help of graphical results. The graphical interpretation justify that the effective utilization of keeping the social-distancing, making the quarantine of people (or contact-tracing policy) and to make hospitalization of confirmed infected people that dramatically reduces the number of infected individuals (enhancing the quarantine or contact-tracing by 50% from its baseline reduces 84% in the predicted number of confirmed infected cases). Moreover, it is observed that without quarantine and hospitalization the scenario of the disease in Pakistan is very worse and the infected cases are raising rapidly. Therefore, the present study suggests that still, a proper and effective application of these non-pharmaceutical interventions are necessary to curtail or minimize the COVID-19 infection in Pakistan.

Recurrent SARS-CoV-2 infections and their potential risk to public health - a systematic review.

To inform quarantine and contact-tracing policies concerning re-positive cases-cases testing positive among those recovered. We systematically reviewed and appraised relevant literature from PubMed and Embase for the extent of re-positive cases and their epidemiological characteristics. In 90 case reports/series, a total of 276 re-positive cases were found. Among confirmed reinfections, 50% occurred within 90 days from recovery. Four reports related onward transmission. In thirty-five observational studies, rate of re-positives ranged from zero to 50% with no onward transmissions reported. In eight reviews, pooled recurrence rate ranged from 12% to 17.7%. Probability of re-positive increased with several factors. Recurrence of a positive SARS-CoV-2 test is commonly reported within the first weeks following recovery from a first infection.

Tracking SARS-CoV-2: Novel Trends and Diagnostic Strategies.

The COVID-19 pandemic has had an enormous impact on economies and health systems globally, therefore a top priority is the development of increasingly better diagnostic and surveillance alternatives to slow down the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In order to establish massive testing and contact tracing policies, it is crucial to have a clear view of the diagnostic options available and their principal advantages and drawbacks. Although classical molecular methods such as RT-qPCR are broadly used, diagnostic alternatives based on technologies such as LAMP, antigen, serological testing, or the application of novel technologies such as CRISPR-Cas for diagnostics, are also discussed. The present review also discusses the most important automation strategies employed to increase testing capability. Several serological-based diagnostic kits are presented, as well as novel nanotechnology-based diagnostic methods. In summary, this review provides a clear diagnostic landscape of the most relevant tools to track COVID-19.

Peran Komunikasi dalam Implementasi Kebijakan Pelacakan Kontak Erat dan Pemantauan Isolasi Mandiri Penderita Covid-19 Oleh Puskesmas di Kota Palembang

Carrying out close contact tracing and immediately isolating cases and contacts, is the chosen mitigation to offset the economic and social impact of the COVID-19 pandemic. This analysis of the implementation of the close contact tracing policy and monitoring of self-isolation is an important step for input from various parties to determine better policies in the future so that the pandemic can end soon. So good communication is needed between the parties involved in implementing the policy. This study is a qualitative research with a descriptive design that aims to determine the role of communication in the implementation of close contact tracing policies and self-isolation monitoring by the comunnity health centers in Palembang City 2020 which can be seen from the transmission, clarity and consistency variables using Edward III Theory. Methods of collecting data were in-depth interviews, observation and document review. The results of the study found that the lack of socialization carried out related to guidelines for prevention and contact tracing and self-isolation of COVID-19 sufferers, the ineffectiveness of socialization of guidelines carried out virtually, as well as inconsistencies in contact tracing due to several factors, firstly patient dishonesty, community stigma, data late case release, unclear address/telephone number, uncooperative patient and changes in guidelines that occurred from revision 4 to revision 5. Suggestions from this study are to evaluate the socialization of guidelines, increase knowledge and abilities of implementors, improve coordination and cooperation of implementers, empowerment of community roles so as to reduce stigma in society.

Investigating the effectiveness of re-opening policies before vaccination during a pandemic: SD modelling research based on COVID-19 in Wuhan

BackgroundLockdown policies were widely adopted during the coronavirus disease 2019 (COVID-19) pandemic to control the spread of the virus before vaccines became available. These policies had significant economic impacts and caused social disruptions. Early re-opening is preferable, but it introduces the risk of a resurgence of the epidemic. Although the World Health Organization has outlined criteria for re-opening, decisions on re-opening are mainly based on epidemiologic criteria. To date, the effectiveness of re-opening policies remains unclear.MethodsA system dynamics COVID-19 model, SEIHR(Q), was constructed by integrating infection prevention and control measures implemented in Wuhan into the classic SEIR epidemiological model and was validated with real-world data. The input data were obtained from official websites and the published literature.ResultsThe simulation results showed that track-and-trace measures had significant effects on the level of risk associated with re-opening. In the case of Wuhan, where comprehensive contact tracing was implemented, there would have been almost no risk associated with re-opening. With partial contact tracing, re-opening would have led to a minor second wave of the epidemic. However, if only limited contact tracing had been implemented, a more severe second outbreak of the epidemic would have occurred, overwhelming the available medical resources. If the ability to implement a track-trace-quarantine policy is fixed, the epidemiological criteria need to be further taken into account. The model simulation revealed different levels of risk associated with re-opening under different levels of track-and-trace ability and various epidemiological criteria. A matrix was developed to evaluate the effectiveness of the re-opening policies.ConclusionsThe SEIHR(Q) model designed in this study can quantify the impact of various re-opening policies on the spread of COVID-19. Integrating epidemiologic criteria, the contact tracing policy, and medical resources, the model simulation predicts whether the re-opening policy is likely to lead to a further outbreak of the epidemic and provides evidence-based support for decisions regarding safe re-opening during an ongoing epidemic.KeyordsCOVID-19; Risk of re-opening; Effectiveness of re-opening policies; IPC measures; SD modelling.

DISCLOSURE OF CORONAVIRUS DISEASE-19 (COVID-19) PATIENT DATA: ETHICAL AND LEGAL PERSPECTIVES IN INDONESIA

The contact tracing policy strategy implemented during the COVID-19 pandemic requires data on COVID-19 patients to be accessible to the public so that people who have been in contact with the positive patient can do self-isolate. However, this is contrary to medical secrets and the confidentiality of COVID-19 patient data as a form of private law. This research is normative research with a statutory approach (statue approach) and conceptual (conceptual approach). Based on ethical and legal aspects, the confidentiality of COVID-19 patient data must be maintained. This data can be disclosed with the patient consent or disclosed to the Health Office to conduct epidemiological investigations. Suppose the contact investigation involves several parties: the neighborhood unit, the village head, Village Community Empowerment Service, police, and other parties. In that case, further regulation is needed to ensure the commitment of these parties in maintaining COVID-19 patient data. Disseminating patient data openly or publicly can make harm to the patient, especially in the not good environment with risk of stigmatization. There is also a need for harmony between existing regulations and the programs or policies implemented by the government.

Cross-country evidence on the association between contact tracing and COVID-19 case fatality rates

The coronavirus disease (COVID-19) outbreak has killed over a million people since its emergence in late 2019. However, there has been substantial variability in the policies and intensity of diagnostic efforts between countries. In this paper, we quantitatively evaluate the association between national contact tracing policies and case fatality rates of COVID-19 in 138 countries. Our regression analyses indicate that countries that implement comprehensive contact tracing have significantly lower case fatality rates. This association of contact tracing policy and case fatality rates is robust in our longitudinal regression models, even after controlling for the number of tests conducted and non-pharmaceutical control measures adopted by governments. Our results suggest that comprehensive contact tracing is instrumental not only to curtailing transmission but also to reducing case fatality rates. Contact tracing achieves the early detection and isolation of secondary cases which are particularly important given that the peak in infectiousness occurs during the presymptomatic phase. The early detection achieved by contact tracing accelerates the rate at which infected individuals receive medical care they need to maximize their chance of recovery. In addition, the combination of reduced transmission and more rapid recovery diminishes the burden on the healthcare system which in turn ensures that the resources remain available for individuals who do become infected.

The Impact of COVID-19 and Government Intervention on Stock Markets of OECD Countries

We study the impact of COVID-19 and various government interventions on the stock market returns of 20 OECD countries from February 1, 2020 to October 1, 2020. We find that stock market returns react significantly negatively to the increase in the number of confirmed cases. The governments’ intervention measures, such as social distancing, testing and contact tracing policies, magnify the negative effect of COVID-19 on stock returns. Our findings have important policy implications.

SARS-CoV-2 seroprevalence survey among health care providers in a Belgian public multiple-site hospital.

Although the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is lasting for more than 1 year, the exposition risks of health-care providers are still unclear. Available evidence is conflicting. We investigated the prevalence of antibodies against SARS-CoV-2 in the staff of a large public hospital with multiple sites in the Antwerp region of Belgium. Risk factors for infection were identified by means of a questionnaire and human resource data. We performed hospital-wide serology tests in the weeks following the first epidemic wave (16 March to the end of May 2020) and combined the results with the answers from an individual questionnaire. Overall seroprevalence was 7.6%. We found higher seroprevalences in nurses [10.0%; 95% confidence interval (CI) 8.9-11.2] than in physicians 6.4% (95% CI 4.6-8.7), paramedical 6.0% (95% CI 4.3-8.0) and administrative staff (2.9%; 95% CI 1.8-4.5). Staff who indicated contact with a confirmed coronavirus disease 2019 (COVID-19) colleague had a higher seroprevalence (12.0%; 95% CI 10.7-13.4) than staff who did not (4.2%; 95% CI 3.5-5.0). The same findings were present for contacts in the private setting. Working in general COVID-19 wards, but not in emergency departments or intensive care units, was also a significant risk factor. Since our analysis points in the direction of active SARS-CoV-2 transmission within hospitals, we argue for implementing a stringent hospital-wide testing and contact-tracing policy with special attention to the health care workers employed in general COVID-19 departments. Additional studies are needed to establish the transmission dynamics.

865. Methicillin-resistant Staphylococcus aureus (MRSA) prevalence among healthcare workers (HCW) in contact tracings in a Dutch teaching hospital, 2010-2018

BackgroundIn The Netherlands, the national guidelines on MRSA prevention and control advocate screening of HCW after unprotected exposure to MRSA carriers. Although this strategy at large is successful, contact tracing of staff is a time consuming and costly component. We evaluated our contact tracing policy for HCW over the years 2010 – 2018.MRSA prevalence among samples in contact tracing MethodsA retrospective, observational study was performed in a Dutch teaching hospital. All HCW who had unprotected contact with an MRSA carrier were included in contact tracing. When there had been a long period of unprotected admission prior to an MRSA finding, or when the index case was a HCW, than the entire (nursing) team was tested. All samples of HCWs who were tested for MRSA carriage as part of contact tracing from 2010 until 2018 were included. A pooled nose, throat and perineum swab was collected using the eSwab medium (Copan) and inoculated on chromID MRSA agar plates (bioMérieux) after enrichment in a broth.ResultsIn total, we included 8,849 samples (range: 677 – 1,448 samples per year) from a total of 287 contact tracings (range: 26 – 55 contact tracings per year). Thirty two HCWs were colonized with MRSA (0.36%; 95%CI 0.26 – 0.51). None of them developed a clinical infection.Eight HCWs (0.10%; 95%CI 0.05% – 0.19%) were colonized with the same MLVA type as the index case, and were detected in 6/287 contact tracings (2%). In 4/8 of these cases, a positive HCW was the index for undertaking contact tracing. In 3/8 cases it was clear that the HCW who was identified in the contact tracing was the source of the outbreak and was the cause of invasive MRSA infections in patients.Notably, a different MLVA type as the index case was found in 24 HCWs (0,27%; 95%CI 0,18 – 0,40) of which 7/24 HCW (29,2%) were intermittent carriers.ConclusionThis study revealed a sustained low MRSA prevalence among samples in contact tracing of healthcare workers, over nine years. Furthermore, it shows that when MRSA contact tracing is performed according to the national guideline only 1 out 1000 samples results in a secondary case. This is similar to the population carriage rate of MRSA in The Netherlands. More frequently, an unrelated strain is found. These findings raise question marks regarding the efficacy of the current strategy to perform contact tracing after unprotected exposure.Disclosures All Authors: No reported disclosures

To quarantine, or not to quarantine: A theoretical framework for disease control via contact tracing

Contact tracing via smartphone applications is expected to be of major importance for maintaining control of the COVID-19 pandemic. However, viable deployment demands a minimal quarantine burden on the general public. That is, consideration must be given to unnecessary quarantining imposed by a contact tracing policy. Previous studies have modeled the role of contact tracing, but have not addressed how to balance these two competing needs. We propose a modeling framework that captures contact heterogeneity. This allows contact prioritization: contacts are only notified if they were acutely exposed to individuals who eventually tested positive. The framework thus allows us to address the delicate balance of preventing disease spread while minimizing the social and economic burdens of quarantine. This optimal contact tracing strategy is studied as a function of limitations in testing resources, partial technology adoption, and other intervention methods such as social distancing and lockdown measures. The framework is globally applicable, as the distribution describing contact heterogeneity is directly adaptable to any digital tracing implementation.

Methicillin-Resistant Staphylococcus aureus Prevalence Among Healthcare Workers in Contact Tracings in a Dutch Hospital

Background: In The Netherlands, the national guidelines on Methicillin-Resistant Staphylococcus aureus (MRSA) prevention and control advocate screening of healthcare workers (HCWs) after unprotected exposure to MRSA carriers. Although this strategy is largely successful, contact tracing of staff is a time-consuming and costly component. We evaluated our contact tracing policy for HCWs over the years 2010–2018. Methods: A retrospective, observational study was performed in a Dutch teaching hospital. All HCWs who had unprotected contact with an MRSA carrier were included in contact tracing. When there had been a long period of unprotected admission prior to an MRSA finding, or when the index case was an HCW, the entire (nursing) team was tested. All samples of HCWs who were tested for MRSA carriage as part of contact tracing from 2010 until 2018 were included. A pooled nose, throat, and perineum swab was collected using the eSwab medium (Copan) and inoculated on chromID MRSA agar plates (bioMérieux) after enrichment in a broth. Molecular typing was performed using multiple-locus variable number of tandem repeat analysis (MLVA). Results: In total, we included 8,849 samples (range, 677–1,448 samples per year) from 287 contact tracings (range, 26–55 contact tracings per year). Overall, 32 HCWs were colonized with MRSA (0.36%; 95% CI, 0.26%–0.51%). None of them developed a clinical infection. Moreover, 8 HCWs (0.10%; 95% CI, 0.05%–0.19%) were colonized with the same MLVA type as the index case and were detected in 6 of 287 contact tracings (2%). In 4 of 8 of these cases, a positive HCW was the index for undertaking contact tracing. In 3 of 8 cases, it was clear that the HCW who was identified in the contact tracing was the source of the outbreak and was the cause of invasive MRSA infections in patients. Notably, a different MLVA type as the index case was found in 24 HCWs (0.27%; 95% CI, 0.18%–0.40%) of whom 7 of 24 HCWs (29.2%) were intermittent carriers. Conclusions: This study revealed a sustained low MRSA prevalence among samples in contact tracing of HCWs over 9 years. Furthermore, it shows that when MRSA contact tracing is performed according to the national guideline, only 1 of 1,000 samples results in a secondary case. This is similar to the population carriage rate of MRSA in The Netherlands. More frequently, an unrelated strain is found. These findings raise questions regarding the efficacy of the current strategy to perform contact tracing after unprotected exposure.Funding: NoneDisclosures: None

Global Utilization of ICT Services in the Fight against COVID-19: The Gains and Way Forward for the Nigerian Economy

The increasing number of COVID-19 cases around the world has subsequently triggered surge in the demand for Information and Communication Technology (ICT) to give “life” to the global economy and keep people together despite the physical separation as a result of the lockdown policy of various countries. This paper has studied the essential support provided by ICT in the global action taken to contain the spread of the COVID-19 pandemic with specific focus on the gains and opportunities for Nigerian economy afterward. It considered the role ICT has played in enabling health experts to share their experiencing and collaborates on medical research findings in the fight against COVID-19. The social care supports through the use of social media platforms, machine learning systems, and others provided by ICT to keep people safe and sustain social distance and contact tracing policies of the various governments and their agencies were considered. The use of ICT tool in by world governments and their respective agencies to raise fund, hold meetings and strategise in winning the fight against the pandemic has been considered. With the use of ICT, remote teaching and learning as well as job interviews and business were sustain activities via online interaction and thereby enabling the educational sector and the global market to be relatively busy and lively. The Nigerian economy also recorded significant gains by leveraging ICT sector especially the contribution of the market to the GDP during the first quarter of the year. The gains achieved notwithstanding, Nigerian government and stakeholders in the ICT sector should implement policies to encourage its population to embrace digital economy as the normal way of life around the world. It should also ensure to grow the ICT market of the country to reduce over dependent on imported parts and other technologies by sincerely pursuing, encouraging and supporting Research and Development (R&D) by collaborating with Universities to fund postgraduate educations especially in the field of science and engineering.

Impact of Type and Timeliness of Public Health Policies on COVID-19 Epidemic Growth: Organization for Economic Co-Operation and Development (OECD) Member States, January – July 2020

Background: As of 21 September 2020, 31.1 million cases and more than 961.000 deaths from SARS-CoV-2 have been reported worldwide. In the absence of a treatment or vaccine and in the light of a possible second wave of infections, it is crucial to determine which policies are effective in controlling the SARS-CoV-2 epidemic. We estimated the effect of a comprehensive and systematic set of public health policies on the growth rate in the number of SARS-CoV-2 cases across the 37 member states of the Organisation for Economic Cooperation and Development (OECD) for the period January 1 - July 1 2020.Methods: We conducted a longitudinal analysis using a multilevel growth model. The dependent variable was the average daily growth rate in weekly SARS-CoV-2 cases, the policy regressors were ordinal variables of the intensity of the following: school closing requirements, workplace closing requirements, public events cancelling requirements, restrictions on gatherings, public transport restrictions, stay at home requirements, restrictions on internal movement, international travel controls, public health information campaigns, mask wearing requirements, testing policy and contact tracing policy. We used both maximum likelihood and Bayesian estimation to fit the model.Findings: Restrictions on gatherings, mask wearing requirements, school closing requirements, work closing requirements and total number of tests per thousand population were, in that order, significant predictors of SARS-CoV-2 epidemic control.Interpretation: These findings provide evidence to support policy decision-making regarding which policies to maintain or (re-)initiate in order to control the current spread of the epidemic and any future surge of COVID-19.Funding Statement: None.Declaration of Interests: All of the co-authors of this paper declare that we have no competing interests.

Epidemiology of human influenza A(H7N9) infection in Hong Kong.

We conducted a case series study to review the epidemiology of human influenza A(H7N9) infection reported in Hong Kong. We reviewed case records of confirmed human cases of influenza A(H7N9) infection reported in Hong Kong in the 2013-2014 winter season. We compared the median viral shedding duration and interval from illness onset to initiation of oseltamivir treatment between severe and mild cases. We estimated the incubation period of influenza A(H7N9) virus from cases with a single known date of poultry exposure. A total of 10 cases were reported and all were imported infection from Mainland China. Four patients died and the cause of death was related to influenza A(H7N9) infection in two patients. The median interval from illness onset to initiation of oseltamivir treatment for the severe cases (4.5 days) was significantly longer than the mild cases (2 days; p=0.025). Severe cases had a significantly longer viral shedding duration than mild cases (p=0.028). The median incubation period for cases with a single known exposure date was 4 days. Nasopharyngeal aspirate taken from the 88 close contacts of the 10 patients all tested negative for influenza A virus using reverse transcription polymerase chain reaction. Delayed administration of antiviral treatment may be associated with a more severe illness for influenza A(H7N9) infection. Despite our aggressive contact tracing policy with laboratory testing of all close contacts, no secondary case was identified which implied that the potential of human-to-human transmission of the circulating influenza A(H7N9) virus remains low.

Institutional preparedness for infectious diseases and improving care

The experience of the 2015 Middle East respiratory syndrome outbreak in the Republic of Korea showed greater impact on healthcare institutions as compared to the previous epidemic in the Middle East in 2012. However, the Middle East respiratory syndrome coronavirus was biologically identical to that of 2012, without evidence of a mutation that would account for increased transmissibility. Due to the higher population density of Korea and lower medical costs, Korean hospitals are usually crowded with high numbers of both inpatients and outpatients, who function as a reservoir for intra-hospital transmission. The fact that the patient referral system between smaller and larger hospitals is very active and efficient in Korea was one reason for high inter-hospital propagation of the Middle East respiratory syndrome outbreak. To prepare for a future epidemic in Korea, an improved contact tracing policy, improved public hospital facilities for critical care of severe infections, and pre-emptive isolation for unknown respiratory infections should be emphasized.