Archives of Medicine and Health Sciences

REVIEW ARTICLE
Year
: 2020  |  Volume : 8  |  Issue : 2  |  Page : 240--246

A comprehensive review of COVID-19 pandemic and community mitigation strategies


Tabrez Uz Zaman1, Hamed Ademola Adetunji2, Shamim Mohammed3, El Fadil Mohammed Salih2, Tariq Sultan Pasha4, Moath Alsolami5,  
1 Department of Health Information Technology and Management, Umm Al-Qura University, Makkah, Saudi Arabia
2 Department of Epidemiology, Umm Al-Qura University, Makkah, Saudi Arabia
3 Department of Health Education and Health Promotion, Umm Al-Qura University Medical Centre, Makkah, Saudi Arabia
4 Department of Occupational Health and Safety, Umm Al-Qura University Medical Centre, Makkah, Saudi Arabia
5 Department of Pharmacy, Umm Al-Qura University Medical Centre, Makkah, Saudi Arabia

Correspondence Address:
Mr. Tabrez Uz Zaman
Faculty of Public Health and Health Informatics, Umm Al-Qura University, P.O. Box: 715, Makkah
Saudi Arabia

Abstract

A novel coronavirus with no previous history of causing disease in humans was reported in December 2019 in the Wuhan province of China. Different community prevention and control measures were used globally with varying outcomes to combat this pandemic. It has infected more than twelve million people worldwide and claimed more than half a million lives, the mortality, and morbidity from the disease ever-growing every day. No approved pharmaceutical intervention or vaccine is available till now, thereby requiring assessment of what has worked well to encourage sharing the best epidemiological control practices. This review aims to examine the COVID-19 epidemiology and relate this with the preventive control measures in use globally and evaluate the strategies for community mitigation to cope with the pandemic so far. A literature review comprising 55 articles and reports was undertaken between 2010 and 2020. Findings showed the person-to-person disease transmission and its severity varied among different subgroups of the populations; the elderly, the obese, and individuals experiencing underlying health complications were affected the most. Virus survival ranges from a few hours to 9 days dependent on nature and environmental conditions. Some studies indicated that there is a probability of disease spread from commonly shared toilets and through the semen of the infected patients. Lessons learned and appropriate recommendations were emphasized. It is hoped that the review will be useful to general readers, researchers, decision-makers, and frontline workers to re-examine their approaches while those communities where COVID-19 is just establishing can learn better ways to deal with it.



How to cite this article:
Zaman TU, Adetunji HA, Mohammed S, Salih EM, Pasha TS, Alsolami M. A comprehensive review of COVID-19 pandemic and community mitigation strategies.Arch Med Health Sci 2020;8:240-246


How to cite this URL:
Zaman TU, Adetunji HA, Mohammed S, Salih EM, Pasha TS, Alsolami M. A comprehensive review of COVID-19 pandemic and community mitigation strategies. Arch Med Health Sci [serial online] 2020 [cited 2021 Mar 8 ];8:240-246
Available from: https://www.amhsjournal.org/text.asp?2020/8/2/240/304714


Full Text



 Introduction



Coronaviruses are enveloped, single-stranded RNA viruses that are distributed extensively among mammals, birds, and humans, but the present novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is not known to cause illnesses in human beings.[1],[2] Four out of the six identified coronavirus species, namely hCoV-229E, OC43, NL63, and HKU1, are predominant and specifically cause milder respiratory diseases.[3],[4] The other two coronaviruses, known as SARS-CoV and Middle East respiratory syndrome coronavirus, emerged in 2002 and 2012, respectively. On December 31, 2019, several pneumonia patients of unidentified source emerged in the Wuhan city of China, and this was conveyed to the World Health Organization (WHO).[5],[6] On January 7, 2020, the WHO named it as COVID-19 (coronavirus disease 2019) and finally declared a Public Health Emergency of International Concern.[7],[8],[9] As on July 13, 2020, the WHO declared 12,750,275 confirmed cases including 566,355 deaths.[7] Across countries, there are accelerated clinical trials underway to produce a vaccine or a pharmaceutical intervention and the breakthrough expected in the near future. This review explains the epidemiology regarding COVID-19, relates it with the preventive control methods in use globally, evaluates the different strategies for community mitigation to stop the outbreak, and highlights the best practices along with some recommendations.

 Methodology



A literature review consisting of 55 articles and various reports (WHO and Centers for Disease Control and Prevention [CDC]) published between 2010 and 2020 in various computerized databases, authoritative texts, and hand searches was conducted. In this study, the inclusion criteria were to select literature having good scientific quality in English language, items reporting epidemiological characteristics of novel coronavirus 2019 and the numerous community mitigation strategies for detection, management, and preventing the COVID-19 outbreak. A preliminary literature search was undertaken between January and July 2020 which was followed with an update search between July and August 2020.

 Results



Epidemiology of COVID-19

Incidence

COVID-19 cases, found in Wuhan, were linked to people working or visiting the Huanan Wholesale Seafood Market.[2] At some stage initially in the outbreak, few cases created chains of human-to-human transmission that initiated the following community outbreak before robust control measures were implemented. Possibly, the disease spread from Wuhan to different portions of Hubei province and China, explaining a fairly high basic reproductive number (R0) of 1.4–5.7.[2] [Figure 1] shows a comparison between the reproductive rate of COVID-19 and other outbreaks in the past.{Figure 1}

Geographic distribution and case fatality ratio

COVID-19 disease is highly contagious that spreads rapidly and is capable of having a huge impact on economic, health, and societal aspects in any environment. The disease has spread out to over 200 countries globally, affecting > 12 million individuals.[3],[10],[11] Although COVID-19 has affected all the countries, some countries recorded that very high number of deaths are shown in [Figure 2].{Figure 2}

We can measure the level of severity of COVID-19 among the detected cases using the case fatality ratio (CFR) which gives the percentage of individuals who were diagnosed with the disease (COVID-19) and who died from it. Consistent CFRs provide an assessment of the severity or fatalness of any outbreak and were used for evaluating different public health actions that were implemented.

[INLINE:1]

[Figure 3] shows the case fatality rate of the pandemic in different countries across the globe.{Figure 3}

Routes of transmission

COVID-19 transmission is via droplets and fomites if anyone directly comes in contact with a diseased person. The WHO regularly emphasized on handwashing coupled with respiratory hygiene throughout the pandemic.[2] The WHO, therefore, recommended airborne precautions during aerosols generating procedures only.[12]

Viral shedding

Virus replication inside our body and its release into the environment is called viral shedding. Some studies suggest that novel coronavirus 2019 shows high contagiousness when symptoms become worse and there is high viral shedding.[13] It was found that when the early throat swabs were successfully isolated, they contained viral materials in high numbers and indicated possible viral replication in the tissues found in the upper respiratory tract. However, another study led in Germany reported that once the disease onset starts, there is viable viral (particles) shedding for nearly 10 days among patients displaying milder symptoms.[13] The samples showed highly infectious viral load during the initial phase of their illness, peaking 4 days following the symptoms' onset [Table 1]. However, virus RNA was still detected in some samples once the symptoms were over, but no infectious viral particles could be detected after the 8th day from the beginning of the symptoms. It referred to patients having slighter symptoms.[13] Some patients showed fecal shedding, but they are not transmission drivers till now.[14] Traces of virus were discovered in the semen of recovering patients also.[15] [Table 1] lists the COVID-19 disease symptoms.{Table 1}

Period of infectivity

Various studies estimated the exposure and beginning of symptoms dates for patients with COVID-19. One study found that the intermediate time starting from the exposure of an individual to the symptom's onset [Table 1] was 5.1 days, and 97.5% of the individuals became ill between 11.5 days from their exposure.[16],[17]

Susceptibility

Individuals with underlying illnesses pose a larger risk of being infected.[18],[19] Adults are not known to possess any preexisting immunity, and children show a fairly diminished attack rate.[2],[20] A study performed in China on SARS-CoV-2-infected patients found that all the 41 participating patients showed pneumonia and some serious respiratory illnesses.[19] The WHO has issued a nutrition advice, suggesting that a healthy diet with vigorous immune system will be essential for fighting the risks related to infectious diseases and chronic illnesses.[21],[22]

Environmental contamination

Substantial environmental contamination through droplets spread and fecal shedding by SARS-CoV-2 patients suggests that the environment can be likely medium of transmission. [Table 2] presents the survival duration on various surfaces.{Table 2}

Possibility of animal transmission

The WHO-China Joint Mission on COVID-19 signifies the disease as a zoonotic disease with bats as the reservoirs of this novel coronavirus.[2],[10] Few coronaviruses which can infect the animals can sometimes spread to people but rarely. The present COVID-19 outbreak still lacks credible evidence with regard to the source of this new virus.[23] Public health organizations and professionals including various partners at the global arena are trying endlessly for identification of the appropriate source for COVID-19. Recent studies showed that people who get infected but remain asymptomatic can spread COVID-19 also.[23] Therefore, there is presently no evidence, suggesting that animals played a substantial role in the COVID-19 spread.

Diagnostic testing for COVID-19

Testing is a suitable answer to COVID-19 outbreak as no pharmaceutical treatments or vaccines have been approved. There are two types of COVID-19 diagnostic tests, namely viral tests and antibody testing.[24] Viral tests notify us whether current infection exists. The test procedure involves nose and throat swab collection from a patient and subsequently examining the viral genetic footprints. It is termed as “reverse transcription–polymerase chain reaction (RT-PCR) test.” The RT-PCR tests performed for COVID-19 patients are now a recommended protocol from the WHO.

On the other hand, an antibody testing informs us about any previous infections and not necessarily a recent infection because it takes approximately 1–3 weeks to generate antibodies after getting infected.[25] Antibodies are basically proteins and offer protection to our body by fighting infections and provide immunity.

Community mitigation strategies

Community mitigation measures help communities and individuals to slower the spreading of viral respiratory infections.[18] However, each community is special and effective mitigation approaches can differ.[18] The goal of using prevention approaches in communities experiencing local COVID-19 transmission to delay the transmission and to protect people at augmented risks of serious ailments, including elder adults and persons of different ages experiencing underlying health conditions. The guiding principles for measures or strategies in community mitigation as described by the CDC are as below:

Each community is special and effective mitigation strategies can differ based on the level of information transmission, neighborhood and population dynamics, and local capacity to enforce strategiesConsider all societal facets that can be impacted, including communities most vulnerable to extreme disease and people who may be socially or economically disadvantaged further, and take appropriate behavior. Mitigation techniques may be scaled up or down reliant on the local situationSocieties should consider ways to guarantee the protection and social security of groups that might be specifically impacted by mitigation approaches, including those at elevated risk for serious illness, while designing mitigation plansTriggering neighborhood emergency plans is key to implementing mitigation strategies. Such plans can include additional authorities and coordination required to implement the interventions [Table 3]Local as well as state public health organizations or agencies need to incorporate prevention approaches for public health functions to classify cases and monitor connections, based on population distribution. If implemented, community prevention initiatives may help promote public health practices such as tracing contacts.{Table 3}

The above strategies of community mitigation discussed in [Table 3] above hold much significance because they help to control the disease thereby decreasing the cases' numbers and deaths. This can be attributed to delay in practicing strategies for community mitigation or totally not implementing any strategies of community mitigation in some countries. Flattening the curve requires implementing community mitigation strategies at the most primitive stage to control the acceleration of COVID-19. We have seen the skyrocketing COVID-19 cases and deaths in China, the US, Italy, Spain, the UK, France, and the Gulf countries. The international community understands that the conditions and incidents in China display that quarantine, isolation, and social distancing measures of infected people can control the epidemic.[2],[27] This COVID-19 impact and response in China are encouraging for other countries where the disease was spreading fast.[27]

Contact tracing – it involves contact identification, contact listing, and contact follow-ups of those persons found in near contact with the infected person[2],[16]Quarantine – it restricts and separates the people's movement, to find whether any person who was exposed to any transmissible disease falls sick[30],[31]Isolation – separating sick individuals with any communicable disease from persons who don't fall sick[2],[16]Cancellation of any events that has the capacity to spread the disease rapidly[26],[31]Use and practice of different social distancing procedures for reduction in close and direct contact among people in communities[28],[31]Complete travel restrictions and lockdowns[27],[29],[46]Voluntary home-based quarantine for members of household contacts[2],[27]Deviations to funeral services to curtail crowd size[26],[27]Wartime strategies[39],[40],[41],[42],[43]Telehealth[29],[45]Closure of schools[30],[41]Containment or buffer regions/zones – these are restricted zones to comprehend the virus spread[31]Identification of hot spots – places with at least 15 confirmed infections or exponential rise in cases[31]Herd immunity – it is people's percentage in a region who have either been infected with any infectious agent or vaccinated already.[33]

 Discussion



The findings in this present review suggest that the prevention approaches adopted by régimes in numerous countries would be a fruitful deterrent until vaccines or treatments are discovered. Viral testing will help the infected people to receive the needed care and take actions to lessen the virus spreading.[24] The stark difference between SARS and COVID-19 with regard to the RT-PCR test is that throat swabs in the former have provided adequate sensitivity at the mild stages of infection as compared to very less samples tested as positive among Hong Kong's SARS patients.[34] Furthermore, the viral loads varied significantly. Unfortunately, the capacity for testing of COVID-19 is still low in many developing countries with few exceptions such as Taiwan and Vietnam. Other impacted countries such as the USA, the UK, Italy, Spain, Germany, South Africa, South Korea, India, and Indonesia have significantly increased their testing capacities. Scarcity of personal protective equipment for health-care workers also reported worldwide. The WHO's guidelines for COVID-19 laboratory testing suggest that negative results do not rule out the possibility of COVID-19.[35] Some results can be “false negative” which means that there may be some errors. So, it is advisable to repeat the test again after few days to minimize errors. The other issues were demand and supply of PCR testing kits locally and regionally in countries and their quality and efficacy.[36]

In China, measures such as social distancing, quarantine, and isolation of infected populations contained the epidemic to a large extent.[37] The lessons learned and shared by Singapore and Hong Kong during SARS epidemic such as prompt government action and adopting the social distancing procedures by individuals helped controlling the pandemic.[32] Travel makes a very important contribution in the COVID-19 transmission, and the suspension of travel helped to control further virus spread.[29],[38],[39] Wartime strategies in the US like boosting medical supplies production and the usage of the national guards for restricting movement of individuals were enforced to control the spread of COVID-19.[40],[41],[42],[43] Countries such as India, Saudi Arabia, and the US had deferred medical product exports to other countries to first meet the demands inside the country.[42],[43] The use and practice of social distancing actions and measures were undertaken by countries such as the USA, the UK, Italy, Spain, Iran, New Zealand, Saudi Arabia, and the UAE.[30],[31] These include restrictions on mass gatherings. Deviations to funeral services were done to curtail crowd size and prevent exposure to body fluids of the dead persons.[26],[27] Saudi Arabia also adjourned the year-round pilgrimage to Makkah for Umrah.[27],[31] All these measures stopped transmission of respiratory infections and offered some time to the health-care systems to prepare themselves for the pandemic.[26],[27],[29] According to the UNESCO, with regard to education, approximately 70% of the student population globally were impacted due to nationwide closures of educational institutions during the lockdowns.[30],[41],[44] Concepts such as telemedicine and urgent virtual care centers were implemented in countries, namely Saudi Arabia, Singapore, China, Indonesia, and Australia as an alternative.[29],[45] Spain, Italy, the UK, Iran, South Korea, Denmark, Germany, India, and France had employed the most restricted mass quarantines known till now.[46] Some countries started home delivery of essential items to avoid overcrowding in supermarkets and stores.[29],[46] The UK and Sweden also tried to develop herd immunity by not enforcing restrictions in the beginning but, unfortunately, resulted in a spike of cases.[47],[48],[49] New Zealand successfully controlled COVID-19 with no fresh cases reported even in quarantine and isolation facilities managed by the government.[50] Environmental contamination needs to be taken seriously also because the virus survived on different surfaces for different periods [Table 2]. The UK then moved from containing to delay mode, which targets flattening the disease curve and lowering peak mortality and morbidity. Finally, nutraceuticals can be increasingly prescribed by physicians nowadays as prevention to boost the patient's health status and immunity.[51]

 Conclusion and Recommendations



Until successful vaccines or treatments are discovered, regional, and global preparedness by practicing respiratory and hand hygiene, increasing testing facilities, quarantine, and isolation facilities and implementing strategies for community mitigation will help fight this pandemic. Individuals with underlying illnesses stand at a larger risk of receiving the infection. The contagiousness of novel coronavirus 2019 is high when the virus shedding becomes elevated and the symptoms are worse, however, highly infectious viral load appeared during the early phases of the disease also. The intermediate time between exposure and symptoms' onset was approximately 5 days. RT-PCR tests confirm whether current infection exists. People who get infected but showed no symptoms (asymptomatic) can spread COVID-19 also. The practice and use of different social distancing procedures or measures by different countries will delay the disease spread. Current data collections and epidemiological investigation are thus essential portions for evaluating the mitigation strategies' impact, together with clinical research for the best management of extremely ill COVID 19 patients.[52],[53] This pandemic calls for introspection and analyzing the steps that are desired to control the spread of this pandemic.[54],[55]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Weiss SR, Leibowitz JL. Coronavirus pathogenesis. Adv Virus Res 2011;81:85164.
2Report of the WHO-China Joint Mission on Coronavirus Disease; 16-24 February, 2020. Available from: https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf. [Last accessed on 2020 Apr 15].
3Available from: https://www.gov.uk/government/publications/wuhan-novel-coronavirus-background-information/wuhan-novel-coronavirus-epidemiology-virology-and-cl inical-features#epidemiology. [Last accessed on 2020 Apr 15].
4Su S, Wong G, Shi W, Liu J, Lai ACK, Zhou J, et al. Epidemiology, Genetic Recombination, and Pathogenesis of Coronaviruses. Trends Microbiol. 2016;24(6):490-502.
5Q. Li, X. Guan, P. Wu, X. Wang, L. Zhou, Y. Tong, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus–infected pneumonia New England Journal of Medicine 2020;382 no. 13, pp. 1199-1206.
6Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
7Available from: https://covid19.who.int/region/wpro/country/cn. [Last accessed on 2020 May 02].
8Available from: https://coronavirus.jhu.edu/map.html. [Last accessed on 2020 Jul 15].
9Available from: https://www.who.int/dg/spee ches/detail/who-director-general-s-statement-on-ihr-emergency-committee-on-novel-coronavirus-(2019-ncov). [Last accessed on 2020 Mar 30].
10Available from: https://www.who.int/health-topics/coronavirus. [Last accessed on 2020 Apr 03].
11Available from: https://www.bbc.com/news/world-51235105. [Last accessed on 2020 Apr 14].
12Available from: https://www.who.int/gpsc/ipc/en/. [Last accessed on 2020 Apr 03].
13Available from: https://www.medrxiv.org/content/10.1101/2020.03.05.20030502v1.full.pdf. [Last accessed on 2020 Apr 06].
14He X, Lau EHY, Wu P, Deng X, Wang J, Hao X, et al. Temporal dynamics in viral shedding and transmissibility of COVID-19. Nat Med. 2020;26(5):672-675. doi: 10.1038/s41591-020-0869-5.
15Available from: https://www.bionews.org.uk/page_149541. [Last accessed on 2020 Apr 10].
16Available from: https://www.bbc.com/news/health-52493574. [Last accessed on 2020 Apr 17].
17Available from: https://doi.org/10.7326/M20-0504. [Last accessed on 2020 Apr 10].
18Available from: http://www.cdc.gov/COVID19. [Last accessed on 2020 Mar 27].
19Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Feb 15;395(10223):497-506. doi: 10.1016/S0140-6736(20)30183-5.
20Eastin C, Eastin T. Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China: Dong Y, Mo X, Hu Y, et al. Pediatrics. 2020; doi: 10.1542/peds.2020-0702. J Emerg Med. 2020;58(4):712-713. doi:10.1016/j.jemermed.2020.04.006
21Available from: http://www.emro.who.int/nutrition/nutrition-infocus/nutrition-advice-for-adults-during-the-covid-19-outbreak.html. [Last accessed on 2020 Jul 19].
22Available from: https://www.who.int/health-topics/coronavirus. [Last accessed on 2020 Jul 15].
23Available from: https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/animals.html. [Last accessed on 2020 Aug 03]
24Available from: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/testing.html. [Last accessed on 2020 Jul 22].
25Available from: http://www.cdc.gov/COVID19. [Last accessed on 2020 Jul 07].
26Markel H, Lipman HB, Navarro JA, Sloan A, Michalsen JR, Stern AM, et al. Nonpharmaceutical interventions implemented by US cities during the 1918-1919 influenza pandemic. JAMA 2007;298:644-54.
27Rashid H, Haworth E, Shafi S, Memish ZA, Booy R. Pandemic influenza: Mass gatherings and mass infection. Lancet Infect Dis 2008;8:526-7.
28Available from: https://www.arabnews.com/node/1680101/saudi-arabia. [Last accessed on 2020 Jun 21].
29Ebrahim SH, Ahmed QA, Gozzer E, Schlagenhauf P, Memish ZA. BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1066 (Published 17 March 2020)Cite this as: BMJ 2020;368:m1066.
30Cauchemez S, Ferguson NM, Wachtel C, Tegnell A, Saour G, Duncan B, et al. Closure of schools during an influenza pandemic. Lancet Infect Dis 2009;9:473-81.
31Available from: https://www.thehindu.com/news/national/coronavirus-india-identi fies-170-of-its-736-districts-as-covid-19-hotspots/article31350460ece. [Last accessed on 2020 May 15].
32Available from: https://doi.org/10.1016/S0140-6736 (20) 30567-5. [Last accessed on 2020 May 25].
33Available from: https://www.jhsph.edu/covid-19/articles/achieving-herd-immunity-with-covid19.html. [Last accessed on 2020 Jul 30].
34Poon LL, Chan KH, Wong OK, Cheung TK, Ng I, Zheng B, et al. Detection of SARS coronavirus in patients with severe acute respiratory syndrome by conventional and real-time quantitative reverse transcription-PCR assays. Clin Chem. 2004;50(1):67-72. doi: 10.1373/clinchem.2003.023663. PMID: 14709637; PMCID: PMC7108136.
35World Health Organization. Laboratory Testing for 2019 Novel Coronavirus (2019-nCoV) in Suspected Human Cases. World Health Organization. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/testing.html [Last accessed on 2020 Jul 31].
36Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/laboratory-guidance. [Last accessed on 2020 Jul 18].
37World Health Organization. Coronavirus Disease 2019 (COVID-19) Situation Report-44. World Health Organization; 2020. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200304-sitrep-44-covid-19.pdfsfvrsn=783b4c9d_2. [Last accessed on 2020 Mar 30].
38Available from: https://doi.org/10.1016/S0140-6736 (20) 30567-5. [Last accessed on 2020 Apr 16].
39Available from: https://www.nytimes.com/article/coronavirus-travel-restrictions.html. [Last accessed on 2020 Apr 16].
40Government eyes war Powers to Speed Medical ManufacturingAhead of Virus. New York Times; 2020. Available from: https://www.nytimes.com/2020/02/28/us/politics/trump-coronavirus.html. [Last accessed on 2020 Mar 08].
41Schools Close, National Guard Deployed to Help New York SuburbStem Spread of Coronavirus. Washington Post; 2020. Available from: http://www.washingtonpost.comnational/newrochelle-coronavirus-new-york/2020/03/ 10/707f5da6-62f4-11ea-acca-80c22bbee96f_story.html. [Lastaccessed on 2020 May 24].
42Khalid T. Saudi Arabia Stops all Exports of Coronavirus Detection and Prevention Products. Al Arabiya; 2020. Available from: available from: http://english.alarabiya.net/en/News/gulf/2020/03/02/Saudi-Arabiastops-all-exports-of-coronavirus-detection-and-prevention-products.html. [Last accessed on 2020 Apr 21].
43As Coronavirus Disrupts Factories, India Curbs Exportsof Key Drugs. New York Times; 2020. Available from: https://www.nytimes.com/2020/03/03/business/coronavirus-india-drugs.html. [Last accessed on 2020 Apr 04.
44Available from: https://en.unesco.org/covid19/educationresponse. [Last accessed on 2020 May 27].
45Available from: https://www.arabnews.com/node/1666576saudi-arabia. [Last accessed on 2020 Jul 31].
46Available from: https://www.businessinsider.com/countries-on-lockdown-coronavirus-italy-2020-3. [Last accessed on 2020 Apr 23].
47Available from: https://www.nationalgeographic.com/science/2020/03/uk-backed-off-on-herd-immunity-to-beat-coronavirus-we-need-it/. [Last accessed on 2020 Apr 30].
48Available from: https://www.mercurynews.com/2020/05/20/swedish-antibody-study-shows-little-sign-of-herd-immunity/. [Last accessed on 2020 Jul 31].
49Available from: https://www.gpbnews.org/post/mrits-risks-and-politics-swedens-herd-immunity-strategy. [Last accessed on 2020 Jun 25].
50Available from: https://www.rnz.co.nz/news/national/421098/no-new-cases-of-covid-19-in-nz-today-bloomfield-conirms. [Last accessed on 2020 Jul 30].
51Zaman TU, Adetunji HA, Salih EF. Nutraceuticals: A slow transition from preventive to curative healthcare and the perceptions among physicians and patients A study of South Delhi in India. Int J Pharm Sci Res 2017;8:3113-17.
52Ye G, Lin H, Chen L, Wang S, Zeng Z, Wang W, et al. Environmental contamination of SARS-CoV-2 in healthcare premises. J Infect. 2020;81(2):e1-e5. doi:10.1016/j.jinf.2020.04.034.
53Cao B, Wang Y, Wen D, Liu W, Wang J, Fan G, et al. A trial of lopinavir-ritonavir in adults hospitalized with severe Covid-19 N. Engl J Med 2020;382:1787-99.
54Gao J, Tian Z, Yang X. Breakthrough: Chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies. Biosci Trends 2020;14:72-3.
55World Health Organization. Clinical Management of Severe Acute Respiratory Infection when Novel Coronavirus (nCoV) Infection is Suspected Interim Guidance World Health Organization; 2020. Available from: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratoryinfection-when-novel-coronavirus-(ncov)-infection-is-suspected. [Last accessed on 2020 Jun 25].