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a bacterial infection caused by Vibrio Cholerae

transmission primarily due to inadequate access to clean water and sanitation facilities

primary symptoms consist of severe diarrhea and dehydration

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ports were already closed the year before the first case in the Philippines

deployment of civilian and military troops

mobilization of civilian and military personnel

sent residents of Farola to detention camp

quarantine measures that were proven to be ineffective

military offensives that focuses on disinfection, isolation, and treatment

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Despite having distinct causative agents and symptoms, the fact remains that both Cholera and COVID-19 caused chaos and lasting impacts on the country

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viral respiratory illness caused by SARS CoV-2

transmission primarily due to respiratory droplets

primary symptoms consist of fever, cough, difficulty breathing, fatigue, and loss of taste or smell

has higher rate of transmission compared to cholera

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Travel restrictions were implemented as early as January 28, 2020

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Travel restrictions were implemented as early as January 28, 2020

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Following initial COVID-19 cases and deaths, the government implemented contact tracing and enforced further travel restrictions, including a mandatory 14-day quarantine and testing for individuals arriving from banned countries.

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University classes and work were suspended on March 09, 2020

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University classes and work were suspended on March 09, 2020

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After the Department of Health reported the first case of local transmission of the virus, President Rodrigo Duterte announced the suspension of classes in all levels in the National Capital Region. Following this statement, other municipalities and private institutions also declared class suspensions from March 9 to 11 or 14.

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Enhanced Community Quarantine was described as instruction to government agencies to ensure:

1. prohibition of public gatherings and implementation of home quarantine for all household

2. executive branch will implement a work from home policy

3. only essential businesses will be allowed to open and operate

4. mass public transport will be suspended

5. travel by land, air, and sea will be restricted

6. development of programs to assist affected businesses and workers

Lastly, the then Presidential spokesperson, Panelo, clarified that the directive is not a total lockdown since marketplaces and essential businesses would remain open to ensure adequate food supply.

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When comparing the two pandemics, communication technology advancement is a critical factor. In 2020, the COVID-19 response was enhanced by the faster dissemination of knowledge and scientific understanding brought about by the greater accessibility and availability of communication, which resulted in a more evidence-based approach compared to Cholera contamination response in 1902. This highlights the requirement of using modern technology and resources to address growing health threats and highlights the evolution of public health strategies as well as the significant impact of technological advancement in enhancing the effectiveness of pandemic response operations.

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Established hospitals for cholera patients

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Established hospitals for cholera patients

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Due to different care given and environment available, the hospital only increased inequalities in care based on social class and race

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The Board of health initially mandated that cadavers must be placed in airtight metal caskets. Eventually, burial in simple wooden coffins placed in lime-filled graves were allowed.

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This government order mandates the burning of "infected" nipa houses and disinfecting wooden houses in affected areas

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In contrast to the cholera pandemic, the COVID-19 response in the Philippines focused on a comprehensive strategy that included extensive testing, contact tracing, and quarantine measures to contain the virus. Efforts were made to shift the emphasis from hospitalization to community-based treatment and assistance in order to alleviate pressure on healthcare facilities and tackle socio-economic inequalities. Public health initiatives during the COVID-19 pandemic focused on public education, mask regulations, and social distancing rules to encourage

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The pandemic was primarily handled by American authorities and health care workers

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Support during the cholera epidemic under American colonization was mostly limited to the governing country. On the other hand, during the COVID-19 pandemic, the Philippines, as a United Nations member with several foreign allies, received significant financial assistance, vaccine contributions, and personal protective equipment. This emphasizes the significance of collaborative cooperation in addressing health emergencies.

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United States of America donated P 14.8 million worth of PPE in July 2020

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United States of America donated P 14.8 million worth of PPE in July 2020

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The United States, in collaboration with the Defense Threat Reduction Agency (DTRA) and the U.S. Agency for International Development (USAID), is providing Php14.8 million ($300,000) worth of regionally-produced personal protective equipment (PPE) to the Philippine General Hospital and COVID-19 treatment facilities in the Philippines.

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WHO donated P174 million worth of PPE in October 2020

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WHO donated P174 million worth of PPE in October 2020

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The World Health Organization (WHO) sent $3.1 million worth of personal protective equipment (PPEs), including 230,900 gowns, 405,000 KN95 masks, 187,800 face shields, 159,540 goggles, 489,000 pairs of gloves, and 1,600,000 surgical masks.

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China donated P2 million worth of Sinovac vaccines in March 2021

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Updated: March 24, 2021 10:16 Xinhua

MANILA - The second batch of Sinovac vaccines donated by China arrived in the Philippines on March 24 amid the rapid surge of COVID-19 infections in the Southeast Asian country.

Chinese Ambassador to the Philippines Huang Xilian turned over the vaccines to the Philippines.

Health Secretary Francisco Duque said the Philippines is "grateful for the arrival of additional donated vaccines."

"The arrival of these vaccines could not have occurred at a more opportune time considering the continued rise in cases, which in turn increases the need to inoculate more high-risk individuals as soon as possible," Duque said.

Vaccine czar Carlito Galvez said the arrival of the additional CoronaVac vaccines "is a testament that when all nations are working together, we can surmount any challenges ahead."

"The Philippine government will continue to strengthen its collaboration with China to put an end to this pandemic finally," Galvez added.

China delivered a first batch of donated Sinovac vaccines to the Philippines on Feb 28. China is the first country to provide COVID-19 vaccines to the Philippines, allowing the Southeast Asian country to kick off its vaccination program.

The Philippines now has 677,653 confirmed COVID-19 cases, including 12,992 deaths.

The Philippines has approved the emergency use for Sinovac vaccines, along with the vaccines made by Pfizer, AstraZeneca, and Russia's Sputnik V vaccines.

The government aims to inoculate up to 70 million Filipinos this year to achieve herd immunity, starting with health care workers, the elderly, and the poor communities. The Philippines has about 110 million population.

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2nd batch of Sinovac vaccines donated by China arrives in Philippines

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The second batch of Sinovac vaccines donated by China arrived in the Philippines on March 24 amid the rapid surge of COVID-19 infections in the Southeast Asian country.

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United States of America donated over 1.6 million doses of Johnson & Johnson’s Janssen vaccine in July 2021

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16 July 2021, Manila - The Philippines received today an initial delivery of over 1.6 million doses of Johnson & Johnson's Janssen vaccine donated by the United States (US) Government through the COVAX Facility. A second delivery, expected to arrive on 17 July 2021, will complete the donation of around 3.2 million doses.

The deliveries are part of global vaccine-sharing strategy by the US Government, which aims to provide at least 80 million vaccine doses to countries most affected by the pandemic.

"These vaccines from the COVAX facility would be given to our senior citizens who are at risk for severe COVID-19 and deaths. These single-dose vaccines would help fully vaccinate more of our lolos and lolas and increase coverage among the A2 priority group. By fully vaccinating them, we could hopefully reduce hospitalization and decongest our hospitals. Kaya naman po inaanyayahan ko ang ating mga lolo at lola na magpabakuna na laban sa COVID-19," said Secretary of Health Francisco T. Duque III.

As of July 14, around 10 million Filipinos have received the first dose of the COVID-19 vaccine, and 4 million have completed two doses. However, the vaccination coverage among the A2 priority group - the senior citizens - remains lagging at 31% coverage for the first dose.

The additional COVID-19 vaccines are expected to urgently fill in the supplies needed to vaccinate the vulnerable and at-risk populations, especially the elderly and those living in geographically-isolated and disadvantaged areas (GIDA). The J&J vaccines can be stored using conventional vaccine storage equipment for routine vaccines, enabling the supplies to be distributed to far-flung areas, where populations can be fully protected with a single dose.

"WHO lauds the United States Government and its people for heeding the global call for vaccine equity, and for its continuing partnership with the Philippines to save lives and end the pandemic," said Dr Rabindra Abeyasinghe, WHO Representative to the Philippines. "COVID-19 vaccines are lifesaving tools, but with a limited supply, prioritizing the most vulnerable is the most optimal way to save lives. In the Philippines, we need to ramp up our efforts in vaccinating the elderly and those with underlying conditions," added Dr Abeyasinghe.

"UNICEF welcomes this significant commitment from the United States Government. As cases rise around the world, as the virus continues to mutate, and as vaccine availability remains low, sharing immediately available excess doses is an essential stop-gap measure. For UNICEF these doses represent more than just protection-it represents hope for the many children who are still unable to go back to school, hug their friends and family, and simply be children," said Oyunsaikhan Dendevnorov, UNICEF Philippines Country Representative.

To date, the Philippines has received about 10 million vaccine doses from the COVAX Facility.

DOH, WHO, and UNICEF continue to urge local governments to make the best use of available vaccines, while continuing with other preventive measures - wearing of masks, hand hygiene, physical distancing.

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Philippines receives over 3.2M vaccines donated by the US Government through the COVAX Facility

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Joint press statement of the Department of Health, World Health Organization and UNICEF

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The World Bank provides financial assistance worth $600 million in January 2023

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WASHINGTON, January 30, 2023 - The World Bank's Board of Executive Directors approved financing to support the Philippine government's efforts to boost the resiliency and sustainability of its financial sector and strengthen economic recovery from the COVID-19 pandemic.

The US$600-million Philippines Second Financial Sector Reform Development Policy Financing provides continuing support to three policy reform areas including strengthening financial sector stability, integrity, and resilience; expanding financial inclusion for individuals and firms, especially micro, small, and medium enterprises (MSMEs); and catalyzing climate and disaster risk finance to help protect Filipino families from the impacts of climate change and natural disasters.

"Policy actions that strengthen the stability of the financial sector - including banks and insurance companies - will help Filipino families, businesses, and investors withstand financial shocks and enhance their resilience by ensuring that problems in these financial institutions are detected at an early stage without severe disruptions to the economy," said Ndiamé Diop, World Bank Country Director for Brunei, Malaysia, Philippines and Thailand.

Despite continuing progress, only 51 percent of Filipinos aged 15 and above have a transaction account with a financial institution, which is below the East Asia and Pacific regional average of 80 percent. In the bottom 40 percent of the population, only 34 percent of adults have an account. Supporting reforms for financial inclusion or enhancing Filipinos' access to financial services is therefore an important part of this financing operation, according to Diop.

"Financial inclusion can be a key enabler to speed up poverty reduction and strengthen recovery from the pandemic," said Diop. "Filipinos who have accounts with financial institutions like banks will have opportunities to use other financial services, such as credit and insurance, to start and expand businesses, invest in education or health of their children, manage risks, and weather financial shocks, which can improve the overall quality of their lives."

Diop said an equally important part of the new program is developing the catastrophe insurance market in the Philippines to prevent people from falling into poverty following natural disasters. Catastrophe insurance products are designed to protect households, assets, and businesses against natural disasters like floods and earthquakes.

He said increased use of catastrophe insurance will allow the government to focus fiscal resources on supporting people who need them most, for example, through actions such as increasing post-disaster cash transfers and subsidizing insurance premiums for the most vulnerable populations.

To expand access to finance by individuals and firms, the program also supports reforms promoting innovative financial services by harnessing digital technologies, strengthening the framework to build consumer trust in the financial sector, and improving the quality of the credit information infrastructure to support MSME access to finance during the recovery.

Under its strengthening financial sector stability, integrity, and resilience pillar, this DPL series supports reforms aiming to strengthen the legal and institutional framework to improve financial sector oversight and integrity, enhance crisis management and resolution framework in the sector and improve the availability of long-term finance.

Finally, this DPL also supports the financial sector resilience to climate-related shocks by integrating climate and environmental risks in financial institutions' risk management frameworks and mobilizing private sector financing for green investments by encouraging banks to incorporate sustainability principles into their investment activities.

Development policy loans or DPLs provide quick-disbursing assistance to countries undertaking reforms. DPLs typically support policy and institutional changes needed to create an environment conducive to equitable growth as defined by countries' own development priorities.

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World Bank Approves Funding to Support Financial Sector Resiliency and Strengthen Recovery in the Philippines

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WASHINGTON, January 30, 2023 - The World Bank's Board of Executive Directors approved financing to support the Philippine government's efforts to boost the resiliency and sustainability of its financial sector and strengthen economic recovery from the COVID-19 pandemic.

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Mandatory social distancing and use of face mask and face shield

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This act established the Bayanihan to Heal as One Act, declaring a national health emergency throughout the Philippines as a result of the COVID-19 situation.

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High risk areas were placed under ECQ while the rest are placed under GCQ, which was implemented May 1, 2020

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High risk areas were placed under ECQ while the rest are placed under GCQ, which was implemented May 1, 2020

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An Enhanced Community Quarantine (ECQ) was enforced in high-risk geographical locations from May 1 to May 15, 2020. The remainder of the nation was put under a General Community Quarantine (GCQ) to reduce the spread of COVID-19 and avoid overwhelming the healthcare system. Under the GCQ standards, restrictions remain on people's mobility, public transit, and the functioning of some companies.

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Several regions were put under GCQ in June 1 - 15, 2020

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Several regions were put under GCQ in June 1 - 15, 2020

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Pangasinan, Region 2 (Cagayan Valley), Region 3 (Central Luzon), Region 4-A (CALABARZON), National Capital Region (NCR) including Pateros, Region 7 (Central Visayas) including Mandaue City and Cebu City, and Mindanao: Zamboanga City and Davao City have been placed under General Community Quarantine in June 1 - 15, 2020

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NCR, Laguna, Cavite, Rizal, and Bulacan were placed under MECQ effective August 03, 2020

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NCR, Laguna, Cavite, Rizal, and Bulacan were placed under MECQ effective August 03, 2020

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The Modified Enhanced Community Quarantine (MECQ) serves as a transitional phase between (ECQ) and (GCQ). During this phase, many quarantine restrictions are eased, although the public is still advised to remain inside

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Quarantine classifications were adjusted based on COVID 19 epidemiologic in different regions, with gradual easing of restrictions in areas with lower transmission rates

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Department of Education implements distance learning as primary mode of education as schools return in August 2020

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Department of Education implements distance learning as primary mode of education as schools return in August 2020

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The Department of Education (DepEd) mandated the use of blended and remote learning programs as educational methods as face to face classes are still prohibited. DepEd promptly developed a learning continuity plan with several learning platforms to address challenges and concerns in the teaching and learning process.

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National Vaccine Drive against COVID-19 started March 1, 2021

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National Vaccine Drive against COVID-19 started March 1, 2021

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The Philippines initiated its countrywide vaccination campaign against COVID-19 on March 1, 2021, aiming to vaccinate seventy million of its residents by December 2021.

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vaccination campaigns continued, aiming to achieve herd immunity.

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Face masks became optional in both outdoors and indoors effective on October 2022

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Face masks became optional in both outdoors and indoors effective on October 2022

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Face masks become optional in indoor and outdoor settings, except in healthcare institutions, medical transport vehicles, and public transportation by land, air, or sea. Additionally, masks are recommended for the elderly, those with comorbidities, immunocompromised individuals, pregnant women, unvaccinated individuals, and sick individuals.

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WEARING a face mask is now optional both indoors and outdoors after President Ferdinand "Bongbong" Marcos Jr. issued an executive order (EO) relaxing the mask mandate in the country.

The President signed on Friday, Oct. 28, EO 7, "allowing voluntary wearing of of face masks in indoor and outdoor settings, reiterating the continued implementation of minimum public health standards during the state of public health emergency relative to the Covid-19 pandemic."

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It's official: Wearing of face masks indoors, outdoors now voluntary

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WEARING a face mask is now optional both indoors and outdoors after President Ferdinand 'Bongbong' Marcos Jr. issued an executive order (EO) relaxing the mask mandate in the country.

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The Philippines launched its national coronavirus vaccination campaign Monday amid widespread public skepticism and a struggle to procure vaccines.

Dr. Gerardo Legaspi, the director of the state-run Philippine General Hospital in Manila, received the first dose of the CoronaVac vaccine developed by China-based Sinovac Biotech Limited. The doctor's inoculation came just hours after President Rodrigo Duterte greeted the arrival of 600,000 doses of Sinovac donated by Beijing.

The Philippines is the last Southeast Asian nation to receive a COVID-19 vaccine supply. The Duterte administration is aiming to vaccinate 70 million of its citizens, but some public opinion polls have revealed a resistance among a majority of people due to uncertainty over the safety and efficacy of the CoronaVac vaccine.

But Carlito Galvez, who is leading the Philippines' vaccine procurement efforts, urged his compatriots to get the first vaccine that becomes available.

"Let's not wait for the best vaccine. There's no such thing," Galvez said in a speech at the Philippine General Hospital. "The best vaccine is the one that's safe and effective, and arrives early."

But just receiving vaccines has been an issue. An expected shipment of 525,600 doses of the AstraZeneca-Oxford University vaccine that was due Monday has been postponed due to supply problems.

The COVID-19 pandemic has devastated the Pacific archipelago, sickening more than 576,000 people, including 12,318 deaths, the second-highest in the region. President Duterte has vowed to ease some of the restrictions imposed in an effort to boost the Philippine economy once more vaccines are available.

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Philippines Finally Receives First Batch of COVID-19 Vaccine

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The Philippines launched its national coronavirus vaccination campaign Monday amid widespread public skepticism and a struggle to procure vaccines. Dr. Gerardo Legaspi, the director of the state-run Philippine General Hospital in Manila, received the first dose of the CoronaVac vaccine developed by China-based Sinovac Biotech Limited.

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Cholera is an acute diarrhoeal infection caused by ingestion of food or water contaminated with the bacterium Vibrio cholerae. Cholera remains a global threat to public health and an indicator of inequity and lack of social development.

Symptoms

Cholera is an extremely virulent disease that can cause severe acute watery diarrhoea. It takes between 12 hours and 5 days for a person to show symptoms after ingesting contaminated food or water (2). Cholera affects both children and adults and can kill within hours if untreated.

Most people infected with V. cholerae do not develop any symptoms, although the bacteria are present in their faeces for 1-10 days after infection and are shed back into the environment, potentially infecting other people.

Among people who develop symptoms, the majority have mild or moderate symptoms, while a minority develop acute watery diarrhoea with severe dehydration. This can lead to death if left untreated.

History

During the 19th century, cholera spread across the world from its original reservoir in the Ganges delta in India. Six subsequent pandemics killed millions of people across all continents. The current (seventh) pandemic started in South Asia in 1961, reached Africa in 1971 and the Americas in 1991. Cholera is now endemic in many countries.

Vibrio cholerae strains

There are many serogroups of V. cholerae, but only two - O1 and O139 - cause outbreaks. V. cholerae O1 has caused all recent outbreaks. V. cholerae O139 - first identified in Bangladesh in 1992 - caused outbreaks in the past, but recently has only been identified in sporadic cases. It has never been identified outside Asia. There is no difference in the illness caused by the two serogroups.

Epidemiology, risk factors, and disease burden

Cholera can be endemic or epidemic. A cholera-endemic area is an area where confirmed cholera cases were detected during the last 3 years with evidence of local transmission (meaning the cases are not imported from elsewhere). A cholera outbreak/epidemic can occur in both endemic countries and in countries where cholera does not regularly occur.

In cholera endemic countries an outbreak can be seasonal or sporadic and represents a greater than expected number of cases. In a country where cholera does not regularly occur, an outbreak is defined by the occurrence of at least 1 confirmed case of cholera with evidence of local transmission in an area where there is not usually cholera.

Cholera transmission is closely linked to inadequate access to clean water and sanitation facilities. Typical at-risk areas include peri-urban slums, and camps for internally displaced persons or refugees, where minimum requirements of clean water and sanitation are not been met.

The consequences of a humanitarian crisis - such as disruption of water and sanitation systems, or the displacement of populations to inadequate and overcrowded camps - can increase the risk of cholera transmission, should the bacteria be present or introduced. Uninfected dead bodies have never been reported as the source of epidemics.

The number of cholera cases reported to WHO has continued to be high over the last few years. During 2020 323 369 cases, 857 deaths were notified from 24 countries ³. The discrepancy between these figures and the estimated burden of the disease is due many cases not being recorded due to limitations in surveillance systems and fear of impact on trade and tourism.

Prevention and control

A multifaceted approach is key to control cholera, and to reduce deaths. A combination of surveillance, water, sanitation and hygiene, social mobilisation, treatment, and oral cholera vaccines are used.

Surveillance

Cholera surveillance should be part of an integrated disease surveillance system that includes feedback at the local level and information-sharing at the global level.

Cholera cases are detected based on clinical suspicion in patients who present with severe acute watery diarrhoea. The suspicion is then confirmed by identifying V. cholerae in stool samples from affected patients. Detection can be facilitated using rapid diagnostic tests (RDTs), where one or more positive samples triggers a cholera alert. The samples are sent to a laboratory for confirmation by culture or PCR. Local capacity to detect (diagnose) and monitor (collect, compile, and analyse data) cholera occurrence, is central to an effective surveillance system and to planning control measures.

Countries affected by cholera are encouraged to strengthen disease surveillance and national preparedness to rapidly detect and respond to outbreaks. Under the International Health Regulations, notification of all cases of cholera is no longer mandatory. However, public health events involving cholera must always be assessed against the criteria provided in the regulations to determine whether there is a need for official notification.

Water and sanitation interventions

The long-term solution for cholera control lies in economic development and universal access to safe drinking water and adequate sanitation. Actions targeting environmental conditions include the implementation of adapted long-term sustainable WASH solutions to ensure use of safe water, basic sanitation and good hygiene practices in cholera hotspots. In addition to cholera, such interventions prevent a wide range of other water-borne illnesses, as well as contributing to achieving goals related to poverty, malnutrition, and education. The WASH solutions for cholera are aligned with those of the Sustainable Development Goals (SDG 6).

More information on IHR Annex 2

Treatment

Cholera is an easily treatable disease. The majority of people can be treated successfully through prompt administration of oral rehydration solution (ORS). The WHO/UNICEF ORS standard sachet is dissolved in 1 litre (L) of clean water. Adult patients may require up to 6 L of ORS to treat moderate dehydration on the first day.

Severely dehydrated patients are at risk of shock and require the rapid administration of intravenous fluids. These patients are also given appropriate antibiotics to diminish the duration of diarrhoea, reduce the volume of rehydration fluids needed, and shorten the amount and duration of V. cholerae excretion in their stool.

Mass administration of antibiotics is not recommended, as it has no proven effect on the spread of cholera may contribute to antimicrobial resistance.

Rapid access to treatment is essential during a cholera outbreak. Oral rehydration should be available in communities, in addition to larger treatment centres that can provide intravenous fluids and 24 hour care. With early and proper treatment, the case fatality rate should remain below 1%.

Zinc is an important adjunctive therapy for children under 5, which also reduces the duration of diarrhoea and may prevent future episodes of other causes of acute watery diarrhoea.

Breastfeeding should also be promoted.

Community Engagement

Community Engagement means that people and communities are part of the process of developing and implementing programmes. Local culture practices and beliefs are central to promoting actions such as the adoption of protective hygiene measures such as handwashing with soap, safe preparation and storage of food and safe disposal of the faeces of children.funeral practices for individuals who die from cholera to prevent infection among attendees.

Community engagement continues throughout outbreak response with increased communication regarding potential risks, symptoms of cholera, precautions to take to avoid cholera, when and where to report cases and to seek immediate treatment when symptoms appear. The communities should be part of developing programmes to address needs including where and when to seek treatment.

Oral cholera vaccines

Currently there are three WHO pre-qualified oral cholera vaccines (OCV): Dukoral®, Shanchol™, and Euvichol-Plus®. All three vaccines require two doses for full protection.

Dukoral® is administered with a buffer solution that, for adults, requires 150 ml of clean water. Dukoral can be given to all individuals over the age of 2 years. There must be a minimum of 7 days, and no more than 6 weeks, delay between each dose. Children aged 2 -5 require a third dose. Dukoral® is mainly used for travellers. Two doses of Dukoral® provide protection against cholera for 2 years.

Shanchol™ and Euvichol-Plus® have the same vaccine formula, produced by two different manufacturers. They do not require a buffer solution for administration. They are given to all individuals over the age of one year. There must be a minimum of two weeks delay between each dose of these two vaccines. Two doses of Shanchol™ and Euvichol-Plus® provide protection against cholera at least for three years, while one dose provides short term protection.

Shanchol™ is prequalified to be used in a Controlled Temperature Chain, an innovative approach to vaccine management allowing vaccines to be kept at temperatures outside of the traditional cold chain of +2°C to +8°C for a limited period of time under monitored and controlled conditions.

More information on Control Temperature Chain can be found here

Shanchol™ and Euvichol-Plus® are the vaccines currently available for mass vaccination campaigns through the Global OCV Stockpile. The stockpile is supported by Gavi, the Vaccine Alliance.

Based on the available evidence, the August 2017 WHO Position Paper on Vaccines against Cholera states that:

OCV should be used in areas with endemic cholera, in humanitarian crises with high risk of cholera, and during cholera outbreaks; always in conjunction with other cholera prevention and control strategies;

vaccination should not disrupt the provision of other high priority health interventions to control or prevent cholera outbreaks.

More than 100 million doses of OCV have been used in mass vaccination campaigns. The campaigns have been implemented in areas experiencing an outbreak, in areas at heightened vulnerability during humanitarian crises, and among populations living in highly endemic areas, known as "hotspots".

WHO response

In 2014 the Global Task Force on Cholera Control (GTFCC), with its Secretariat based at WHO, was revitalised. The GTFCC is a network of more than 50 partners active in cholera control globally, including academic institutions, non-governmental organisations and United Nations agencies.

Through the GTFCC and with support from donors, WHO works to:

promote the design and implementation of global strategies to contribute to capacity development for cholera prevention and control globally;

provide a forum for technical exchange, coordination, and cooperation on cholera-related activities to strengthen country capacity to prevent and control cholera;

support countries for the implementation of effective cholera control strategies and monitoring of progress;

disseminate technical guidelines and operational manuals;

support the development of a research agenda with emphasis on evaluating innovative approaches to cholera prevention and control in affected countries; and

increase the visibility of cholera as an important global public health problem through the dissemination of information about cholera prevention and control, and conducting advocacy and resource mobilization activities to support cholera prevention and control at national, regional, and global levels.

To strengthen GTFCC support to countries, in 2020 a Country Support Platform ( CSP) was established. The CSP, hosted by the International Federation of Red Cross and Red Crescent Societies (IFRC) provides multisectoral operational support as well as advocacy, coordination, and policy guidance necessary for countries to develop, fund, implement and monitor their NCPs effectively in alignment with the Global Roadmap.

More about the Global Task Force on Cholera Control (GTFCC) and the Country support Platform (CSP)

Ending Cholera: a Roadmap to 2030

In October 2017, GTFCC partners launched a strategy for cholera control Ending Cholera: A global roadmap to 2030. The country led strategy aims to reduce cholera deaths by 90% and to eliminate cholera in as many as 20 countries by 2030.

The Global Roadmap focuses on three strategic axes:

1. Early detection and quick response to contain outbreaks: the strategy focuses on containing outbreaks-wherever they may occur- through early detection and rapid multisectoral response including community, engagement, strengthening surveillance and laboratory capacity, health systems and supply readiness, and supporting rapid response teams.

2. A targeted multi-sectoral approach to prevent cholera recurrence: the strategy calls on countries and partners to focus on cholera "hotspots", the relatively small areas most heavily affected by cholera. Cholera transmission can be stopped in these areas through measures including improved WASH and through use of OCV.

3. An effective mechanism of coordination for technical support, advocacy, resource mobilisation, and partnership at local and global levels: The GTFCC provides a strong framework to support countries to intensify efforts to control cholera, building upon country-led cross-sectoral cholera control programs and supporting them with human, technical, and financial resources.

A resolution promoting control of cholera and endorsing "Ending Cholera: A global roadmap to 2030" was passed in May 2018 at the 71st World Health Assembly.
More about the strategy
Cholera Kits

To ensure efficient and effective deployment of necessary materials for the investigation and confirmation of cholera outbreaks, as well as the treatment of cholera patients, WHO has developed a set of cholera kits.

In 2016, after consultation with implementing partners, WHO revised the cholera kits to better meet field needs. There are 6 kits:

1 for investigation

1 with supplies for laboratory confirmation

3 for treatment at each of the community, peripheral and central levels

1 support kit with logistical materials including solar lamps, fencing, water bladders and taps.

Each treatment kit provides enough material to treat 100 patients. The revised cholera kits are designed to help prepare for a potential cholera outbreak and to support the first month of the initial response.

More about cholera kits

References

(1) Updated global burden of cholera in endemic countries.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4455997/

Ali M, Nelson AR, Lopez AL, Sack D. (2015). PLoS Negl Trop Dis 9(6): e0003832. doi:10.1371/journal.pntd.0003832.

(2) The incubation period of cholera: a systematic review.
https://www.ncbi.nlm.nih.gov/pubmed/23201968
Azman AS, Rudolph KE, Cummings DA, Lessler J. J Infect. 2013;66(5):432-8. doi: 10.1016/j.jinf.2012.11.013. PubMed PMID: 23201968; PubMed Central PMCID: PMC3677557.

(3) Cholera Annual Report 2020 Weekly Epidemiological Record 37 September 2021, Vol 96, (pp 445-460).

(4) Cholera vaccines: WHO position paper - August 2017
http://apps.who.int/iris/bitstream/10665/258764/1/WER9234-477-498.pdf

Weekly Epidemiological Record 25 August 2017, No 34, 2017, 92, 477-500.

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Epidemiol Infect. 2020; 148: e130.

Malahat Khalili, 1, 2,* Mohammad Karamouzian, 1, 3,* Naser Nasiri, 1, ² Sara Javadi, 2, ⁴ Ali Mirzazadeh, 1, ⁵ and Hamid Sharifi 1, ²

Abstract

Our understanding of the Coronavirus disease 2019 (COVID-19) continues to evolve and there are many unknowns about its epidemiology. This study aims to synthesise case fatality rate (CFR) among confirmed COVID-19 patients, incubation period and time from onset of COVID-19 symptoms to first medical visit, intensive care unit (ICU) admission, recovery, and death. We searched MEDLINE, Embase, Google Scholar, and bibliographies of relevant articles from 01 December 2019 to 11 March 2020 without any language restrictions. Quantitative studies that recruited people with confirmed COVID-19 diagnosis were included. Two independent reviewers extracted the data. Out of 1675 non-duplicate studies, 43 were included in the meta-analysis. The pooled mean incubation period was 5.68 (99% confidence interval [CI]: 4.78, 6.59) days. The pooled mean number of days from the onset of COVID-19 symptoms to first clinical visit was 4.92 (95% CI: 3.95, 5.90), ICU admission was 9.84 (95% CI: 8.78, 10.90), recovery was 18.55 (95% CI: 13.69, 23.41), and death was 15.93 (95% CI: 13.07, 18.79). Pooled CFR among confirmed COVID-19 patients was 0.02 (95% CI: 0.02, 0.03). We found that the incubation period and lag between the onset of symptoms and first clinical visit for COVID-19 are longer than other respiratory viral infections including Middle East respiratory syndrome and severe acute respiratory syndrome; however, the current policy of 14 days of mandatory quarantine for everyone potentially exposed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) might be too conservative. Longer quarantine periods might be more justified for extreme cases.

Key words: Coronavirus, COVID-19, epidemiology, pandemic

Introduction

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first identified in a few unusual pneumonia patients linked to the Wuhan seafood wholesale market in China in December 2019 [ 1]. However, it soon grew out of China and the Coronavirus disease 2019 (COVID-19) was declared a pandemic on 11 March 2020, and has been reported in 216 countries, areas, or territories [ 2]. While the epidemic has slowed down in China due to the strict quarantine and preventive regulations, the numbers of COVID-19 patients (i.e. 10021401 as of 28 June, 2020) and confirmed deaths (i.e. 499913 as of 28 June, 2020) are rapidly increasing [ 2] and have surpassed that of other viruses in the coronavirus family with similar genomes to SARS-CoV-2. For example, SARS which emerged in 2003, infected 8098 patients and caused 774 deaths across 29 countries. The Middle East respiratory syndrome (MERS) which appeared in 2012, led to 2494 patients and 858 deaths across 27 countries [ 3- 6]. The healthcare systems in many countries such as the USA, Spain, Italy, France, UK, Turkey and Iran have been overwhelmed and struggling with the soaring number of patients [ 7].

Although our understanding of COVID-19's epidemiology is evolving, it is assumed that SARS-CoV-2 is mainly transmitted via droplets and close contacts with people carrying the virus [ 2]. However, recent reports have also proposed the possibility of the virus being contracted via various surfaces, gastrointestinal transmission [ 8] and potentially airborne exposures [ 2, 9]. Based on the existing evidence, elderly population, those with suppressed immune systems and underlying metabolic, cardiovascular or respiratory diseases are at an increased risk for adverse outcomes; however, recent reports from outside China, point to a considerable risk of severe outcomes among the general adult population (i.e. <65 years old) [ 10, 11].

As we continue to learn more about COVID-19 and its characteristics, there are many unknowns about its epidemiology such as hospitalisation and recovery-related outcomes that are critical for healthcare system preparedness [ 12, 13]. For example, the mean number of incubation days for COVID-19 varies greatly across the existing literature ranging from 2.5 [ 14] to >20 days [ 15, 16]. Our understanding of time from contracting the disease to recovery or death is even more limited. In this systematic review and meta-analysis, we tried to identify the studies that recruited patients diagnosed with COVID-19 and calculate pooled estimates for several epidemiological and clinical outcomes to help provide an overall picture of the epidemiological characteristics of COVID-19. Findings of this study could help inform the ongoing public health and public policy practices across the world.

Methods

The details of inclusion criteria and our analytical approach were designed a priori and are documented in Open Science Framework ( https://osf.io/a3k94/).

Literature search

Following the Systematic Reviews and Meta-Analyses (PRISMA) checklist (see Supplementary Table S1) and the Peer Review of Electronic Search Strategies (PRESS) guideline [ 17, 18], we searched PubMed, Embase and Google Scholar from 1 December 2019 to 11 March 2020 for studies that measured and reported several characteristics of COVID-19 (e.g. incubation period, hospitalisation, death). Search terms were combined using appropriate Boolean operators and included subject heading terms/keywords relevant to COVID-19 (e.g. novel coronavirus, sars-cov2, coronavirus disease). Please see Supplementary Table S2 for our sample search strategy.

Inclusion criteria

Quantitative studies were included in the review if they reported incubation period of of SARS-CoV-2 as well as time from onset of the symptoms to first medical visit, intensive care unit (ICU) admission, recovery (as defined by studies' authors) or death. Studies were also included if they reported the number of deaths among patients with a confirmed COVID-19 diagnosis. Studies were included in the meta-analysis if they provided data on the above-mentioned outcomes along with their standard error and sample size. Case-reports with a sample size of one were removed from the meta-analysis as they did not provide any dispersion estimate. Studies were not excluded based on language, location or measurement method. Given that this study used secondary data and involved no interaction with humans, no ethics approval was required.

Study selection

Two authors (SJ and NN) completed the abstract and full-text screening, independently. The full-texts of citations that met our inclusion criteria or were unclear were screened by two independent reviewers (SJ and NN). Disagreements over the inclusion of studies were resolved through discussion or by arbitration with the senior author (HS). Duplicate records were excluded.

Data extraction

Data were extracted independently by the two authors (SJ and NN) and discrepancies were resolved through discussion or by arbitration with the senior author (HS). Data were extracted on publication date, study type (e.g. cross-sectional, case-series, cohort), location, sample size, as well as patients' age and sex. We also extracted data on exposure history, X-ray and computed tomography scan findings, symptoms and underlying conditions in addition to the main outcomes of interests including the number of deaths among confirmed COVID-19 patients (i.e. case fatality rate [CFR]), incubation period and time from onset of COVID-19 symptoms to first medical visit, ICU admission, recovery, and death.

Statistical analysis

Meta-analysis was performed using STATA's (V.15.1) metan (for numerical variables) and metaprop (for binary variables) commands. The 95% confidence intervals (CI) for binary variables were computed using the exact binomial method. Heterogeneity between the studies was assessed using both the I ² statistic with a cut-off of 50% and the χ ² test with P-value <0.10 [ 19]. As all results turned out to be significantly heterogeneous, we used random-effects models to calculate the pooled point estimate and 95% CI for the CFR, mean time from onset of COVID-19 symptoms to first medical visit, ICU admission, recovery, and death. For the mean incubation period, we estimated 99% CI. We also conducted a random-effects meta-regression using STATA's metareg command to identify the sources of heterogeneity and explored the effect of study-level covariates where data were available (Supplementary Table S3). Meta-regression was considered when there were at least 10 studies included in the meta-analysis [ 20]. A two-sided P-value <0.05 was considered as statistically significant.

Results

Participants and study characteristics

We found a total of 1675 non-duplicate studies, 57 of which were included in the qualitative synthesis and 43 were included in the meta-analysis ( Fig. 1 ). A description of the main characteristics of the included studies is provided in Table 1 . The 57 studies included 27 cross-sectional, one case-control, one retrospective cohort and 28 case series/case report studies with sample sizes ranging greatly from one in case-reports to 58 182 for a study in the Hubei province [ 21]. Inclusion criteria varied greatly across the studies but most study participants were hospitalised patients living or travelling from various provinces in China. Median (range) age of the participants was 46.2 (range: 17 days to 78.5 years) and about 60% were male. Most studies were conducted between January and February 2020. Clinical and epidemiological characteristics of the patients included in the study are presented in Table 2 . Among studies that reported exposure history among their participants, most patients were directly or indirectly traced back to the city Wuhan (e.g. lived in Wuhan or had recently travelled to Wuhan) and the Huanan seafood market in Hubei province, China. Several cases of contracting SARS-CoV-2 through close contacts with family members were also reported across the studies. Frequent CT or X-ray findings included thickened texture of the lungs, bilateral focal consolidation, lobar consolidation, ground-glass opacity, patchy consolidation, and unilateral/bilateral pneumonia. Common symptoms reported across the studies included fever, cough, shortness of breath, and fatigue/weakness. Only 15 studies reported some information about the pre-existing conditions of the patients; most of whom had metabolic and cardiovascular underlying conditions.

Table 1.

First author

Publication date (DD-MM-YY)

Study setting/location

Study type

Sample size

Age; mean/range

Male proportion

Holshue [ 24]

31-Jan-20

USA, Washington

Case-report a

1

35

1.00

Cai [ 27]

4-Feb-20

China, Shanghai

Case-report b

2

7

0.67

26-Feb-20

China, Hubei

Cross-sectional

33 366

NR

NR

China, Other provinces

Cross-sectional

12 264

NR

NR

Outside of China

Cross-sectional

425

NR

NR

Outside mainland China

Cross-sectional

108

NR

NR

Tong [ 73]

17-May-20 c

China, Zhoushan

Case-report

3

33

1.00

Arashiro [ 74]

17-Jun-20 c

Japan, Cruise ship

Case-report

2

31

0.50

Liu [ 75]

17-Jun-20 c

China, Shenzhen

Cross-sectional

365

46.2

0.50

Table 2.

First author

Exposure history

X-ray/CT findings

Symptoms

Underlying conditions

Incubation perioda

Time to first clinical visitb

Time to ICU admission

Time to recovery

Time to death

Death

Chan [ 22]

Family cluster;
History of travel to Wuhan; No contact with animals; Huanan seafood wholesale market in Wuhan.

14.3% Ground-glass lung opacities; 85.7% Pulmonary infiltrates and multifocal patchy ground-glass opacities, especially around the peripheral parts of the lungs

71.4% Fever; 57.1% Cough; 42.9% Generalised weakness;
14.3% Nasal congestion; 14.3%
Sneezing; 14.3% Rhinorrhoea; 14.3% Sore throat; 14.3% Pleuritic chest pain; 28.6% Diarrhoea

28.6% Hypertension;
14.3% Benign intracranial tumour; 14.3% Chronic sinusitis; 14.3% Diabetes

4.5 (0.64)

7.8 (0.74)

NR

NR

NR

NR

Li [ 23]

11.8% Huanan Seafood Wholesale Market;
4.0% Other wet market but not Huanan Seafood Wholesale Market; 15.3% Contact with another person with respiratory symptoms;
49.9% No exposure to either market or person with respiratory symptoms

NR

NR

NR

5.2 (0.74)

9.7 (0.22)

NR

NR

NR

NR

Chen [ 1]

49% Huanan seafood market

25% Unilateral pneumonia; 74% Bilateral pneumonia; 14% Multiple mottling and ground-glass opacity

83% Fever; 82% Cough;
31% Shortness of breath; 11% Muscle pain; 9% Confusion; 8% Headache; 5% Sore throat; 4% Rhinorrhoea; 2% Chest pain; 2% Diarrhoea; 1% Nausea and vomiting; 90% More than one sign or symptom; 15% Fever, cough and shortness of breath

51% Chronic medical illness; 40% Cardiovascular and cerebrovascular diseases;
11% Digestive system disease;
13% Endocrine system disease;
1% Malignant tumour; 1% Nervous system disease; 1% Respiratory system disease

NR

NR

NR

NR

NR

11

Kim [ 26]

Living in Wuhan

Initial X-ray: No infiltrations;
Illness day 8: Chest infiltrates in the right lower lung field;
CT: Illness day 4: Multiple ground-glass opacities in both subpleural spaces

Fever; Chill; Myalgia; Nasal Congestion; Cough; Sputum; Pleuritic chest discomfort; Watery Diarrhoea

Obese (body mass index, 33.4 kg/m ²)

NR

1 (0.0)

NR

13 (0.0)

NR

NR

Cai [ 27]

History of travel to Wuhan;
Familial contacts

X-ray in child: Thickened texture of both lungs; Blurred right inner lung zone and left posterior region of the heart; Without obvious patch shadows

Fever; Cough; Nasal secretions.
Mother of the child: Asymptomatic

NR

NR

2.5 (1.0)

NR

7 (0.0)

NR

NR

Ki [ 30]

34.6% Arrived from Wuhan; 46.2% Close contact; 3.9% History of travel to Japan; 3.9% History of travel to Thailand; 7.7% Attended a conference in Singapore

NR

Mostly fever; Sore throat; Cough; Chill; Fatigue; Muscle pain

NR

3.9 (0.47)
Range: 3-15

NR

NR

13 (0.31)

NR

NR

Huang [ 37]

66% Direct exposure to Huanan seafood market

98% Bilateral involvement;
CT in ICU patients on admission: Bilateral multiple lobular; Subsegmental areas of consolidation

98% Fever; 76% Cough; 44% Myalgia or Fatigue; 28% Sputum production; 8% Headache; 5% Haemoptysis; 3% Diarrhoea; 55% Dyspnoea

20% Diabetes; 5% Hypertension; 15% Cardiovascular disease;
2% Chronic obstructive pulmonary disease; 2% Malignancy; 2% Chronic liver disease

NR

7 (0.15)

10.5 (0.35)

NR

NR

6

Zhang [ 14]

66.7% History of travel to Wuhan; 11.1% History of travel to Xiaogan, Hubei; 11.1% Clinician at 3 hospitals in Beijing;
11.1% Familial transmission

X-ray: 22.2% A little exudation of lung;
CT: 77.8% Multiple ground glass shadows in the lungs; 33.4% Accompanied by consolidation on the basis of ground glass shadows

88.9% Fever; 55.6% Cough; 44.5% Sore throat; 44.5% Fatigue; 11.1% Nasal congestion; 11.1% Tonsil enlargement; 11.1% Rhinorrhoea

11.12% Diabetes

2.5 (0.65)

4.6 (0.85)

NR

NR

NR

NR

Yu [ 42]

Arrived from Wuhan;
Family transmission

CT: Patient 1: Interstitial hyperplasia with infection in both of lungs; Chronic bronchitis; Emphysema; Pulmonary bullae of a lingual segment of the left lung; Pulmonary hypertension in both lungs; Increased heart shadow; Calcification of the aorta and aortic wall.
Patient 2: 2 Ground-glass opacities on the inferior lobe of the right lung

100% Fever; 25% Poor appetite; 25% Dry cough; 25% Chills

Patient 1: Hypertension, Heart disease; Chronic obstructive pulmonary disease

NR

0.5 (2.9)

1 (0.0)

NR

5 (0.0)

1

Wang [ 45]

8.7% were exposed to Huanan Seafood Wholesale Market

CT: 100% Bilateral involvement

98.6% Fever; 69.6% Fatigue; 59.4% Dry cough; 39.9% Anorexia; 34.8% Myalgia; 31.2% Dyspnoea; 26.8% Expectoration; 17.4% Pharyngalgia; 10.1% Diarrhoea; 10.1% Nausea; 9.4% Dizziness; 6.5% Headache; 3.6% Vomiting; 2.2% Abdominal pain

31.2% Hypertension; 14.5% Cardiovascular disease; 10.1% Diabetes;
7.2% Malignancy; 5.1% Cerebrovascular disease; 2.9% COPD; 2.9% Chronic kidney disease; 2.9% Chronic liver disease; 1.4% HIV infection

NR

NR

NR

NR

NR

6

Bai [ 47]

An asymptomatic carrier arrived from Wuhan;
Family transmission

CT: Multifocal ground-glass opacities; Subsegmental areas of consolidation and fibrosis

16% Asymptomatic; Fever; Respiratory symptoms; Sore throat

NR

12.17 (2.06)

NR

NR

NR

NR

NR

Shi [ 49]

38% Direct exposure to Huanan seafood market;
19% Healthcare workers having close contact with patients; 9% Familial transmission;
35% Without any obvious history of exposure

All patients with abnormal CT imaging features; All lung segments can be involved, and 27% predilection for the right lower lobe;
mean number of segments involved: 10.5

73% Fever; 42% Dyspnoea; 22% Chest tightness; 59% Cough; 19% Sputum; 26% Rhinorrhoea; 1% Anorexia; 9% Weakness; 5% Vomiting; 6% Headache; 2% Dizziness; 4% Diarrhoea

11% Chronic pulmonary disease; 12% Diabetes; 15% Hypertension; 4% Chronic renal failure; 10% Cardiovascular disease; 7% Cerebrovascular disease; 5% Malignancy; 9% Hepatitis or Liver cirrhosis

NR

NR

NR

23.2 (0.67)

18.7 (5.7)

3

Yang [ 52]

53.7% Stayed in Wuhan;
3.4% Stay in Hubei province except for Wuhan;
32.9% Contact with people from Hubei province;
10.1% No relation with Hubei province

CT: 3 Involved pulmonary lobes; 6 Involved segments in each patient;
Segment 6 and 10 most involved;
2.1% Segments presented ground-glass opacities; 26.8% Segments presented mixed opacity; 7.2% Segments presented consolidation;
More localised lesions in the periphery rather than the centre of the lung; More patchy lesions than oval lesions

76.5% Fever; 58.4% Cough; 32.2% Expectoration; 1.3% Dyspnoea; 3.4% Muscle pain; 8.7% Headache; 14.1% Sore throat; 3.4% Snotty; 3.4% Chest pain; 10.7% Chest tightness; 14.1% Chill; 7.4% Diarrhoea; 1.3% Nausea and Vomiting

18.8% Cardio-cerebrovascular disease; 5.4% Digestive system disease; 6.1% Endocrine diseases; 1.3% Malignant tumour; 0.7% Respiratory system diseases; 2.7% Others

NR

6.8 (5.0)
Median (IQR)

NR

NR

NR

0

Tian [ 54]

40.5% Arrived from; 49.2% Contact with a symptomatic case in the previous 14 days;
67.2% Cluster case

NR

82.1% Fever; 45.8% Cough; 26.3% Fatigue; 6.9% Dyspnoea; 6.5% Headache.

NR

6.7 (5.2)
Median (IQR)

4.5 (3.7)
Median (IQR)

NR

NR

NR

3

Guan [ 55]

43.9% Living in Wuhan;
1.9% Contact with wildlife; 31.3% Arrived from Wuhan; 72.3% Contact with Wuhan residents

X-ray: 20.1% Ground-glass opacity; 28.1% Local patchy shadowing; 36.5% Bilateral patchy shadowing; 4.4% Interstitial abnormalities;
CT: 56.4% Ground-glass opacity; 41.9% Local patchy shadowing; 51.8% Bilateral patchy shadowing; 14.7% Interstitial abnormalities

88.7% Fever; 0.8% Conjunctival Congestion; 4.8% Nasal congestion; 13.6% Headache; 67.8%% Cough; 13.9% Sore throat; 33.7% Sputum production; 38.1% Fatigue; 0.9% Haemoptysis; 18.7% Shortness of breath; 5.0% Nausea or Vomiting; 3.8% Diarrhoea; 14.9% Myalgia or Arthralgia; 11.5% Chills

1.1% Chronic obstructive pulmonary disease; 7.4% Diabetes; 15.0% Hypertension; 2.5% Coronary heart disease; 1.4% Cerebrovascular disease; 2.1% Hepatitis B infection, 0.9% Cancer, 0.7% Chronic renal disease, 0.2% Immunodeficiency

4 (0.02)
Range: 2-7

NR

NR

NR

NR

15

Liu [ 75]

43% Close contact; 51% Arrived from Hubei province; 6% Unknown

NR

NR

NR

6.0 (0.70)
Range: 1-16

3.89 (0.11)

NR

NR

NR

NR

Mean incubation period

The estimated mean incubation period obtained from the included studies and the pooled mean are presented in Figure 2 . Out of the 18 studies included in the meta-analysis, 15 were conducted in China. The pooled mean incubation period was 5.68 (99% CI: 4.78, 6.59) days. Heterogeneity testing ( I ² = 98.4%) revealed notable differences among the included studies in the meta-analysis. Multivariate meta-regression results showed no significant differences in incubation period time by country (China vs. others, Adjusted β = 1.76; P-value = 0.375), age (Adjusted β = −1.16; P-value = 0.151) or male percentage of the participants (Adjusted β = −12.35; P-value = 0.058).

Mean time from onset of symptoms to first clinical visit

The estimated mean number of days from the onset of COVID-19 symptoms to first clinical visit was 4.92 (95% CI: 3.95, 5.90). As shown in Figure 3 , out of the 24 studies included in the meta-analysis, only six were conducted outside China. Heterogeneity testing ( I ² = 98.3%) revealed notable differences among the included studies in the meta-analysis. Multivariate meta-regression results showed no significant differences in time from onset of symptoms to first clinical visit by country (China vs. others, Adjusted β = 1.51; P-value = 0.411), age (Adjusted β = 0.92; P-value = 0.153) or male percentage of the participants (Adjusted β = −2.60; P-value = 0.626).

Mean time from onset of symptoms to ICU admission

The estimated mean number of days from the onset of COVID-19 symptoms to ICU admission was 9.84 (95% CI: 8.78, 10.90), an estimate that was derived from one study in Singapore and two studies in Wuhan, China ( Fig. 4 ).

Mean time from onset of symptoms to recovery

The estimated mean number of days from the onset of symptoms to recovery was reported in seven studies and the resulting pooled mean was 18.55 (95% CI: 13.69, 23.41). Only two studies were conducted in China and the rest were completed in France, South Korea, the UK, Singapore and Japan ( Fig. 5 ).

Mean time from onset of symptoms to death

The estimated mean number of days from the onset of symptoms to death was reported in three studies with a pooled mean of 15.93 (95% CI: 13.07, 18.79). All of the studies were conducted in China ( Fig. 6 ).

Case fatality rate

The estimated CFR among COVID-19 patients was reported in 23 studies; most of which included hospitalised patients, three included ICU patients [ 37, 45, 60], and none included outpatients. The pooled CFR was estimated as 0.02 (95% CI: 0.02, 0.03) ( Fig. 7 ). Heterogeneity testing ( I ² = 97.6%) revealed notable differences among the included studies in the meta-analysis. Multivariate meta-regression results showed a significant difference in CFR by age (Adjusted β = 0.056; P-value = 0.003).

Discussion

We conducted a systematic review and meta-analysis to provide an overview of the epidemiological characteristics of COVID-19 based on the existing evidence as of 11 March 2020. Our findings suggest that COVID-19 has an average incubation period of 5.68 days and there is a lag of 4.92 days from onset of symptoms to the first clinical visit. On average, the symptoms of the patients lasted less than 20 days (18.55 days) before recovery was achieved and the CFR among confirmed COVID-19 patients was 2%, which significantly increased by age. Similar to previous studies [ 77], fever, dry cough, shortness of breath and fatigue were common symptoms among the patients in the included studies. As expected, history of direct or indirect exposure to Wuhan was frequently reported. The most common radiologic findings were bilateral consolidation and pneumonia [ 78, 79].

We found the average incubation period of COVID-19 infection to be less than 6 days which is broadly consistent with previously reported estimates [ 23, 29, 80, 81]. The right tail of the 99% CI of the incubation period for COVID-19 was less than 7 days (6.59). This finding is of particular interest as there are many uncertainties about the incubation period of COVID-19. For example, both the World Health Organization and Centers for Disease Control and Prevention in the USA suggest an incubation period of 2-14 days. However, single outlier cases as long as 19 [ 47], 24 [ 15] or 27 days [ 16] have been reported; estimates that are possibly reflecting a double exposure. Our findings are of particular importance for quarantine-related policies and planning and suggest that the current 14-day quarantine period might be rather conservative. Indeed, we found that except for one small study from China in Anyang city on a cluster of six patients [ 47], all other studies reported incubation periods less than 10.6 days; therefore, a shorter period of 14 days would suffice and almost all people exposed to SARS-CoV-2 would show symptoms within 11 days of their initial exposure. All in all, decisions to modify or keep the existing policies need to weigh the costs of extending active quarantine against the potential or costs of missing a few patients with delayed-onset symptoms.

COVID-19 seems to have a longer incubation period than that of other acute respiratory viral infections such as human coronavirus (3.2 days), influenza A (1.43-1.64 days), parainfluenza (2.6 days), respiratory syncytial virus (4.4 days) and rhinovirus (1.4 days) [ 82, 83]. Furthermore, the median incubation period for SARS has been estimated as 4.0 days in 2009 [ 82], which is considerably lower than what we observed for COVID-19. The longer incubation period of the COVID-19 may be one of the major factors that helps explain its rapid spread in comparison with previous respiratory infection viruses. Other factors contributing to the spread of COVID-19 are the lag between the onset of symptoms and first clinical visit (i.e. 4.92 days) and the high number of asymptomatic COVID-19 patients. These findings suggest that MERS and SARS patients may progress to severe symptoms and respiratory failures [ 84] much faster than most COVID-19 patients [ 85].

In comparison to MERS with a fatality rate of 35.67% [ 86] and SARS with a fatality rate of 11% [ 87], we found COVID-19 to have a much lower CFR (2%) that significantly increased by age (5.6% increase for every 10-year increase). Although this estimate is comparable with previous studies [ 40, 88], it is important to recognise the limitations of calculating fatality rates of COVID-19 while the epidemic is still growing. As most COVID-19 patients remain asymptomatic and may recover without seeking medical care, it is likely that the true CFR among people infected with SARS-CoV-2 could be even lower. On the other hand, the estimated fatality rates reported in most studies need to be interpreted with caution as they are often based on the cumulative number of deaths relative to the number of confirmed cases, while patients who die on a given day have been infected at a much earlier date and this would bias the denominator used to calculate the fatality rate [ 89].

We acknowledge four main limitations of our systematic review. First, our findings are mainly based on studies that recruited patient from clinics and hospitals and therefore, may be biased towards more severe cases. Moreover, our data might be skewed towards early reporting from provinces in China and outcomes might be different in other countries in the Western context. We are, therefore, aiming to update the review as more data become available in the next 12 months to provide more accurate estimates. Second, many studies did not report the study outcomes by subgroups such as age or sex and we could not report group-specific outcomes. Third, we used the mean and the standard error of the incubation period assuming a normal distribution which may have led to the underestimation of the right tail of the distribution. Lastly, given the urgency of the topic and the heterogeneity of the studies included in the review, we did not conduct the risk of bias or quality assessment of the studies. Given the emerging nature of COVID-19 and the observational study design of most of the available evidence, most studies in the review are at a high risk of bias and the quality of existing evidence is relatively low. Nonetheless, our systematic review of literature provides an insightful picture of the epidemiological characteristics of COVID-19 which could inform ongoing public health and public policy decision makings.

Conclusions

Our findings of the epidemiological characteristics of COVID-19 provide important insight into healthcare systems' prevention and planning efforts. The incubation period (i.e. <11 days in most studies) and the lag between the onset of symptoms and diagnosis (i.e. ~5 days) are longer for COVID-19 compared to other respiratory viral infections including MERS and SARS. Current policies of 14 days of mandatory quarantine for everyone potentially exposed to SARS-CoV-2 might be too conservative and longer quarantine periods might be more justified for extreme cases. As effective vaccination or treatment for COVID-19 are yet to be developed, practising the fundamentals of public health and prevention science such as physical distancing and personal hygiene are critical and need to be emphasised and enforced further to reduce the risk of SARS-CoV-2 transmission.

Acknowledgements

Authors did not receive any fund for this study. MK is a member of Pierre Elliott Trudeau Foundation's COVID-19 impact committee and is supported by the Vanier Canada Graduate Scholarship and the Pierre Elliott Trudeau Foundation Doctoral Scholarship.

Data availability statements

All of the data are presented in the paper. The dataset for meta-analysis is available upon reasonable request from the corresponding author (Hamid Sharifi; E-mail: ri.ca.umk@ifirahsh).

Supplementary material

For supplementary material accompanying this paper visit http://dx.doi.org/10.1017/S0950268820001430.

Conflict of interest

The authors declare no competing interests.

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Articles from Epidemiology and Infection are provided here courtesy of Cambridge University Press

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Epidemiological characteristics of COVID-19: a systematic review and meta-analysis

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Our understanding of the Coronavirus disease 2019 (COVID-19) continues to evolve and there are many unknowns about its epidemiology. This study aims to synthesise case fatality rate (CFR) among confirmed COVID-19 patients, incubation period and time from ...

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In recent Memorandum from the Executive Secretary (Office of the President), the opening of classes for Academic Year 2020-2021 will be on October 5, 2020.

In the previous announcement of the Department of Education (DepEd), the opening of classes was initially scheduled on August 24, 2020. They even launched the National Kick-Off Program on " Handang Isip, Handa Bukas! " in preparation for the August 24 opening of classes.

Read Also: DOST Scholarship 2021 | Now Accepting Applicants

Copy of the Memo for October 5 Opening of Classes

[Text] Please be informed that pursuant to the instructions of President Rodrigo Roa Duterte, and as recommended by the DepEd, the opening of classes is deferred to 05 October 2020. In this regard, the DepEd is hereby instructed to ensure that all preparations have been made for the smooth and successful virtual opening of classes for Academic Year 2020-2021.

How about Private Schools?

Based on the latest DepEd Advisory, they clarified that private schools or non-Deped schools that have already started their classes or are scheduled to start classes on August 24 or on other dates ahead of October 5, are allowed to proceed provided they are strictly using only distance learning modalities and there are no face-to-face classes.

Read Also: DepEd Advisory re Opening of Classes for Private Schools

If ever this deferred date will be changed in the future depending on the pandemic situations of our country, we will update you directly via email, just make sure to subscribe to our mailing list below.

School Calendar | SY 2020-2021

October 5, 2020 - First Day of Classes

June 16, 2021 - Last Day of Classes

December 20, 2020 to January 3, 2021 - Christmas Vacation

Source: deped.gov.ph

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DepEd Opening of Classes for Public Schools | October 5, 2020

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In recent Memorandum from the Executive Secretary (Office of the President), the opening of classes for Academic Year...

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A ship carrying cholera landed in Manila from Hong Kong in March of 1902.

The first cholera cases were found soon after the aforementioned vessel arrived in Manila, despite extensive quarantine checks and limitations on incoming boats.

The first cholera cases were found in the Farola neighborhood, which is close to the Pasig River's mouth.

Immediately after that, a global epidemic continued to wreak havoc in the Philippines until February 1904, with an estimated 4,389 fatalities occurring in Manila alone.

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In the case of the Cholera epidemic, despite the precautions taken of inspections and prohibitions, it was still easy for the disease to spread and infect numerous Filipinos living near the Pasig River. On the other hand, the COVID 19 pandemic showed the complacent mindset of the Philippine government as travel restrictions were only implemented after the discovery of the first case of COVID 19 in the Philippines.

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The first COVID-19 case was reported in Manila, Philippines, in January 2020.

In a case study, two Chinese citizens left their home in Wuhan, China and traveled to the Philippines. From January 20 to 25, both of them began to experience fever, coughing, and sore throat symptoms.

One of those affected passed away from COVID-19 in February 2020, which was the first COVID-19 death outside of China.

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In the town of Bauan, the first verified case of cholera infection in Batangas was discovered on May 24.

The outbreak had an extensive effect on the death rates in Laguna, Batangas, and the nearby province of Tayabas by mid-June, even though numerous instances went unreported.

The death toll in Batangas alone was 20,000; these deaths were almost certainly caused by the disheartening and weakening effects of war.

2,340 of the 3,093 individuals who had been affected by the disease would pass away, for an astounding 75% fatality rate, by September 1st.

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For both instances in Cholera and COVID 19, we can observe that the number of cases at the first few months continue to increase and multiply in large quantities. This increasing trend implies that infection control procedures were either not implemented correctly or the virus is extremely contagious and extra caution should be taken.

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As of March 9, 2020, 10 COVID-19 cases have been verified in the Philippines, with 1 fatality reported on February 1, 2020.

As of April 1, 2020, there were 2,311 confirmed COVID-19 cases and 96 fatalities.

As of May 1, 2020, there were 8,772 confirmed cases of COVID-19, including 579 fatalities.

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For the goal of isolation, cholera patients and contacts were handled by nine hospitals and two prison camps.

However, it was insufficient to hold all of the cholera patients.

Despite being bigger than expected with approximately 2,000 citizens, the San Lazaro detention camp had a shortage of the necessary amenities for caring for the people inside.

The infection could be monitored across several facilities.

Every practical step was done to eradicate the virus and stop it from spreading.

However, cholera medication was occasionally hazardous and generally worthless.

Healthcare professionals rely on benzozone, a medication that's been linked to a high death rate, but instead of helping patients' health, it made them more ill.

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Strong inflammation to the skin, eyes, and mucous membranes; toxic if consumed; potent oxidizer; can result in serious burns to the skin; vapor can induce blindness in minutes.

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Filipino hospitals lacked the resources and expertise necessary to lower the death toll, as was widely noted during the COVID 19 pandemic and the cholera outbreak. Both scenarios include an excess of patients compared to the number of medical institutions that can handle the harmed people. Furthermore, medical professionals were unaware that the medicine being given to patients during the cholera outbreak was really having an adverse effect on their health. Rather than lowering the death rate, these variables could have contributed to its rise.

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There were more than forty beds full of individuals who were in a critical state, and additional patients in wheelchairs crowded the corridor.

People pleading for their family members to be accommodated had to be turned away by medical personnel.

57 patients had to be housed in a 50-bed COVID emergency ward.

A 12-hour shift uncovers 13 fatalities.

4–6 fatalities on average each shift

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The cholera patients received experimental medical treatments from American doctors, indicating that neither scientific study nor a scientific foundation supported their treatment strategies.

Instead of depending on a scientific and structural foundation for medical treatment, they were depending on the hope that a medication would eradicate the cholera.

Patients with cholera who lived in homes built with nipa-palm materials had to burn their homes down to eliminate the disease's germs.

Ultimately, the impoverished were unable to replace their homes because they lacked the resources to do so.

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The established policies and procedures are insufficient to provide the right solution for the current issue. We can see that during the cholera outbreak, those in charge of treating the sick administered experimental medications, along with setting fire to dwellings to destroy the pathogenic germs. The COVID-19 outbreak brought to light the Philippine government's complacency and lack of urgency in addressing the problem. Both circumstances call for increased awareness of choices or policies that shouldn't go against morality or human rights as they will determine how far the nation can go in its pursuit for restoration.

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During the COVID-19 pandemic, the Philippines' lack of access to high-quality healthcare services got worse.

In response to the COVID 19 pandemic, the Philippine government has neglected to provide the necessary tools and resources.

According to a University of the Philippines, the main obstacles to the Philippine response to COVID-19 were a shortage of critical care beds and medical personnel, particularly nurses and physicians.

When the pandemic first erupted, the Philippines' healthcare system was already suffering from an insufficient supply of personal protective equipment (PPE), which reportedly led to the deaths of medical personnel

It was only after that the government spent 1.8 billion on PPEs.