What are the latest COVID protocols amid rising cases and hospitalizations?
Experts reveal guidelines around testing, treating, vaccination and masking.
As COVID-19 cases and hospitalizations rise across the United States , many Americans may be wondering how to best keep themselves and their loved ones safe.
In the years since the pandemic began, protocols and recommendations from the Centers for Disease Control and Prevention have been updated as new information and interventions have become available.
ABC News spoke to public health experts about what's the latest to know about vaccine availability, when to test, who should receive treatment and if people should be masking in any situations.
MORE: Why you may want to think twice before throwing out those old at-home COVID tests
"COVID-19 has never really left us," Dr. Graham Snyder, medical direction of infection prevention and hospital epidemiology at the University of Pittsburgh Medical Center said. "There have been ups and downs throughout the pandemic…but with this uptick, we're seeing that steady churn pattern again where there's a mix of variants and the variants are constantly changing and reemerging."
"But the disease itself -- and, for the most part, the impact that the virus has on us -- is much the same as it's been for the last year plus," he continued.
Which vaccines and boosters are available?
The U.S. Food and Drug Administration is soon expected to greenlight updated boosters targeting currently circulating COVID subvariants.
This will be followed by a meeting of the CDC's advisory committee, scheduled for Sept. 12, who will they vote on whether to approve, and the final step will be a sign off from CDC director Dr. Mandy Cohen.
Provided there are no hiccups, this should make the boosters available by mid-to-late September .
Data from Moderna has shown the new boosters offers additional protection against EG.5 and FL.1.5.1 -- which are currently the two most prevalent variants -- and against the newer variant BA.2.86,
The experts have said that most people can wait to get the updated booster but specific groups who are not up to date may want to consider getting vaccinated sooner.
"I've been telling people who are medically vulnerable, older people, if they're not up to date on their vaccines now and there's a chance that they could be exposed to the virus in between now and next week, it's probably best that they get the vaccine that they that they can get today," Dr. Denis Nash, a professor of epidemiology at the CUNY Graduate School of Public Health & Health Policy, told ABC News.
For people who are not up to date who want to receive a primary series first, they can receive either one of three vaccine s, made by Pfizer-BioNTech, Moderna or Novavax.
When should I take a test?
CDC guidelines recommend that people take a COVID test if they are experiencing symptoms or if they were exposed to someone with COVID.
Those with symptoms should take a test right away and those exposed should take a test a full five days after the last interaction with the positive person.
MORE: Biden tests negative for COVID, will wear mask when close to others, White House says
If someone tests positive, they don't need to take a confirmatory PCR test but should stay home and isolate, experts say. They should stay home for five days and can end isolation if they have no symptoms, if symptoms are improving or are fever free for 24 hours without medications.
Those who were positive should wear a mask for 11 days when indoors and around others at-home in public and those exposed should do so for 10 days.
Nash said that if someone has symptoms and they test negative on an at-home rapid test, they shouldn't assume they don't have COVID.
"If your symptoms are persisting, it's possible that it's still COVID and you need to test again a day or two later, just to be sure," he said. "And also, I would add, if it's not COVID, you still might have something that you don't want to spread to your loved ones who might be vulnerable."
Who is eligible for treatment?
Not everybody needs to be treated if they test positive for COVID-19.
Dr. Sarah Hochman, a hospital epidemiologist and infectious diseases physician at NYU Langone Health, said treatment is recommended for those who are at higher risk of severe illness including those who have underlying lung disease, underlying heart disease, are immunocompromised, are very young or aged 65 and older.
There are currently three treatments available , according to the CDC. Two of them -- Paxlovid and Lagevrio -- are antivirals taken orally at home. The third, Velkury (remdesivir), is an IV infusion taken at a healthcare facility for three consecutive days.
However, the CDC and experts stress that these medications should be taken as soon as symptoms start.
"We know these treatments are most effective if they're given earlier in the disease, so it's important as soon as you have symptoms that might be a respiratory virus infection and ask your doctor about treatment," Snyder said.
Should I be masking?
Currently, the CDC only recommends wearing a high-quality mask or respirator if the COVID-19 hospital admission level where someone lives is in the high category and says certain high-risk groups should consider masking.
Hochman said data shows masks are effective at reducing the odds of contracting COVID or spreading it to others, but she believes that people should assess their own risk tolerance when it comes to wearing masks in public.
"I think it's really up to the individual and how much what their comfort level is in potentially either being exposed to COVID or exposing others to COVID," she said. "It's a risk benefit decision that people can make."
MORE: Biden, first lady last together Monday, same day she tested positive for COVID-19
However, Snyder said people should consider masking in high-risk settings, such as being in crowded indoor settings or areas with poor circulation, and in healthcare settings.
"Obviously, in the healthcare setting, it's very particularly important for us to provide a safe setting for people to get care," he said. "We have a different threshold as well for masking in healthcare settings and that's why we're starting to hear reports…about hospitals adopting universal masking, again."
Snyder added, "I don't know if there was one right approach to that. Always in healthcare, we've made an assessment and put in place protection, depending on the level of risk that our community has seen. So, it's understandable that there might be some variation in hospitals adopting or not yet adopting that approach."
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- Published: 23 November 2020
Global strategies and effectiveness for COVID-19 prevention through contact tracing, screening, quarantine, and isolation: a systematic review
- Tadele Girum 1 ,
- Kifle Lentiro 1 ,
- Mulugeta Geremew 2 ,
- Biru Migora 2 &
- Sisay Shewamare 3
Tropical Medicine and Health volume 48 , Article number: 91 ( 2020 ) Cite this article
COVID-19 is an emerging disease caused by highly contagious virus called SARS-CoV-2. It caused an extensive health and economic burden around the globe. There is no proven effective treatment yet, except certain preventive mechanisms. Some studies assessing the effects of different preventive strategies have been published. However, there is no conclusive evidence. Therefore, this study aimed to review evidences related to COVID-19 prevention strategies achieved through contact tracing, screening, quarantine, and isolation to determine best practices.
We conducted a systematic review in accordance with the PRISMA and Cochrane guidelines by searching articles from major medical databases such as PubMed/Medline, Global Health Database, Embase, CINAHL, Google Scholar, and clinical trial registries. Non-randomized and modeling articles published to date in areas of COVID prevention with contact tracing, screening, quarantine, and isolation were included. Two experts screened the articles and assessed risk of bias with ROBINS-I tool and certainty of evidence with GRADE approach. The findings were presented narratively and in tabular form.
We included 22 (9 observational and 13 modeling) studies. The studies consistently reported the benefit of quarantine, contact tracing, screening, and isolation in different settings. Model estimates indicated that quarantine of exposed people averted 44 to 81% of incident cases and 31 to 63% of deaths. Quarantine along with others can also halve the reproductive number and reduce the incidence, thus, shortening the epidemic period effectively. Early initiation of quarantine, operating large-scale screenings, strong contact tracing systems, and isolation of cases can effectively reduce the epidemic. However, adhering only to screening and isolation with lower coverage can miss more than 75% of asymptomatic cases; hence, it is not effective.
Quarantine, contact tracing, screening, and isolation are effective measures of COVID-19 prevention, particularly when integrated together. In order to be more effective, quarantine should be implemented early and should cover a larger community.
Coronavirus disease 2019 (COVID-19) is an emerging infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The novel coronavirus was first identified in December 2019 in Wuhan China, then spread globally within weeks and resulted in an ongoing pandemic [ 1 , 2 , 3 , 4 , 5 ]. Currently, coronavirus is affecting 213 countries and territories around the world. As of 27 May 2020, more than 5.7 million cases and 353,664 deaths were reported globally [ 2 , 3 ]. Thirteen percent of the closed cohorts and 2–5% of the total cohort reportedly died [ 2 , 3 , 4 , 5 ]. The USA, Brazil, Russia, Spain, Italy, France, and the UK are the most affected countries [ 3 , 4 , 5 , 6 , 7 ].
The full spectrum of COVID-19 infection ranges from subclinical self-limiting respiratory tract illness to severe progressive pneumonia with multi-organ failure and death. As evidenced from studies and reports, more than 80% of cases remained asymptomatic and 15% of cases appeared as mild cases with common symptoms like fever, cough, fatigue, and loss of smell and taste [ 2 , 3 , 4 , 5 , 6 ]. Severe disease onset that needs intensive care might result in death due to massive alveolar damage and progressive respiratory failure [ 1 , 4 , 5 , 6 , 7 , 8 ].
The virus transmits through direct and indirect contacts. Person-to-person transmissions primarily occur during close contact, droplets produced through coughing, sneezing, and talking. Indirect transmission occurs through touching contaminated surfaces or objects and then touching the face. It is more contagious during the first few days after the onset of symptoms, but asymptomatic cases can also spread the disease [ 5 , 6 , 7 , 8 ].
Recommended prevention measures was designed based on overcoming the mode of transmissions including frequent hand washing, maintaining physical distance, quarantine, covering the mouth and nose during coughs, and avoiding contamination of face with unwashed hands. In addition, use of mask is recommended particularly for suspected individuals and their caregivers. There is limited evidence against the community wide use of masks in healthy individuals. However, most of these preventive measures are recommended and were not researched well [ 4 , 5 , 6 , 7 , 8 ].
To the extent of our search, there is no systematic review on the preventive aspects and effectiveness of COVID-19 infection through contact tracing, screening, quarantine, and isolation. The findings were inconclusive; in some studies, certain preventive mechanisms were shown to have minimal effects, while in others different preventive mechanisms have better effect than expected. On the other hand, some studies have reported that integration of interventions is more effective than specific interventions [ 2 , 6 , 8 ].
Therefore, we aimed to conduct a comprehensive systematic review through reviewing globally published studies on the strategies and effectiveness of different preventive mechanisms (contact tracing, screening, quarantine, and isolation) developed to prevent and control COVID-19. This synthesized measure will be important to bring conclusive evidence, so that policy makers and other stakeholders could have clear evidence to rely on during decision making.
To support the existing local and national COVID-19 prevention program with tangible evidence, we conducted a systematic review on global strategies for COVID-19 prevention through contact tracing, screening, quarantine, and isolation. We aimed to answer issues related to alternative strategic implementation and effectiveness in the prevention of the disease or death. The following key questions were considered:
Is contact tracing, screening, quarantine, and isolation effective to control the COVID-19 outbreak?
Is there difference in the effectiveness of contact tracing, screening, quarantine, and isolation in different settings?
How and when these strategies should be applied to control the COVID-19 outbreak?
We conducted the review in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidance for reporting of systematic reviews and meta-analyses [ 9 ] and the Cochrane Handbook of Systematic Review [ 10 ] through systematic literature search of articles published to date (June 02/2020) containing information on COVID-19 prevention by contact tracing, screening, quarantine, and isolation. First, a working protocol was developed (but unpublished) and followed in the process.
Eligibility (inclusion and exclusion) criteria for the review
Based on the relevance of the reported evidence for decision making at local, national, and international levels, the papers were selected and prioritized for the review. The relevant outcomes observed in the review were reduction in incidence, transmission, adverse outcome, and cost-effectiveness of COVID-19 prevention through contact tracing, screening, quarantine, and isolation.
Types of studies
Due to the infancy of the epidemic, lack of researches, and ethical concerns, randomized controlled trials were not included. Therefore, we considered non-randomized observational studies and modeling (mathematical and/or epidemiological) studies to supplement the existing evidences.
We included cohort studies, case-control studies, time series, case series, and mathematical modeling studies conducted anywhere, in any area, and in any setting reported in the English language. Whereas, commentaries, letter to editor, case reports, and governmental reports were excluded.
Types of participants
Depending on the type of the research, for each preventive methods, different participants were included. These includes individuals who have had contacts with confirmed or suspected case of COVID-19, or individuals who lived in areas with COVID-19 outbreak, or individuals considered to be at high risk for COVID-19/suspected cases or cases of COVID-19 infection. The number of participants varies according to the individual researches. Individuals who have confirmed other symptomatic respiratory diseases were excluded.
Types of interventions
We included different types of interventions applied specifically or in combination, either voluntary or mandatory and in different settings (facility or community). In comparative studies, the interventions were compared with the non-applied groups or other comparison groups. We excluded interventions other than the aforementioned strategies.
Types of outcome measures
To identify the extent to which these interventions were applied globally and to measure their effectiveness in COVID-19 prevention, we used the following outcome measures: incidence of COVID-19, onward transmission, mortality or other adverse outcomes, and cost-effectiveness. We did not address secondary outcomes such as psychological impacts, economic impacts, and social impacts.
Literature search strategy
A systematic literature search of articles was done by information system professionals and the researchers. Articles published between January 1, 2020, and June 2, 2020, containing information on different prevention strategies such as contact tracing, screening, quarantine, and isolation, and studies assessing their effectiveness were retained for the review. Electronic bibliographic databases and libraries such as PubMed/Medline, Global Health Database, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature; Ebsco), the Cochrane Library, and African Index Medicus were used.
In addition, we searched gray literatures, pre-prints, and resource centers of The Lancet , JAMA , and N Engl J Med . Lastly, we screened the reference lists of systematic reviews for additional source. Combination of the following search terms were used with (AND, OR, NOT) Boolean (Search) Operators.
- Contact tracing
1 or 2 or 3 or 4 or 5 and 6 and 7 or 8 or 9 or 10
Data collection and analysis
Study selection process.
The team screened all the titles and abstracts based on predefined eligibility criteria. Two authors independently screened the titles and abstracts and reached consensus by discussion or by involving a third author. After that, the review author team retrieved the full texts of all included abstracts. Two review authors screened all the full-text publications independently, and disagreements were resolved with consensus or by a third person involvement.
Data extraction and management
Titles and abstracts found through primary electronic search were thoroughly assessed for the possibility of reporting the intended outcome and filtered for potential eligibility. One of the review authors who have experience extracted data from the included studies into standardized tables, and the second author checked completeness. From each eligible research, the following information was extracted based on the preformed format: author information, title, study participants, study design, study setting, type of intervention, length of intervention, year of publication, study duration, eligibility criteria, rate, and effect of intervention measures. For modeling studies, the data extraction items also included the type of model and the data source.
Assessment of risk of bias in included studies
Risk of bias was assessed through evaluating reliability and validity of data in included studies based on the Risk-Of-Bias In Non-randomized Studies - of Interventions (ROBINS-I) tool [ 11 ]. The first author rated the risk of bias, the second author checked the ratings, and the third author was involved in the disagreements. For each studies, the study design, participants, outcome, and presence of bias were assessed based on the eligibility criteria and quality assessment check list. Moreover, all studies with the same participants and outcome were measured using the same standard.
On the other hand, modeling studies were assessed by the International Society for Pharmaco-economics and Outcomes (ISPOR) and the Society for Medical Decision making (SMDM) for dynamic mathematical transmission model tools [ 12 ]. Modeling studies that fulfilled all the three criteria were rated as “no concerns to minor concerns, ” and if one or more categories were unclear, it is rated as “moderate concerns,” and if one or more categories were not fulfilled, we had it rated as “major concerns.”
Data synthesis and analysis
The qualitative data was systematically reviewed and presented in accordance with the Cochrane guide line. We synthesized results from quantitative measures narratively and reported in tabular form. Because of the heterogeneity of the primary studies, quantitative analyses (meta-analysis) were not conducted.
Assessment of the certainty of the evidence
By using the GRADE approach [ 13 ], we graded the certainty of evidence for the main outcomes, reported in standard terms using tables. One of the authors conducted the certainty assessment which consists of assessments of risk of bias, indirectness, inconsistency, imprecision, and publication bias, and then, classified to one of the four categories: a high certainty (estimated effect lies close to the true effect), a moderate certainty (estimated effect is probably close to the true effect), a low certainty (estimated effect might substantially differ), and very low certainty (estimated effect is probably markedly different) from the true effect.
The PRISMA flow diagram for the selected studies in the search process and the eligibility assessment are summarized in (Fig. 1 ). The initial electronic database search led to 1542 potentially relevant citations in the form of a title, abstract, bibliography, and full-text research. After removal of duplicates and initial screening, 125 articles were selected for further evaluation via full-text articles. Of these full-text articles, 103 articles were excluded due to the following reasons: 38 studies reported the prevention of SARS other than COVID-19; 36 have measured prevention measures other than contact tracing, screening, quarantine, and isolation; 19 had inappropriate study designs (commentaries, letters and case reports); and 10 were reviews or protocols. Thus, 22 studies [ 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ] met the inclusion criteria and were included in the systematic review.
Flow chart for study search, selection, and screening for the review
The 22 studies [ 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ] that were retained for the final analysis were published in the period from January 15, 2020, to June 02, 2020, based on participant populations in the following countries: China ( n = 10), UK ( n = 4), USA ( n = 2), Hong Kong ( n = 2), and Netherlands, Japan, France, and Taiwan ( n = 1 from each). The included studies comprised of 9 observational [ 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 ] and 13 modeling studies [ 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ]. With duplicates (repeated count), 3 of the studies assessed the overall prevention strategies [ 21 , 22 , 23 ], 5 assessed the effect of contact tracing [ 14 , 24 , 25 , 33 , 35 ], 2 assessed screening strategies [ 17 , 34 ], 12 assessed the effect of quarantine [ 15 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 ], and 6 assessed the effect of isolation [ 17 , 25 , 26 , 31 , 33 , 35 ]. The sample sizes in the studies varied from hundreds to millions. Four studies were investigated for effect at the health facility level, while the remaining 18 studies explored at the community or national level. Survey characteristics and summary results are described in Table 1 .
Quality (risk of bias) assessment within included studies
Summaries of the risk of bias assessment of non-randomized studies and quality rating of the modeling studies are presented in Tables 2 and 3 , respectively. Two studies [ 14 , 19 ] have low bias due to confounding, eight studies have low bias in selection of participants into the study, and all studies have low bias in classification of interventions. The overall risk of bias is moderate for eight studies and serious for one study. On the other hand, we have no concern for nine modeling studies, and two studies have major concerns.
COVID-19 prevention strategies and effectiveness
The summary result is presented in Table 1 . Among the nine observational studies, three of them assessed COVID-19 transmission with the existing prevention measures at a community level in Taiwan, China, and Hong Kong [ 18 , 19 , 20 ]. The other two studies assessed the effect of escalating prevention measures at health facilities in China and Hong Kong [ 21 , 22 ], and three studies [ 15 , 16 , 17 ] assessed national- and metropolitan-based quarantine strategies and the effect of laboratory-based quarantine in the prevention of COVID-19. The last study evaluated the effect of community-based contact tracing in UK [ 14 ].
The three studies [ 18 , 19 , 20 ] that assessed the overall prevention strategies found out that integration of interventions need to be applied instead of adhering to a single intervention. Cheng [ 18 ] reported that isolating symptomatic patients alone may not be sufficient enough to contain the epidemic. Wang [ 19 ] and Law [ 20 ] also concluded that in intimate contacts the transmission is 40–60%. Preventing contact through different strategies and integration is very important.
Studies conducted on the effect of quarantine [ 15 , 16 , 17 ] found that it can have a massive preventive effect. One of the studies [ 15 ] that assessed the effect of quarantine in different populations and quarantine strategies found that it should be integrated with input population reduction (travel restriction), and the other study [ 16 ] that assessed the effects of metropolitan-wide quarantine on the Spread of COVID-19 in China found that quarantine would prevent 79.27% (75.10–83.45%) of deaths and 87.08% (84.68–89.49%) of infections. Also, the other researcher [ 17 ] evidenced that laboratory-based screenings accomplished within hours can enhance the efficiency of quarantine.
Two studies described infection control preparedness measures in health care settings of Hong Kong and China [ 21 , 22 ]. One of these studies [ 21 ] reported that infection transmission is highly increased within a short period of time and multiplicity of infection prevention strategies were recommended for prevention in health care setups. The other study [ 22 ] also concluded that practicing working shift among professionals working in facilities can be used as strategy to prevent thetransmission of COVID infection.
A study conducted by Keeling et al. [ 14 ] assessed the efficacy of contact tracing for the containment of COVID-19 in the UK. The study evaluated the contact pattern of the community and concluded that rapid contact tracing to reduce the basic reproduction number ( R 0 ) from 3.11 to 0.21 enables the outbreak to be contained. Additionally, it was found that each new case requires an average of 36 individuals to be traced, with 8.7% of cases having more than 100 close traceable contacts.
In this review, we identified 13 modeling studies [ 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ] that assessed the effectiveness of contact tracing, screening, quarantine, and isolation for prevention of COVID-19 in different settings and groups. The simulation was done in individual or group basis and with different assumptions. Most of these studies used a model parameter from Chinese reports.
Three of these researches [ 25 , 26 , 27 ] particularly emphasized on the way how the R 0 can be reduced and the epidemic would be reduced. The simulation by Tang et al. [ 25 ] aimed to estimate the R 0 of SARS-CoV-2 and infer the required effectiveness of isolation and quarantine to contain the outbreak. Their susceptible-exposed-infected-recovered (SEIR) model estimated R 0 of 6.47 and generalized that 50% reduction of contact rate achieved by isolation and quarantine would decrease the confirmed cases by 44%; reducing contacts by 90% also can decrease the number of cases by 65%. The other researcher, Rocklov (27), by using data from the Diamond Princess Cruise ship, concluded that quarantine of passengers prevented 67% of cases and lowered the R 0 from 14.8 to 1.78. Similarly, the reduction of R 0 was achieved from quarantine [ 28 ].
In addition to these, five studies [ 24 , 28 , 30 , 31 , 35 ] which modeled the effectiveness of different public interventions consistently reported that integrated intervention is better than a single intervention. One of these research conducted in the UK [ 24 ] found that combined isolation and tracing strategies would reduce transmission more than mass testing or self-isolation alone (50–60% compared to 2–30%). The other study [ 28 ] also reported that with R 0 of 2.4, a combination of case isolation and voluntary quarantine for 3 months could prevent 31% of deaths. The others also concluded that quarantine should be strict and integrated with contact tracing, screening, and other interventions [ 30 , 31 , 35 ].
Five modeling studies also assessed the effect of quarantine [ 23 , 29 , 32 ], contact tracing [ 33 ], and screening [ 34 ]. All of the studies [ 23 , 29 , 32 ] reported that quarantine has reduced the incidence of infection and shortened the duration of the epidemic. However, the effectiveness depends on the level of integration with other strategies. Similarly, model simulations that assessed the effect of contact tracing and screening reported that the strategies are effective. However, as the report of Hellewell [ 33 ] stated, contact tracing and isolation might not contain outbreaks of COVID-19 unless very high levels of contact tracing are achieved. Similarly, the other researcher [ 34 ] reported that in a stable epidemic, under the assumption that 25% of cases are subclinical, it is estimated that arrival screening alone would detect roughly one-third of infected travelers.
This study aimed to assess the effectiveness of contact tracing, screening, and quarantine and isolation to prevent COVID-19 infection by reviewing existing literatures. The review identified and systematically synthesized the findings of 22 studies (9 observational and 13 modeling studies) [ 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ] to bring the best available evidence that policy makers and implementers can use in the process of infection prevention interventions.
The studies consistently reported the benefit of contact tracing, screening, quarantine, and isolation in the prevention of COVID-19. The effectiveness of quarantine in particular is very high. Compared to individuals without any intervention quarantined people exposed to a confirmed case highly averted infections and deaths [ 15 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 ]. Also, the effectiveness of quarantine increases whenever it is implemented along with other prevention measures such as isolation, contact tracing, and travel ban [ 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 ]. Although, screening and contact tracing are very important to control the epidemic, early initiation, larger coverage, and integration with other programs are very important. Unless the level of contact tracing and screening is high, prevention through isolation only is very limited, as the screening programs misses 75% of cases [ 3 , 24 ].
Quarantine measures applied alone or integrated with other measures were reported to be the most effective measures [ 25 , 26 , 27 , 28 , 29 , 30 , 31 ]. However, integration of quarantine with other public health measures increases the effectiveness and efficiency of the program [ 36 ]. Implementation of early quarantine measures makes the strategy a more cost effective one [ 28 , 30 ]. Quarantine implemented as self-quarantine and group quarantine is effective at varying levels once effectively implemented [ 28 , 32 ]. Total lockdown measures enhance the effectiveness of quarantine measures [ 15 , 16 , 17 , 18 , 19 ]. When laboratory tests are very fast, laboratory-based quarantine could be an effective in health care setups [ 17 ].
This evidence is in line with the finding of other reviews and modeling studies conducted to assess the effectiveness of these measures in the prevention of SARS, MERS, and COVID-19 [ 28 , 35 , 36 , 37 ]. As reported before, combination of case isolation and voluntary quarantine for 3 months could prevent 31% of deaths compared to any single intervention. And adding social distancing on the previous interventions on people aged 70 years or older for 4 months increases the prevention proportion of deaths to 49%. It can also reduce the reproductive number by half; hence, it can tremendously reduce the incidence of infection, reduce the period of epidemic, and enhance effectiveness of control [ 28 , 36 ].
Our findings also witnessed the effectiveness of contact tracing measures used for pandemic response efforts at multiple levels of health care systems. Isolation of suspected and confirmed patients and their contact is at the heart of the prevention strategy. However, for the contact tracing to be an effective measure, it has to be integrated with other measures such as quarantine and screening. Because larger shares of individuals are asymptomatic, contact tracing may be difficult in areas where contact recording is unachievable. According to world health organization, contact tracing is also one of the most essential and effective strategies to control the epidemic [ 14 , 24 , 25 , 33 , 35 ]. Other studies also evidenced the importance of contact tracing and isolation in different settings [ 36 , 37 ].
The finding of our review revealed that screening and isolation are important measures of disease prevention [ 17 , 25 , 26 , 31 , 33 , 35 ]. Most of the researches recommend high-risk group screening and contact cases screening in a resource-limited setting. However, these programs are effective when the screening capacity is higher and contact tracing is effective. Otherwise, screening and isolation programs miss more than half of cases and may not be implemented alone [ 25 , 33 , 35 ]. Also evidences from different countries indicated that screening and isolation measures are implemented along with other measures, yet their role in the prevention of the epidemic is high [ 2 , 3 , 8 , 36 , 37 ].
This review included a wide variety of study designs (observational and model studies); hence, it failed to include meta-analysis (statistical measures). Modeled studies also assume different scenarios, where it may not be true in the general cases. Also, the review has included only publications reported in the English language and open access resources.
Conclusion and recommendation
Quarantine, contact tracing, screening, and isolation are effective measures of COVID-19 prevention, particularly whenever integrated together. In order to be more effective, quarantine should be implemented early and covers larger community. Controlling population travel will enhance the effectiveness of quarantine. Screening, contact tracing, and isolation are effective particularly in areas where contact tracing is easily attainable. Although screening is the effective measure recommended by the WHO, since the disease is asymptomatic, it may miss a larger share of the population. Therefore, this should be integrated with other preventive measures. In order to control the COVID-19 epidemic, the health care system should consider high level of contact tracing, early initiation of nationwide quarantine measures, increasing coverage of screening service, and preparing effective isolation centers.
Availability of data and materials
Please contact author for data requests.
Coronavirus disease 2019
Middle East respiratory syndrome
Severe acute respiratory syndrome
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
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Girum, T., Lentiro, K., Geremew, M. et al. Global strategies and effectiveness for COVID-19 prevention through contact tracing, screening, quarantine, and isolation: a systematic review. Trop Med Health 48 , 91 (2020). https://doi.org/10.1186/s41182-020-00285-w
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COVID-19: Prevention and control measures in community
1 Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine,Yıldırım Beyazıt University,Ankara City Hospital, Ankara, Turkey
2 COVID-19 Advisory Committee of the Ministry of Health of Turkey, Turkey
The authors declare no conflict of interest.
On January 30, 2020, the WHO declared the COVID-19 outbreak a public health emergency of international concern and, in March 2020, began to characterize it as a pandemic in order to emphasize the gravity of the situation and urge all countries to take action in detecting infection and preventing spread. Unfortunately, there is no medication that has been approved by the FDA, gone through controlled studies and demonstrated an effect on the virus for this global pandemic. Although there are cures for illnesses and developments made by leaps and bounds in our day, the strongest and most effective weapon that society has against this virus that is affecting not just health but also economics, politics, and social order, is the prevention of its spread. The main points in preventing the spread in society are hand hygiene, social distancing and quarantine. With increased testing capacity, detecting more COVID-19 positive patients in the community will also enable the reduction of secondary cases with stricter quarantine rules.
In late 2019, a novel coronavirus, now designated SARS-CoV-2, was identified as the cause of an outbreak of acute respiratory illness in Wuhan, a city in the Hubei province of China. In February 2020, the World Health Organization (WHO) designated the disease COVID-19, which stands for coronavirus disease 2019. The clinical presentation of 2019-nCoV infection ranges from asymptomatic to very severe pneumonia with acute respiratory distress syndrome, septic shock and multi-organ failure, which may result in death . On January 30, 2020, the WHO declared the COVID-19 outbreak a public health emergency of international concern and, in March 2020, began to characterize it as a pandemic in order to emphasize the gravity of the situation and urge all countries to take action in detecting infection and preventing spread.
The virus that causes COVID-19 is thought to spread mainly from person to person, mainly through respiratory droplets produced when an infected person coughs or sneezes. These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs. Other routes have also been implicated in the transmission of coronaviruses, such as contact with contaminated fomites and inhalation of aerosols, produced during aerosol generating procedures. Transmission of SARS-CoV-2 from asymptomatic individuals (or individuals within the incubation period) has also been described. However, the extent to which this occurs remains unknown .
Unfortunately, there is no medication that has been approved by the FDA, gone through controlled studies and demonstrated an effect on the virus for this global pandemic. Although there are cures for illnesses and developments made by leaps and bounds in our day, the strongest and most effective weapon that society has against this virus that is effecting not just health but also economics, politics, and social order, is the prevention of its spread. The interim guidance published by the WHO on 7 March 2020, “Responding to community spread of COVID-19,” states that preventing COVID-19 from spreading is through the development of coordination mechanisms not just in health but in areas such as transportation, travel, commerce, finance, security and other sectors which encompasses the entirety of society .
Preventive measures are the current strategy to limit the spread of cases. Early screening, diagnosis, isolation, and treatment are necessary to prevent further spread. Preventive strategies are focused on the isolation of patients and careful infection control, including appropriate measures to be adopted during the diagnosis and the provision of clinical care to an infected patient. Important COVID-19 prevention and control measures in community are summarized in Table.
COVID-19 prevention and control measures in community.
The most important strategy for the population to undertake is to frequently wash their hands and use portable hand sanitizer and avoid contact with their face and mouth after interacting with a possibly contaminated environment. To reduce the risk of transmission in the community, individuals should be advised to wash hands diligently, practice respiratory hygiene (i.e., cover their cough), and avoid crowds and close contact with ill individuals, if possible. There are posters and brochures prepared by many organizations on all issues related to protection from COVID-19 and are widely used all over the world (Figure 1).The WHO and other similar health organizations have published visual tools such as videos and posters to demonstrate the correct application of hand hygiene throughout the entire society (Figure 2).These posters, distributed throughout different parts of society in order to draw maximum attention to the importance of hand hygiene, created awareness among all of them. With the increase in the number of people carrying hand sanitizer with them for the application of instant hand hygiene and the spread of mask usage among people in countries such as China, Korea, and Japan, the pandemic was brought under control much more quickly. In those countries where such measures were not made mandatory, the exponential rise in the number of cases continues.
Poster regarding important prevention measures for COVID-19, prepared by Turkish Ministry of Health.
Poster regarding hand washing, prepared by Turkish Ministry of Health.
Social distancing is advised, particularly in locations that have community transmission. Many countries have installed quarantine and social/physical distancing as measures to prevent the further spread of the virus.
These measures can include:
· The full or partial closure of educational institutions and workplaces,
· Limiting the number of visitors and limiting the contact between the residents of confined settings, such as long-term care facilities and prisons,
· Cancellation, prohibition and restriction of mass gatherings and smaller meetings,
· Mandatory quarantine of buildings or residential areas,
· Internal or external border closures, and
· Stay-at-home restrictions for entire regions or countries.
Personal protective equipment
For people without respiratory symptoms, the WHO does not recommend wearing a medical mask in the community, since it does not decrease the importance of other general measures to prevent infection. The single use of a mask does not obstruct the disease; the improper use of the mask actually increases the risk of COVID-19 infection. In the WHO’s “Advice on the use of masks in the context of COVID-19” interim guidance, the prioritized use of medical masks by health personnel was emphasized .
To reduce COVID-19 transmission from potentially asymptomatic or presymptomatic people, the ECDC recommends the use of face masks . The use of face masks in the community may primarily serve as a means of source control. This measure can be particularly relevant in epidemic situations when the number of asymptomatic but infectious persons in the community can be assumed to be high. Wearing a face mask could be considered, especially when visiting busy, closed spaces, such as grocery stores, shopping centres, etc.; when using public transport; and for certain workplaces and professions that involve physical proximity to many other people (such as members of the police force, cashiers – if not behind a glass partition, etc.) and when teleworking is not possible.
In the United States, the CDC updated its recommendations in early April to advise individuals to wear a cloth face covering (i.e., homemade masks or bandanas) when in public settings where social distancing is difficult to achieve, especially in areas with substantial community transmission . Individuals should be counseled to avoid touching the eyes, nose, and mouth when removing the covering, practice hand hygiene after handling it, and launder it routinely.
The rationale for the face covering is primarily to contain secretions of and prevent transmission from individuals who have asymptomatic or presymptomatic infection. The CDC also reiterates that the face covering recommendation does not include medical masks, which should be reserved for health care workers.
Individuals who are caring for patients with suspected or documented COVID-19 at home should also wear a face cover when in the same room as that patient (if the patient cannot wear a face cover).
Social distancing is designed to reduce interactions between people in a broader community, in which individuals may be infectious but have not yet been identified hence not yet isolated . As diseases transmitted by respiratory droplets require a certain proximity of people, social distancing of persons will reduce transmission. Social distancing is particularly useful in settings where community transmission is believed to have occurred, but where the linkages between cases is unclear, and where restrictions placed only on persons known to have been exposed is considered insufficient to prevent further transmission. Examples for social distancing include closure of schools or office buildings and suspension of public markets, and cancellation of gatherings. In public markets where it is difficult to maintain social distance, limitation of the entered person and encouraging online shopping can reduce the amount of contact.
Workplaces are also one of the high-risk areas for COVID-19 transmission. Therefore, home office working must be encouraged if possible. In workplaces where home office working is not possible, adherence to recommendations of WHO remains quite important .
Studies have been conducted that support the infectiousness of SARS-CoV-2 in the presymptomatic stage; social distancing is thus of critical importance in establishing control over the pandemic.
Quarantine is one of the oldest and most effective tools of controlling communicable disease outbreaks. This public health practice was used widely in fourteenth century Italy, when ships arriving at the Venice port from plague-infected ports had to anchor and wait for 40 days (in Italian: quaranta for 40) before disembarking their surviving passengers. The quarantine of persons is the restriction of activities of or the separation of persons who are not ill but who may been exposed to an infectious agent or disease, with the objective of monitoring their symptoms and ensuring the early detection of cases. Quarantine is different from isolation, which is the separation of ill or infected persons from others to prevent the spread of infection or contamination.
Looking at the available studies in the literature, quarantine is the most effective method in reducing both the number of infected and dead [9,10]. It has been much more effective in countries which initiated strict quarantine rules right from the beginning. In an article quickly published by the Cochrane Library evaluating 29 studies, results indicate that quarantine can reduce the number of infected at rates from 81% to 44%, and in the number of dead from 61% to 31% .
In a mathematical model done on the spread of COVID-19 in Italy, it was shown that without strict quarantine rules the pandemic could not be controlled and that the number of secondary cases increased in proportion to the size of households. According to the simulation, if the household is comprised of 2 people and full quarantine has been put in place, expected secondary cases are 3 within the 14-day period; with a household of 6, this number increases to 16 .
Despite more than 2 months passing after the discovery of the first case in the US, the calls to stay at home put out in 33 states and by many local governments were insufficient. On the other hand, while it was greatly criticized, the quarantine and severe rules applied by China’s central government to people from Wuhan meant that they were able to effectively control the number of cases in states outside of Hubei and that death rates were reduced.
In the influenza pandemic in 1918, the importance of quarantine measures was demonstrated very clearly . The most striking example of this comes from the US–the first case in the city of Philadelphia, Pennsylvania, was observed on September 17, but social restrictions to prevent spread such as reducing crowds in public spaces were instituted on October 3, when there were 40 deaths per every 100,000 people. Unfortunately, the measures instituted after this point were insufficient and by the middle of October, this number reached 250/100,000 people. In contrast, the first case in St. Louis, Missouri, was observed on October 5, social restrictions were instituted on October 7, and both the number of cases and the rate of mortality was kept at low numbers.
The WHO recommends that contacts of patients with laboratory-confirmed COVID-19 be quarantined for 14 days from the last time they were exposed to the patient . For the purpose of implementing quarantine, a contact is a person who is involved in any of the following from 2 days before and up to 14 days after the onset of symptoms in the patient:
· Having face-to-face contact with a COVID-19 patient within 1 meter and for >15 min,
· Providing direct care for patients with COVID-19 disease without using proper personal protective equipment,
· Staying in the same close environment as a COVID-19 patient (including sharing a workplace, classroom or household or being at the same gathering) for any amount of time,
· Travelling in close proximity with (that is, within 1 m separation from) a COVID-19 patient in any kind of conveyance.
Active monitoring of people who are quarantined is one of the important points for controlling the epidemic in the society. There are several mandatory mobile phone applications that control the compliance of people to quarantine in countries such as China, Japan and Korea. In Turkey, with the support of mobile phone operators, all persons who are quarantined are alerted instantly when they move away from their location. Certainly, deterrent fines will also increase compliance with quarantine.
Cleaning and disinfection
High-touch areas such as bedside tables and door handles should be disinfected daily with regular household disinfectant containing a diluted bleach solution (that is, 1-part bleach to 99 parts water). For surfaces that cannot be cleaned with bleach, 70% ethanol can be used. Toilets and bathrooms should be cleaned and disinfected with a diluted bleach solution (one part bleach to 9 parts water to make a 0.5% sodium hypochlorite solution). Disposable gloves should be used when cleaning or handling surfaces, clothing, or linen soiled with body fluids. All used disposable contaminated items should be placed in a lined container before disposing of them with other household waste. Clothes, bed linens, and bath and hand towels should cleaned using regular laundry soap and water or machine washed at 60–90°C with common laundry detergent. Disposable gloves should be used when cleaning or handling surfaces, clothing, or linen soiled with body fluids. All used disposable contaminated items should be placed in a lined container before disposing of them with other household waste.
Increasing testing capacity
Another important point in preventing the spread of the disease throughout society is to increase the number of tests and thus pinpoint more cases, isolate them, and trace those who have been in contact. For this reason, increasing laboratories’ test capacity and developing new testing strategies are of utmost importance. Different methods such as rapid-testing kits, serologic methods and self-collected specimen tests are being used throughout the world to determine cases which in turn help adherence to isolation rules.
In South Korea, which acted quickly to administer free-of-charge and extensive public testing for COVID-19, “drive through testing” was initiated for the first time . The ease of its application, reduction in the number of people who applied to health centres, and the capacity to investigate more people in lesser time appears as a successful strategy. Similar applications based on this model are being instituted in Germany and other countries after South Korea.
Prevention and control measures in Turkey
Several different containment measures were implemented by the Turkish government. These included social distancing, travel restrictions on visitors arriving from high-risk counties, quarantine for nationals returning from high-risk locations, and closure of schools and certain types of workplaces. The government declared on March 12th that all schools including universities were to be closed starting from March 16th.
Turkey put into place several measures to limit movement of people. Citizens 65 years old or older, patients with immune system deficiency, chronic lung disease, asthma, COPD, chronic cardiovascular disease, chronic renal disease, hypertension, chronic liver disease as well as users of drugs that disrupt the immune system were restricted from leaving their homes and using public transportation.
Major containment actions taken are summarized in Figure 3. All ministries published general instructions on COVID-19 prevention and control measures in their organizations . As of April 13, approximately 40,000 tests have been reached per day with a total of 73 authorized laboratories, and the number of performed daily tests is gradually increasing.
Timeline for prevention and control measures in Turkey.
In COVID-19, which has no approved treatment, it is very important to prevent the spread in the society. The main points in preventing the spread in society are hand hygiene, social distancing and quarantine. With increased testing capacity, detecting more positive patients in the community will also enable the reduction of secondary cases with stricter quarantine rules.
Rahmet GÜNER and Firdevs AKTAŞ are the members of the COVID-19 Advisory Committee of the Ministry of Health of Turkey. Rahmet GÜNER and İmran HASANOĞLU are working in the main pandemic hospital, Ankara City Hospital, a 3800-bed hospital with 700 ICU beds.
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COVID-19 vaccines help our bodies develop immunity to the virus that causes COVID-19 without us having to get the illness. [ 4 ]
When we get a vaccine, it activates our immune response. This helps our bodies learn to fight off the virus without the danger of an actual infection. If we are exposed to the virus in the future, our immune system “remembers” how to fight it.
All COVID-19 vaccines, authorized by the U.S. Food and Drug Administration, provide significant protection against serious illness and hospitalization due to COVID-19. 
Again, it takes time for your body to build immunity after vaccination, so you won’t have full protection until 2 weeks after your final dose.
- COVID vaccines will not give you COVID-19. 
- COVID-19 vaccines do not contain live virus.
- Getting vaccinated can help prevent serious illness and hospitalization with COVID-19. 
- People who have gotten sick with COVID-19 may still benefit from getting vaccinated. 
- COVID-19 vaccines will not cause you to test positive on COVID-19 viral tests. 
- COVID-19 vaccines do not change or interact with your DNA in any way. 
- There is currently no evidence that COVID-19 vaccination causes any problems with pregnancy, including the development of the placenta. In addition, there is no evidence that female or male fertility problems are a side effect of any vaccine, including COVID-19 vaccines.
What are the most common side effects?
After getting vaccinated, you might have some side effects, which are normal signs that your body is building protection. Common side effects are pain, redness and swelling in the arm where you received the shot, as well as tiredness, headache, muscle pain, chills, fever and nausea. These side effects could affect your ability to do daily activities, but they should go away in a few days. Learn more about what to expect after getting a COVID-19 vaccine.
Are COVID-19 vaccines safe?
COVID-19 vaccines are safe and effective. COVID-19 vaccines are being held to the same safety standards as other common vaccines. Several expert and independent groups evaluate the safety of vaccines being given to people in the United States. Medical experts carefully tested the vaccines among thousands of adults with diverse backgrounds.
How do I protect my child?
- Help protect your whole family by getting yourself vaccinated as soon as you can.
- Get your children vaccinated as soon as they're eligible.
- Ensure everyone in your family wears a mask when they are indoors in public places.
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What to Know about COVID-19 and Blood Donation
The American Red Cross has an urgent and ongoing need for blood and platelet donations to prevent another blood shortage as hospitals resume surgical procedures and patient treatments that were temporarily paused in response to the COVID-19 pandemic. In recent weeks, hospital demand for blood products has significantly increased and patients are relying on the generosity of blood and platelet donors to help ensure hospital shelves are stocked.
The safety of our donors, volunteers and staff remains a top priority. Each Red Cross blood drive and donation center follows a high standard of safety and infection control. Learn more about our COVID-19 safety protocols here .
Donating blood products is essential to community health and the need for blood products is constant. The Red Cross urgently needs the help of donors and blood drive hosts to ensure blood products are readily available for patients. If you are feeling well, please make an appointment to give by using the Red Cross Blood Donor App, visiting RedCrossBlood.org or calling 1-800-RED CROSS.
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The Red Cross began working in early March to ensure the continued delivery of our lifesaving mission amid the many challenges presented by this coronavirus outbreak. This report provides an accounting of our activities during the first year under COVID-19.
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The Impact of the Global COVID-19 Vaccination Campaign on All-Cause Mortality
The global COVID-19 vaccination campaign is the largest public health campaign in history, with over 2 billion people fully vaccinated within the first 8 months. Nevertheless, the impact of this campaign on all-cause mortality is not well understood. Leveraging the staggered rollout of vaccines, we find that the vaccination campaign across 141 countries averted 2.4 million excess deaths, valued at $6.5 trillion. We also find that an equitable counterfactual distribution of vaccines, with vaccination in each country proportional to its population, would have saved roughly 670,000 more lives. However, this distribution approach would have reduced the total value of averted deaths by $1.8 trillion due to redistribution of vaccines from high-income to low-income countries.
Funding provided by NIA R01AG073286 (Whaley) and the Peter G. Peterson Foundation Pandemic Response Policy Research Fund (Agrawal). We thank Coady Wing and seminar participants at the 2023 ASHE conference for helpful comments. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.
Neeraj Sood reports personal fees from Amazon outside the submitted work.
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Importance of preventive health care during COVID-19 pandemic
Preventive health care helps you maintain your health. Screenings are important to avoid future health problems or catch them early when they are easier to treat. But the COVID-19 pandemic has led to a decrease in preventive screenings because some patients have been hesitant to see their health care provider.
"People are driven to seek medical care by pain. Pain is a strong driver to get relief. And since prevention is when you are without symptoms, people tend to put that on the back burner or they may feel unsafe to come in because of the uncertainty about COVID-19," says Dr. Cindy Kermott , a Mayo Clinic preventive medicine physician. "We know enough now about COVID-19, and we have personal protective equipment. We also have vaccines that have been available for health care workers now, and essentially all have been offered it. And it is safe to come in to get these preventive screens and vaccines done."
Watch: Dr. Cindy Kermott discusses the importance of preventive health care.
Journalists: Broadcast-quality sound bites with Dr. Kermott are available in the downloads at the end of the post. Please courtesy: "Cindy Kermott, M.D./Preventive Medicine/Mayo Clinic."
The U.S. Preventive Services Task Force recommends many evidence-based preventive screenings. The most common for older men are prostate cancer and abdominal aortic aneurysm screenings. Women should schedule Pap smears to check for cervical cancer and mammograms to detect breast cancer.
Other important preventive health measures for every adult include:
- Colorectal cancer screening
- Checking cholesterol levels
- Blood pressure screening
- Testing blood glucose levels for diabetes
The timing and frequency of these screenings depend on your age and risk factors, and most are covered by your insurance.
"A screen is just a tool to detect the disease earlier," says Dr. Kermott. "It could be a lab. It could be vital signs. It could be questions — a survey instrument for depression, for example. It could be taking a family history and finding clues for genetics because some genetic testing is covered as a screen. And sometimes we do imaging, such as bone density or colonoscopy and endoscopy to detect things."
Whether you're nervous about COVID-19 safety or simply putting off your next trip for care, don't delay in talking to your health care provider about scheduling your preventive health screenings.
"If we pick it up too late, then we don't have as good of a leg up on the situation. And we're hoping to intervene so that you can live longer and have more quality life years as a result of these screens," says Dr. Kermott.
For the safety of its patients, staff and visitors, Mayo Clinic has strict masking policies in place. Anyone shown without a mask was either recorded prior to COVID-19 or recorded in a nonpatient care area where social distancing and other safety protocols were followed.
For more information and all your COVID-19 coverage, go to the Mayo Clinic News Network and mayoclinic.org .
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Original research article, determinants of observing health protocols related to preventing covid-19 in adult women: a qualitative study in iran.
- 1 Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
- 2 Master of Tourism Planning, Department of Geography and Tourism Planning at Kharazmi University, Tehran, Iran
- 3 Social Determinants of Health Research Center, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran
- 4 Cardiovascular Research Center, Health Institute, Imam-Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
- 5 Faculty of Psychology and Educational Sciences, Allameh Tabataba'i University, Tehran, Iran
- 6 Social Development and Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
Background: The best way to prevent COVID-19 is to observe health protocols. Therefore, identifying the reasons of following these protocols in order to plan and make intervention seems necessary. Therefore, the purpose of this study was to identify the determinants of observing health protocols related to prevention of COVID-19 among the Iranian adult women with a qualitative approach.
Method: In this qualitative study, the conventional content analysis approach was used. saturation was obtained after face-to-face semi-structured interviews with 38 women from Kermanshah who were selected through purposeful sampling and snowball sampling. Guba and Lincoln criteria were used for the strength of the research and Graneheim and Lundman method was used for its analysis.
Results: After analyzing the interviews, 5 categories, 12 subcategories and 110 initial codes were obtained. Categories and sub-categories were: 1- Individual factors (personality traits, health literacy about COVID-19); 2- Perceived risk having underlying disease in oneself and family, history of getting COVID-19 and death in close relatives; 3- Fear of the destructive consequences of the disease (concern about the economic consequences of getting the disease, concern about the treatment process); 4- Social and cultural factors (social monitoring, religious insight, ability to properly manage social interactions, impressionability from important others); 5- Environmental factors (supportive living environment, access to health and anti-infective materials).
Conclusion: Increasing the adherence of adult women to health instructions related to COVID-19 requires interventions at different levels of individual, environmental and social, and without accurate knowledge of the customs and culture of a society effective interventions cannot be established.
COVID-19 from China spread to other parts of the world ( 1 , 2 ). Due to the ambiguous nature of this virus and its high transmission power, as well as the problems it imposes on the individual and family after infection, the most important and in fact the main way to control the disease is to eliminate the virus transmission chain ( 3 , 4 ). The incidence and death rate of the disease led governments to implement a set of health protocols to prevent the disease. Depending on the situation, these protocols ranged from simple health rules such as wearing a mask to quarantine and social distancing ( 5 ). Observance of issues such as the use of masks and gloves, washing and disinfecting the hands and surfaces, maintaining proper distance and using vaccines have been mentioned as ways to prevent COVID-19 ( 6 , 7 ).
In Iran, on 19 February 2020, the first definitive case of COVID-19 was announced ( 8 ) and by 19 December 2021, a total of more than 6 million people have been infected with this disease, and the death rate has reached more than 131,000 ( 9 , 10 ).
In line with global warnings to break the chain of transmission, the Iranian government also implemented a variety of restrictive behaviors, such as quarantining cities and closing public centers and places, and at the same time, informed the people about various methods of preventing infection through national media and social networks ( 11 , 12 ). However, despite warnings from health organizations and governments, some people did not follow health protocols because of reasons such as poverty and economic hardship ( 13 ), personal characteristics, lack of access, etc. ( 14 ). Observing health guidelines has become one of the main concerns since the outbreak of COVID-19 ( 15 , 16 ), which is influenced by various physical, psychological, political, social and cultural factors ( 17 , 18 ). Studies of past pandemic crises, such as influenza and SARS, have shown that factors such as perceived risk of disease, strength of transmission, death rate, and stress experienced due to the disease play an important role in the type of preventive behaviors of the general public ( 14 ). The results of Webster et al.'s ( 19 ) study showed that factors such as public awareness of disease and quarantine procedures, social norms, perceived benefits of quarantine and understanding of disease risk, as well as practical issues such as resource depletion or financial consequences of unemployment are related to the degree of observing quarantine ( 19 ). In a study conducted in Indonesia, the variables of knowledge, personality and concern were reported as important determinants of observing health protocols related to COVID-19 ( 20 ). In a review study conducted by Shushtari et al. ( 17 ), living and working conditions, social support, trust, social norms, economic and social status, and mental health were reported to be the most important social determinants of following the COVID-19 health protocols. In another review study, environmental resources and contexts, belief in consequences, feelings, and social effects have been reported as important determinants of observing social distancing ( 21 ).
Regarding COVID-19, men have a higher rate of infection and death than women ( 22 , 23 ), most studies have reported that health protocols observing in women is higher than men ( 24 – 27 ). This may be due to various reasons such as having enough opportunity, more access, more patience or also the general perception that women are more inclined to maintain their health than men ( 28 ). Of course, men's working conditions can also be a factor ( 14 ).
Given the importance of observing health protocols in the prevention of COVID-19, identifying the factors affecting the observance of these protocols is a necessity of any planning and intervention to protect public health. Most previous research has been done quantitatively and has examined the reasons for non-compliance with health protocols, and the reasons for compliance with health protocols has been less examined with a qualitative method, while a qualitative method can help a lot. Also, few studies have examined the reasons for observing health protocols among Iranian women. Since some Iranian women are illiterate, it is not appropriate to use a quantitative method to investigate this phenomenon. Therefore, this study aimed to explor the determinants of observing health protocols related to the prevention of COVID-19 in Iranian adult women.
Materials and methods
This study was conducted with a qualitative approach and conventional content analysis method ( 29 ) among women in kermanshah. Participants in the study were women who had followed COVID-19 health protocols such as wearing masks, physical distance, washing hands, etc. over the past 2 months. Inclusion criteria consisted of being a woman, observing health protocols during the last 2 months and willingness to participate in the study. Exclusion criterion was an incomplete interview.
Purposeful sampling and then snowball sampling were used to reach the participants. Initially, a call was published in social media in order that those who follow the health protocols and are eligible to participate in the study tell their names and leave their phone numbers in order to be contacted to determine the time and place of the interview. Researchers attended the society and asked the women who were following health protocols, if they had fully observed health protocols in recent months, and if so, the interview would begin. At the end of the interview, the women were also asked to introduce other women who met the inclusion criteria among their friends and acquaintances, so that they could be contacted as soon as possible and the interview would be coordinated. A total of 16 women were selected through purposeful sampling and 22 women through snowball sampling. All interviews were recorded with the participants' consent, and field notes were used wherever the researcher needed them.
Semi-structured face-to-face interviews were used to collect data. The interview guide was developed to conduct the interviews; all the authors of the article designed questions to achieve the objectives of the research during three discussion sessions, then these questions were tested in interviews with three participants and after three pilot interviews, researchers corrected it during a meeting and the final interview was compiled ( Table 1 ). All interview questions were asked of all participants, but their order depended on the participants' answers, and other minor questions were asked to complete the interview. The average duration of the interviews was 61 min, the shortest interview lasted 23 minutes and the longest one lasted 80 min. The time and place of the interviews were determined in advance with the participants and based on their opinions. Interviews were conducted in secluded public places such as parks or cultural sites such as libraries or the workplaces of some participants which were secluded and no one but the researcher and participant was present.
Table 1 . The guide for interview question.
In order for the participants to be able to share their experiences more easily with the researcher, a female colleague with a master's degree in women studies who had sufficient experience in qualitative research methods and interviews was used. Data collection continued until theoretical saturation was reached. Saturation means when the continuation of the interview adds nothing to the research and the codes are repeated and no new code is formed, so the researcher decides not to continue the interviews ( 30 , 31 ). In this study, saturation was obtained by interviewing 38 women.
Maxqda 2020 software was used for data classification and Graneheim and Lundman method was used for its analysis ( 29 ). Data analysis was performed by the first, second, and corresponding author of the article, with the supervision and cooperation of all authors. Thus, in the first step, immediately after each interview, the interviews were typed and saved by two members of the research team in Word 2010 software. In the second step, the text of the interviews was read and reviewed several times by the researchers to get a general understanding of the text of the interviews. In the third step, all the texts were read word for word and with great care and the codes were extracted. In the fourth step, the codes that were similar in terms of content and meaning were placed in a class and it was determined how they were related. In the fifth step, the data were placed in the main categories, which were more general and abstract than the previous classification, and the themes were extracted.
Guba and Lincoln criteria were observed to improve the quality of results ( 32 ). To increase the dependability, all contributors to the article were informed about process of analyzing and coding, and in the meetings that were held, expressed their views, and finally the names of the categories and subcategories were finalized with the approval of all authors. To increase the credibility of the study, the researchers selected participants with the greatest differences in terms of demographic characteristics to observe the principle of diversity in sampling. At the end of each interview, the researcher briefly expressed his general understanding of the participants' experiences and it should be confirmed by the participant. Also, after coding and analyzing the data, the findings of the present article were provided to 12 participants to determine whether the researchers reported their experiences correctly or not and it was confirmed after a few minor corrections. To gain Confirmability, the researchers sent data analysis and findings to 5 leading researchers in qualitative research as well as 3 people who had research experience in similar subjects to this research and, where necessary, modified them according to their opinions. In order to increase the transferability of the research, a complete description of the whole research process was provided and the quotations of the participants were given directly and in large numbers. The research findings were also sent to 6 people who met the inclusion criteria but did not participate in the study, which was finally confirmed by them.
Ethics approval and consent to participate
To observe research ethics, the researchers considered the following issues: Ethical approval was obtained from the Kermanshah University of Medical Sciences (IR.IUMS.REC.1401.023). obtaining written consent from all participants, obtaining written consent to record the interview, introducing themselves and the necessity and objectives of the research at the beginning of each interview, observing the principles of confidentiality and maintaining the names of participants in publishing research results, determining the time and place of the interview and the desired time of cutting it by the participants, and observing the health protocols during the interview.
The present study was conducted with the participation of 38 adult women in Kermanshah, whose demographic characteristics are listed in Table 2 . Findings showed that most of the participants in the age range of 30 to 50 years had higher education than diploma and were married and housewife. Also, by analyzing the data obtained from the interviews, 110 initial codes, 12 subcategories and 5 categories were obtained (Table 3 ).
Table 2 . Demographic information of the participants.
Table 3 . Codes, categories and subcategories obtained from interviews with participating women.
The first category that was obtained was individual factors consisting of two subcategories of personality traits and having health literacy about COVID-19. In fact, part of the observance of health protocols by women was related to their personality and others to their knowledge and awareness of COVID-19.
Having some personality traits in people caused them to observe health behaviors more. In this study, women who felt more responsible followed health protocols more because they considered themselves responsible for their own health and that of others. Women who were kind and compassionate also followed health protocols properly. Although observing health protocols has sometimes been difficult, women who are more patient and have more hope for the future are more likely to follow them. Also, women who are less risk-averse and have a conservative personality are more likely to follow health protocols for fear of COVID-19.
“Observing the COVID-19 health protocols is related to both myself and others. Even if I am not worried about my own health, I have to wear a mask because of the health of others, which is why I always try to follow them.” (27 years old, married with a bachelor's degree).
“I can never imagine that I could endanger anyone's health by my negligent behavior. I can't be so cruel. I think not following health protocols shows the peak of cruelty” (39 years old, married, bachelor's degree).
“I'm too patient. I've been wearing a mask since COVID-19 came. Even at home when a guest comes, I wear a mask again. Sometimes my family tells me you're so patient that you observe a lot.” (48 years old, married, under diploma).
“I love my life and I do not want to die, so I wear a mask and I do not go to crowded places” (22 years old, single with a bachelor's degree).
Having health literacy about COVID-19
In fact, most participants had comprehensive information on various aspects of COVID-19 and had obtained this information from a variety of sources, not just one source of information. Participants who had good information about all aspects of COVID-19, such as how to transmit and prevent COVID-19, how to observe social distance, and how to use masks and other health supplies, were more observant.
“I tried to increase my knowledge in this field from the early outbreak, so in addition to following scientific news, I collected information on various websites, and sometimes I even used English sources, so I knew what a bad disease we were facing, which made me pay more attention” (50 years old, married with under diploma education).
“My husband works in the health office and he passed on good information to us, so I tried to follow all the health protocols” (33 years old, married, higher than a diploma).
“I wear both masks and gloves and I always use alcohol. I haven't traveled since COVID-19 came because I know that not following any of these things will make me much more likely to get infected and my life and my family life will be in danger.” (51 years old, married with elementary education).
“I try not to go to crowded places at all, or every time I go I put on two masks and When I get in a taxi or bus, I immediately roll down the windows so that there is air flow, because I know that if there is no air flow, I might get infected.” (29 years old, single with a bachelor's degree).
People who feel more at risk for COVID-19 are more likely to observe health protocols. This fear increases with a history of underlying disease in the individual and family members. Also, if one of her close relatives gets COVID-19 and she observes the treatment process, she feels fearful, which causes her to follow health protocols more.
Having an underlying disease in herself and her family
Some participants, due to having a dangerous underlying illness in themselves or their family members, considered themselves obliged to follow health protocols. In fact, it can be said that they feel more fearful due to having an underlying disease and that made them more observant.
“I have diabetes, so I'm very scared of COVID-19 and I always try to observe because I know I will die if I get it.” (61 years old, widow, illiterate).
“My mother has asthma and her lungs are very weak. If she gets COVID-19, it is very dangerous for her, so I try to be very careful and observant so that nothing bad happens.” (37 years old, single with a diploma).
“My mother-in-law has cancer and lives with us. Because of her I have to pay a lot of attention and be very observant so that, God forbid, nothing bad happens to her” (27 years old, married with a bachelor's degree).
“My father is on dialysis and if he gets COVID-19 it is not clear what will happen to him, so I and other family members try to be very observant so that nothing bad happens” (21 years old, single with a diploma).
History of COVID-19 in close relatives
History of COVID-19 in close relatives and observing the life of these people after getting it and the difficulties they experienced caused the participating women to express that by observing such an experience, they feel more at risk and follow health protocols better. Also, people who experienced COVID-19 death in close relatives and family felt more at risk and observed the protocols more than others.
“My father took COVID-19, he got very bothered, our lives were disrupted for a few weeks. Frankly speaking, after my father became ill, I was very scared and I observed more” (35 years old, single with a bachelor's degree).
“At first I thought that COVID-19 was not dangerous for me, but when I saw that our neighbor had taken COVID-19 and was being bothered by it a lot, I was scared and tried to observe more.” (65 years old, divorced, illiterate).
“One or two of my friends and colleagues took COVID-19 and went to the brink of death, and one of them died. When I found out that my colleague was dead, I was very worried and I have been observing more since that day.” (44 years old, married with a bachelor's degree).
Fear of the destructive consequences of the disease
This category on the one hand refers to the economic consequences of COVID-19 and on the other hand is concerned about the process of treatment of the disease that may endanger the health of associates and disrupt their lives.
Concerns about the economic consequences of getting the disease
Getting COVID-19 in Iran is associated with high economic costs, and families with a COVID-19 patient have to spend a lot of money on a daily basis. Also, with getting this disease and deprivation of work, people's income decreases, so some participants stated that they followed COVID-19 health protocols for fear of the economic consequences of it.
“If I get covd-19, I have to stay home until I die, because they say the cost is too high, so I try to observe a lot not to get infected.” (27 years old, single with a bachelor's degree).
“I am a hairdresser. If I take COVID-19, I have to stay home for at least a few weeks and my job is closed, so I have to be very observant in order not to lose my job” (42 years old, divorced with a bachelor's degree).
“I observe because I know the cost of medical tests, etc. is too high. Also, because public hospitals do not have the capacity, I have to go to a private hospital where overnight expenses are the same as my husband's a month income” (37 years old, married with a master's degree).
Social and cultural factors
Social and cultural factors were one of the important determinants of observing health protocols by participants. Part of these social factors were related to social pressures that required a person to observe health protocols, part to the religious views of individuals about their own health and the health of others. Proper management of social interactions and being influenced by important others were other social and cultural factors.
In Iranian society, someone who does not follow health protocols, especially the use of masks, is usually reprimanded by the public, and others may distance themselves from him or criticize him for not observing health protocols properly. Most participants stated that they followed health protocols for fear of being rejected or warned by others. In fact, non-compliance with health protocols in society causes others to label the wrongdoer as a silly person, and this issue causes some people to observe health protocols to avoid such labels.
“I get very upset that someone criticizes me, so I always try to follow health protocols so that no one nags at me” (32 years old, married with a master's degree).
“If I see that someone does not follow the health protocols, I distance myself from them and do not talk to them, and since I do not want anyone to treat me like this, I try to follow the health protocols as much as I can.” (67 years old, married, illiterate).
“In the bus, anyone who does not wear a mask is labeled a thousand times, and I really give people the right. I do not want anyone to think that I do not have understanding and wisdom, so I try to wear a mask” (55 years old, married with a bachelor's degree).
“There is a friend of mine who does not believe in wearing a mask at all, etc. Other friends label her a thousand times.” (47 years old, widow, under diploma).
Religious people consider themselves responsible for their own health and the health of others, and consider any harm to their own health and the health of others a sin. According to these people, non-observance of health protocols is an example of intentional harm to oneself and others because it endangers health and this is a sin, so they try to observe health protocols as much as they can in order to avoid sin.
“God has given us a body which we have to take care of, and if we are not careful we have sinned” (38 years old, married with a master's degree).
“Just as drug use is a sin and endangers health, not observing protocols is just as, and perhaps more, a sin because it endangers the health of others in addition to one's own health” (41 years old, married with a master's degree).
“If I do not follow the protocols and cause someone else to get COVID-19, I have committed a great sin, so I always try to observe it for the sake of others” (29 years old, single with a bachelor's degree).
“When I know that not wearing a mask endangers the health of others, I convince myself to wear a mask even if I am bothered, because if I cause the health of others to be endangered, I have committed a sin and I will be punished in the Hereafter” (40 years old, single, under diploma).
Ability to properly manage social interactions
Iranian culture is based on stable social relationships, so that most Iranians visit close relatives during the week, which can be dangerous during COVID-19 prevalence. While the ability to properly manage these interactions can be very helpful, some participants tried to fill this gap by reducing face-to-face communication and making more use of telephone and virtual communication, and by holding various social events in virtual space, they were could observe health protocols.
“My main concern about not following health protocols was related to attending various events that I tried to participate in them in through virtual space as much as possible” (39 years old, married with a bachelor's degree).
“I did not attend any ceremonies from the beginning of COVID-19. I called and congratulated or offered my condolences wherever necessary.” (29 years old, single with a bachelor's degree).
“During COVID-19 period, I did not attend all the birthday parties and various anniversary ceremonies, etc. We made it through virtual space.” (44 years old, married with a bachelor's degree).
Impressionability from important others
There are always some people in individuals' lives who play a decisive role in shaping behavior. For this reason, in the face of COVID-19, some participants stated that they had tried to follow health protocols, following the statements of some celebrities, clerics, prominent doctors, nurses and other important people in life. And perhaps in the absence of such people, the rate of compliance with health protocols would be lower than before.
“When I saw celebrities wearing masks and holding their weddings in private, I learned to follow health protocols” (44 years old, married with a bachelor's degree).
“Many of our religious scholars have told us to observe health protocols. Well, we have to follow their instructions” (42 years old, divorced, under diploma).
“Doctors have been very bothered during these 2 years. When I see they want us to observe. The least we can do is to be careful about our behavior” (35 years old, single with a doctorate).
“Many nurses have lost their lives in order to maintain our health. The only thing they ask us to do is to observe more. I try to do it because of them” (57 years old, married with a bachelor's degree).
Environmental factors consisting of two sub-categories of supportive living environment and access to health and anti-infective materials were other determinants of health protocols. In fact, if people are in an environment where most people follow the protocols and also have access to the necessary health materials, the rate of compliance with the protocols will increase, as most participants stated that most people in their environment were sensitive to health protocols and they have had sufficient access to hygienic materials such as glove, masks, etc., and this has led to their encouragement to observe health protocols.
Supportive living environment
Most of the participants stated that other family members followed the health protocols and were sensitive to their behavior, which led them to observe more. Also, some people considered the observance of health protocols by colleagues and neighbors as the reason for their observance.
“My mother reminds me every day to put on a mask and wear gloves when I go out, which makes me very self-conscious” (37 years old, single, with PhD degree).
“In our apartment building, from the early time the COVID-19 came, we took a washing liquid and put it in the yard, and we required all people to wash their hands with water and liquid when they come from the outside, and they do not have the right to take off their masks until they reach their apartment. These made me become more sensitive to the observance of health protocols” (62 years old, married with a diploma).
“Many families do not care and they go to party every day, but our family is not like that. We have observed a lot during these 2 years. When I see that we observe that much at home, I also try to observe it outside as much as I can.” (27 years old, married with a bachelor's degree).
“Most of my colleagues follow the protocols, and when I see them, I observe. If they did not observe them, I would not observe them.” (44 years old, married with a bachelor's degree).
Access to hygienic and anti-infective materials
Adequate access to hygienic materials causes other people not to use the lack of materials as an excuse not to observe health protocols, and this issue itself can affect the observance of health protocols.
“We have several packages of masks in different designs and colors at home. I have no problem accessing the masks.” (32 years old, married with a master's degree).
“I have both hand sanitizer and surface sanitizer for each of my children. I check every time they go out to take them.” (39 years old, married with a bachelor's degree).
“I always put a mask and alcohol in my bag to use whenever I need.” (27 years old, single with a bachelor's degree).
The aim of this study was to explor the determinants of observing health protocols related to the prevention of COVID-19 in Iranian adult women with a qualitative approach. The results showed that the observance of health protocols by women is affected by various factors, some of which are related to the personality of individuals and others to the social factors and behaviors of others and the social environment in which they live.
Individual factors consisting of personality traits and having health literacy about COVID-19 was one of the important determinants of observing health protocols by women. In fact, women who felt more responsible for their own health and that of others around them were more likely to follow health protocols. In Ningsih et al. ( 33 ) study, a significant relationship was found between social responsibility and observance of health protocols. Also, due to the dangerous conditions of COVID-19, women who had a conservative personality followed health protocols better to avoid getting COVID-19. And because observing health protocols was sometimes really difficult and tedious, women who were patient were more inclined to follow health protocols. This finding is consistent with the research of Soleimanvandi Azar et al. ( 14 ) conducted in Iran because in their research, laziness and impatience were reported as one of the most important reasons for not wearing masks and observing other health protocols. In the research of Sari and Fawzi ( 20 ) personality traits have also been reported as one of the important determinants of compliance with health protocols.
Having a health literacy about COVID-19 was another determinant of women's observance of health protocols. In most studies, health literacy in the field of COVID-19 has been reported as one of the most important reasons for compliance or non-compliance with health protocols ( 34 – 36 ). In fact, the more people know about prevention methods and how to follow health protocols, the more they are encouraged to follow these protocols.
Perceived risk, consisting of two subcategories of underlying disease in oneself and family, as well as a history of COVID-19 and death in close relatives, was one of important determinants of women's observing health protocols. This finding was in line with the 2021 Plohl and Musil study ( 37 ). Also in Wise et al. ( 38 ) research, understanding the risk and understanding the economic and health effects of COVID-19 have been reported as factors affecting the observance of COVID-19 health protocols. Because the incidence and death from COVID-19 were higher in people with the underlying disease, women who had such diseases or a family member of theirs had, felt more at risk and tried to follow health protocols. They also felt more at risk when they saw the conditions of people with COVID-19 or their death, and tried to observe health protocols. In a study conducted in Italy, susceptibility of risk of contracting COVID-19 disease was significantly associated with observing health protocols related to the prevention of COVID-19 ( 25 ).
Another important finding of the study was the fear of the destructive consequences of COVID-19. In the study of Harper et al. ( 39 ), fear and anxiety about COVID-19 played an important role in influencing hygienic behaviors such as hand washing and social distancing. The expenses of COVID-19 patients in Iran were sometimes very high due to shortages of medical supplies, and the families of the patients had to pay a lot of money, and the disease itself caused people to stay away from working conditions for weeks or even months. This issue put a lot of economic pressure on the family, therefore, COVID-19 in Iran would lead to a lot of economic pressure on families, so some participants observed protocols to prevent these costs.
Concern about the disease treatment process was another determinant of women's adherence to health protocols. In fact, in addition to the economic cost of COVID-19, the length of the treatment process and the risk to other family members and disruption of their lives caused women to observe health protocols. In the study of Webster et al. ( 19 ), understanding the risk of disease has been reported as one of the important determinants of adhering to health protocols.
Social and cultural factors were another new and interesting finding in this study and showed that the health behavior of individuals is affected by the cultural and social context of societies and to intervene more effectively in this field, cultural and social components must be considered. In the study of Indrayathi et al. ( 40 ), social norms have been mentioned as one of the determinants of compliance with health protocols. In most researches on the observance or non-observance of health protocols related to COVID-19 social and cultural factors have been reported as one of the important determinants ( 17 , 41 ).
Social monitoring was one of the important determinants of women's adherence to health protocols, which was one of the new and significant findings in this study. When most people in the environment follow health protocols and a person ignores these protocols, it causes other people in the community to warn that person and look at him negatively and stigmatize them and show with their behaviors that they would not like to communicate with them. In fact, it can be said that by turning health behaviors into a social norm, people accept it more easily and there is no need for government inspectors to implement it, but it is inspected and controlled by the people themselves ( 18 ). Therefore, it seems that in order to observe health protocols more, people can be encouraged more by creating more social supervision, rather than legislation and legal punishment.
Religious insight was another important determinant of health protocols. Religious people consider themselves responsible for their own health and even that of others, and according to the rules of Islam, which is the most common religion in Iran, harming their own health and the health of others is forbidden and punishable. Therefore, most women considered not following health protocols as harming their own health and the health of others, so they tried to follow these protocols as much as possible. In general, various studies have shown that during the COVID-19 pandemic, the number of religious practices increased and most people prayed or performed religious acts to end COVID-19 ( 42 ). Yoosefi lebni et al. 2021 in a study conducted among housewives in Iran during the COVID-19 period reported that women resorted to religious practices such as praying, supplication, etc. to relieve the anxiety caused by the COVID-19 outbreak ( 43 ). However, in some communities, religious people may describe quarantine laws or other health protocols as anti-religious because they stay them away from mass religious practices, so they may not follow these protocols ( 44 ). Of course, due to the religious context of Iranian society, clerics were also effective in observing health protocols because they invited people from different forums to observe health protocols ( 45 ).
Another new and interesting finding in this study was the ability to properly manage social interactions, which was one of the important determinants of observing health protocols. In fact, this finding showed that even in communities where there are a lot of family interactions, COVID-19 expansion can be prevented with proper management of these interactions. Expanding the use of social media for communication can be a good alternative to real communication, so it is suggested that health officials and planners facilitate and accelerate the use of virtual communication in society. In societies like Iran, where people still have extensive contact with close and distant relatives, observing health protocols such as social distancing and quarantine had become a problem, and the cases of COVID-19 increased whenever there were special social ceremonies. In a study conducted by Soleimanvandi Azar et al. ( 14 ). In Iran, they reported that social customs are one of the main obstacles to compliance with health protocols in Iran. In another study conducted among Iranian women, the use of social media was reported as one of the alternative solutions for real communication in the COVID-19 period ( 43 ).
Impressionability from important others was another important finding in this study. In any society, some people learn by looking at the lifestyles of those who are important to them or try to behave like them. Now these important others may come from every stratum and guild in society (such as artists, clerics, footballers, prominent doctors, Etc.). Various studies have reported the effect of celebrities in encouraging people to follow COVID-19 protocols ( 46 , 47 ).
Environmental factors including a supportive living environment and access to health and anti-infective materials was another determinant of observing health protocols. When in a community in living and working places, most people follow health protocols and are sensitive to the behavior of others and feel responsible, other people in that community are encouraged to follow health protocols. Research by Coroiu et al. ( 26 ) also showed that people's health behaviors to prevent COVID-19 are influenced by the behavior of other people living in the community, that is, when people see that most people observe health protocols, they are encouraged to observe the protocols.
Access to sanitary and anti-infective materials was another determinant of compliance with health protocols. In most previous researches, lack of access or difficult access to health and anti-infective materials has been reported as one of the main reasons for not observing health protocols ( 14 , 48 , 49 ).
Strengths and limitations of the study
This study is one of the few studies that qualitatively seeks to identify the determinants of observing health protocols related to COVID-19 among Iranian adult women, which can provide new and first-class information to health and social planners so that they can intervene to increase people's adherence to health protocols. There were some limitations in this study. One of the main limitations was that some participants were reluctant to do the interview due to fear of getting COVID-19. The researchers obtained their consent by explaining the conditions of the interview and the full observance of health protocols such as the use of masks, gloves, etc. during the interview. The willingness of the participants as well as the observance of some social customs caused the researchers to use a trained and experienced woman in the field of interviews and qualitative research to conduct interviews.
The results showed that women observe health protocols under the influence of various factors such as individual factors, perceived risk, fear of the destructive consequences of the disease, social and cultural factors and environmental factors. Therefore, increasing the adherence of adult women to the health instructions related to COVID-19 requires interventions at different levels. At the individual level, it seems necessary to promote health literacy about COVID-19, to strengthen their sense of responsibility for their own health and the health of others, to increase the feeling of fear of getting COVID-19, and to show the consequences of getting it in the media, in order to encourage people to follow protocols more. At the social level, strengthening and cultivating more social monitoring to control the behavior of people who do not follow health protocols, using the capacity of religious clerics and celebrities to encourage people to observe health protocols, and training and instructing to better manage social interactions are seemed necessary. At the environmental level, it appears necessary to provide and make available health supplies to the public so that they can observe health protocols without any worries or restrictions.
Data availability statement
The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding authors.
The studies involving human participants were reviewed and approved by the Kermanshah University of Medical Sciences (IR.IUMS.REC.1401.023). The patients/participants provided their written informed consent to participate in this study.
JY, MK, and AA were responsible for the study conceptualization and led the paper's writing. JY and AZ conducted the literature review and assisted in writing the paper. SP and AA performed the analysis, assisted in interpreting the data, and writing the paper. JY and MS assisted with the interpretation of the results and drafting programmatic implications and responsible for the data collection and coordination of the study. AZ co-led the conceptualization, supervised all aspects of writing the paper, and provided extensive comments on the manuscript. All authors were responsible for the study. All authors have read and approved the final manuscript.
This study received funding from Kermanshah University of Medical Sciences (4010279). The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.
We are grateful to the Deputy for Research and Technology, Kermanshah University of Medical Sciences, for co-operating in this research. The authors would like to thank all the participants who patiently participated.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
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Keywords: COVID-19, women, observing the health protocols, qualitative study, adult
Citation: Yoosefi Lebni J, Pavee S, Saki M, Ziapour A, Ahmadi A and Khezeli M (2022) Determinants of observing health protocols related to preventing COVID-19 in adult women: A qualitative study in Iran. Front. Public Health 10:969658. doi: 10.3389/fpubh.2022.969658
Received: 15 June 2022; Accepted: 18 July 2022; Published: 19 August 2022.
Copyright © 2022 Yoosefi Lebni, Pavee, Saki, Ziapour, Ahmadi and Khezeli. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Ahmad Ahmadi, firstname.lastname@example.org ; Mehdi Khezeli, email@example.com
This article is part of the Research Topic
Women in Science: Public Health Education and Promotion 2022
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Classroom precautions during covid-19, tips for teachers to protect themselves and their students..
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As schools reopen, it’s important that precautions are taken both inside and outside the classroom to prevent the spread of COVID-19. This article aims to support teachers with information and tips on:
- Physical distancing at school
- Practicing health and hand hygiene
- Cleaning and disinfecting tips for the classroom
- Actions to take if a student appears sick
A key lesson learned during the pandemic is the important role teachers play in ensuring that learning continues. As schools reopen, a lot will depend on teachers to ensure that children will be able to continue their education in a safe and healthy environment; and make up for knowledge and skills that may have been lost.
As a teacher, knowing the facts will not only protect yourself but also your students. Be aware of fake information and dangerous myths about COVID-19 circulating that are feeding fear and stigma.
Some of your students might be returning to school from households where they heard false information about COVID-19. You will need to educate them on the facts.
Understanding COVID-19, how it spreads and how we can protect ourselves and others is an important first step in establishing classroom procedures and protocols. Students need to understand what it is in order for them to follow the rules. Listen to their concerns and ideas and answer their questions in an age-appropriate manner. Discuss the different reactions they may experience and explain that these are normal reactions to an abnormal situation.
Teachers need to be protected from transmission of COVID-19 in the community to keep schools open. Teachers are therefore encouraged, and should be prioritized, to get vaccinated against COVID-19 once frontline health personnel and high-risk populations are vaccinated. Though vaccination against COVID-19 should not be a requirement for school reopening and in-person learning, COVID-19 vaccines are safe, effective tools for preventing severe illness and death from COVID-19.
> Read: What you need to know before, during and after receiving a COVID-19 vaccine
Make sure to use information about COVID-19 from reliable sources such as UNICEF and WHO, as well as the health authorities in your country. By staying informed about the situation and following the recommendations of public health experts, we can protect our own wellbeing and those around us.
Physical distancing at schools
When it comes to physical distancing, it is important that you establish some classroom ground rules in accordance with the procedures established by your school’s administration, as well as the protocols established by your respective country’s Ministry of Health and/or local health bodies and authorities. Recommended measures include:
- Maintain a distance of at least 1 metre between everyone present at school
- Increase desk spacing (at least 1 metre between desks), stagger recesses/breaks and lunch breaks (if difficult, one alternative is to have lunch at desks)
- Limit the mixing of classes for school and after-school activities. For example, students in a class will stay in one classroom throughout the day, while teachers move between classrooms; or classes could use different entrances, if available, or establish an order for each class to enter and leave the building/classroom
- Stagger the school day to vary the start and end times and avoid having all the students and teachers together at once
- Consider increasing the number of teachers, if possible, to allow for fewer students per classroom (if space is available)
- Advise against crowding during school pick-up or day care, and if possible avoid pick up by older family or community members (i.e. grandparents). Arrange school pick up/drop off times differently (according to age group) to decrease any large gatherings of children at a given time
- Use signs, ground markings, tape, barriers and other means to maintain 1 metre distance in queues around entrances
- Discuss how to manage physical education and sports lessons
- Move lessons outdoors or ventilate rooms as much as possible
- Encourage students not to gather and socialize in big groups upon leaving school grounds.
To encourage your students to stick to the rules, it can be helpful to create a dos and dont’s list with them. Develop a list together around how students will greet each other; how desks will be arranged; physical distancing measures during lunch breaks (who they will sit with, play with during breaks, how they can schedule time with all of their friends across the week).
Health and hand hygiene
Teachers have a critical role to play in ensuring students understand the precautions they should take to protect themselves and others from COVID-19, and it is important you lead by example in the classroom.
Handwashing is one of easiest, more cost efficient and effective way of combating the spread of germs and keeping students and staff healthy.
Teach the five steps for handwashing
- Wet hands with safe, running water
- Apply enough soap to cover wet hands
- Scrub all surfaces of the hands – including backs of hands, between fingers and under nails – for at least 20 seconds. You can encourage students to sing a quick song at this point to make it a fun habit
- Rinse thoroughly with running water
- Dry hands with a clean cloth or single-use towel.
If there is limited access to a sink, running water or soap in the school, then use a hand sanitizer that contains at least 60 per cent alcohol.
Did you know? Cold water and warm water are equally effective at killing germs and viruses – as long as you use soap!
> Read: Everything you need to know about washing your hands to protect against coronavirus (COVID-19)
Encourage students to get into the practice of regularly washing their hands and/or applying hand sanitizers at key moments, such as entering and leaving the classroom; touching surfaces, learning materials, books, and after using a tissue to blow their nose.
Students should always cough and/or sneeze into their elbow. However, if by accident they do so in/on their hands, instruct them to immediately wash their hands or apply hand sanitizer. If students sneeze or cough into a tissue, ensure that it is disposed of immediately and that they wash their hands. It is extremely important to normalize the idea of frequent and routine handwashing.
Even with clean hands, encourage students to avoid touching their eyes, nose and mouth. Germs can transfer from those areas on to their clean hands and spread around the classroom this way.
Reinforce frequent handwashing and sanitation and procure needed supplies. Prepare and maintain handwashing stations with soap and water, and if possible, place alcohol-based hand sanitizers in each classroom, at entrances and exits, and near lunchrooms and toilets.
Identify some practical steps/activities you can take to demonstrate good hygiene practices to your students. Examples include:
- Creating a hand hygiene song to sing with your students
- Have students draw hygiene posters for the classroom
- Set a hand hygiene ritual. You can select a specific time during the day, such as before/after lunchtime for everyone to wash their hands/apply hand sanitizer
- Physically demonstrate how to wash your hands and apply sanitizer
- Keep a points system in your classroom, giving points to students each time they wash their hands or apply sanitizer
- Have students create a public service announcement on hand hygiene and place these posters/ announcements throughout the classroom or school in highly visible places
Mask wearing in schools
If wearing masks is recommended in your school, then make sure your students are familiar with when they should wear masks and any related school policies, such as how to dispose of used masks safely to avoid the risk of contaminated masks in classrooms and playgrounds.
Explore with your students how to handle and store masks properly .
All efforts should be made to ensure the use of a mask does not interfere with learning. No children should be denied access to education because of mask wearing or the lack of a mask because of low resources or unavailability.
If you have students with disabilities, such as hearing loss or auditory problems in your class, then consider how these children may miss learning opportunities because of the degraded speech signal stemming from mask wearing, the elimination of lipreading and speaker expressions and physical distancing. Adapted masks to allow lipreading (e.g. clear masks) or use of face shields may be explored as an alternative to fabric masks.
Cleaning and disinfecting
Information on how to maintain the cleanliness and sanitization of your classroom.
Daily cleaning and disinfecting of surfaces and objects that are touched often, such as desks, countertops, doorknobs, computer keyboards, hands-on learning items, taps, phones and toys. Immediately clean surfaces and objects that are visibly soiled. If surfaces or objects are soiled with body fluids or blood, use gloves and other standard precautions to avoid coming into contact with the fluid. Remove the spill, and then clean and disinfect the surface.
Tips for staff using cleaning materials
- Ensure you understand all instruction labels and understand safe and appropriate use
- Follow the instructions on the labels
- Cleaning products and disinfectants often call for the use of gloves or eye protection. For example, gloves should always be worn to protect your hands when working with bleach solutions
- Do not mix cleaners and disinfectants unless the labels indicate it is safe to do so. Combining certain products (such as chlorine bleach and ammonia cleaners) can result in serious injury or death
- Diluted household bleach solutions may also be used if appropriate for the surface
- Check the label to see if your bleach is intended for disinfection and has a sodium hypochlorite concentration of 0.5%. Ensure the product is not past its expiration date. Some bleaches, such as those designed for safe use on coloured clothing or for whitening may not be suitable for disinfection
- Household bleach will be effective against coronaviruses when properly diluted
- Follow manufacturer’s instructions for application and proper ventilation. Never mix household bleach with ammonia or any other cleanser
- Leave solution on the surface for at least 1 minute.
- Come up with some fun and creative ideas and rules with your students for avoiding high-risk and high-touch areas in their school/classroom. For example, not touching the railing while walking up and down the stairs, or keeping classroom doors open to avoid touching door-knobs
- Come up with some rules together as a group and write these down on a flipchart paper that you can later hang up in the classroom
- Create fun reminders/posters that can be hung in the hallways to remind others to stick to the sanitation rules.
Actions to take if one of your students appears to be sick
Identifying covid-19 symptoms.
The most common symptoms are fever, cough, and tiredness. Other symptoms can include shortness of breath, chest pain or pressure, muscle or body aches, headache, loss of taste or smell, confusion, sore throat, congestion or runny nose, diarrhea, nausea and vomiting, abdominal pain, and skin rashes.
School preparations and what to do if one of your students displays any of the symptoms
- Designate a specific area in the school (i.e. near the entrance) as a waiting room where children can wait. Ideally, this room should be well-ventilated. If there are school nurses available, it is recommended that they are designated staff in this waiting area. If students feel ill and/or exhibit symptoms of COVID-19, they should wait in the designated room to be picked up by their parents/caregiver. Afterwards, the room should be cleaned, disinfected and sanitized
- Provide the sick student with a medical mask if available
- Consider daily screening for body temperature, and history of fever or feeling feverish in the previous 24 hours, on entry into the building for all staff, students and visitors to identify persons who are sick
- Ensure a procedure for separating sick students and staff from those who are well – without creating stigma – and a process for informing parents, and consulting with health care providers/ health authorities wherever possible
- Students/ staff may need to be referred directly to a health facility, depending on the situation/ context, or sent home
- Encourage all students to stay home and self-isolate should they feel ill
- Develop a standard of operation if temperature screening is required
- Share procedures with parents and students ahead of time.
There have been several reports of children acquiring a multisystem inflammatory condition, which is possibly linked with COVID-19. If you notice any rash, hypertension, or acute gastrointestinal problems in your students, it could be an indication that they are experiencing multisystem inflammatory syndrome and should seek medical attention immediately.
Create your own infection control plan. What actionable steps do you take if a student reports feeling ill during the school day? Consider all possible steps you can take from the moment they tell you.
< Back to UNICEF COVID-19 portal
This article is based on Ready to Come Back: Teacher Preparedness Training Package
- Framework for reopening schools
- WHO, UNICEF, UNESCO Considerations for school-related public health measures in the context of COVID-19
This article was originally published on 20 September 2020. It was last updated on 14 September 2021.
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COVID-19 school health and safety protocols: good practices and lessons learnt to respond to Omicron
The COVID-19 pandemic and the recent Omicron variant wave have dramatically impacted societies in all sectors and at all levels. After near universal school closures in March 2020 that affected 1.6 billion learners and more than 100 million teachers and educators worldwide, countries around the world have developed health and safety protocols in an effort to safely keep schools open and protect students, teachers and other educational staff from the transmission of COVID-19. However, since the emergence of the Omicron variant in December 2021, these protocols have been disrupted and are being reevaluated as schools struggle to address a new set of challenges marked by staff shortages, threats to school safety and political battles over health measures. Based on an analysis of 35 countries, this brief report aims to provide a current overview of national health and safety protocols to keep schools open, their dimensions and how they are designed, implemented and regulated to ensure the continuation of education. It also aims to guide education systems by outlining some lessons learnt and effective practices on how the reopening of schools might be achieved safely and successfully. Finally, the report seeks to contribute to a better understanding of the impacts of the protocols on learning as well as the social and emotional wellbeing, health and development of learners and teachers. In a changing environment where infection rates are increasing at an exponential rate, it also explores how the Omicron variant is affecting current operations and what education systems should do to keep schools open while ensuring that all students are safe and learning.
Essay on COVID-19 Pandemic
As a result of the COVID-19 (Coronavirus) outbreak, daily life has been negatively affected, impacting the worldwide economy. Thousands of individuals have been sickened or died as a result of the outbreak of this disease. When you have the flu or a viral infection, the most common symptoms include fever, cold, coughing up bone fragments, and difficulty breathing, which may progress to pneumonia. It’s important to take major steps like keeping a strict cleaning routine, keeping social distance, and wearing masks, among other things. This virus’s geographic spread is accelerating (Daniel Pg 93). Governments restricted public meetings during the start of the pandemic to prevent the disease from spreading and breaking the exponential distribution curve. In order to avoid the damage caused by this extremely contagious disease, several countries quarantined their citizens. However, this scenario had drastically altered with the discovery of the vaccinations. The research aims to investigate the effect of the Covid-19 epidemic and its impact on the population’s well-being.
There is growing interest in the relationship between social determinants of health and health outcomes. Still, many health care providers and academics have been hesitant to recognize racism as a contributing factor to racial health disparities. Only a few research have examined the health effects of institutional racism, with the majority focusing on interpersonal racial and ethnic prejudice Ciotti et al., Pg 370. The latter comprises historically and culturally connected institutions that are interconnected. Prejudice is being practiced in a variety of contexts as a result of the COVID-19 outbreak. In some ways, the outbreak has exposed pre-existing bias and inequity.
Thousands of businesses are in danger of failure. Around 2.3 billion of the world’s 3.3 billion employees are out of work. These workers are especially susceptible since they lack access to social security and adequate health care, and they’ve also given up ownership of productive assets, which makes them highly vulnerable. Many individuals lose their employment as a result of lockdowns, leaving them unable to support their families. People strapped for cash are often forced to reduce their caloric intake while also eating less nutritiously (Fraser et al, Pg 3). The epidemic has had an impact on the whole food chain, revealing vulnerabilities that were previously hidden. Border closures, trade restrictions, and confinement measures have limited farmer access to markets, while agricultural workers have not gathered crops. As a result, the local and global food supply chain has been disrupted, and people now have less access to healthy foods. As a consequence of the epidemic, many individuals have lost their employment, and millions more are now in danger. When breadwinners lose their jobs, become sick, or die, the food and nutrition of millions of people are endangered. Particularly severely hit are the world’s poorest small farmers and indigenous peoples.
Infectious illness outbreaks and epidemics have become worldwide threats due to globalization, urbanization, and environmental change. In developed countries like Europe and North America, surveillance and health systems monitor and manage the spread of infectious illnesses in real-time. Both low- and high-income countries need to improve their public health capacities (Omer et al., Pg 1767). These improvements should be financed using a mix of national and foreign donor money. In order to speed up research and reaction for new illnesses with pandemic potential, a global collaborative effort including governments and commercial companies has been proposed. When working on a vaccine-like COVID-19, cooperation is critical.
The epidemic has had an impact on the whole food chain, revealing vulnerabilities that were previously hidden. Border closures, trade restrictions, and confinement measures have limited farmer access to markets, while agricultural workers have been unable to gather crops. As a result, the local and global food supply chain has been disrupted, and people now have less access to healthy foods (Daniel et al.,Pg 95) . As a consequence of the epidemic, many individuals have lost their employment, and millions more are now in danger. When breadwinners lose their jobs, the food and nutrition of millions of people are endangered. Particularly severely hit are the world’s poorest small farmers and indigenous peoples.
While helping to feed the world’s population, millions of paid and unpaid agricultural laborers suffer from high levels of poverty, hunger, and bad health, as well as a lack of safety and labor safeguards, as well as other kinds of abuse at work. Poor people, who have no recourse to social assistance, must work longer and harder, sometimes in hazardous occupations, endangering their families in the process (Daniel Pg 96). When faced with a lack of income, people may turn to hazardous financial activities, including asset liquidation, predatory lending, or child labor, to make ends meet. Because of the dangers they encounter while traveling, working, and living abroad; migrant agricultural laborers are especially vulnerable. They also have a difficult time taking advantage of government assistance programs.
The pandemic also has a significant impact on education. Although many educational institutions across the globe have already made the switch to online learning, the extent to which technology is utilized to improve the quality of distance or online learning varies. This level is dependent on several variables, including the different parties engaged in the execution of this learning format and the incorporation of technology into educational institutions before the time of school closure caused by the COVID-19 pandemic. For many years, researchers from all around the globe have worked to determine what variables contribute to effective technology integration in the classroom Ciotti et al., Pg 371. The amount of technology usage and the quality of learning when moving from a classroom to a distant or online format are presumed to be influenced by the same set of variables. Findings from previous research, which sought to determine what affects educational systems ability to integrate technology into teaching, suggest understanding how teachers, students, and technology interact positively in order to achieve positive results in the integration of teaching technology (Honey et al., 2000). Teachers’ views on teaching may affect the chances of successfully incorporating technology into the classroom and making it a part of the learning process.
In conclusion, indeed, Covid 19 pandemic have affected the well being of the people in a significant manner. The economy operation across the globe have been destabilized as most of the people have been rendered jobless while the job operation has been stopped. As most of the people have been rendered jobless the living conditions of the people have also been significantly affected. Besides, the education sector has also been affected as most of the learning institutions prefer the use of online learning which is not effective as compared to the traditional method. With the invention of the vaccines, most of the developed countries have been noted to stabilize slowly, while the developing countries have not been able to vaccinate most of its citizens. However, despite the challenge caused by the pandemic, organizations have been able to adapt the new mode of online trading to be promoted.
Ciotti, Marco, et al. “The COVID-19 pandemic.” Critical reviews in clinical laboratory sciences 57.6 (2020): 365-388.
Daniel, John. “Education and the COVID-19 pandemic.” Prospects 49.1 (2020): 91-96.
Fraser, Nicholas, et al. “Preprinting the COVID-19 pandemic.” BioRxiv (2021): 2020-05.
Omer, Saad B., Preeti Malani, and Carlos Del Rio. “The COVID-19 pandemic in the US: a clinical update.” Jama 323.18 (2020): 1767-1768.
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Lessons learned from the COVID-19 pandemic. Researchers identify key takeaways for AIDS service organizations to ensure resilience
October 26, 2023 | Erin Bluvas, [email protected]
The COVID-19 pandemic overwhelmed health care systems across the United States. More than 100 million cases and one million deaths later, clinicians and researchers are still unraveling the lessons learned from this global public health crisis.
In a recent publication in AIDS and Behavior, scientists from the University of South Carolina identified seven lessons regarding health care system resilience learned from the COVID-19 pandemic. Specifically, these takeaways detail ways that AIDS service organizations in South Carolina were able to persevere through the pandemic. Taken together, these facilitators may offer a roadmap for organizational resilience when faced with the next public health crisis.
These facilitators are unique to the context of the COVID-19 pandemic yet are relevant going forward, as this study highlights their importance in providing a continuity of care to people living with HIV and other vulnerable groups under circumstances requiring nontraditional methods of treatment.
“Throughout the pandemic, South Carolina has been categorized as highly vulnerable to COVID-19 infections, complications and deaths due to our unemployment levels, limited income, housing and transportation instability, crowded living and working conditions, and aging population,” says Shan Qiao , associate professor of health promotion, education, and behavior and a core faculty member with the South Carolina SmartState Center for Healthcare Quality . “These conditions worsened existing health disparities and put a strain on the local health care systems that vulnerable groups depend on to manage chronic conditions, such as HIV/AIDS.”
With the eighth highest rate of HIV/AIDS incidence in the country, South Carolina has a population of nearly 18,000 residents who are living with HIV. Supply chain disruptions (e.g., safety equipment, pharmaceuticals used prevent and treat HIV), staffing shortages, capacity limitations and other challenges resulted in disruptions to services offered by 82 percent of the state’s HIV clinics at the beginning of the COVID-19 outbreak.
Researchers at the Center for Healthcare Quality have been examining impacts of the pandemic on people living with HIV, including service delays/interruptions, mental health, co-infection with COVID-19, vaccine efficacy, stigma, viral suppression, and more. Qiao’s study sought to identify recurring themes among AIDS service organizations who were better able to overcome many of these challenges. Their analysis resulted in seven facilitators of organizational resilience.
“These facilitators are unique to the context of the COVID-19 pandemic yet are relevant going forward, as this study highlights their importance in providing a continuity of care to people living with HIV and other vulnerable groups under circumstances requiring nontraditional methods of treatment,” Qiao says. “Our findings highlight the importance of effective health care system policies, management, and leadership that have clear and preemptive protocols to facilitate organizational resilience. This work necessitates organizational, local, state, and federal policies, drafted in times of crisis, to consider their immediate and long-term impacts on health care settings serving vulnerable populations and, more broadly, organizational resilience.”
This research was funded by NIH/NIAID (R01AI174892).
Read the full paper: Facilitators of Organizational Resilience Within South Carolina AIDS Service Organizations: Lessons Learned from the COVID-19 Pandemic
Find out more
The South Carolina SmartState Center for Healthcare Quality conducts research to enhance the quality of health for individuals in South Carolina and around the world. Other HIV/COVID-19 projects led by CHQ focus on nationwide trends of co-infection, mental health impacts from the pandemic, and vaccine efficacy.
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CDC COVID-19 Vaccination Program Provider Requirements and Support
The US government is no longer purchasing COVID-19 vaccines; therefore, the CDC COVID-19 Vaccination Program has ended. Updated 2023–2024 COVID-19 vaccines are now available for private purchase in the commercial marketplace.
- On Monday, Sept. 11, 2023, the FDA took action authorizing and approving the updated 2023–2024 monovalent XBB.1.5 variant mRNA COVID-19 vaccines by Moderna and Pfizer-BioNTech. On September 12, 2023, CDC recommended use of these updated 2023–2024 COVID-19 vaccines in all individuals ages 6 months and older.
- And, on October 3, 2023, FDA authorized the updated 2023–2024 monovalent XBB.1.5 variant Novavax COVID-19 Vaccine, Adjuvanted, which is recommended by CDC for use in individuals 12 years and older.
CDC has also withdrawn previous recommendations for use of the earlier versions of COVID-19 vaccines.
- Closing Out the CDC COVID-19 Vaccination Program
CDC COVID-19 Vaccination Program Has Ended
With these FDA and CDC actions, the CDC COVID-19 Vaccination Program ended as of September 12, 2023 , as it applied to the administration of the bivalent Moderna and Pfizer-BioNTech mRNA COVID-19 vaccines previously provided by the US Government (USG). Now, with FDA’s authorization on October 3, 2023, of the 2023–2024 Novavax COVID-19 Vaccine, Adjuvanted, the CDC COVID-19 Vaccination Program has fully ended as of October 3, 2023. All authorized/approved doses of COVID-19 vaccine in the United States are now the 2023–2024 formulas.
See below for required close-out activities for enrolled providers, including those enrolled through the jurisdictions and through the Federal Retail Pharmacy Program (FRPP), and other commercial partners, as well as federal and tribal entities participating in the CDC COVID-19 Vaccination Program.
Bivalent (Original and Omicron BA.4/BA.5 variant) Moderna and Pfizer-BioNTech mRNA COVID-19 vaccines and ancestral (Original) Novavax COVID-19 vaccines should no longer be administered; 2023-2024 versions should be administered instead.
With the end of USG-purchase of COVID-19 vaccines for administration through the CDC COVID-19 Vaccination Program, providers are encouraged to continue administering COVID-19 vaccines through their offices/pharmacies/other practices by:
- Commercially procuring doses of the updated 2023–2024 COVID-19 vaccine(s),
- Participating in the vaccines.gov vaccine locator service to help inform patients regarding availability of COVID-19 vaccine at their medical/pharmacy/other practice, and
- Otherwise informing their patients of CDC recommendations for receipt of the updated 2023–2024 monovalent XBB-containing COVID-19 vaccines .
Details on the CDC COVID-19 Vaccination Program discontinuation and required closeout activities are noted below. (Updated October 6, 2023)
This page serves as repository for any updates to the CDC COVID-19 Vaccination Program Provider Agreement , including recommendations, requirements, and other useful information for vaccination providers enrolled in the program.
CDC COVID-19 Vaccination Program Provider Agreement
Updates – cdc covid-19 vaccination program provider agreement requirements, closing out the cdc covid-19 vaccination program (updated 10/6/2023).
Step One: Reporting and Disposal of Remaining USG-Provided Vaccine Inventory
From the Program’s beginning, the COVID-19 Vaccination Program Provider Agreement has required all enrolled providers to report the number of unused, spoiled, expired, or wasted vaccine doses. Now, with the Program ended, providers must:
- Report all excess remaining USG-provided COVID-19 vaccine inventory using the wastage transaction in their jurisdictional reporting systems.
- Properly dispose of those vaccines according to state and local regulations.
This reporting requirement is for inventory purposes only and will not be used to judge provider performance. Direct questions about disposal activities to your state or local immunization program.
Deadline – These reports and disposal of remaining doses must be completed by October 27, 2023.
Step Two: Check this CDC Provider Agreement Update Website for Additional Program Close-out Steps
Providers must check this website for any additional actions required to close out participation in the CDC COVID-19 Vaccination Program.
Step Three: Using Unexpired Ancillary Supplies
Until September 12, 2023, all COVID-19 vaccine in the United States had been purchased by the United States Government (USG) for administration exclusively through the CDC COVID-19 Vaccination Program. Providers are prohibited from selling USG-purchased COVID-19 vaccine doses.
In addition, until September 12, 2023, all ancillary supplies provided by the USG through the CDC COVID-19 Vaccination Program could only be used as part of the process for administering USG-provided COVID-19 vaccine doses.
Providers may now use ancillary supplies provided by the USG through the CDC COVID-19 Vaccination Program to administer their commercially purchased vaccines.
Note : The expiration date printed on the exterior box of the CDC ancillary kit does not apply to all items in the kit. The date on the external label is based on the earliest expiry of any of the kit’s components.
Providers may exercise discretion and continue using unexpired kit components (e.g., needles and syringes) until they expire. Dispose of expired components in accordance with state and local requirements.
Unexpired ancillary kits or the items contained within cannot be sold or otherwise exchanged for anything of value , but can be shared domestically, at no charge, with other immunization programs, including:
- Other clinics within the practice
- Other sites offering healthcare services
- Veterinary clinics
Per federal funding requirements, ancillary kits cannot be donated outside of the United States or to organizations that will use the supplies outside the US.
Again, USG-provided ancillary supplies cannot be sold.
Step Four: Participate in Vaccines.gov vaccine locator service
During the CDC COVID-19 Vaccination Program, the website Vaccines.gov helped the public find the USG-provided COVID-19 vaccines they needed. With the Program over, Vaccines.gov will become a resource for locating providers administering the 2023–2024 COVID-19 vaccines both in the private commercial marketplace and through CDC’s Bridge Access Program .
Providers already participating in Vaccines.gov (including those whose data previously was updated by the jurisdiction public health agency) can update their information using the instructions in the Provider Resources section of Vaccines.gov.
Providers not previously enrolled in Vaccines.gov will follow a different process. Instructions will be forthcoming. Check back on this webpage.
Use of Vaccine Recipient Data for Commercial Marketing Purposes Prohibited (5/18/2021)
Notwithstanding uses or disclosures otherwise allowed by law, providers are prohibited from using or disclosing data collected from vaccine recipients for and through the CDC COVID-19 Vaccination Program for commercial marketing purposes or for any other purpose not allowed under this updated provision of the COVID-19 Vaccination Provider Agreement. Such data include COVID-19 vaccination registration information and vaccine administration data. These data are collected solely for the purposes of the CDC COVID-19 Vaccination Program and must be maintained in a manner that protects the integrity of the CDC COVID-19 Vaccination Program by only being used or disclosed for the purposes of the COVID-19 Vaccination Program and other limited purposes that promote public health, advance positive patient outcomes, and promote health equity.
This prohibition is not intended to limit communications by health care providers to vaccine recipients with whom the provider has an existing relationship prior to contact about COVID-19 vaccination.
The following are not included in the above prohibition:
- Communications regarding receipt of an additional dose of COVID-19 vaccine
- Communications to vaccine recipient for public health purposes
- Communications to vaccine recipients involving pharmacy or clinical services of the provider, personalized to the vaccine recipient’s medical needs, even if those services are not directly related to COVID-19 vaccination
- Availability of other vaccines (e.g., shingles, pneumococcal conjugate, seasonal influenza, routine childhood vaccines)
- Clinical emails
- Disease screening services
- Communications about the availability of programs to manage particular health conditions (e.g., asthma, diabetes, heart disease)
In addition, de-identified, aggregate datasets can be used by providers and shared with other partners for public health, population health, and health equity purposes.
Communications with COVID-19 vaccine recipients involving the store component of any pharmacy or other provider enrolled in the CDC COVID-19 Vaccination Program are considered prohibited commercial marketing. For example, text, e-mail, mail, or other communications to COVID-19 vaccine recipients about products on sale in the store are prohibited as commercial marketing.
COVID-19 vaccination registration information and vaccine administration data collected in the course of participation in the CDC COVID-19 Vaccination Program cannot be sold, for direct or indirect remuneration, even with permission of the vaccine recipient.
Reporting Suspected Fraud or Abuse
Individuals becoming aware of any suspected fraud or abuse related to the CDC COVID-19 Vaccination Program or violations of provider agreement requirements are encouraged to report them to the Office of the Inspector General, U.S. Department of Health and Human Services at 1-800-HHS-TIPS or TIPS.HHS.GOV .
CDC No Longer Distributing COVID-19 Vaccination Record Cards (10/6/23)
- Providers are no longer required to complete CDC COVID-19 Vaccination Record Cards.
Ongoing Requirements to Report Vaccinations to Jurisdiction Immunization Information Systems (10/6/23)
- Separate from participation in the CDC COVID-19 Vaccination Program, vaccinating providers must submit vaccine administration data for all covered vaccines through the immunization information system (IIS) of the state and local or territorial jurisdiction, as applicable.
- Enrolling in your jurisdiction/state-based IIS system
Exit Notification / Disclaimer Policy
- The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website.
- Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website.
- CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website.
Australian Government Department of Health and Aged Care
COVID-19 advice for in-home aged care providers
In-home aged care providers must take steps to minimise COVID-19 risks for older people and staff. Find information to help navigate the ongoing impacts of COVID-19.
Home Care Package (HCP) and Commonwealth Home Support Programme (CHSP) providers must deliver quality and safe care to older people, including during outbreaks of COVID-19.
State and territory public health advice
- follow any public health orders or work health and safety laws in their state or territory
- be familiar with the relevant state and territory information on COVID-19 .
The state or territory public health agency can provide advice relevant to each state or territory about caring for older people who test positive for COVID‑19.
Infection prevention and control
The Communicable Diseases Network Australia (CDNA) has developed national guidelines for the prevention, control and public health management of outbreaks of acute respiratory infection (including COVID-19 and influenza) in residential aged care homes .
Although there are no national guidelines specifically for in-home aged care, these guidelines can be adapted for the in-home aged care sector.
Aged care providers are responsible for ensuring all aged care workers are trained in infection prevent and control (IPC), such as cleaning and disinfection principles .
For online training see:
- Hand hygiene and infection prevention and control eLearning modules
- IPC for aged care eLearning modules – for all aged care workers
- IPC advanced education eLearning modules – for health care, aged and disability care workers and organisations, and workforce groups.
Where close personal care and support services are provided, in-home aged care is classed as a high-risk setting as it involves frequent close contact with older people.
Providers must have a COVIDSafe Plan that is reviewed and updated regularly, especially when public health advice changes.
A COVIDSafe Plan should:
- outline what control measures a provider will implement to eliminate or minimise the spread of COVID-19
- ensure the health and safety of workers, older people and others in their workplace, including peoples’ homes.
Providers should develop a workforce management plan to reduce risks that could affect staffing.
Aged care workers who test positive for COVID-19 should not attend work for at least 7 days after testing positive and until they have no symptoms of COVID-19.
Where a provider or service has staffing shortages due to COVID-19, providers can:
- prioritise delivering services that are necessary for the health and safety of older people
- seek assistance from other nearby organisations that may be able to subcontract workers to deliver services.
Read about surge workforce support for providers affected by COVID-19 .
When an older person has COVID-19
When an older person tests positive for COVID-19 , providers should:
- monitor for signs and symptoms of COVID‑19 , and, if their condition gets worse, workers should contact their GP or call an ambulance
- refer to their emergency care plan, which should outline alternative models of delivery, if required
- help them access alternative care arrangements, if needed.
To keep workers and older people safe, providers should:
- enact COVIDSafe measures when providing in-home aged care services
- minimise the number of workers who come into personal contact
- consider which services are critical to keep the older person safe.
Workers must follow the national infection control guidelines , including advice on when and how to use personal protective equipment when entering the home or room of a person who has tested positive to COVID-19.
Providers should support staff and older people to get vaccinated for COVID-19 and other vaccine-preventable illnesses such as influenza.
HCP and CHSP providers must report on the COVID-19 vaccination status of their staff.
Read more about COVID-19 vaccination and reporting for care recipients, workers and providers .
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ATAGI 2023 booster advice update
If it has been 6 months since a COVID-19 vaccine, an additional dose:
- is recommended for people aged 75 years or older
- should be considered for people aged 65 to 74 years, following discussion with their healthcare provider.
Providers are encouraged to talk about vaccinations with older people.
Read about the ATAGI 2023 booster advice .
Home Care Packages protocols
Delivery of HCP services that are necessary for the health and safety of care recipients must continue:
- where it is safe to do so
- in line with the relevant state or territory public health order
- is awaiting test results
- has tested positive for COVID-19
- is unvaccinated or will not disclose their vaccination status
- refuses a COVID-19 test.
Emergency care plans
HCP providers must have an emergency care plan in place with advice on different types of emergencies such as COVID-19 outbreaks, flood or bushfire.
Providers are responsible for:
- supporting care recipients access alternative care arrangements, if needed
- not stopping services without arranging an alternative model of delivery
- making sure all care recipient details are current, including emergency contacts and current GP.
Before an emergency, providers must work with the care recipient, their family, their authorised representatives and their GP or other health practitioners to discuss the plan, including what would trigger the plan's use.
Developing an emergency care plan with care recipients can be incorporated into the usual care management planning discussions .
Read more about preparing an emergency management plan .
Supplying RAT kits to care recipients, family and visitors
When supplying RAT kits and personal protective equipment to care recipients, HCP providers can:
- charge the care recipients what it cost you
- seek an increase in the price of care management to cover the costs (which spreads costs across all care recipients in your care)
- seek agreement from the care recipient to access home care funds in their package budget for purchases made on their behalf.
If care recipients have purchased RAT kits out of pocket to support the safe delivery of aged care services, these may be reimbursed from their HCP funds, or the care recipient may agree to pay additional fees if their HCP budget is already fully allocated.
Care recipients and providers should discuss these issues and ensure all costs and services are agreed and documented in the home care agreement.
Care recipients who want RAT kits for personal use may be able to get them for free under state or territory government programs:
- New South Wales
- Australian Capital Territory
- Northern Territory
- South Australia
- Western Australia .
Security of tenure requirements
HCP providers are bound by security of tenure requirements and must deliver the agreed care and services for as long as the care recipient needs those services (see Section 17 of the User Rights Principles 2014) .
Providers may only pause or stop delivering home care where they meet the requirements under the User Rights Principles 2014 .
Where a provider cannot continue services for a care recipient, you must continue in a safe manner until they move to another provider willing and able to accept them.
Read more information on security of tenure .
Commonwealth Home Support Programme providers
CHSP providers are responsible for addressing the safety of employees and volunteers delivering services to a client or carer in their home.
This includes operating under the provider’s COVIDSafe Plan and adhering to the infection control procedures, where applicable.
Read more information about CHSP provider responsibilities .
Financial support for providers and workers
We fund grants to support aged care providers and workers impacted by COVID-19.
Some COVID-19 testing expenses are tax deductible when they relate to a person’s job or business.
Publications and fact sheets
Advice for the aged care sector during COVID-19 Find up to date information and advice on COVID-19 for aged care providers, aged care workers and people who access residential or in-home aged care.
COVID-19 resources for health professionals, including aged care providers, pathology providers and health care managers
For more information, watch webinars:
- on the COVID-19 response for the health and aged care sector
- for the aged care sector .
To stay up to date on aged care and COVID-19:
- see our aged care news
- subscribe to aged care news .
Find the latest advice and resources in your state or territory from your local public health agency .
- Communicable diseases
- Emergency health management
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Arizona Nonprofit Helping Those Who Feel They Were Harmed by COVID-19 Medical Protocols
There was a time when Kurtis Bay of Arizona believed in the health care system and that the Hippocratic Oath to "do no harm" had real meaning.
His ultimate loss of faith followed the complete loss of medical freedom he experienced in January 2022 when his wife, Tammy, went to the emergency room at a Phoenix-area hospital for a respiratory ailment.
They told him instead that she had pneumonia but "isolated her" in the COVID unit anyway. They labeled him "combative" for wanting answers about his wife's condition.
Then they called the police and issued a no-trespass order against him, which meant he couldn't see his wife unless the hospital permitted him.
"If they had treated Tammy for what she was in there for, she'd be alive today," said Mr. Bay, a member of the board of directors of the nonprofit COVID-19 patient rights advocacy group "1,000 Widows."
Mr. Bay joined the grass-roots organization in 2022 to help others who said they lost loved ones to standard medical protocols during the government-declared pandemic.
Lori Sederstrom founded the group in 2021 after her husband died while undergoing hospital treatment for COVID-19.
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Mr. Bay said he realized there were many others just like him—more than 30,000 in the group—who were just as "confused or had no idea this was occurring" throughout the hospital system.
On its website, the group said its primary mission is to raise awareness of the "destruction of countless lives during the pandemic" with a focus on civic action and community support.
Members can also access financial and mental health resources and information through faith-based initiatives.
As important, Mr. Bay said, are 1,000 Widows' legislative efforts to strengthen medical freedom and accountability with a revised Arizona patient bill of rights.
The group helped overturn Arizona SB1377, pandemic legislation that declared a medical health provider immune to liability for negative outcomes if it acted in "good faith" during a public health emergency.
"COVID-19 patients in Arizona who feel they were harmed by healthcare providers during the pandemic are now able to pursue legal claims and seek damages," said 1000 Widows member Sara Behmer-Pinheiro in a letter to The Epoch Times.
"Our vision is to create a world where families impacted by tragedies, like the COVID-19 pandemic, can access real-time support and resources tailored to their unique needs.
"We aim to bring together individuals, organizations, and partners from all walks of life, fostering a community that stands together in times of crisis."
One Arizona lawmaker who supports the group is Sen. Janae Shamp, a Republican member of the state legislature's Coronavirus Southwestern Intergovernmental Committee.
On Oct. 20, the body met in Phoenix to hear presentations on COVID-19 protocols, autopsy findings, and ways to protect medical and religious vaccine exemptions.
"While I believe that there is a need to review and enhance the patient's bill of rights, we will not be discussing a formal proposal at this hearing," Ms. Shamp, vice-chairwoman of Arizona's Health and Human Services, told The Epoch Times.
"However, the general concept of the patient's bill of rights is an important and unavoidable component of the discussion we will be having regarding proper informed consent, adverse events, and other implications of the widespread deployment of COVID-19 vaccines and other related countermeasures."
On May 11, the Biden administration ended the COVID-19 pandemic health emergency declaration, allowing government health agency authorizations for collecting medical health data to expire.
In late 2020, the World Health Organization (WHO) issued a conditional recommendation against the use of the antiviral drug Remdesivir in hospitalized COVID-19 patients, "regardless of disease severity, as there is currently no evidence that Remdesivir improves survival and other outcomes in these patients."
Remdesvir is one of two National Institutes of Health (NIH) preferred therapies after the antiviral Paxlovid used to prevent hospitalization for COVID-19, according to Yale Medicine.
However, at least two studies linked the drug's use to acute kidney injury in COVID patients.
"Once you arrive, they put you into a particular process," Mr. Bay said, noting that some hospitals still use peak COVID-19 protocols to treat patients.
"It doesn't matter what your loved one came in with. They don't have to be COVID-positive. They can still treat them for COVID whether they are COVID-positive or not. They can move them in this system and check the box for the [government financial] incentive plan," he said.
'Had A Feeling'
"We called it the sleeping disease because we were tired for 10 or 12 days [but] we were fine," Mr. Bay said.
The night Tammy experienced chest discomfort on Jan. 5, 2022, the couple were on their way to an urgent care facility after hours.
"Are you taking me to the emergency room?" Tammy asked her husband, who said, "No."
"Well, I think that's where I'm going to end up," Tammy said. "I just have a feeling."
Mr. Bay said his wife's apprehensions were correct. And when the hospital admitted her hours later, he wrote on a medical whiteboard: "No sedation. No high-flow oxygen. No Remdesivir."
Within 24 hours of her admittance, "they were already sedating her," he said. "I was labeled combative on the first day. They called security to try to remove me. The cops came, and I was trespassed."
On day three, Mr. Bay requested a transfer for Tammy—and on that day, they intubated her. A panic attack landed her in the intensive care unit, simply because of the hospital's COVID-19 protocol for elevated breathing and heart rate.
One night, Tammy called her husband, pleading to come and take her home—"and I couldn't—I couldn't come and get her," Mr. Bay said, breaking into tears. "They wouldn't let me."
"They were following a regimen. Nobody asked how Tammy was feeling. They didn't even know her [expletive] name."
Tammy eventually developed a leaking perforation in her bowel that required emergency surgery.
"All of this happened because she was in the hospital," said Mr. Bay, who received the devastating news that Tammy couldn't have the life-saving operation.
The surgeons said that to do the procedure, Tammy would have to lie on her stomach. If that happened, she would stop breathing and die. Without the surgery, her body would become septic and she would die.
"So I said goodbye to her," Mr. Bay said. "And that's the way it went."
On Jan. 20, 2022, Tammy took her last breath—two weeks after her hospital admittance for pneumonia, her husband said.
Mr. Bay said the medical bill from the insurance company—more than $300,000—was like adding insult to injury.
With COVID-19 as a post-mortem diagnosis, the hospital received $12,000 under the CARE Act, he said.
"It's still happening today—the same protocols. It doesn't matter whether you give consent or not," he said.
Mr. Bay said a "driving message" from 1,000 Widows members is their shared desire for justice and medical accountability denied by the legal establishment.
"It was clear we needed to establish more local and civic responsibility in the form of legislation," Mr. Bay said.
"This isn't about me. It isn't about my wife. It's about us—the victims. None of us wants to be here. But here we are."