Welcome to the University of Houston contact tracing training program. This is a self-paced online certificate course developed by the University of Houston College of Medicine and College of Nursing, that will inform nurses about contact tracing through the COVID-19 pandemic. Course materials are particular to the state of Texas. An overall pre-test, as well as a five item post-test after each module will be required. As always, please remember that the COVID-19 pandemic is evolving by the minute. We will make every effort to update material as needed. Please, review this disclosure at your earliest convenience. The course will be divided into 4-Module. First, we will do an overview of COVID-19. Then, we will understand public health in the era of COVID-19. We will move to contact tracing, communication, as well as strategies, and finally, we will cover ethical and legal issues, as well as the effect of COVID-19 on vulnerable populations. Let's begin with an overview of COVID-19. After this module, you will be able to summarize the history of pandemics, what's the current signs and symptoms of COVID-19, explain strategies to reduce the transmission of COVID-19, describe the basic principles and methods of epidemiology and demonstrate their broad applicability to COVID-19, describe the history of COVID-19, it's clinical presentation, transmission and reproduction, and describe the current state of vaccine development and treatment for the pandemic. Coronaviruses are a large family of viruses that are common in people and many different animal species, including camels, cattle, cats, and bats. In rare instances, animal coronaviruses can infect people, then spread among people. This occurred with the Middle East Respiratory Syndrome, with severe acute respiratory syndrome, and now with a strain that causes COVID-19. The bat is natural host of these three coronaviruses. COVID-19 is the newest coronavirus, is also called Severe Acute Respiratory Syndrome Coronavirus two or SARS-COV-2. The term COVID-19 can be broken down as follows; CO represents corona, VI represents virus, D represents disease, and 19 represents the year 2019, the first year it was reported. The COVID-19 Tracking Project collects and publishes the most complete testing data available for the US states and territories. This is especially important to understand transmission, spread and current trends. Please, review this site to learn more. In addition, the Centers for Disease Control, state governments and local public health departments are tracking cases of Coronavirus disease. Many public health departments have their information published online. As you can see here, we have the data for the city of Houston at this link. Humans have a long experience with infectious diseases. However, the beginning of mass casualty outbreaks of infectious diseases, of epidemic and pandemic disease begins at a certain time point, and that time is the growth of civilization. Even those homo sapiens go back much further from the beginning of civilization. Our recorded history begins with the civilizations in Egypt, Mesopotamia, etc. This is when we start to have written language, records with our encounters in the world and with each other, and thus documentation of our encounters with disease. But this is not the only reason we don't have records of the mass casualties before then. It is not because infectious diseases were unknown to our a hunter-gatherer for bearers. It is more that the mass outbreak of infectious disease was directly related to the growth of the city, the growth of the empire and civilization. It is ways in which we changed how we lived in the world that changed how we experienced infectious diseases. Think about where most infectious diseases come from. There were certainly pathogens in the soil like anthrax or botulism, and those would have been known to our prehistoric ancestors. But when we start to settle on land, possibly because of the pressures of the population expansion after the last Ice Age, and green it, we get marshy areas and malaria. When we start to domesticate cattle, this presents a new reservoir of disease and we see the phenomenon of zoonosis appear. With our close interactions with animals, we will see disease jump the species barrier. Mutations will take hold in the human-to-human transmission, which is how we get measles, influenza and swine flu. That domestication, combined with the growth of these cities, states, and empires, is when we start to see these mass casualty disease outbreaks. This brings us to the Plague of Justinian, which is typically seen by medical historians as the first of the three big deadly pandemics in our history. When talking about the Plague of Justinian, we must talk about the Roman Empire and how it's newer ways of operating with it's fast travel, troop movements and trade, exemplified those changes in the way we interacted with the world and one another. Transporting disease from population to population is critical to the reason like endemic disease becomes epidemic. Transportation combined with dense populations is how a disease outbreak becomes explosive. Then we have an empire that stretches beyond our shores, we can spread it across the world, and then we have our first pandemic. So it is with the Roman Empire and the Emperor Justinian that we see the first of history's deadliest plagues, the Plague of Justinian, which is an example of the bubonic plague. Not all plagues in history have been bubonic plague, but we call them plagues. The word plague is a metaphor as much as it is anything else. It comes from the Latin root plata for strike or a blow. This is a Latin translation of the plagues that we see in the Hebrew Bible, the plagues of the pharaoh. This reminds us that this is a common human experience in history. These are world-changing events with so much loss of human life, but they are also events of resilience, endurance, and adaptation. Talking about epidemics, let's review some of the largest epidemics in the 20th and 21st century. Between 1918 and 1920, we had the influenza pandemic, commonly called the Spanish flu. It infected 500 million people and killed 50 million across Europe, the Americas, and parts of Asia. At that time, there were no drugs or vaccines to treat the disease. People were ordered to wear masks and schools, theaters and businesses were shut down. This was by far the deadliest epidemic in history. Forty years later, we had the influenza A pandemic, which was caused by the avian flu viruses. It claimed more than one million lives. Then the Hong Kong flu pandemic, which occurred between 1968 and 69, killed an estimate of one to four million people globally. In 2003, we had the Severe acute respiratory syndrome outbreak, commonly referred to as SARS. SARS is a viral respiratory illness caused by a corona-virus. We will learn more about this on the next slide. This disease infected 8,098 people worldwide, of which 774 died. The 2009 Swine flu pandemic originated in Mexico, and infected as many as 1.4 billion people across the world. It is estimated that between a 151,700 and 575,400 people died as a result of the Swine flu. Middle Eastern Respiratory Syndrome, or MERS, also called the camel virus, is a viral respiratory illness caused by corona virus. It resulted in 2,500 cases and 800 deaths. Ebola virus disease, commonly called Ebola, occurred between 2013 and 2016. It mostly affected Sub-Saharan Africa, infecting almost 30 thousand persons and causing 11 thousand deaths. Now, we have COVID-19, which is also caused by a corona virus. On the next slide, we will talk a little bit more about the Spanish flu. The Spanish flu can easily be compared to COVID-19. As we saw with the two previous pandemic examples, a huge percentage of the world's population was infected. We see the activity of World War I as a stimulus and a setting for an outbreak of influenza and a trigger to other influenza outbreaks. Because of World War I, we see conflicted decision making in the United States about what to prioritize. Cities with different social distancing measures had different outcomes in terms of death rates. Philadelphia prioritized displays of patriotism and support for the war effort. It wasn't that the information from public health officials was different in Philadelphia than it was in St. Louis. It was that these cities made different decisions with regards to what to do with the information leading to tragic outcomes. Thus, this displays that public health information and public health crises are constantly competing with a need to open economies and to keep communities together. What are the lessons of history? First, that cities and modern ways of living have produced conditions necessary for both pandemics to emerge and pandemics to be controlled. Catastrophic disease outbreaks always presents unique challenges, but it also showcases our resilience and our adaptability in the face of uncertainty and opportunities for solidarity and shared human experiences. It's also important to learn from our past mistakes and apply these principles to future outbreaks. Please review this TED talk in which Bill Gates talks about ways that we can learn from history. As stated previously, COVID-19 and the Spanish flu have many similarities. They are both transmitted via respiratory droplets. Older adults were most at risk of developing severe symptoms with Spanish flu as well. However, in stark contrast to COVID-19, the Spanish flu also impacted children under the age of five and adults age 20 to 40. The virulent nature of this particular H1N1 strain and the lack of medication available made it the most severe pandemic in recent history. So now that we've learned from history, let's review some basic epidemiology and transmission of COVID- 19. What is epidemiology? The word itself stems from three root words. Epi, which means upon, demos, which is the Greek word for people and logos to study. Now bringing these words together, epidemiology is the study of what befalls or what falls upon the population. In other words, the study of epidemics and their prevention. An epidemic is a disease occurrence among a population that has an excess of what is expected in a given time and place. A pandemic, on the other hand, is a word you've probably heard in regards to Covid-19, and it is an epidemic that has spread over multiple regions of the world. For example, Covid-19 is a pandemic because it has spread over multiple countries and continents. Now that we know what epidemiology is, let's review some key terms commonly associated with the study. You will see these terms throughout the course. An epidemic or outbreak, is a disease occurrence among a population that is in excess of what is expected in a given time and place. A cluster is a group of cases in a specific time and place that might be more than expected. An endemic is a disease or condition present among a population at all times. A pandemic is a disease or condition that spreads across regions. Finally, the rate is the number of cases occurring during a specific period, which is always dependent on the side of a population during that period. Considering the definition of epidemiology, how do we apply its concepts to the current pandemic? To do that, we need to review the purpose of epidemiology. The first purpose of epidemiology is to measure disease frequency in populations. In other words, counting the number of cases and measuring the rate of infections. With rates, we use specific terms like prevalence and incidence. Prevalence is the proportion of persons in a population who have a particular disease at a specified point in time or over a specified period of time. Incidence represents the rate of occurrence of new cases in a given period in a specified population. These will be explained. The second purpose of epidemiology is to assess the distribution of disease. There are three characteristics that we look for in conducting this assessment. The first has to do with the persons. Who is getting the disease? Is there a specific age, gender, ethnicity, socioeconomic status, or behaviors, that more likely predispose to the disease? The second characteristic has to do with place. Where's the disease occurring? Is it geographically restricted or widespread? The third characteristic has to do with time. When is that disease occurring? Is it seasonal? Is it changing or stable with time? The third purpose is to form hypotheses about causes and preventative factors. Lastly, we test those hypotheses to identify determinants of disease. To calculate rate, we first need to determine the frequency of disease, which includes the number of cases of the illness or condition you're counting, the size of the population at risk, and the period during which we are calculating the rate. After the frequency of disease is identified, the illness rate is calculated by dividing the number of cases of the disease, for the selected period, by the size of the population at risk for that same period. Then that number is multiplied by 100. This formula provides a number of cases as a percentage of the population for a given period. Prevalence and incidence are commonly used disease rate measures. Prevalence is the proportion of a population who have a particular disease. Incidence refers to the occurrence of new cases in a disease in a population over a specific period of time. Coronavirus can be transmitted from person to person through small droplets from the nose or mouth when an infected person coughs and exhales. Those droplets can land on surfaces, which means that any person that touches those surfaces in their eyes, nose or mouth can become infected. As these respiratory droplets move in the air, they can land in the nose, mouth, and lungs of another person or as seen previously, land on objects and surfaces that will be eventually touched by other persons, and then that person will eventually touch their nose and mouth, leading to another route of transmission. Once infected, Coronavirus attacks your respiratory tract, which includes your nose, throat, and lungs. This leads to a wide range of symptoms, including fever, cough, shortness of breath or difficulty breathing, chills, muscle pain, sore throat, or a loss of taste and smell. This list is not exhaustive. Other symptoms have been reported like nausea, vomiting, and diarrhea. If the people you are contacting have questions about their symptoms, you should connect them with their primary care practice. Another reason, Coronavirus is so contagious, is because people can transmit it without having any symptoms. This is important to keep in mind when discussing symptoms with those that you are speaking to about contact tracing. There are a couple ways that we measure the transmission of Coronavirus, which is very important for understanding contact tracing. First is reproduction number. Reproduction number is the expected number of additional cases produced by one case. The duration of infectiousness is the amount of time that one remains infectious after having contracted the virus. The contact rate is the average number of susceptible people that an infected person encounters per day. The transmissibility of a disease is the probability of an infection per contact. Compared to other infections, Coronavirus is highly contagious. Each infected person with Covid-19, is expected to infect 2 - 2.5 additional people. While this number is high, it also is not as high as other diseases. For example, Measles, has a reproduction number of 15. Fortunately, the reproduction number is not destiny. We can change our behavior and reduce the number of additional people that are infected. Lower reproduction numbers, translate to flatter epidemic curves. Epidemic curves, show the progression of an outbreak over time. On the news, you may have heard about flattening the curve. This is the curve they're talking about. You may have noticed, that the reproduction number depends on characteristics of the virus. Like how it's spread and how long it stays in our bodies, and behaviors, how many people infected individuals come into contact with. Because we can prevent infected people from coming into contact with others and do things to reduce the transmission of the virus, our behavior acts as a social vaccine, helping to flatten this curve. During this course, you'll learn more about what you can do to help. Flattening the curve, is important for several reasons. First, it delays the outbreak peak. This buys time, so that we can get equipment like masks and ventilators, and develop vaccines. Second, it reduces the peak burden on hospitals and the existing health care infrastructure. This ensures that we have enough hospital beds and ventilators, for the people that need them. Finally, it may reduce the total number of cases. Many people infected with Covid-19, show mild symptoms, especially during the first stages of the disease. Thus, you can still catch the disease from an infected person who has no symptoms or one who has a mere cough and doesn't feel ill. It is important to follow four steps, if you believe that you are experiencing symptoms of Covid-19. First, it's a good idea to call the designated phone number in your region to obtain a Covid-19 test at a testing center. As you practice social distancing, while waiting for your results. When the results are available, follow the instructions provided by your doctor in order to mitigate the spread of disease. Here are some references to help you find state, territorial, county and local testing sites. They will be included in the reading section of this module. Two types of tests are available for Covid-19, viral and antibody tests. A viral test, tests for the presence of virus genetic material in your upper respiratory tract. The first test for SARS-CoV-2, was developed by the World Health Organization. In the United States, the Centers for Disease Control and Prevention, developed its own virus test early in 2020. There are now many commercial diagnostic labs and hospital labs which have developed their own FDA approved tests. When a person is exposed to a virus, their immune system makes special proteins to combat the infection. These are called antibodies and they can be measured in the blood. Every test looks for a specific combination of antibodies and antibody types. The result can be a yes or no result or the result can specify how much, or how little antibody to Covid-19 is present. Antibody tests, which are already commercially available are in the process of being validated by the FDA. This slide, shows a helpful guide in interpreting your Covid-19 test results. A positive viral test result, likely means that you currently have an active Covid-19 infection and can give the virus to others. A positive antibody test result however, means that you likely had a Covid-19 infection. The good news is that 80 percent of people will recover from Covid-19, without any special treatment. However, to prevent those who will develop complications, we can do six things. First, you can wash your hands often and wash them with soap and water for at least 20 seconds. If soap and water are not readily available, you can use hand sanitizer, that contains at least 60 percent alcohol. Cover all surfaces of your hands and rub them together, and then until they feel dry. Second, avoid close contact. This includes people who are sick, even if they live with you. If possible, maintain six feet between the person who is sick and other household members. Remember that some people without symptoms, may be able to spread the virus. Stay at least six feet away from other people. This is a little longer than the hockey stick or noodle pool. Third, cover your mouth and nose with a cloth face covering, whenever you are around others. Everyone should wear cloth face cover, when they have to go out in public. It is meant to protect others as well as yourself. Fourth, cover coughs and sneezes. If you are in a private setting and you don't have on your cloth face covering, remember always to cover your mouth and nose with a tissue, when you cough or sneeze into your elbow. Throw used tissues in the trash and then immediately wash your hands. Finally, clean and disinfect frequently touched surfaces daily. This includes tables, doorknobs, light switches, counter-tops handles, desks, phones, keyboards, toilets, faucets and sinks. As always, follow directions of the national and local health authorities, and seek medical attention, if you have difficulty breathing or a high fever. In order to elaborate a little bit more on the proper use of face masks, follow these tips. Before wearing a mask, wash your hands with alcohol-based disinfectant or with soap and water. Both your nose and your mouth must be covered by the mask. Do not touch the mask while you're wearing it. Replace the mask as soon as it gets wet and do not reuse disposable masks. Remove the mask from behind, do not touch the front side, and throw it away in a closed container. After, wash your hands for at least 20 seconds, with an alcohol based disinfectant or with soap and water. More information can be found at the link which will be included in the readings. We all have a responsibility to make the transmission of Covid-19, look more, like it does, on the left rather than on the right. We can see that without proper social distancing measures, the rise in infected members is incredibly large. So we all have a part to play in reducing this footprint. Now that we've discussed a little bit of the epidemiology and transmission of Covid-19. Let's switch to a more general public health approach to outbreak assessment. This can be specific to Covid-19, or it could be in response to other outbreaks. Public health problems are diverse and can include infectious disease, chronic diseases, emergencies, injuries, environmental health problems, as well as other health threats. But regardless of topic, we take the same approach to halt public health problems by following four general steps. First, we ask, what is the problem? We use surveillance systems to monitor the health events and behaviors occurring among the population. After we have identified the problem, the next question is, what is the cause of a problem? For example, are there factors that might make certain populations more susceptible to disease, such as something in the environment or certain behaviors that people are practicing? Once we've identified the risk factors related to the problem, we ask, what intervention works to address the problem? We've looked at what has worked in the past in addressing the same problem, and if a proposed intervention makes sense with our affected population. And the last step, we ask, how can we implement the intervention? Given the resources we have, and what we know about the affected population, will this work? As we go through this course, you will see different examples of public health approach at work. One such example is vaccines. But what exactly is a vaccine? A vaccine is essentially a microbe, such as a virus or bacteria, or a component of that particular microbe, that does not cause disease because it has been killed or attenuated. Although this non-infectious microbe no longer causes disease [inaudible] administered, it will activate the immune system to produce antibodies that protect the person against the live pathogen. This activation of the immune system and production of antibodies leads to long-term immunity and protection from the live infectious agent. Thus, the goal of a vaccine is to mimic our natural immune system and induce the production of antibodies that will protect us from the infectious virus or bacteria. We can then say that the vaccination is the manipulation of our immune system under controlled conditions. That is, the use of a non-infectious agent to induce the production of antibodies, just as an infectious agent would do, but without causing disease. Antibodies are proteins that are produced by specific immune cells in response to infection by a microbe. As shown in this figure, antibodies express two micro binding sites that can bind to the microbe for which they were produced. For example, when a person is infected with microbe like SARS-CoV-2, our immune system responds by producing antibodies that can specifically bind to a specific part of SARS-CoV-2. The ability of antibodies to bind microbes enables them to carry out their most basic and primitive functions, which is to neutralize microbes and prevent them from infecting cells. As shown in this figure, in the absence of antibodies, microbes are freely able to bind to receptors on the surface of cells, allowing them to enter and affect those cells. On the other hand, antibodies, when present, can bind too, and coat the infecting microbe. By coating the infecting microbe, antibodies prevent that microbe from interacting with receptors on the target cells, effectively neutralizing or blocking the microbe from infecting those cells. A vaccine against Covid-19 will be a non-infectious SARS-CoV-2 virus or component of the virus that does not cause Covid-19, but if successful, will lead to production of antibodies against SARS-CoV-2. Over time, a successful vaccine, because of its ability to induce specific antibodies, will lead to long-term immunity against this particular corona virus that will provide protection from future infections with this virus strain. A serological test is a test to determine if a person has antibodies against an infecting microbe. This test is also used to determine if a vaccine is successful, since successful vaccines lead to antibody production. Because there is no vaccine currently for Covid-19, a positive test for SARS-CoV-2 antibodies, means that the person has previously been infected with SARS-CoV-2 and produced antibodies. Immunity means that this patient is protected from future exposure to SARS-CoV-2. Since there's no vaccine against COVID-19, one strategy to treat patients infected with COVID-19 is to transfer antibodies from a person who was previously being infected with the virus, but no longer has the virus in their body into a person who has COVID-19. This form of immunization is termed passive immunization. Because passive immunization does not activate the recipient's immune system to produce their own antibodies, this form of immunization does not lead to long-term immunity, it's effective only as long as the transferred antibodies remain in the body of the recipient. The development of vaccine against COVID-19 is providing many medical and research challenges. However, we know from historical examples such as smallpox which was eradicated following the discovery of vaccines and the process vaccination, that vaccines are the most effective strategy and preventing disease. What strategies do we have to aid us in this vaccine development? There are several strategies that are currently used. For example, vaccines against Polio or Rabies use Live Attenuated Viruses. Similarly, vaccines against Cholera or Tuberculosis use Live Attenuated or Killed Bacteria. Vaccines against specific toxins such as those that cause Tetanus and Diptheria use sub-units of those toxins, synthetic proteins created in labs are another strategy. Other strategies can also be listed in the table. The different strategies for vaccine development are essentially different methods used to present the infectious agent or component of the agent to B-cells, the immune cells that produce antibodies. Of all the immune cells, only B-cells producing antibodies. When B-cells encounter a microbe naturally or in a vaccine, they become activated and begin producing antibodies that will specifically bind to the microbe. Therefore, the different strategies used for vaccine development are designed to efficiently and effectively present the microbe to B-cells leading to antibody production. It is known that SARS-CoV-2 uses a protein called a spike or S-protein to enter and infect respiratory cells. Therefore, one goal for COVID-19 vaccine is for B-cells to produce antibodies that bind to the spike protein in order to prevent the virus from infecting those cells. In this case, the successful strategy will efficiently activate B-cells in a way that they will produce antibodies against the spike protein. Currently, a massive international effort is underway to develop a vaccine against COVID-19. Although it can take some time, SARS-CoV-2 appears to have many of the characteristics that make it a good candidate for the development of a successful vaccine. The identification of a potential target for these antibodies would also add to the promise that a successful vaccine can be developed. Although the vaccine development outlook is very positive, significant challenges lie in the way of final vaccine approval and large-scale administration. Most current research and development is being conducted by private companies that have never manufactured products on a scale that will be demanded unnecessary. Moreover, those companies are primarily located in North America, Europe and Asia. Meaning that vaccines developed in one region may not be as effective in another region. Also, despite the fact that development timelines had been accelerated at an unprecedented rate, there is uncertainty as to how fast the process can become before efficacy and safety are in danger of being compromised. Thus, it may be at least another year before a vaccine will be available for large-scale use. Even if the process is shortened, it remains expensive. Sophisticated bio-safety containment measures and specific animal models are required to conduct this type of research. Finally, once a vaccine is available, profound global coordination will be required to produce, distribute, and administer the vaccine in the fastest, most efficient way possible. However, despite all these hurdles and is not unreasonable to be optimistic that an effective vaccine is even now in the development pipeline. The treatments for COVID-19 vary widely and developed each day. Please review this New York Times article to obtain a very nice synopsis of current treatments. In Summary, COVID-19 is an infectious disease caused by the recently found virus known as SARS-CoV-2. COVID-19 is one of many pandemics throughout history that have had worldwide impact. COVID-19 is highly infectious and can be spread by people with little or no symptoms. Epidemiology, however, is a critical tool in understanding and developing ways to prevent outbreaks like COVID-19. While there's no cure and currently no vaccine for COVID-19, prevention measures such as social distancing and mask wearing are imperative to stopping the spread of the virus. Promising treatments are created however for corona virus and are being utilized while vaccine development continues. Please refer to these references and additional resources that will be listed on the readings portion of the module for more information about the information contained in this module.
