a literature review on covid 19

Literature Review of COVID-19, Pulmonary and Extrapulmonary Disease

Affiliations.

• 1 University of Maryland Medical System, Capital Region Health, Internal Medicine Department, Cheverly, MD.
• 2 University of Maryland Medical System, Capital Region Health, Internal Medicine Department, Cheverly, MD. Electronic address: [email protected].
• 3 Federal University of Santa Catarina, Dentistry Department, Florianopolis, Brazil. Electronic address: [email protected].
• PMID: 33785204
• PMCID: PMC7859706
• DOI: 10.1016/j.amjms.2021.01.023

In December 2019 novel coronavirus-Severe Acute Respiratory Syndrome-Corona Virus2 (SARS-CoV2)-originated from Wuhan, China, and spread rapidly around the world. This literature review highlights the dynamic nature of COVID-19 transmission and presentation. Analyzing 59 relevant articles up to May 1st, 2020 reflects that the main reported clinical manifestation of COVID-19 pandemic is fever and respiratory involvement. Also, current literature demonstrates a wide spectrum of different and atypical presentation(s) of COVID-19. The definite route of SARS-CoV2 transmission is respiratory droplets, however, virus nucleic acid has been detected in the stool and urine specimens as well. The severity of symptoms and outcomes of COVID-19 vary based on the patient's medical background, age, sex, and concurrent medical conditions (e.g. pregnancy). This is the first review that classifies all essential points regarding COVID-19 manifestations at a glance to improve the outcome of the patients by a better insight into diagnosis and management.

Keywords: COVID-19; Manifestations; Novel corona virus (2019-ncov); Presentations; Severe acute respiratory syndrome-corona virus2 (sars-cov2); Transmission.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

Publication types

• COVID-19* / epidemiology
• COVID-19* / metabolism
• COVID-19* / physiopathology
• COVID-19* / transmission
• Lung* / metabolism
• Lung* / physiopathology
• Lung* / virology
• SARS-CoV-2 / metabolism*

• Open access
• Published: 20 September 2023

Older adults’ experiences during the COVID-19 pandemic: a qualitative systematic literature review

• Elfriede Derrer-Merk   ORCID: orcid.org/0000-0001-7241-0808 1 ,
• Maria-Fernanda Reyes-Rodriguez   ORCID: orcid.org/0000-0002-2645-5092 2 ,
• Laura K. Soulsby   ORCID: orcid.org/0000-0001-9071-8654 1 ,
• Louise Roper   ORCID: orcid.org/0000-0002-2918-7628 3 &
• Kate M. Bennett   ORCID: orcid.org/0000-0003-3164-6894 1  

BMC Geriatrics volume  23 , Article number:  580 ( 2023 ) Cite this article

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Relatively little is known about the lived experiences of older adults during the COVID-19 pandemic. We systematically review the international literature to understand the lived experiences of older adult’s experiences during the pandemic.

Design and methodology

This study uses a meta-ethnographical approach to investigate the included studies. The analyses were undertaken with constructivist grounded theory.

Thirty-two studies met the inclusion criteria and only five papers were of low quality. Most, but not all studies, were from the global north. We identified three themes: desired and challenged wellbeing; coping and adaptation; and discrimination and intersectionality.

Overall, the studies’ findings were varied and reflected different times during the pandemic. Studies reported the impact of mass media messaging and its mostly negative impact on older adults. Many studies highlighted the impact of the COVID-19 pandemic on participants' social connectivity and well-being including missing the proximity of loved ones and in consequence experienced an increase in anxiety, feeling of depression, or loneliness. However, many studies reported how participants adapted to the change of lifestyle including new ways of communication, and social distancing. Some studies focused on discrimination and the experiences of sexual and gender minority and ethnic minority participants. Studies found that the pandemic impacted the participants’ well-being including suicidal risk behaviour, friendship loss, and increased mental health issues.

The COVID-19 pandemic disrupted and impacted older adults’ well-being worldwide. Despite the cultural and socio-economic differences many commonalities were found. Studies described the impact of mass media reporting, social connectivity, impact of confinement on well-being, coping, and on discrimination. The authors suggest that these findings need to be acknowledged for future pandemic strategies. Additionally, policy-making processes need to include older adults to address their needs. PROSPERO record [CRD42022331714], (Derrer-Merk et al., Older adults’ lived experiences during the COVID-19 pandemic: a systematic review, 2022).

Peer Review reports

Introduction

In March 2020 the World Health Organisation declared a pandemic caused by the virus SARS-CoV2 (COVID-19) [ 1 ]. At this time 118,000 cases in 114 countries were identified and 4,291 people had already lost their lives [ 2 ]. By July 2022, there were over 5.7 million active cases and over 6.4 million deaths [ 2 ]. Despite the effort to combat and eliminate the virus globally, new variants of the virus are still a concern. At the start of the pandemic, little was known about who would be most at risk, but emerging data suggested that both people with underlying health conditions and older people had a higher risk of becoming seriously ill [ 3 ]. Thus, countries worldwide imposed health and safety measures aimed at reducing viral transmission and protecting people at higher risk of contracting the virus [ 4 ]. These measures included: national lockdowns with different lengths and frequencies; targeted shopping times for older people; hygiene procedures (wearing masks, washing hands regularly, disinfecting hands); restricting or prohibiting social gatherings; working from home, school closure, and home-schooling.

Research suggests that lockdowns and protective measures impacted on people’s lives, and had a particular impact on older people. They were at higher risk from COVID-19, with greater disease severity and higher mortality compared to younger people [ 5 ]. Older adults were identified as at higher risk as they are more likely to have pre-existing conditions including heart disease, diabetes, and severe respiratory conditions [ 5 ]. Additionally, recent research highlights that COVID-19 and its safety measures led to increased mental health problems, including increased feelings of depression, anxiety, social isolation, and loneliness, potentially cognitive decline [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 ]. Other studies reported the consequences of only age-based protective health measures including self-isolation for people older people (e.g. feeling old, losing out the time with family) [ 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ].

Over the past decade, the World Health Organisation (WHO) has recognised the importance of risk communication within public health emergency preparedness and response, especially in the context of epidemics and pandemics. Risk communication is defined as “the real-time exchange of information, advice and opinions between experts or officials, and people who face a threat (hazard) to their survival, health or economic or social well-being” ([ 31 ], p5). This includes reporting the risk and health protection measurements through media and governmental bodies. Constructing awareness and building trust in society are essential components of risk communication [ 32 ]. In the context of the pandemic, the WHO noted that individual risk perception helped to prompt problem-solving activities (such as wearing face masks, social distancing, and self-isolation). However, the prolonged perception of pandemic-related uncertainty and risk could also lead to heightened feelings of distress and anxiety [ 31 , 33 ], see also [ 34 , 35 , 36 , 37 ].

This new and unprecedented disease provided the ground for researchers worldwide to investigate the COVID-19 pandemic. To date (August 2022), approximately 8072 studies have been recorded on the U.S. National Library of Medicine ClinicalTrials.gov [ 38 ] and 12002 systematic reviews have been registered at PROSPERO, concerning COVID-19. However, to our knowledge, there is little known about qualitative research as a response to the COVID-19 pandemic and how it impacted older adults’ well-being [ 39 ]. In particular, little is known about how older people experienced the pandemic. Thus, our research question considers: How did older adults experience the COVID-19 pandemic worldwide?

We use a qualitative evidence synthesis (QES) recommended by Cochrane Qualitative and Implementation Methods Group to identify peer-reviewed articles [ 40 ]. This provides an overview of existing research, identifies potential research gaps, and develops new cumulative knowledge concerning the COVID-19 pandemic and older adults’ experiences. QES is a valuable method for its potential to contribute to research and policy [ 41 ]. Flemming and Noyes [ 40 ] argue that the evidence synthesis from qualitative research provides a richer interpretation compared to single primary research. They identified an increasing demand for qualitative evidence synthesis from a wide range of “health and social professionals, policymakers, guideline developers and educationalists” (p.1).

Methodology

A systematic literature review requires a specific approach compared to other reviews. Although there is no consensus on how it is conducted, recent systematic literature reviews have agreed the following reporting criteria are addressed [ 42 , 43 ]: (a) a research question; (b) reporting database, and search strategy; (c) inclusion and exclusion criteria; (d) reporting selection methods; (e) critically appraisal tools; (f) data analysis and synthesis. We applied these criteria in our study and began by registering the research protocol with Prospero [ 44 ].

The study is registered at Prospero [ 44 ]. This systematic literature review incorporates qualitative studies concerning older adults’ experiences during the COVID-19 pandemic.

Search strategy

The primary qualitative articles were identified via a systematic search as per the qualitative-specific SPIDER approach [ 45 ]. The SPIDER tool is designed to structure qualitative research questions, focusing less on interventions and more on study design, and ‘samples’ rather than populations, encompassing:

S-Sample. This includes all articles concerning older adults aged 60 +  [ 1 ].

P-Phenomena of Interest. How did older adults experience the COVID-19 pandemic?

D-Design. We aim to investigate qualitative studies concerning the experiences of older adults during the COVID-19 pandemic.

E-Evaluation. The evaluation of studies will be evaluated with the amended Critical Appraisal Skills Programme CASP [ 46 ].

R-Research type Qualitative

Information source

The following databases were searched: PsychInfo, Medline, CINAHL, Web of Science, Annual Review, Annual Review of Gerontology, and Geriatrics. A hand search was conducted on Google Scholar and additional searches examined the reference lists of the included papers. The keyword search included the following terms: (older adults or elderly) AND (COVID-19 or SARS or pandemic) AND (experiences); (older adults) AND (experience) AND (covid-19) OR (coronavirus); (older adults) AND (experience) AND (covid-19 OR coronavirus) AND (Qualitative). Additional hand search terms included e.g. senior, senior citizen, or old age.

Inclusion and exclusion criteria

Articles were included when they met the following criteria: primary research using qualitative methods related to the lived experience of older adults aged 60 + (i.e. the experiences of individuals during the COVID-19 pandemic); peer-reviewed journal articles published in English; related to the COVID-19 pandemic; empirical research; published from 2020 till August 2022.

Articles were excluded when: papers discussed health professionals’ experiences; diagnostics; medical studies; interventions; day-care; home care; or carers; experiences with dementia; studies including hospitals; quantitative studies; mixed-method studies; single-case studies; people under the age of 60; grey literature; scoping reviews, and systematic reviews. We excluded clinical/care-related studies as we wanted to explore the everyday experiences of people aged 60 + . Mixed-method studies were excluded as we were interested in what was represented in solely qualitative studies. However, we acknowledge, that mixed-method studies are valuable for future systematic reviews.

Meta-ethnography

The qualitative synthesis was undertaken by using meta-ethnography. The authors have chosen meta-ethnography over other methodologies as it is an inductive and interpretive synthesis analysis and is uniquely “suited to developing new conceptual models and theories” ([ 47 ], p 2), see also [ 48 ]. Therefore, it combines well with constructivist grounded theory methodology. Meta-ethnography also examines and identifies areas of disagreements between studies [ 48 ].

This is of particular interest as the lived experiences of older adults during the COVID-19 pandemic were likely to be diverse. The method enables the researcher to synthesise the findings (e.g. themes, concepts) from primary studies, acknowledging primary data (quotes) by “using a unique translation synthesis method to transcend the findings of individual study accounts and create higher order” constructs ([ 47 ], p. 2). The following seven steps were applied:

Getting started (identify area of interest). We were interested in the lived experiences of older adults worldwide.

Deciding what was relevant to the initial interest (defining the focus, locating relevant studies, decision to include studies, quality appraisal). We decided on the inclusion and exclusion criteria and an appropriate quality appraisal.

Reading the studies. We used the screening process described below (title, abstract, full text)

Determining how the studies were related (extracting first-order constructs- participants’ quotes and second-order construct- primary author interpretation, clustering the themes from the studies into new categories (Table 3 ).

Translating the studies into one another (comparing and contrasting the studies, checking commonalities or differences of each article) to organise and develop higher-order constructs by using constant comparison (Table 3 ). Translating is the process of finding commonalities between studies [ 48 ].

Synthesising the translation (reciprocal and refutational synthesis, a lines of argument synthesis (interpretation of the relationship between the themes- leads to key themes and constructs of higher order; creating new meaning, Tables 2 , 3 ),

Expressing the synthesis (writing up the findings) [ 47 , 48 ].

Screening and Study Selection

A 4-stage screening protocol was followed (Fig.  1 Prisma). First, all selected studies were screened for duplicates, which were deleted. Second, all remaining studies were screened for eligibility, and non-relevant studies were excluded at the preliminary stage. These screening steps were as follows: 1. title screening; 2. abstract screening, by the first and senior authors independently; and 3. full-text screening which was undertaken for almost all papers by the first author. However, 2 papers [ 9 , 23 ] were assessed independently by LS, LR, and LMM to avoid a conflict of interest. The other co-authors also screened independently a portion of the papers each, to ensure that each paper had two independent screens to determine inclusion in the review [ 49 ]. This avoided bias and confirmed the eligibility of the included papers (Fig.  1 ). Endnote reference management was used to store the articles and aid the screening process.

Prisma flow diagram adapted from Page et al. [ 50 ]. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ, 372, n71. https://doi.org/10.1136/bmj.n71 )

Data extraction

After title and abstract screening, 39 papers were selected for reading the full article. 7 papers were excluded after the full-text assessment (1 study was conducted in 2017, but published in 2021; 2 papers were not fully available in English, 2 papers did not address the research question, 1 article was based on a conference abstract only, 1 article had only one participant age 65 +).

The full-text screening included 32 studies. All the included studies, alongside the CASP template, data extraction table, the draft of this article, and translation for synthesising the findings [ 47 , 48 ] were available and accessible on google drive for all co-authors. All authors discussed the findings in regular meetings.

Quality appraisal

A critical appraisal tool assesses a study for its trustworthiness, methodological rigor, and biases and ensures “transparency in the assessment of primary research” ([ 51 ], p. 5); see also [ 48 , 49 , 50 , 51 , 52 , 53 ]. There is currently no gold standard for assessing primary qualitative studies, but different authors agreed that the amended CASPS checklist was appropriate to assess qualitative studies [ 46 , 54 ]. Thus, we use the amended CASP appraisal tool [ 42 ]. The amended CASP appraisal tool aims to improve qualitative evidence synthesis by assessing ontology and epistemology (Table 1 CASP appraisal tool).

A numerical score was assigned to each question to indicate whether the criteria had been met (= 2), partially met (= 1), or not met (= 0) [ 54 ]; see also [ 55 ]. The score 16 – 22 are considered to be moderate and high-quality studies. The studies scored 15 and below were identified as low-quality papers. Although we focus on higher-quality papers, we did not exclude papers to avoid the exclusion of insightful and meaningful data [ 42 , 48 , 52 , 53 , 54 , 55 , 56 , 57 ]. The quality of the paper was considered in developing the evidence synthesis.

We followed the appraisal questions applied for each included study and answered the criteria either ‘Yes’, ‘Cannot tell’, or ‘No’. (Table 1 CASP appraisal criteria). The tenth question asking the value of the article was answered with ‘high’ of importance, ‘middle’, or low of importance. The new eleventh question in the CASP tool concerning ontology and epistemology was answered with yes, no, or partly (Table 1 ).

Data synthesis

The data synthesis followed the seven steps of Meta-Ethnography developed by Noblit & Hare [ 58 ], starting the data synthesis at step 3, described in detail by [ 47 ]. This encompasses: reading the studies; determining how the studies are related; translating the studies into one another; synthesis the translations; and expressing synthesis. This review provides a synthesis of the findings from studies related to the experiences of older adults during the COVID-19 pandemic. The qualitative analyses are based on constructivist grounded theory [ 59 ] to identify the experiences of older adults during the COVID-19 pandemic (non-clinical) populations. The analysis is inductive and iterative, uses constant comparison, and aims to develop a theory. The qualitative synthesis encompasses all text labelled as ‘results’ or ‘findings’ and uses this as raw data. The raw data includes participant’s quotes; thus, the synthesis is grounded in the participant's experience [ 47 , 48 , 60 , 61 ]. The initial coding was undertaken for each eligible article line by line. Please see Table 2 Themes per author and country. Focused coding was applied using constant comparison, which is a widely used approach in grounded theory [ 61 ]. In particular, common and recurring as well as contradicting concepts within the studies were identified, clustered into categories, and overarching higher order constructs were developed [ 47 , 48 , 60 ] (Tables 2 , 3 , 4 ).

We identified twenty-seven out of thirty-two studies as moderate-high quality; they met most of the criteria (scoring 16/22 or above on the CASP; [ 54 ]. Only five papers were identified as low qualitative papers scoring 15 and below [ 71 , 73 , 74 , 86 , 91 ]. Please see the scores provided for each paper in Table 4 . The low-quality papers did not provide sufficient details regarding the researcher’s relationship with the participants, sampling and recruitment, data collection, rigor in the analysis, or epistemological or ontological reasoning. For example, Yildirim [ 91 ] used verbatim notes as data without recording or transcribing them. This article described the analytical process briefly but was missing a discussion of the applied reflexivity of using verbatim notes and its limitations [ 92 ].

This systematic review found that many studies did not mention the relationship between the authors and the participant. The CASP critical appraisal tool asks: Has the relationship between the researcher and participants been adequately considered? (reflecting on own role, potential bias). Many studies reported that the recruitment was drawn from larger studies and that the qualitative study was a sub-study. Others reported that participants contacted the researcher after advertising the study. One study Goins et al., [ 72 ] reported that students recruited family members, but did not discuss how this potential bias impacted the results.

Our review brings new insights into older adults’ experiences during the pandemic worldwide. The studies were conducted on almost all continents. The majority of the articles were written in Europe followed by North America and Canada (4: USA; 3: Canada, UK; 2: Brazil, India, Netherlands, Sweden, Turkey 2; 1: Austria, China, Finland, India/Iran, Mauritius, New Zealand, Serbia, Spain, Switzerland, Uganda, UK/Ireland, UK/Colombia) (see Fig.  2 ). Note, as the review focuses on English language publications, we are unable to comment on qualitative research conducted in other languages see [ 72 ].

Numbers of publications by country

The characteristics of the included studies and the presence of analytical themes can be found in Table 4 . We used the following characteristics: Author and year of publication, research aims, the country conducted, Participant’s age, number of participants, analytical methodology, CASP score, and themes.

We identified three themes: desired and challenged wellbeing; coping and adaptation; discrimination and intersectionality. We will discuss the themes in turn.

Desired and challenged wellbeing

Most of the studies reported the impact of the COVID-19 pandemic on the well-being of older adults. Factors which influenced wellbeing included: risk communication and risk perception; social connectivity; confinement (at home); and means of coping and adapting. In this context, well-being refers to the evidence reported about participants' physical and mental health, and social connectivity.

Risk perception and risk communication

Politicians and media transmitted messages about the response to the pandemic to the public worldwide. These included mortality and morbidity reports, and details of health and safety regulations like social distancing, shielding- self-isolation, or wearing masks [ 34 , 35 , 36 , 37 ]. As this risk communication is crucial to combat the spread of the virus, it is also important to understand how people perceived the reporting during the pandemic.

Seven studies reported on how the mass media impacted participants' well-being [ 23 , 67 , 68 , 70 , 72 , 81 , 85 ]. Sangrar et al. [ 68 ] investigated how older adults responded to COVID-19 messaging: “My reaction was to try to make sure that I listen to everything and [I] made sure I was aware of all the suggestions and the precautions that were being expressed by various agencies …”. (p. 4). Other studies reported the negative impact on participants' well-being of constant messaging and as a consequence stopped watching the news to maintain emotional well-being [ 3 , 67 , 68 , 70 , 72 , 81 , 85 ]. Derrer-Merk et al. [ 23 ] reported one participant said that “At first, watching the news every day is depressing and getting more and more depressing by the day, so I’ve had to stop watching it for my own peace of mind” (p. 13). In addition, news reporting impacted participants’ risk perception. For example, “Sometimes we are scared to hear the huge coverage of COVID-19 news, in particular the repeated message ‘older is risky’, although the message is useful.” ([ 81 ], p5).

• Social connectivity

Social connectivity and support from family and community were found in fourteen of the studies as important themes [ 9 , 62 , 66 , 67 , 68 , 75 , 76 , 77 , 78 , 79 , 80 , 83 , 84 , 90 ].

The impact of COVID-19 on social networks highlighted the diverse experiences of participants. Some participants reported that the size of social contact was reduced: “We have been quite isolated during this corona time” ?([ 80 ], p. 3). Whilst other participants reported that the network was stable except that the method of contact was different: “These friends and relatives, they visited and called as often as before, but of course, we needed to use the telephone when it was not possible to meet” ([ 77 ], p. 5). Many participants in this study did not want to expand their social network see also [ 9 , 77 , 78 , 79 ]. Hafford-Letchfield et al. [ 76 ] reported that established social networks and relationships were beneficial for the participants: “Covid has affected our relationship (with partner), we spend some really positive close time together and support each other a lot” (p. 7).

On the other hand, other studies reported decreases of, and gaps in, social connectedness: “I couldn’t do a lot of things that I’ve been doing for years. That was playing competitive badminton three times a week, I couldn’t do that. I couldn’t get up early and go volunteer in Seattle” [ 9 , 67 , 75 ]. A loss of social connection with children and grandchildren was often mentioned: “We cannot see our grandchildren up close and personal because, well because they [the parents] don’t want us, they don’t want to risk our being with the kids … it’s been an emotional loss exacerbated by the COVID thing” ([ 68 ] p.10); see also [ 9 , 67 , 78 ]. On the contrary, Chemen & Gopalla [ 66 ] note that those older adults who were living with other family members reported that they were more valued: “Last night my daughter-in-law thanked me for helping with my granddaughter” (p.4).

Despite reports of social disconnectedness, some studies highlighted the importance of support from family members and how support changed during the COVID-19 pandemic [ 9 , 62 , 81 , 83 , 90 ]. Yang et al. [ 90 ] argued that social support was essential during the Lockdown in China: “N6 said: ‘I asked my son-in-law to take me to the hospital” (p. 4810). Mahapatra et al. [ 81 ] found, in an Indian study, that the complex interplay of support on different levels (individual, family, and community) helped participants to adapt to the new situation. For example, this participant reported that: “The local police are very helpful. When I rang them for something and asked them to find out about it, they responded immediately” (p. 5).

Impact of confinement on well being

Most articles highlighted the impact of confinement on older adults’ well-being [ 9 , 62 , 63 , 65 , 67 , 69 , 70 , 72 , 75 , 77 , 78 , 79 , 81 , 82 , 83 , 85 , 89 , 90 ].

Some studies found that participants maintained emotional well-being during the pandemic and it did not change their lifestyle [ 79 , 80 , 82 , 83 , 89 , 92 ]: “Actually, I used this crisis period to clean my house. Bookcases are completely cleaned and I discarded old books. Well, we have actually been very busy with those kind of jobs. So, we were not bored at all” ([ 79 ], p. 5). In McKinlay et al. [ 82 ]’s study, nearly half of the participants found that having a sense of purpose helped to maintain their well-being: “You have to have a purpose you see. I think mental resilience is all about having a sense of purpose” (p. 6).

However, at the same time, the majority of the articles (12 out of 18) highlighted the negative impact of confinement and social distancing. Participants talked of increased depressive feelings and anxiety. For example, one of Akkus et al.’s [ 62 ] participants said: “... I am depressed; people died. Terrible disease does not give up, it always kills, I am afraid of it …” (p. 549). Similarly, one of Falvo et al.’s [ 67 ] participants remarked: “I am locked inside my house and I am afraid to go out” (p. 7).

Many of the studies reported the negative impact of loneliness as a result of confinement on participants’ well-being including [ 69 , 70 , 72 , 78 , 79 , 90 , 93 ]. Falvo et al. [ 67 ] reported that many participants experienced loneliness: “What sense does it make when you are not even able to see a family member? I mean, it is the saddest thing not to have the comfort of having your family next to you, to be really alone” (p. 8).

Not all studies found a negative impact on loneliness. For example, a “loner advantage” was found by Xie et al. ([ 82 ], p. 386). In this study participants found benefits in already being alone “It’s just a part of who I am, and I think that helps—if you can be alone, it really is an asset when you have to be alone” ([ 82 ], p. 386).

Bundy et al. [ 80 ] investigated loneliness from already lonely older adults and found that many participants did not attribute the loneliness to the pandemic: “It’s not been a whole lot, because I was already sitting around the house a whole lot anyway ( …). It’s basically the same, pretty well … I’d pretty well be like this anyway with COVID or without COVID” (p. 873) (see also [ 83 ]).

A study from Serbia investigated how the curfew was perceived 15 months afterward. Some participants were calm: “I realized that … well … it was simply necessary. For that reason, we accepted it as a measure that is for the common good” ([ 70 ], p.634). Others were shocked: “Above all, it was a huge surprise and sort of a shock, a complete shock because I have never, ever seen it in my life and I felt horrible, because I thought that something even worse is coming, that I even could not fathom” ([ 70 ], p. 634).

The lockdowns brought not only mental health issues to the fore but impacted the physical health of participants. Some reported they were fearful of the COVID-19 pandemic: “... For a little while I was afraid to leave, to go outside. I didn’t know if you got it from the air” ([ 75 ]. p. 6). Another study reported: “It’s been important for me to walk heartily so that I get a bit sweaty and that I breathe properly so that I fill my lungs—so that I can be prepared—and be as strong as possible, in case I should catch that coronavirus” ([ 77 ], p. 9); see also [ 70 , 78 , 82 , 85 ].

Coping and adaptation

Many studies mentioned older adults’ processes of coping and adaptation during the pandemic [ 63 , 64 , 68 , 69 , 72 , 75 , 79 , 81 , 85 , 87 , 88 , 89 , 90 ].

A variety of coping processes were reported including: acceptance; behavioural adaptation; emotional regulation; creating new routines; or using new technology. Kremers et al. [ 79 ] reported: “We are very realistic about the situation and we all have to go through it. Better days will come” (p. e71). Behavioural adaptation was reported: “Because I’m asthmatic, I was wearing the disposable masks, I really had trouble breathing. But I was determined to find a mask I could wear” ([ 68 ], p. 14). New routines with protective hygiene helped some participants at the beginning of the pandemic to cope with the health threat: “I am washing my hands all the time, my hands are raw from washing them all the time, I don't think I need to wash them as much as I do but I do it just in case, I don’t have anybody coming in, so there is nobody contaminating me, but I keep washing” ([ 69 ], p. 4391); see also [ 72 ]. Verhage et al. [ 87 ] reported strategies of coping including self-enhancing comparisons, distraction, and temporary acceptance: “There are so many people in worse circumstances …” (p. e294). Other studies reported how participants used a new technology: “I have recently learned to use WhatsApp, where I can make video phone calls.” ([ 88 ], p. 163); see also [ 89 ].

Discrimination -intersectionality (age and race/gender identity)

Seven studies reported ageism, racism, and gender discrimination experienced by older adults during the pandemic [ 23 , 63 , 67 , 70 , 76 , 84 , 88 ].

Prigent et al. [ 84 ], conducted in a New Zealand study, found that ageism was reciprocal. Younger people spoke against older adults: “why don’t you do everyone a favour and drop dead you f******g b**** it’s all because of ones like you that people are losing jobs” (p. 11). On the other hand, older adults spoke against the younger generation: “Shame to see the much younger generations often flout the rules and generally risk the gains made by the team. Sheer arrogance on their part and no sanctions applied” (p.11). Although one study reported benevolent ageism [ 23 ] most studies found hostile ageism [ 23 , 63 , 67 , 70 , 76 , 84 ]. One study from Canada exploring 15 older adult’s Chinese immigrants’ experiences reported racism as people around them thought they would bring the virus into the country. The negative impact on existing friendships was told by a Chinese man aged 69 “I can tell some people are blatantly despising us. I can feel it. When I talked with my Caucasian friends verbally, they would indirectly blame us for the problem. Eventually, many of our friendships ended because of this issue” ([ 88 ], p161). In addition, this study reported ageism when participants in nursing homes felt neglected by the Canadian government.

Two papers reported experiences of sexual and gender minorities (SGM) (e.g. transgender, queer, lesbian or gay) and found additional burdens during the pandemic [ 63 , 76 ]. People experienced marginalisation, stereotypes, and discrimination, as well as financial crisis: “I have faced this throughout life. Now people look at me in a way as if I am responsible for the virus.” ([ 63 ], p. 6). The consequence of marginalisation and ignorance of people with different gender identities was also noted by Hafford- Letchfield et al. [ 76 ]: “People have been moved out of their accommodation into hotels with people they don't know …. a gay man committed suicide, community members know of several that have attempted suicide. They are feeling pretty marginalised and vulnerable and you see what people are writing on the chat pages” (p.4). The intersection of ageism, racism, and heterosexism and its negative impact on people’s well-being during the pandemic reflects additional burden and stressors for older adults.

This systematic literature review is important as it provides new insights into the lived experiences of older adults during the COVID-19 pandemic, worldwide. Our study highlights that the COVID-19 pandemic brought an increase in English-written qualitative articles to the fore. We found that 32 articles met the inclusion criteria but 5 were low quality. A lack of transparency reduces the trustworthiness of the study for the reader and the scientific community. This is particularly relevant as qualitative research is often criticised for its bias or lack of rigor [ 94 ]. However, their findings are additional evidence for our study.

Our aim was to explore, in a systematic literature review, the lived experiences of older adults during the COVID-19 pandemic worldwide. The evidence highlights the themes of desired and challenged wellbeing, coping and adaptation, and discrimination and intersectionality, on wellbeing.

Perceived risk communication was experienced by many participants as overwhelming and anxiety-provoking. This finding supports Anwar et al.’s [ 37 ] study from the beginning of the pandemic which found, in addition to circulating information, that mass media influenced the public's behaviour and in consequence the spread of disease. The impact can be positive but has also been revealed to be negative as well. They suggest evaluating the role of the mass media in relation to what and how it has been conveyed and perceived. The disrupted social connectivity found in our review supports earlier studies that reported the negative impact of people’s well-being [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ] at the beginning of the pandemic. This finding is important for future health crisis management, as the protective health measures such as confinement or self-isolation had a negative impact on many of the participants’ emotional wellbeing including increased anxiety, feelings of depression, and loneliness during the lockdowns. As a result of our review, future protective health measures should support people’s desire to maintain proximity with their loved ones and friends. However, we want to stress that our findings are mixed.

The ability of older adults to adapt and cope with the health crisis is important: many of the reported studies noted the diverse strategies used by older people to adapt to new circumstances. These included learning new technologies or changing daily routines. Politicians and the media and politicians should recognise both older adults' risk of disease and its consequences, but also their adaptability in the face of fast-changing health measures. This analysis supports studies conducted over the past decades on lifespan development, which found that people learn and adapt livelong to changing circumstances [ 95 , 96 , 97 ].

We found that discrimination against age, race, and gender identity was reported in some studies, in particular exploring participants’ experiences with immigration backgrounds and sexual and gender minorities. These studies highlighted the intersection of age and gender or race and were additional stressors for older adults and support the findings from Ramirez et al. [ 98 ] This review suggests that more research should be conducted to investigate the experiences of minority groups to develop relevant policies for future health crises.

Our review was undertaken two years after the pandemic started. At the cut-off point of our search strategy, no longitudinal studies had been found. However, in December 2022 a longitudinal study conducted in the USA explored older adult’s advice given to others [ 99 ]. They found that fostering and maintaining well-being, having a positive life perspective, and being connected to others were coping strategies during the pandemic [ 100 ]. This study supports the results of the higher order constructs of coping and adaptation in this study. Thus, more longitudinal studies are needed to enhance our understanding of the long-term consequences of the COVID-19 pandemic. The impact of the COVID-19 restrictions on older adults’ lives is evident. We suggest that future strategies and policies, which aim to protect older adults, should not only focus on the physical health threat but also acknowledge older adults' needs including psychological support, social connectedness, and instrumental support. The policies regarding older adult’s protections changed quickly but little is known about older adults’ involvement in decision making [ 100 ]. We suggest including older adults as consultants in policymaking decisions to ensure that their own self-determinism and independence are taken into consideration.

There are some limitations to this study. It did not include the lived experiences of older adults in care facilities or hospitals. The studies were undertaken during the COVID-19 pandemic and therefore data collection was not generally undertaken face-to-face. Thus, many studies included participants who had access to a phone, internet, or email, others could not be contacted. Additionally, we did not include published papers after August 2022. Even after capturing the most commonly used terms and performing additional hand searches, the search terms used might not be comprehensive. The authors found the quality of the papers to be variable, and their credibility was in question. We acknowledge that more qualitative studies might have been published in other languages than English and were not considered in this analysis.

To conclude, this systematic literature review found many similarities in the experiences of older adults during the Covid-19 pandemic despite cultural and socio-economic differences. However, we stress to acknowledge the heterogeneity of the experiences. This study highlights that the interplay of mass media reports of the COVID-19 pandemic and the policies to protect older adults had a direct impact on older adults’ well-being. The intersection of ‘isms’ (ageism, racism, and heterosexism) brought an additional burden for some older adults [ 98 ]. These results and knowledge about the drawbacks of health-protecting measures need to be included in future policies to maintain older adults’ well-being during a health crisis.

Availability of data and materials

The systematic literature review is based on already published articles. And all data analysed during this study are included in this manuscript. No additional data was used.

World Health Organisation (WHO): WHO Director-General’s opening remarks at the media briefing on COVID-19 - 11 March 2020. 2020. Retrieved from https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020.

WorldOMeter: Coronavirus toll update: Cases & deaths by country. 2022. Worldometers. https://www.worldometers.info/coronavirus/ .

World Health Organisation (WHO): Coronavirus disease. 2022. https://www.who.int/health-topics/coronavirus#tab=tab . Aaccessed 5 Oct 2022.

Ayouni I, Maatoug J, Dhouib W, Zammit N, Fredj SB, Ghammam R, Ghannem H. Effective public health measures to mitigate the spread of COVID-19: a systematic review. BMC Public Health. 2021;21(1):1015.

PubMed   PubMed Central   CAS   Google Scholar  

Cerasoli B. The frail future of geriatrics. Lancet Healthy Longev. 2020;1(1):e11.

PubMed   PubMed Central   Google Scholar  

Allen K-A, Arslan G, Craig H, Arefi S, Yaghoobzadeh A, Sharif Nia H. The psychometric evaluation of the sense of belonging instrument (SOBI) with Iranian older adults. BMC Geriatr. 2021;21(1):211.

Bailey L, Ward M, DiCosimo A, Baunta S, Cunningham C, Romero-Ortuno R, Kenny RA, Purcell R, Lannon R, McCarroll K, et al. Physical and mental health of older people while cocooning during the COVID-19 pandemic. QJM. 2021;114(9):648–53.

Dahlberg L. Loneliness during the COVID-19 pandemic. Aging Ment Health. 2021;25(7):1161–4.

PubMed   Google Scholar  

Derrer-Merk E, Ferson S, Mannis A, Bentall R, Bennett KM. Older people's family relationships in disequilibrium during the COVID-19 pandemic. What really matters? Ageing Soc. 2022:1–18.

Derrer-Merk E, Ferson S, Mannis A, Bentall RP, Bennett KM. Belongingness challenged: Exploring the impact on older adults during the COVID-19 pandemic. PLoS ONE. 2022;17(10):e0276561.

Heidinger T, Richter L. The effect of COVID-19 on loneliness in the elderly. An empirical comparison of pre-and peri-pandemic loneliness in community-dwelling elderly. Front Psychol. 2020;11:(585308).

Richter L, Heidinger T. Hitting close to home: the effect of COVID-19 illness in the social environment on psychological burden in older adults. Front Psychol. 2021;12:(737787).

Krendl AC, Perry BL. The impact of sheltering in place during the COVID-19 pandemic on older adults’ social and mental well-being. J Gerontol B Psychol Sci Soc Sci. 2021;76(2):e53–8.

Litwin, H., & Levinsky, M. Social networks and mental health change in older adults after the Covid-19 outbreak. Aging Ment Health. 2021:1–6. https://doi.org/10.1080/13607863.2021.1902468 .

De Pue S, Gillebert C, Dierckx E, Vanderhasselt MA, De Raedt R, Van den Bussche E. The impact of the COVID-19 pandemic on wellbeing and cognitive functioning of older adults. Sci Rep. 2021;11(1):4636.

Shahid Z, Kalayanamitra R, McClafferty B, Kepko D, Ramgobin D, Patel R, Aggarwal CS, Vunnam R, Sahu N, Bhatt D, et al. COVID-19 and older adults: what we know. J Am Geriatr Soc. 2020;68(5):926–9.

Smith M, Steinman L, Casey E. Combatting social isolation among older adults in a time of physical distancing: the COVID-19 social connectivity paradox. Front Public Health. 2020;8:403.

Cohn-Schwartz E, Finlay JM, Kobayashi LC. Perceptions of societal ageism and declines in subjective memory during the COVID-19 pandemic: longitudinal evidence from US adults aged ≥55 years. J Soc Issues. 2022;78(4):924–38.

Tsoukalis-Chaikalis N, Demsia S, Stamatopoulou A, Chaniotis D, Tel Nu. Systematic Mapping Study of Covid-19 Psychological Impact. 2021;15(3):820.

van Gerwen M, Alsen M, Little C, Barlow J, Genden E, Naymagon L, Tremblay D. Risk factors and outcomes of COVID-19 in New York City; a retrospective cohort study. J Med Virol. 2021;93(2):907–15.

Victor CR, Rippon I, Barreto M, Hammond C, Qualter P. Older adults’ experiences of loneliness over the lifecourse: an exploratory study using the BBC loneliness experiment. Arch Gerontol Geriatr. 2022;102:104740.

Vrach IT, Tomar R. Mental health impacts of social isolation in older people during COVID pandemic. Prog Neurol Psychiatry. 2020;24(4):25–9.

Google Scholar  

Derrer-Merk E, Reyes-Rodriguez M-F, Salazar A-M, Guevara M, Rodríguez G, Fonseca A-M, Camacho N, Ferson S, Mannis A, Bentall RP, et al. Is protecting older adults from COVID-19 Ageism? A comparative cross-cultural constructive grounded theory from the United Kingdom and Colombia. J Soc Issues. 2022;78(4):900–23.

Lytle A, Levy SR. Reducing ageism toward older adults and highlighting older adults as contributors during the COVID-19 pandemic. J Soc Issues. 2022;78(4):1066–84.

McDarby M, Ju CH, Picchiello MC, Carpenter BD. Older adults’ perceptions and experiences of ageism during the COVID-19 pandemic. J Soc Issues. 2022;78(4):939–64.

Drury L, Abrams D, Swift HJ. Intergenerational contact during and beyond COVID-19. J Soc Issues. 2022;78(4):860–82.

Kanık B, Uluğ ÖM, Solak N, Chayinska M. “Let the strongest survive”: Ageism and social Darwinism as barriers to supporting policies to benefit older individuals. J Soc Issues. 2022;00:1–25.

Spaccatini F, Giovannelli I, Pacilli MG. “You are stealing our present”: Younger people's ageism towards older people predicts attitude towards age-based COVID-19 restriction measures. J Soc Issues. 2022;78(4):769–89.

Sutter A, Vaswani M, Denice P, Choi KH, Bouchard H, Esses VM. Ageism toward older adults during the COVID-19 pandemic: Intergenerational conflict and support. J Soc Issues. 2022;78(4):815–41.

Swift H, Chasteen A. Ageism in the time of COVID-19. Group Process Intergroup Relat. 2021;24:246–52.

World Health Organisation (WHO): Risk Communication in times of an epidemic or pandemic. Asset paper series Epidemics and Pandemics: 2017. https://www.who.int/emergencies/risk-communicationsWHORCaCERaoSAo .

Bailey A, Harris MA, Bogle D, Jama A, Muir SA, Miller S, Walters CA, Govia I. Coping with COVID-19: health risk communication and vulnerable groups. Disaster Med Public Health Prep. 2021;17:e22.

Li X, Lyu H. Epidemic risk perception PS, and mental health during COVID-19 pandemic: a moderated mediating model. Front Psychol. 2021;11:563741. https://doi.org/10.3389/fpsyg.2020.563741 .

Article   PubMed   PubMed Central   Google Scholar  

Sandman P M & American Industrial Hygiene Association: Responding to community outrage: strategies for effective risk communication. American Industrial Hygiene Association. 2003.

Sandman, P M. Introduction and orientation index.  https://www.psandman.com/index-intro.htm . Retrieved 13 October 2022.

Anderson M, Pitchforth E, Asaria M, Brayne C, Casadei B, Charlesworth A, Coulter A, Franklin BD, Donaldson C, Drummond M, et al. LSE-Lancet Commission on the future of the NHS: re-laying the foundations for an equitable and efficient health and care service after COVID-19. Lancet. 2021;397(10288):1915–78.

PubMed   CAS   Google Scholar  

Anwar A, Malik M, Raees V, Anwar A. Role of mass media and public health communications in the COVID-19 pandemic. Cureus. 2020;12(9):e10453.

U.S. National Library of Medicine: COVID-19 - Search Details - ClinicalTrials.gov: Clinicaltrials.gov 2022. Retrieved October 13, 2022, from https://clinicaltrials.gov/ct2/results/details?cond=COVID-19 .

Tremblay S, Castiglione S, Audet L-A, Desmarais M, Horace M, Peláez S. Conducting qualitative research to respond to COVID-19 challenges: reflections for the present and beyond. Int J Qual Methods. 2021;20:16094069211009680.

Flemming K, Noyes J. Qualitative evidence synthesis: where are we at? Int J Qual Methods. 2021;20:1609406921993276.

Booth A. Searching for qualitative research for inclusion in systematic reviews: a structured methodological review. Syst Rev. 2016;5(1):74.

Krnic Martinic M, Pieper D, Glatt A, Puljak L. Definition of a systematic review used in overviews of systematic reviews, meta-epidemiological studies and textbooks. BMC Med Res Methodol. 2019;19(1):203.

Phillips V, Barker E. Systematic reviews: structure, form and content. J Perioper Pract. 2021;31(9):349–53.

Derrer-Merk E, Soulsby L, Reyes Rodriguez M, Ferson S, Mannis A, Bennett KM. Older adults' lived experiences during the COVID-19 pandemic: a systematic review. 2022. PROSPERO 2022 CRD42022331714. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022331714 .

Cooke A, Smith D, Booth A. Beyond PICO: the SPIDER tool for qualitative evidence synthesis. Qual Health Res. 2012;22:1435–43.

Long HA, French DP, Brooks JM. Optimising the value of the critical appraisal skills programme (CASP) tool for quality appraisal in qualitative evidence synthesis. Res Methods Med Health Sci. 2020;1(1):31–42.

Sattar R, Lawton R, Panagioti M, Johnson J. Meta-ethnography in healthcare research: a guide to using a meta-ethnographic approach for literature synthesis. BMC Health Serv Res. 2021;21(1):50.

Soundy A, Heneghan NR. Meta-ethnography. Int Rev Sport Exerc Psychol. 2022;15(1):266–86.

Fallon V, Groves R, Halford JCG, Bennett KM, Harrold JA. Postpartum anxiety and infant-feeding outcomes: a systematic review. J Hum Lact. 2016;32(4):740–58.

Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. PLoS Med. 2021;18(3):e1003583.

Tod D, Booth A, Smith B. Critical appraisal. Int Rev Sport Exerc Psychol. 2022;15(1):52–72.

Morse J. Why the Qualitative Health Research (QHR) review process does not use checklists. Qual Health Res. 2021;31(5):819–21.

Munthe-Kaas HM, Glenton C, Booth A, Noyes J, Lewin S. Systematic mapping of existing tools to appraise methodological strengths and limitations of qualitative research: first stage in the development of the CAMELOT tool. BMC Med Res Methodol. 2019;19(1):113.

Njau B, Covin C, Lisasi E, Damian D, Mushi D, Boulle A, Mathews C. A systematic review of qualitative evidence on factors enabling and deterring uptake of HIV self-testing in Africa. BMC Public Health. 2019;19(1):1289.

Butler A, Hall H, Copnell B. A guide to writing a qualitative systematic review protocol to enhance evidence-based practice in nursing and health care. Worldviews Evid Based Nurs. 2016;13(3):241–9.

Soilemezi D, Linceviciute S. Synthesizing qualitative research: reflections and lessons learnt by two new reviewers. Int J Qual Methods. 2018;17(1):1609406918768014.

Booth A. Harnessing energies, resolving tensions: acknowledging a dual heritage for qualitative evidence synthesis. Qual Health Res. 2019;29(1):18–31.

Carroll C, Booth A. Quality assessment of qualitative evidence for systematic review and synthesis: Is it meaningful, and if so, how should it be performed? Res Synth Methods. 2015;6(2):149–54.

Charmaz K. Constructing Grounded Theory. 2nd ed. London: Sage; 2014.

Toye F, Seers K, Allcock N, Briggs M, Carr E, Barker K. Meta-ethnography 25 years on: challenges and insights for synthesising a large number of qualitative studies. BMC Med Res Methodol. 2014;14(1):80.

Noblit GW, Hare RD. Meta-ethnography: synthesizing qualitative studies. California: Sage Publications Ltd; 1988.

Akkus Y, Parlak A, Karacan Y, Karatay G. Perceptions and experiences of older people regarding the COVID-19 pandemic process: a phenomenological study. Turk Geriatri Dergisi. 2021;24:546–56.

Banerjee D, Rao TSS. “The Graying Minority”: lived experiences and psychosocial challenges of older transgender adults during the COVID-19 pandemic in India, A qualitative exploration. Front Psychiatry. 2021;11:604472.

Brooke J, Jackson D. Older people and COVID-19: Isolation, risk and ageism. J Clin Nurs. 2020;29(13-14):2044–6.

Bundy H, Lee HM, Sturkey KN, Caprio AJ. The lived experience of already-lonely older adults during COVID-19. Gerontologist. 2021;61(6):870–7.

Chemen S, Gopalla YN. Lived experiences of older adults living in the community during the COVID-19 lockdown - The case of mauritius. J Aging Stud. 2021;57:100932.

Falvo I, Zufferey MC, Albanese E, Fadda M. Lived experiences of older adults during the first COVID-19 lockdown: a qualitative study. PLoS ONE. 2021;16(6):e0252101.

Fiocco AJ, Gryspeerdt C, Franco G. Stress and adjustment during the COVID-19 pandemic: a qualitative study on the lived experience of Canadian older adults. Int J Environ Res Public Health. 2021;18(24):12922.

Fristedt S, Carlsson G, Kylén M, Jonsson O, Granbom M. Changes in daily life and wellbeing in adults, 70 years and older, in the beginning of the COVID-19 pandemic. Scand J Occup Ther. 2022;29(6):511–21.

Gazibara T, Maksimovic N, Dotlic J, Jeremic Stojkovic V, Cvjetkovic S, Milic M. Experiences and aftermath of the COVID-19 lockdown among community-dwelling older people in Serbia: a qualitative study. J Eval Clin Pract. 2022;28(4):631–40.

Giebel C, Ivan B, Ddumba I. COVID-19 public health restrictions and older adults’ well-being in Uganda: psychological impacts and coping mechanisms. Clin Gerontol. 2022;45(1):97–105.

Goins RT, Anderson E, Minick H, Daniels H. Older adults in the United States and COVID-19: a qualitative study of perceptions, finances, coping, and emotions. Front Public Health. 2021;9:660536.

Gomes MACFC, Fontenele NAO, Galindo Neto NM, Barros LM, Frota NM. Elderly people’s experience facing social isolation in the COVID-19 pandemic. Rev Rene. 2021;22:e69236. https://doi.org/10.15253/2175-6783.20212269236 .

Article   Google Scholar  

Gonçalves AR, Barcelos JLM, Duarte AP, Lucchetti G, Gonçalves DR. Silva e Dutra FCM, Gonçalves JRL: Perceptions, feelings, and the routine of older adults during the isolation period caused by the COVID-19 pandemic: a qualitative study in four countries. Aging Ment Health. 2022;26(5):911–8.

Greenwood-Hickman MA, Dahlquist J, Cooper J, Holden E, McClure JB, Mettert KD, Perry SR, Rosenberg DE. “They’re Going to Zoom It”: a qualitative investigation of impacts and coping strategies during the COVID-19 pandemic among older adults. Front Public Health. 2021;9:679976.

Hafford-Letchfield T, Toze M, Westwood S. Unheard voices: a qualitative study of LGBT+ older people experiences during the first wave of the COVID-19 pandemic in the UK. Health Soc Care Community. 2022;30(4):e1233–43.

Huntley R, Bratt AS. An interpretative phenomenological analysis of the lived experiences of older adults during the covid-19 pandemic in sweden. Nordic Psychol. 2022;75(1)3–19.

Jiménez-Etxebarria E, Bernaras Iturrioz E, Jaureguizar J. Impact of the COVID-19 pandemic as perceived by older people in Northern Spain. Psychol Res Behav Manag. 2021;14:1789–803.

Kremers EM, Janssen JHM, Nieuwboer MS, Olde Rikkert MGM, Peeters GMEE. The psychosocial adaptability of independently living older adults to COVID-19 related social isolation in the Netherlands: a qualitative study. Health Soc Care Community. 2022;30(1):e67–74.

Kulmala J, Tiilikainen E, Lisko I, Ngandu T, Kivipelto M, Solomon A. Personal social networks of community-dwelling oldest old during the Covid-19 pandemic—A qualitative study. Front Public Health. 2021;9:1–10.

Mahapatra P, Sahoo KC, Desaraju S, Pati S. Coping with COVID-19 pandemic: reflections of older couples living alone in urban Odisha India. Prim Health Care Res Dev. 2021;22:e64.

McKinlay AR, Fancourt D, Burton A. A qualitative study about the mental health and wellbeing of older adults in the UK during the COVID-19 pandemic. BMC Geriatr. 2021;21(1):1–10.

Pfabigan J, Wosko P, Pichler B, Reitinger E, Pleschberger S. Under reconstruction: the impact of COVID-19 policies on the lives and support networks of older people living alone. Int J Care Caring. 2022;6(1-2):211–28.

Prigent C, Morgan T, Wiles J, Morgan K, Williams L, Gott M. Intergenerational tension or cohesion during the covid-19 pandemic?: A letter-writing study with older new zealanders. J Intergenerational Relationsh. 2022;20(4):386–405.

Sangrar R, Porter MM, Chesser S. Exploring the interpretation of COVID-19 messaging on older adults. Experiences of vulnerability. Can J Aging Rev Can Vieil. 2021;40(4):533–42.

Sattari S, Billore S. Bring it on Covid-19: being an older person in developing countries during a pandemic. Working Older People. 2020;24(4):281–91.

Verhage M, Thielman L, Kock L, Lindenberg J. Coping of older adults in times of COVID-19: considerations of temporality among dutch older adults. J Gerontol B. 2021;76(7):e290–9.

Wang Q, Liu JKK, Walsh CA. Identities: experiences and impacts of the COVID-19 pandemic from the perspectives of older Chinese immigrants in Canada. China J Soc Work. 2021;14(2):153–71.

Xie B, Shiroma K, De Main AS, Davis NW, Fingerman K, Danesh V. Living through the COVID-19 pandemic: community-dwelling older adults’ experiences. J Aging Soc Policy. 2021;33(4–5):380–97.

Yang Q, Wang Y, Tian C, Chen Y, Mao J. The Experiences of Community-dwelling older adults during the COVID-19 lockdown in Wuhan: a qualitative study. J Adv Nurs (John Wiley & Sons, Inc). 2021;77(12):4805–14.

Yıldırım H. Psychosocial status of older adults aged 65 years and over during lockdown in Turkey and their perspectives on the outbreak. Health Soc Care Community. 2022;30(3):899–907.

Hill Z, Tawiah-Agyemang C, Kirkwood B, Kendall C. Are verbatim transcripts necessary in applied qualitative research: experiences from two community-based intervention trials in Ghana. Emerg Themes Epidemiol. 2022;19(1):5.

Giles D. Performed across Europe and written up in English: the double challenge for qualitative psychologists. Qual Res Psychol. 2019;16(3):503–7.

Anderson C. Presenting and evaluating qualitative research. Am J Pharm Educ. 2010;74(8):141.

Nikitin J, Freund A. The Adaptation Process of Aging. The Cambridge Handbook of Successful Aging. Chapter: 17. Cambridge University Press. 2019. p. 281–98.

Deimling GT, Kahana B, Bowman KF, Schaefer ML. Cancer survivorship and psychological distress in later life. Psychooncology. 2002;11(6):479–94.

Baltes PB, Staudinger UM, Lindenberger U. Lifespan psychology: theory and application to intellectual functioning. Annu Rev Psychol. 1999;50:471–507.

Ramirez L, Monahan C, Palacios-Espinosa X, Levy SR. Intersections of ageism toward older adults and other isms during the COVID-19 pandemic. J Soc Issues. 2022;78(4):965–90.

Van Vleet B, Fuller HR, Hofmann B, Huseth-Zosel A. Untapped insight: a longitudinal qualitative analysis of older adults’ advice during the COVID-19 pandemic. Innov Aging. 2022;6(7):igac071.

Gietel-Basten S, Matus K, Mori R. COVID-19 as a trigger for innovation in policy action for older persons? Evid Asia Policy Soc. 2022;41(1):168–86.

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Derrer-Merk, E., Reyes-Rodriguez, MF., Soulsby, L.K. et al. Older adults’ experiences during the COVID-19 pandemic: a qualitative systematic literature review. BMC Geriatr 23 , 580 (2023). https://doi.org/10.1186/s12877-023-04282-6

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SYSTEMATIC REVIEW article

Systematic review of the literature about the effects of the covid-19 pandemic on the lives of school children.

• Department of Didactics of Musical, Plastic and Corporal Expression, University of Jaén, Jaén, Spain

Background: The year 2020 has been marked by the emergence of coronavirus disease 2019 (COVID-19). This virus has reached many countries and has paralyzed the lives of many people who have been forced to stay at home in confinement. There have been many studies that have sought to analyze the impact of this pandemic from different perspectives; however, this study will pay attention to how it has affected and how it may affect children between 0 and 12 years in the future after the closure of schools for months.

Objective: The objective of this article is to learn about the research carried out on the child population in times of confinement, especially those dealing with the psychological and motor aspects of minors.

Methods: To carry out this systematic review, the PRISMA statement has been followed to achieve an adequate and organized structure of the manuscript. The bibliography has been searched in the Web of Science (WOS), Scopus, and Dialnet databases, using as keywords: “COVID-19” and “Children.” The criteria that were established for the selection of the articles were (1) articles focusing on an age of up to 12 years, (2) papers relating COVID-19 to children, and (3) studies analyzing the psychological and motor characteristics of children during confinement.

Results: A total of nine manuscripts related to the psychological and motor factors in children under 12 have been found. The table presenting the results includes the authors, title, place of publication, and key ideas of the selected manuscripts.

Conclusion: After concluding the systematic review, it has been detected that there are few studies that have focused their attention on the psychological, motor, or academic problems that can occur to minors after a situation of these characteristics. Similarly, a small number of studies have been found that promote actions at the family and school level to reverse this situation when life returns to normal. These results may be useful for future studies that seek to expand the information according to the evolution of the pandemic.

Introduction

When news of an epidemic began to spread in a Chinese city in early 2020, no one anticipated the scope of the epidemic for the entire world in a very short period. From Wuhan (China) to New York (USA) through Africa, South America, Asia, and Europe, the new coronavirus, coronavirus disease 2019 (COVID-19) or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has paralyzed, to a greater or lesser extent, the life in many countries, causing thousands of deaths and about 6 million infections. For these reasons, the scientific community is on the alert by conducting studies on the virus, the disease it produces, the situation it creates, and the population it attacks, from different perspectives, including systematic reviews of the literature, such as the one presented in this paper.

However, researchers on this topic are not only biologists or physicians. It is worth noting the contribution of Maestre Maestre (2020) , President of the Society for Latin Studies, in an article on the virus that has caused the pandemic, in which, playing with different related terms, he explains that the neutral noun “virus” means “poison” in Latin, so most current research is trying to find a medicine that will kill the virus. Likewise, the Greek term ϕάρμακoν (in Latin pharmacum) also means poison. The relationship between the two terms is that pharmacies are looking for poisons that will kill the “poisons” that undermine people's health or their desire to be safe. Remember the symbol of the pharmacies, the “Bowl of Hygieia” with the snake that pours a “poison” into it that stops being a poison to become an antidote. The name “coronavirus” is given to it because, through the microscope, the “virus-poison” is shaped like a “crown” that makes it king of poisons.

However, in addition to scientists who study the pandemic, biologists, doctors, and humanists, educators are obliged to care for the psychological and emotional health, as well as cultivate the minds, of children. The consequences of the containment measures of COVID-19 are being detrimental to the mental health of people around the world. It is logical that the most vulnerable are children who do not understand what is happening and who, along with the concern and frustration of their elders, may present risk factors, such as anxiety and affective and post-traumatic stress disorders ( Giallonardo et al., 2020 ). However, not only minors are affected. According to Roy et al. (2020) , more than 80% of people over 18 have shown the need for attention to their mental health as a result of the anxiety and stress experienced during the pandemic. Forte et al. (2020) agree with this idea, stating that the pandemic has caused stress, psychological discomfort, sleep disorders, and instability, among others, in a large part of the population.

In this sense, many questionnaires have been applied to obtain information in the educational context or related to it from research groups at different universities, including the one from the IDIBAPS research group at the Hospital Universitario de Barcelona, concerning behaviors to reduce emotional distress during the pandemic and confinement by COVID-19, https://enquesta.clinic.cat/index.php/268395?lang=es ; Universidad de las Palmas de Gran Canaria on family relationships during confinement: Study of the effect of COVID-19 in the family context, https://forms.gle/2xpmqRtQ8mtBMAz77 ; Universidad de Oviedo, as a longitudinal study on how isolation and the practice of physical activity (PA) during confinement is affecting to offer effective strategies that it called “pills”: EDAFIDES Questionnaire COVID-19, https://docs.google.com/forms/d/e/1FAIpQLSfyID6X7YgUejwXNv2YyOQ1YU2LrFsPkkvHzux_TD_BjPIGNw/viewform?usp=sf_link ; Euskal Herriko Unibertsitatea, to find out about the situation of university students in confinement and to propose improvements: https://forms.gle/jDkFgW7xeKfSFNHB6 ; Universidad da Coruña y Universidad de Jaén, on the activities of children in Spanish homes in times of confinement. This last questionnaire was applied in Spain and in South America: https://docs.google.com/forms/d/e/1FAIpQLSeyBBkMEmPxj-AoPQG98QorsaLyNex9wlI2FJ2Ku2q8nbsdNQ/viewform .

Based on the above-mentioned questionnaires, there is a concern to analyze how confinement has affected children under 12 at the motor and psychological levels. This literature review is carried out and explained in detail in the procedure and search strategy of the methodology. The impact of the pandemic is such that many national and international journals are offering special issues on COVID-19, including Frontiers, which, being digital, contains 229 articles signed by many authors from various countries, which look at the subject from different perspectives: there are eight that refer to age and especially to children in some way, including: who cares about the elderly ( Fischer et al., 2020 ), physical inactivity ( Ricci et al., 2020 ), age distribution ( Cortis, 2020 ), and newborns ( Ovali, 2020 ), but none discusses parents' views on the period of confinement from the psychological, educational, academic, physical, and emotional points of view of their children. Neither do they inquire into the opinion of the children themselves, understanding by these those who are in infant and primary education, that is, up to the age of 12.

Education must seek to provide the child with a comprehensive education, trying to help his or her physical, emotional, intellectual, family, social, and moral development. Active methods are crucial for early childhood education, and teachers are needed to apply them in schools ( Salvador, 2008 ), now in the homes of their students, which they access through the Internet. The role of parents is also to educate, but from different perspectives, complementing those of teachers in the acquisition of children's learning. For these reasons, many families say that they do not know how to undertake these activities with their children for so long.

Likewise, the lack of other family members, such as grandparents, who had been playing a role in accompanying, especially with children in preschool, complicates the state of confinement and the lack of school attendance that is taking place, initially planned for 6 months in a row. The study by Clemente-González (2016) of the University of Murcia highlights the relevance of grandparent–grandchild relationships and the role of the former in the social and emotional development of the child, which gives great significance to their grandparents for the appreciation observed in them, recognizing their importance in the family structure. At this point, it is also necessary to point out the lack of relationships between equals, which is so important for the correct emotional development of children.

Another important aspect that has been affected by the coronavirus pandemic is the practice of PA. Many schoolchildren practice physical exercise based solely on the subject of Physical Education. This subject is not only based on motor skills but is a practice that affects schoolchildren in a global way, influences many aspects of their daily lives, and helps teachers to better understand students in their different dimensions ( Founaud and González-Audicana, 2020 ). Lack of PA is associated with obesity, as indicated by different studies that relate the regular practice of physical exercise with the reduction of health problems ( Castañeda-Vázquez et al., 2020 ).

The opinion article written by the Spanish secondary school teacher, Fandino-Pérez (2020) , is significant in which he reflects on the virtuality of education and his position regarding personalized education, so demanded in times of normality, where teachers and students know each other, interact, and socialize, precisely the attitude that has taken away the virus. Fandino-Pérez says that the pandemic has put us in front of the mirror to see a distorted and absurd image of the work of teachers as producers of programming and good results, which turns them and their students into a kind of machine. We have forgotten the main thing: to be human beings capable of creating a better world and of overcoming ignorance, fear, and demagogy.

As a background to this study, we refer to March 11, 2020 when the World Health Organization ( World Health Organization, 2020a ) declared this disease produced by the coronavirus (COVID-19) to be a pandemic. It was first reported in Wuhan (China) on December 31, 2019. According to World Health Organization (2009) , the global public health community recognized the need for standardized research and data collection after the 2009 flu epidemics, so the WHO Expert Working Group on Special Research and Studies has developed several standard protocols for pandemic flu. This has led World Health Organization (2019a , 2020b) to develop similar protocols for the Middle East respiratory syndrome coronavirus (MERS-CoV) and, with the support of expert advisors, has adapted the protocols for influenza and MERS-CoV to help better understand the clinical, epidemiological, and virological characteristics of COVID-19.

Some months have passed, and most of the inhabitants of planet Earth, more or less surprised, have been confined to their homes for about 60 days, where they have carried out their work online and have had to attend to their younger children, also confined without attending school and without being able to go out into the street or use the recreational facilities that some residential areas have.

When we find ourselves at the moment of reincorporation into the daily life known before the appearance of the pandemic (May 2020), other illnesses arise as a consequence of the involuntary confinement to which the population has been subjected; this is the cave syndrome or agoraphobia (fear of open spaces), and it is possible that with the passage of time, other psychological and affective disorders will arise in the adults who will be those who have suffered this confinement and this disaster as children.

The disease mainly attacks people over 70 years old and only 0.3% of children in countries where there have been more deaths (for example, Spain). According to the Instituto de Salud Carlos, this may be the reason why medical research does not deal with children, but these subjects have special psychological, academic, and emotional characteristics at a stage of their lives when they are in full development, so from the educational point of view, it is necessary to find out how children have developed in their homes, what their parents think, and what future expectations experts, teachers, and psychologists have for them.

For all these reasons, the aim of this work is to find out about the research carried out on the child population in times of confinement, especially those that deal with the psychological and motor aspects of minors.

Considering this objective and following the Population, Intervention, Comparison, and Outcome (PICO) strategy, the following research question arises: what do the studies already published determine about how confinement has affected children under the age of 12 on a psychological and motor level?

Methodology

For the elaboration of this systematic review, we have followed the items to publish systematic reviews and meta-analyses of the PRISMA statement ( Sotos-Prieto et al., 2014 ; Hutton et al., 2015 ), in order to achieve an adequate and organized structure of the manuscript. The guidelines of Cochrane Training ( Higgins and Green, 2011 ) have also been used.

Procedure and Search Strategy

The literature review took place during the last weeks of May 2020 and focused mainly on the Web of Science (WOS) database, using Scopus and Dialnet as support. The topic considered for the selection of articles was the one related to the global pandemic caused by COVID-19 and how it has affected psychologically and motorically children up to 12 years old. The following keywords were used: “COVID-19” and “children” and the Boolean operator “and.” After this first search and taking into account only the works published in 2020 (since that is when the pandemic occurred), 837 scientific documents were obtained. By restricting the search to only journal articles, the documents were reduced to 576 articles, after which the language filter was applied, selecting only those papers published in English and Spanish, leaving a total of 537. Since the pandemic started in China, the initial search was also done in that language, not finding any related articles. The articles signed by researchers of Chinese nationality are written in English. Finally, the following areas of research were chosen: “Psychology,” “Sociology,” and “Education Educational Research,” finally limiting the search to 48 scientific articles, which make up the sample of this study.

Inclusion and Exclusion Criteria

The criteria that were established for the selection of the articles were (1) articles focusing on an age of up to 12 years, (2) papers relating COVID-19 to children, and (3) studies analyzing the psychological and motor characteristics of children during confinement.

In order to apply these criteria, a first preliminary reading of the title and summary of each article was carried out, which made it possible to rule out papers that did not meet the above-mentioned criteria. A more exhaustive reading of the selected articles was then carried out, leaving a final sample of nine scientific papers ( Figure 1 ).

Figure 1 . PRISMA flowchart.

Article Coding

To extract the data from the articles, the following coding process was followed: (1) author/authors and year of publication, (2) title of the research, (3) place/country of publication, and (4) key ideas of the research.

The research included in this systematic review was coded by four of the authors, in order to check the reliability of the coding and the degree of agreement among the researchers in relation to the selection and extraction of the data ( González-Valero et al., 2019 ). The degree of agreement on the rating of the articles was 93%. This was obtained by dividing the number of coincidences by the total number of categories defined for each study and multiplying it by 100.

In order to establish the methodological quality of the present study, reliability was determined according to the detection and selection of the Fleiss' Kappa (Fk) statistical index for more than two evaluators ( Fleiss, 1971 ). A value of Fk = 0.780 was obtained for data extraction and selection, which indicates that there is substantial agreement (0.61–0.80).

Table 1 presents the main results of different studies following the codification indicated in the previous section: (1) author/authors and year of publication, (2) title of the research, (3) place/country of publication, and (4) key ideas of the research.

Table 1 . Basis of the study.

Of the nine articles analyzed because they met the characteristics of the search, three have been published in The Lancet , which began as an independent international weekly medical journal, founded in 1823 by Thomas Wakley. Since its first issue, it has strived to make science widely available so that medicine can serve, transform society, and positively impact people's lives. It has evolved into a family of journals including The Lancet Child & Adolescent Health , in which one of the three articles cited appears. These three articles, and most of those analyzed, relate to the classical medicine that should serve society to help improve life.

Most of the references in this article (84.22%) are from the year 2020, a sign of the interest in the subject and the dedication of scientists and teachers. Only three are earlier, the one by Hutton et al. (2015) that deals with a more technical content, the extension of PRISMA for network meta-analysis, and the ones by Salvador (2008) and Clemente-González (2016) that highlight the role of grandparents in children's lives.

Of the two articles by Spanish teachers, the one by Álvarez-Zarzuelo (2020) is a personal opinion of a social educator who is ahead of other research. It only provides the experts' ideas on the possible repercussions of confinement. For his part, Gómez-Gerdel (2020) writes an opinion article that, exceptionally, is being published by the International Journal of Education for Social Justice in its special issue 9(e) on “Consequences of the Closure of Schools by COVID-19 on Educational Inequalities.” The author, from the perspective of the departments of Educational Guidance that deal with inclusive education, raises the chaos that it has meant for the Spanish Educational System to apply teaching only on line, which means for the most vulnerable families: difficulties in accessing technologies and delays in education. On the other hand, it raises what could be a return to the family whose members had been living together for a long time, something absolutely necessary for the correct development of the minors who spend too much time away from home.

The teaching–learning system, which should seek the comprehensive training of the child, in which parents and teachers should participate, has been drastically modified, trying not to abandon the active methods used in schools ( Salvador, 2008 ), with the difficulties that this entails for families, which in many cases have no training in this area.

Of the three articles by Chinese authors, Liu et al. (2020) analyze the situation of children whose parents have been infected with the virus or have died; Zhang et al. (2020) observe the behavior of children with attention-deficit/hyperactive disorder (ADHD) during this period; and finally, Guan et al. (2020) deal with the practice of childhood PA during confinement. Therefore, only one of them studies a type of activity in this period, the one dealing with PA coinciding with what is written by the Italians Ricci et al. (2020) ; in the same line, we find the Turks Yarimkaya and Esentürk (2020) who deal with the importance of PA in confinement for children with autism spectrum disorder (ASD). It is important to remember that World Health Organization (2010 , 2019b) recommends a minimum of 1 h/day of moderate–vigorous PA in children, but that only one-third of children exceed these recommendations ( Salas-Sánchez et al., 2020 ).

The American and British authors analyze the role of parents in the confinement of their children and provide some advice on this subject. They also look at the future psychological problems that may arise as a result of over-information, change of routines, and manifestation of feelings of distress and guilt, as well as the need to see peers and other carers (teachers, grandparents). They coincide with Clemente-González (2016) project based on the grandparent–grandchild relationship and the promotion of identity, which seemed to be a premonition of what would happen with the arrival of the COVID-19 pandemic that would force the disappearance of these relationships for a long time.

It is important to note that, according to the review carried out, there are authors who analyze the pandemic from different perspectives with which we agree: cultural aspects ( Maestre Maestre, 2020 ); actions of biologists and doctors, more distant from our intentions; humanists ( Fandino-Pérez, 2020 ), and especially for this study, of educators who are aware that the essence of being in the classroom and the immediate feedback that students offer in this situation has been lost. To this must be added the role of the WHO, overwhelmed by the health events that have occurred so quickly, as described in these lines.

We believe that the application of many questionnaires during the confinement and currently post-COVID-19 pandemic has saturated the patience of the respondents, although most have helped scientists and educators to obtain information that will facilitate a smooth exit from this disaster.

Conclusions

The above leads us to the general conclusion that there are very few studies on how confinement has affected children under 12 years old psychologically and motorly. These articles agree on the consequences that confinement can have on minors and on the importance of psychological support from the family, and the establishment of routines can be effective. The manuscripts that deal with PA remind us of the importance of it and indicate that the rates of sedentarism have increased during these months.

It is necessary to insist on the search for and analysis of other activities, as well as the behavior of parents and children in these circumstances, in order to prevent possible psychological and academic problems and because if the online teaching situation is prolonged, it is very important to know how to act from the educational and family environment.

The main limitation the authors have faced has been the small number of scientific articles related to the area of study. This scarcity of published works makes it necessary to continue researching this. This is the reason why our study can serve as a starting point or theoretical foundation for further studies.

Author Contributions

JC-Z, MS-Z, DS-M, GG-V, AL-S, and MZ-S contributed to the conception and design of the revision. All authors wrote some part of the manuscript and all reviewed the manuscript.

This article has been financed by the Ministry of Science, Innovation and Universities through two grants for university teacher training (FPU) with references FPU17/00803 and FPU18/02567. This article has counted with the collaboration of the group HUM-653 of the University of Jaén.

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.

* Álvarez-Zarzuelo, M. (2020). El confinamiento de niñas y niños en España en 2020 por la crisis del COVI-19: propuesta desde la Educación Social Escolar para la vuelta al centro escolar. Revista de Educ. Soc. 30, 457–461.

Google Scholar

Castañeda-Vázquez, C., Corral-Pernía, J. A., and Chacón-Borrego, F. (2020). Influencia de la actividad física sobre la capacidad aeróbica en escolares españoles. J. Sport Health Res. 12(Suppl. 1), 31–38.

Clemente-González, M. (2016). “Proyecto de investigación basado en la relación abuelos-nietos y fomento de identidad,” in Propuestas de Intervención en Educación Infantil. eds A. B. Mirete Ruiz, M. C. Habib Allah, M. C. Hernández Cantero (Murcia: Universidad de Murcia. Servicio de Publicaciones), 131–144.

Cortis, D. (2020). On determining the age distribution of COVID-19 Pandemic. Front. Public Health 8:202. doi: 10.3389/fpubh.2020.00202

PubMed Abstract | CrossRef Full Text | Google Scholar

* Dalton, L., Rapa, E., and Stein, A. (2020). Protecting the psychological health of children through effective communication about COVID-19. Lancet 4, 346–347. doi: 10.1016/S2352-4642(20)30097-3

Fandino-Pérez, R. G. (2020). Educar en el encierro. La Rioja . Available online at: https://www.larioja.com/opinion/educarencierro-20200331235930-ntvo.html

PubMed Abstract | Google Scholar

Fischer, F., Raiber, L., Boscher, C., and Winter, M. H.-J. (2020). COVID-19 and the elderly: Who cares? Front. Public Health 8:151. doi: 10.3389/fpubh.2020.00151

Fleiss, J. L. (1971). Measuring nominal scale agreement among many raters. Psychol. Bull. 76, 378–382. doi: 10.1037/h0031619

CrossRef Full Text | Google Scholar

Forte, G., Favieri, F., Tambelli, R., and Casagrande, M. (2020). COVID-19 pandemic in the italian population: validation of a post-traumatic stress disorder questionnaire and prevalence of PTSD symptomatology. Int. J. Environ. Res. Public Health 17:4151. doi: 10.3390/ijerph17114151

Founaud, M. P., and González-Audicana, C. (2020). La vivencia emocional en los estudiantes de Educación Primaria en Educación Física. J. Sport Health Res. 12(Suppl. 1), 15–24.

Giallonardo, V., Sampogna, G., Del Vecchio, V., Luciano, M., Albert, U., Carmassi, C., et al. (2020). The impact of quarantine and physical distancing following COVID-19 on mental health: study protocol of a multicentric Italian population trial. Front. Psychiatr. 11:533. doi: 10.3389/fpsyt.2020.00533

* Gómez-Gerdel, M. A. (2020). “El cerebro pleno del niño/a: la labor de un/a maestro/a de Educación Inclusiva con las familias en tiempos de confinamiento,” in Una reflexión educativa. Revista Internacional de Educación para la Justicia Social. 9, 1–10.

González-Valero, G., Zurita-Ortega, F., Ubago-Jiménez, J. L., and Puertas-Molero, P. (2019). Use of meditation and cognitive behavioral therapies for the treatment of stress, depression and anxiety in students. A systematic review and meta-analysis. Int. J. Environ. Res. Public Health. 16:4394. doi: 10.3390/ijerph16224394

* Guan, H., Okely, A. D., Aguilar-Farias, N., Cruz, B., Draper, C. E., El Hamdoouchi, A., et al. (2020). Promoting healthy behaviours among children during the COVID-19 pandemic. Lancet Child Adolesc. Health 4, 416–418. doi: 10.1016/S2352-4642(20)30131-0

Higgins, J. P. T., and Green, S. (2011). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration. www.cochrane-handbook.org

Hutton, B., Salanti, G., Caldwell, D. M., Chaimani, A., Schmid, C. H., Cameron, C., et al. (2015). The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations PRISMA extension for network meta-analysis. Ann. Int. Med. 162, 777–784. doi: 10.7326/M14-2385

Instituto de Salud Carlos, I. I. I. (2020). Ministerio de Ciencia e Innovación . Available online at: https://cnecovid.isciii.es/covid19/#grupos-de-poblaci%C3%B3n (accessed May 15, 2020).

* Liu, J. J., Bao, Y., Huang, X., Shi, J., and Lu, L. (2020). Mental health considerations for children quarantined because of COVID-19. Lancet 4, 347–349. doi: 10.1016/S2352-4642(20)30096-1

Maestre Maestre, J. M. (2020). Finis Coronabit Virvs . Available online at: http://selat.org/data/documents/00_FINIS_CORONABIT_VIRVS_JoseMariaMaestreMaestre_SELat.pdf (accessed May 15, 2020).

Ovali, F. (2020). SARS-CoV-2 infection and the newborn. Front. Pediatr. 8:294. doi: 10.3389/fped.2020.00294

* Ricci, F., Izzicupo, P., Moscucci, F., Sciomer, S., Maffei, S., Di Baldassarre, A., et al. (2020). Recommendations for physical inactivity and sedentary behavior during the coronavirus disease (COVID-19) Pandemic. Front. Public Health 8:199. doi: 10.3389/fpubh.2020.00199

Roy, D., Tripathy, S., Kar, S. K., Sharma, N., Verma, S. K., and Kaushal, V. (2020). Study of knowledge, attitude, anxiety & perceived mental healthcare need in Indian population during COVID-19 pandemic. Asian J. Psychiatr. 51:102083. doi: 10.1016/j.ajp.2020.102083

Salas-Sánchez, M. I., Muntaner-Mas, A., and Vidal-Conti, J. (2020). Intervención educative en el tiempo de patio en un centro escolar para mejorar aspectos relacionados con la salud y el bienestar de los alumnus. J. Sport Health Res. 12(Suppl. 2), 127–136.

Salvador, M. (2008). Los abuelos: un Papel Imprescindible . Madrid, DL: Grupo Desfomedia.

Sotos-Prieto, M., Prieto, J., Manera, M., Baladia, E., Martínez-Rodríguez, R., and Basulto, J. (2014). Ítems de referencia para publicar Revisiones Sistemáticas y Metaanálisis: La Declaración PRISMA. Revista Española de Nutr. Hum. y Dietética 18, 172–181. doi: 10.14306/renhyd.18.3.114

* Szabo, T. G., Richling, S., Embry, D. D., Biglan, A., and Wilson, K. G. (2020). From helpless to hero: promoting values-based behavior and positive family interaction in the midst of COVID-19. Behav. Anal. Pract. 13, 568–576. doi: 10.31234/osf.io/sgh5q

World Health Organization (2009). Gripe Pandémica (H1N1) - Nota Informativa n 21. Ginebra . Available online at: https://www.who.int/csr/disease/swineflu/notes/briefing_20100610/es/ (accessed May 16, 2020).

World Health Organization (2010). Global for Health . Available online at: https://apps.who.int/iris/bitstream/handle/10665/44399/9789241599979_eng.pdf?sequence=1 (accessed May 16, 2020).

World Health Organization (2019a). Coronavirus Causing Middle Eastern Respiratory Syndrome (MERS-CoV) . Available online at: https://www.who.int/es/news-room/fact-sheets/detail/middle-east-respiratory-syndrome-coronavirus-(mers-cov) (accessed May 16, 2020).

World Health Organization (2019b). Guidelines on Physical Activity, Sedentary Behaviour and Sleep for Children Under 5 Years of Age . Available online at: https://apps.who.int/iris/handle/10665/311664 (accessed May 16, 2020).

World Health Organization (2020a). Coronavirus Disease (COVID-19) Pandemic [press release] . Available online at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019 (accessed May 16, 2020).

World Health Organization (2020b). COVID-19 Early Epidemiologic and Clinical Investigations for Public Health Response . Available online at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/early-investigations (accessed May 16, 2020).

* Yarimkaya, E., and Esentürk, O. K. (2020). Promoting physical activity for children with autism spectrum disorders during Coronavirus outbreak: benefits strategies, and examples. Int. J. Dev. Disabil. 1–6. doi: 10.1080/20473869.2020.1756115

* Zhang, J., Shuai, L., Yu, H., Wang, Z., Qiu, M., Lu, L., et al. (2020). Acute stress, behaviorual symptoms and mood states among school-age children with attention déficit/hiperactive disorder during the COVID-19 outbreak. Asian J. Psychiatr. 51:102077. doi: 10.1016/j.ajp.2020.102077

* ^ References marked with an asterisk are those articles analyzed in the systematic review.

Keywords: children, COVID-19, coronavirus, physical activity, psychology

Citation: Cachón-Zagalaz J, Sánchez-Zafra M, Sanabrias-Moreno D, González-Valero G, Lara-Sánchez AJ and Zagalaz-Sánchez ML (2020) Systematic Review of the Literature About the Effects of the COVID-19 Pandemic on the Lives of School Children. Front. Psychol. 11:569348. doi: 10.3389/fpsyg.2020.569348

Received: 03 June 2020; Accepted: 27 August 2020; Published: 14 October 2020.

Reviewed by:

Copyright © 2020 Cachón-Zagalaz, Sánchez-Zafra, Sanabrias-Moreno, González-Valero, Lara-Sánchez and Zagalaz-Sánchez. 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: Déborah Sanabrias-Moreno, dsmoreno@ujaen.es

Disclaimer: 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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• Tommaso Osti 1 ,
• Angelica Valz Gris 1 ,
• Valerio Flavio Corona 1 ,
• http://orcid.org/0000-0001-9375-8731 Leonardo Villani 1 ,
• Floriana D’Ambrosio 1 ,
• Marta Lomazzi 2 , 3 ,
• Carlo Favaretti 4 ,
• Fidelia Cascini 1 ,
• http://orcid.org/0000-0001-7357-2892 Maria Rosaria Gualano 4 , 5 ,
• Walter Ricciardi 1 , 4
• 1 Section of Hygiene, University Department of Life Sciences and Public Health , Università Cattolica del Sacro Cuore-Campus di Roma , Rome , Italy
• 2 World Federation of Public Health Association , Geneva , Switzerland
• 3 Institute of Global Health , University of Geneva , Geneva , Switzerland
• 4 Leadership Research Center , Università Cattolica del Sacro Cuore-Campus di Roma , Rome , Italy
• 5 UniCamillus - Saint Camillus International University of Health and Medical Sciences , Rome , Italy
• Correspondence to Professor Maria Rosaria Gualano, UniCamillus, Rome 00131, Italy; mar.guala{at}gmail.com

The COVID-19 pandemic has put a lot of pressure on all the world’s health systems and public health leaders who have often found themselves unprepared to handle an emergency of this magnitude. This study aims to bring together published evidence on the qualities required to leaders to deal with a public health issue like the COVID-19 pandemic. This scoping literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. A search of relevant articles was performed in the PubMed, Scopus and Web of Science databases. A total of 2499 records were screened, and 45 articles were included, from which 93 characteristics of effective leadership were extrapolated and grouped into 6 clusters. The qualities most frequently reported in the articles were human traits and emotional intelligence (46.7%) and communication skills such as transparency and reliability (48.9%). Responsiveness and preparedness (40%), management skills (33.3%) and team working (35.6%) are considered by a significant percentage of the articles as necessary for the construction of rapid and effective measures in response to the emergency. A considerable proportion of articles also highlighted the need for leaders capable of making evidence-based decisions and driving innovation (31.1%). Although identifying leaders who possess all the skills described in this study appears complex, determining the key characteristics of effective public health leadership in a crisis, such as the COVID-19 pandemic, is useful not only in selecting future leaders but also in implementing training and education programmes for the public health workforce.

• public health
• leadership assessment
• medical leadership

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/leader-2022-000653

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Introduction

The COVID-19 pandemic represents a major public health issue with a huge health, social and economic impact worldwide. 1–3 After more than 3 years from the beginning of the pandemic, hundreds of millions confirmed cases and more than 6 million deaths have been reported worldwide. 4

Indeed, the pandemic has undoubtedly generated enormous pressure on health systems, not only in terms of the scientific and logistical challenge of countering a new virus, but also in terms of allocation of resources and frequent disruption of essential services. 5 This situation has created new barriers between the general population and the demand for healthcare, resulting in an intensification of health inequalities. 2 6 Despite the lessons learnt from previous infectious diseases outbreaks, 7 the COVID-19 pandemic demonstrated the lack of preparedness of healthcare systems, with significant implications for population health, economic growth of countries, social cohesion of communities and stability of governments and democracies. 8 Moreover, shortage of investment in sectors such as healthcare, education and research has contributed to miscommunication, growing distrust in institutions and science, challenging public health decision-makers in implementing necessary measures to tackle the pandemic. 9 10 Addressing these challenges requires strong evidence-driven public health leadership to coordinate an integrated policy response that can reduce the impact of the crisis and provide effective responses to increase resilience of health systems. 11 In this context, keeping in mind Roger Gill’s quote ‘There is no one correct definition of leadership, or any one set of personal qualities or competencies that characterize leaders’, 12 leadership is traditionally conceptualised through theoretical models that consider competence, behaviours and values. However, public health issues are complex, involve almost every sector of management and have consequences for every aspect of people’s lives, requiring public health leaders to engage multiple stakeholders in activities that are public and open to broad scrutiny and public debate. 13 Models of health leadership need to consider the complexity of healthcare organisations, the intersectionality of challenges, and the need to involve and empower the population to give sustainability to the actions and the policies adopted. During the COVID-19 emergency, people who had to manage the pandemic both at a macro (political, governmental and institutional) and micro level (eg, in a hospital and local healthcare settings) faced several challenges, such as the limited or constantly changing nature of information, the need for rapid and problem-oriented responses, and fear and mistrust of the population. 14 Therefore, leaders are required to direct, guide and establish the most appropriate strategies to make a difference between success and failure in the management of potentially catastrophic situations at all levels.

In this context, the aim of this review is to summarise evidence on the main leadership’s characteristics reported during the COVID-19 pandemic. Identifying capacities, values and traits of leaders can help institutions and educators to build programmes that ensure a workforce capable of strengthening the resilience and preparedness of healthcare systems and leading public health to address possible future threats. 15

Search strategy

This scoping review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. 16 A search of relevant articles was performed in the PubMed, Scopus and Web of Science databases using a query related to leadership skills and characteristics during the COVID-19 pandemic ( online supplemental figure 1 ). The search was performed from January 2020 to February 2022. The resulting records were entered on the web application Rayyan-Intelligent Systematic Review, 17 to be subsequently screened according to the inclusion/exclusion criteria. After the removal of duplicates, the selection of articles was made by reading titles and abstracts, and then full texts.

Supplemental material

Inclusion/exclusion criteria.

Eligible articles were any type of publication that outlined one or more characteristics of public health leadership during the COVID-19 pandemic, such as communication abilities, soft skills, ethics and values, management skills, training and work experience. We included articles concerning local healthcare settings, specifically hospital directorate and medical and nursing management of wards, or public health management at a national or international level. We considered articles published between the beginning of the healthcare emergency in January 2020 and February 2022. We considered only articles written in English or Italian. We excluded all articles that did not explicitly address the COVID-19 pandemic or with a different setting (eg, veterinarian, schools, enterprise). Moreover, we excluded articles that did not identify any leadership characteristics, intended as communication abilities, soft skills, ethics and values, management skills, training and work experience (wrong outcome).

Selection process and data extraction

Each record was assessed by title and abstract by two independent reviewers (VFC and FD’A). Any disagreement between reviewers, whether necessary, was discussed and solved with a third reviewer (TO).

The full-text assessment was performed in the same manner, thereby identifying the final list of eligible articles. Data extraction was performed by two reviewers (TO and AVG), and every disagreement was resolved by discussion with a third reviewer (LV). The data from the eligible studies were extracted in a predefined Excel sheet, defined by the following columns regarding information extracted from the studies: authors’ name, publication year, study country, study design, type of publication, study setting and main findings. Three reviewers (TO, AVG, LV) analysed and clustered elements that emerged from the analysis by using an iterative process rooted in grounded theory to compare and develop emergent themes. 18 Thus, characteristics emerged as relevant and the number of times each characteristic was discussed was clustered in six macro groups: human traits, behaviour and emotional intelligence; management skills and decision-making; team working, collaboration and empowerment; responsiveness and preparedness; communication skills and stakeholder engagement; evidence-based approach and innovation. Finally, the entire research team discussed the clustering results to identify and resolve any disagreements.

The overall research in the three databases yielded a total of 2449 articles. After duplicates removal, 1471 articles were screened based on the title and abstract. In total, 132 full-text articles were selected. Following the inclusion and exclusion criteria, the screening resulted in the final inclusion of 45 articles. Details about the study selection process are shown in figure 1 . Of these, 7 were literature reviews (15.6%), 16 were research articles (35.6%) and 22 were classified as ‘other’ (48.8%), including editorials, commentaries, opinion pieces and reports.

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Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.

Data were recruited from a variety of countries, with the USA being the most represented, although about 30% of the articles are not placed in any specific geographical setting but produce general considerations.

More than 57.8% of the articles (n=26) addressed public health management setting, at national or government level, while 19 (42.2%) hospital setting, involving physicians (11.1%), nurses (11.1%), healthcare directorate and management (20%) ( table 1 ).

• View inline

General characteristics of the included studies

Leadership characteristics and clustering

We identified 93 characteristics (a characteristic can be expressed several times in different studies, for a total of 170 citations) that we clustered into six main groups: human traits, behaviour and emotional intelligence; management skills and decision-making; team working, collaboration and empowerment; responsiveness and preparedness; communication skills and stakeholder engagement; evidence-based approach and innovation.

Among the groups, in three cases (management skills and decision-making; team working, collaboration and empowerment; evidence-based approach and innovation), we found both positive and negative aspects related to the leaders’ characteristics. The groups identified are shown in table 2 , while table 3 specifically reports the nomenclature and the frequency of each item found.

Number of articles reporting leadership characteristics by categories

Aspects of leadership mentioned in articles by categories

Characteristics attributable to the first group, ‘human traits, behaviour and emotional intelligence’, were identified in 21 articles (46.7%), 8 of which were research articles, 19–26 11 opinion pieces 27–37 and 2 reviews. 38 39 In particular, empathy and ‘honesty and truthfulness in relationships’ were the two most cited characteristics (six and three times, respectively), followed by compassion, emotional intelligence and psychological safety, attention to psychological well-being, emotional effectiveness, equity and values, sense-making and sense-giving (all cited two times). Other characteristics emerged only once from the analysis ( table 3 ).

In group 2, ‘management skill and decision-making’, we identified 15 articles (33.3%) containing features from this domain: 5 research articles, 19 21 40–42 7 opinion pieces 29 33 35 36 43–45 and 3 reviews. 38 46 47 Elements that have emerged most frequently are decision-making (eight times), organisation and planning (both three times), adherence to rules, influencing policies, prepare (twice each). Moreover, in this group, three characteristics emerged as negatively associated with public health leadership: ‘inconsistent policy position’, ‘management at federal level’ and ‘unpredictable behaviour’. 48 49

Sixteen articles (35.6%) were related to group 3, ‘team working, collaboration and empowerment’, of which eight research articles, 19 20 22 24 26 42 50 51 six opinion pieces 34 36 37 52–54 and two reviews. 38 55 Notable characteristics are collaboration, which emerged predominantly five times, accountability, empowerment and team building (three times each), and shared decision-making/leadership (twice). Lack of coordination was underlined once as a negative aspect, 49 while autocratic leadership was still presented as a deductive factor. 56

Eighteen studies (40%) were included in group 4, ‘responsiveness and ‘preparedness’ (10 research articles, 19–21 24 40–42 50 51 57 5 opinion pieces 32 34 35 44 51 and 3 reviews 38 46 47 ). ‘Adapt according to the situation’ was the most cited characteristic (seven times), followed by resilience (four times), act fast, creating strategies, ‘integrative and systematic thinking skills’ (three times), and pragmatism (twice).

The characteristics of the fifth group, ‘communication skills and stakeholder engagement’, were reported in 7 research articles, 19–22 24 26 42 13 opinion pieces 27 29–31 35–37 43 45 52 58–60 and 2 reviews 38 61 (48.9%). About this topic, elements that emerged with greater frequency are clear communication, (10 times), transparency (6 times), advocacy, risk and crisis communication (2 times each).

Finally, group 6, ‘evidence-based approach and communication’ aspects have been found in 14 articles (31.1%), of which 5 research articles, 19 20 25 62 63 7 opinion pieces 27 32 35 36 44 53 60 and 2 reviews. 46 47 ‘Evidence-based decision-making’ (six times) and technological skills (two times) are the most represented characteristics. Finally, one opinion piece 48 highlighted ‘mistrust of science’ as a negative feature.

Finally, we found a different distribution of the characteristics according to the healthcare setting and type of professionalism ( table 4 ). In particular, characteristics related to communication and team working, human traits and management capabilities were reported in articles dealing with medical professionalism, while no articles focused on the importance of the evidence-based approach. The importance of team working was reported also in articles dealing with nursing professionalism, as well as evidence-based approaches. In the articles dealing with the healthcare directorate, we found many leadership characteristics, such as human traits, preparedness and communicative elements. Finally, in the public health management setting, we mainly found leadership characteristics such as communication, team working and those related to human traits.

Distribution of leadership characteristics according to the healthcare setting and type of professionalism

In this scoping review we summarised the main leadership’s characteristics that emerged during the COVID-19 pandemic, addressing both governmental and international as well as local settings. In detail, we identified six macro groups referring to several aspects of leadership that are reported as fundamental in order to be a good leader, capable of managing a public health emergency. Elements emerged from this analysis outline a varied profile, ranging in different characteristics and capacity areas. Human traits, behaviour and emotional intelligence emerged as really necessary to create and transmit trust and confidence, both at an institutional level (and therefore to citizens) and in the work team. In particular, empathy, compassion, attention to well-being and honesty are reaffirmed as key characteristics for ensuring credibility and trust, 64–66 allowing the implementation of actions and measures, specifically during the pandemic, without causing doubt, perplexity and, in extreme cases, anger from the population. These points are closely linked to communication skills. Our study, in fact, shows that clear communication and transparency are the most cited characteristics in the description of the communication skills of a good leader during the pandemic. Indeed, the ability to communicate information in a clear, empathetic and evidence-based manner is critical to enable people to understand and accept measures being taken. 67 68 The same could be highlighted at a micro level, like for example in hospital setting, where clear and transparent communication within the team and towards patients is fundamental for effective project development and goals’ achievement. 69 70 A clear example of wrong communication and misinformation is about the COVID-19 vaccine campaign, where, based on assumptions and not on data, the administration of the AstraZeneca vaccine was stopped claiming associations between vaccination and increased risk of death. 71 The suspension of this vaccine generated great panic among citizens, increasing doubts, fear and vaccine hesitancy, 72 causing a slowdown of the campaign.

Similarly, the lack of transparency and objective communication of risk by several political leaders all over the world led to underestimation of the risk and made it impossible to control the spread of the infection in many countries, resulting in a high number of cases and deaths. 73–75

Second, the results report as characteristics of a good leader, ‘management skill and decision-making’, closely related to ‘team working, collaboration and empowerment’. Another important theme is related to ‘responsiveness and preparedness’, with reference to the ability to plan and predict events in order to optimise resources available. Extending this vision to an international level, the definition of a clear chain of command and the centralisation of some decisions are a necessary prerogative for the correct management of an emergency. 76 This is consistent with the vision of the dynamics that regulate the events during a pandemic as attributable to a system that we can define as ‘complex adaptive’, 77–79 so it requires not only careful planning 14 but also a considerable adaptability and resilience.

Leaders, by definition, never work alone, so it is essential that he or she is supported by a loyal and responsive working group, creating a constructive synergy. Of course, to achieve this type of relationship, it is important for leaders to provide inputs aimed at conveying a sense of empowerment to the group, promoting team-building dynamics that shift the structure of some decisions on a more shared level. 80

Finally, another important aspect emerged from our study is the focal role of ‘evidence-based decision-making’ acquired during the COVID-19 pandemic. A leader’s activity in public health cannot be done without a robust system of scientific evidence to support decisions. This both to implement decisions that will positively impact the course of events and to fully justify the direction taken in a public health perspective. 81 82

Regarding the distribution of leadership characteristics according to different settings, we noted a homogeneous distribution of qualities in specific settings. Indeed, both of the health directorate in local health authorities and hospitals and the public health management are representations, at macro and meso levels, of organisational and health planning settings, in which the leader is called to deal with multidisciplinary and varied inputs, 83 thus requiring all the different categories highlighted by our study. Therefore, in these specific contexts, the clusters we have identified constitute paramount cross-cutting and key elements in the identification of the figure of a leader. Indeed, these are settings that can be traced to the complex system model, and as such require a systemic and inclusive approach of multiple elements, 84 such as the one proposed in this work. Indeed, leaders operating in these areas should have a profile that reflects the multiplicity of challenges they face. This element suggests the importance of a cross-fertilisation of skills and capabilities between healthcare workers, including clinicians, surgeons, nurses and public health professionals. Thus, creating joint training programmes, taking into account the various characteristics we have identified, would improve professional capabilities and knowledge, fostering collaboration within complex systems at different levels.

Strengths and limitations

As far as we know, this is the first scoping review investigating characteristics of leadership during COVID-19 and succeeds in providing a comprehensive set of all the main qualities of a public health leader described in the literature. However, it is necessary to highlight the structural limits of some of the studies included in the analysis, as they lacked a standardised methodology in the process of identification and evaluation in terms of the characteristics and qualities regarding leadership in public health. Furthermore, in the search for articles, only articles in English and Italian were selected, which may have resulted in the omission of literature from some geographical areas. Given the limited number of studies in the literature aimed at measuring the effectiveness of a leader’s competencies in various contexts and the possible variables of interest, it is advisable to increase research aimed at finding methods to measure how leadership competencies actually influence the impact of public health measures and consequently the well-being of the population.

Conclusions

The pandemic has highlighted the need for leaders highly prepared to manage public health emergency contexts. Of course, identifying a leader who possesses all the qualities we highlighted in our study could appear difficult or even impossible; however, for this reason, it is necessary and more urgent than ever to continue and increase investment in the preparation of those in charge of guiding people across difficult situations like the one we are experiencing with the COVID-19 pandemic. In this context, the training of professionals and leaders is a paramount action to address the challenges of the future in public health. In the area of communication, it would be appropriate to integrate training programmes specifically targeting communication skills into health professionals’ and decision-makers’ curricula at different organisational levels. We cannot assume that a single communication style fits all settings and situations in which a leader operates; however, by taking advantage of the available evidence, 85 it is possible to identify the most appropriate educational tool for the development of effective communication skills. Similarly, the other elements that emerged from our study, such as adherence to an evidence-based approach in decision-making processes, emotional intelligence and team working abilities, should be included in the training programmes, in order to prepare leaders who interface with public health issues.

The development of research in the field of public health leadership can, starting from the characteristics we have identified, make use of quantitative and qualitative methods to investigate with increasing rigour the weight these attributes have in the management of critical public health issues. In this sense, future studies that can analyse more thoroughly the specific role in health crises of elements related to human traits, team working and communication skills are desirable, possibly proposing objective evaluations of how these factors have weighed in the management of the COVID-19 pandemic in different global settings. It would also be useful to investigate further the gaps in the literature referring to the lack of articles highlighting the importance of the evidence-based approach in a physicians' leadership setting and the crucial role of communication in nursing.

Finally, it is necessary to dwell on technological and digital skills, particularly related to the information sector and social media, as those deeply affecting the dynamics underlying the social response to health policies aimed at responding to a pandemic situation. 86 The importance, today, in knowing how to use digital and information technology tools for the benefit of shared health is, in our view, critical in defining the characteristics that compete for a public health leader.

Thus, the value of our research lies in providing a comprehensive view of the attributes to look for in the figures we place at the top of our decision-making systems, promoting the value of leadership research and training to ensure we are prepared for future public health emergencies and emerging challenges affecting public health interventions.

Ethics statements

Patient consent for publication.

Not required.

Ethics approval

Not applicable.

• Sohrabi C , et al
• Mofijur M ,
• Fattah IMR ,
• Alam MA , et al
• Cascini F ,
• Zaçe D , et al
• Damiani G ,
• Specchia ML ,
• Ricciardi W
• Aristei L ,
• D’Ambrosio F ,
• Villani L , et al
• Carlton EL ,
• Holsinger JW ,
• Riddell MC , et al
• Tricco AC ,
• Zarin W , et al
• Ouzzani M ,
• Hammady H ,
• Fedorowicz Z , et al
• Strauss A ,
• McGuire D ,
• Cunningham JEA ,
• Reynolds K , et al
• Wagstaff MF ,
• Villanueva S
• Hartney E ,
• Taylor D , et al
• Aboramadan M ,
• Seijts GH ,
• de Clercy C ,
• Pecoraro F , et al
• Hochman KA ,
• Pochapin MB , et al
• Raderstorf T ,
• Ackerman M , et al
• Sanders J ,
• Freudenberg LS ,
• Pomykala KL ,
• Bosworth H ,
• Butow P , et al
• Crayne MP ,
• Medeiros KE
• Hertelendy AJ ,
• Goniewicz K ,
• Khorram-Manesh A
• Czabanowska K ,
• Ebeid N , et al
• Taylor DC ,
• Andolsek KM
• Sriharan A ,
• Banaszak-Holl J , et al
• Bavel JJV ,
• Baicker K ,
• Boggio PS , et al
• Hølge-Hazelton B ,
• Kjerholt M ,
• Rosted E , et al
• Strudsholm T ,
• Stucky CH ,
• Demircioglu MA
• The Editors
• Agarwal P ,
• Mukerji G , et al
• Harrington A
• Dirani KM ,
• Alizadeh A , et al
• Bourgeault IL ,
• Dieleman M , et al
• Colangeli T ,
• Thaivalappil A , et al
• Sevy Majers J ,
• Warshawsky N
• Forster T ,
• Huikko-Tarvainen S
• Stevenson L ,
• Coulter A , et al
• Berland L ,
• Jacobson J , et al
• Glenton C ,
• Flottorp S , et al
• Ameratunga S ,
• Nunn A , et al
• Diderichsen F
• Gonsalves G
• Fonseca EM da ,
• Nattrass N ,
• Lazaro LLB , et al
• Ricciardi W ,
• Tarricone R
• Holland John H
• Gell-Mann M
• Anderson RA ,
• McDaniel RR
• Salas-Vallina A ,
• Ferrer-Franco A ,
• Brownson RC
• Brownson RC ,
• Fielding JE ,
• Figueroa CA ,
• Harrison R ,
• Chauhan A , et al
• Belrhiti Z ,
• Nebot Giralt A ,
• Bachmann C ,
• Rosenbaum M
• Pantovic A ,
• Al-Ajlouni YA , et al

Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1

Collaborators Public Health Leadership Coalition: Natasha Azzopardi Muscat, WHO Regional Office for Europe, Copenhagen, Denmark; Georges Benjamin, American Public Health Association, Washington, DC, USA; Bettina Borisch, Institute of Global Health, University of Geneva, Geneva, Switzerland, World Federation of Public Health Association, Geneva, Switzerland; Luis Eugenio de Souza, Health Collective Institute, Federal University of Bahia, Salvador, Brazil; Sharon Friel, Menzies Centre for Health Governance, School of Regulation and Global Governance, The Australian National University, Canberra, Australian Capital Territory, Australia; Alejandro Jadad, Centre for Global eHealth Innovation, University of Toronto, Toronto, Ontario, Canada; Jeff Smith, Australian Centre for Climate and Environmental Law, University of Sydney, Sydney, Australia; K Srinath Reddy, Public Health Foundation of India, New Delhi, India; Rüdiger Krech, Division of Universal Health Coverage and Healthier Populations, Department of Health Promotion, WHO, Geneva, Switzerland; Martin McKee, London School of Hygiene and Tropical Medicine, London, UK; Michael Moore, Public Health Association Australia, Curtin, Australian Capital Territory, Australia; Iveta Nagyova, European Public Health Association (EUPHA)-president, Utrecht, the Netherlands; Jean-Marie Okwo-Bele, Board of Trustees of the International Vaccine Institute; María del Rocío Sáenz Madrigal, School of Public Health, University of Costa Rica, San José, Mercedes, Costa Rica; Stefano Scarpetta, Director for Employment, Labour and Social Affairs at the OECD, Paris, France; Melissa Sweet, Croakey Health Media, Sydney School of Public Health, University of Sydney, Sydney, Australia; Sheila Tlou, Department of Nursing Education, University of Botswana, Gaborone, Botswana; Collin Tukuitonga, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.

Contributors All authors, including the collaborating group, contributed to the study conception and design. Material preparation and data collection were performed by TO, AVG, LV, VFC and FD'A. The data extraction was performed by TO and AVG, and every disagreement was resolved by LV. The first draft of the manuscript was written by TO, AVG, FC and ML. MRG and WR commented on the latest version of the manuscript and supervised the study. All authors, including the collaborating group, read and approved the final manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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• Case Report
• Open access
• Published: 01 April 2024

Cytomegalovirus colitis as intestinal obstruction in an immunocompetent adolescent: a case report and literature review

• Jiongshan Ge 1   na1 ,
• Yan Li 1   na1 ,
• Jiaxin Wei 1 ,
• Jing Wang 2 &
• Jihai Liu 1  

BMC Infectious Diseases volume  24 , Article number:  365 ( 2024 ) Cite this article

Metrics details

Cytomegalovirus infection manifests varying clinical characteristics and severity in diverse populations with different immune statuses. The signs and symptoms of gastrointestinal involvement are nonspecific. Here, we present a case of cytomegalovirus colitis in an immunocompetent adolescent, which manifested as intestinal pseud-obstruction.

Case presentation

A 15-year-old man who had contracted novel coronavirus infection one month earlier was admitted to our hospital with fever, abdominal pain, and hematochezia. His abdomen was distended, and laboratory evaluation revealed a decrease in the blood count, an increase in inflammatory indicators and hepatic impairment. Imaging shows bowel wall thickening and dilatation of the colon. A diagnosis of intestinal infection combined with acute intestinal pseud-obstruction was made. Diarrhea persisted despite conservative treatment with empirical antibiotics. A colonoscopy was performed. Pathology confirmed cytomegalovirus infection. Ganciclovir therapy was initiated, and subsequent review showed a good recovery.

Conclusions

The case was diagnosed as cytomegalovirus colitis. We reviewed the reports of 9 cases of bowel obstruction, including our own, and found that the majority of the adult patients were elderly with underlying disease. Clinical and endoscopic manifestations are typically nonspecific, and imaging shows typical signs of intestinal obstruction. The final diagnosis was confirmed by pathology. Most of them have a good prognosis. We suggest that cytomegalovirus colitis can also lead to intestinal obstruction and that viral reactivation in immunocompetent individuals may be associated with inflammatory conditions and viral coinfection, particularly with the novel coronavirus.

Peer Review reports

Cytomegalovirus (CMV) infection is common, with approximately 83% of the global population testing seropositive [ 1 ]. People with normal immune function usually have no symptoms, or they may experience fever, mononucleosis, or hepatitis. Immunodeficient individuals are susceptible to viral reactivation, which can affect end organs, such as the lungs, central nervous system, and digestive tract. Recently, there has been a notable increase in CMV colitis among immunocompetent patients, which has garnered significant attention. In healthy individuals, the most affected part of the digestive tract is the colon, exhibiting symptoms like hemorrhage, abdominal pain, and diarrhea [ 2 ]. CMV colitis with intestinal obstruction as the primary manifestation has rarely been reported before.

A 15-year-old male was admitted to the emergency room after presenting a high fever for 10 days, abdominal colic, and mucous bloody stool for 4 days. He had severe abdominal distension and a cessation of passing gas. A month ago, he was suspected of being infected with the novel coronavirus (SARS-CoV-2) due to fever and a sore throat. He took ibuprofen to defervesce. Afterward, jaundice developed. Laboratory tests in other hospitals found that transaminase levels increased, and liver injury caused by acute infection was considered, but no additional pathogenic tests were conducted. Silybin and other hepatoprotective drugs were administered. One week later, symptoms were relieved, and transaminase levels decreased. In addition, he had no other notable medical or family history.

His complete blood count showed a white blood cell count of 0.36 × 10 9 /L (Normal range(NR): 3.50–9.50 × 10 9 /L), with neutrophils accounting for 45.8% (NR: 50%-75%), lymphocytes accounting for 42.0% (NR: 20%-40%), hemoglobin 57 g/L (NR: 120-160 g/L), and platelet count of 59 × 10 9 /L (NR: 100–350 × 10 9 /L); his C-reactive protein was 267 mg/L (NR: < 8.0 mg/L). There was also hepatic impairment, with ALT was 72U/L (NR: 9-50U/L) and AST was 54U/L (NR: 15-40U/L). The stool sample showed an elevated level of white blood cells (20–30/HPF, NR: 0–1) and red blood cells (2–3/HPF, NR: 0). Abdominal computed tomography (CT) showed thickening of the rectal and sigmoid bowel wall with dilation of the proximal colon (Supplementary Fig.  1 ).

We diagnosed as probable intestinal infection and acute intestinal pseud-obstruction. Colonoscopy is considered risky at this time. We promptly inserted an ileus catheter and initiated empirical therapy with meropenem, vancomycin, and human immunoglobulin. His abdominal pain resolved, and his blood count and liver function gradually normalized, but diarrhea continued.

The persistence of the symptoms compelled us to continue the search for the cause. Plasma metagenomic next-generation sequencing (mNGS) showed 50 Epstein‒Barr viruses; serum polymerase chain reaction showed that CMV copy was negative, and plasma CMV-IgG/IgM were also negative. Plasma SARS-CoV-2 IgG was positive, confirming a recent case of novel coronavirus disease (COVID-19). The test for Clostridium difficile, fungi, Mycobacterium tuberculosis, Salmonella, Shiga, rotavirus, and parasites in feces was negative. Other tests, such as antinuclear antibody, antiphospholipid antibody, and HIV tests, were negative. Seventeen days later, he was scheduled for a colonoscopy. Sigmoid colonic and rectal ulcers were observed (Supplementary Fig.  2 A, B). Hematoxylin–eosin (HE) staining revealed CMV inclusion bodies, and immunohistochemical (IHC) staining demonstrated positive CMV antigen (Fig.  1 ), confirming colitis caused by CMV infection.

Histopathological examination of the patient. a HE staining, × 10 magnification. Multiple cytomegalic inclusions are present. b IHC staining, × 10 magnification. A positive area of CMV antigen stained brown is visible

We started intravenous ganciclovir at a dosage of 500 mg/daily for 21 days. Meanwhile, due to the destruction of the superficial intestinal mucosa and persistent diarrhea, considering that inflammatory bowel disease cannot be definitely ruled out, he was also given oral mesalazine and prednisone (starting at 70 mg/daily) to repair the intestinal mucosa and reduce inflammatory reactions after consulting with the Department of Gastroenterology. During a follow-up examination three months later, his blood count and biochemical indicators were normal. Endoscopic findings revealed stenosis of colon lumen and histological signs of chronic inflammation (Supplementary Fig.  2 C, D). CMV was negative for the IHC test, and his stool gradually returned to normal.

This is a case of CMV colitis with acute intestinal pseud-obstruction. After the catheter was inserted, the obstructive symptoms were quickly relieved. Although there was no direct serological evidence, CMV infection was subsequently confirmed through pathological examination. However, this case occurred in an immunocompetent adolescent who was infected with the novel coronavirus one month ago. Liver injury before onset is considered most probably as one of the manifestations of CMV reactivation. After extensive evaluation, no evidence of existing immunodeficiency leading to CMV disease was found.

A total of 9 cases [ 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 ], including our case, were identified by searching PubMed using the keywords "cytomegalovirus" and "colitis" and reviewing relevant literature citations to retrieve previously reported cases of CMV colitis with intestinal obstruction. Patients with inflammatory bowel disease, AIDS, organ transplantation, and treatment with steroids or immunosuppressive agents were excluded (Supplementary Table  1 ). Of these, 6 (66.7%) were male. The average age was 61 years (range: 15–91), and 66.7% of the participants were over 60 years old. 6 (66.7%) of them had multiple co-morbidities, including chronic constipation, diabetes, chronic obstructive pulmonary disease, and other complications. Most of the cases were diagnosed through pathology. 7 of them were treated with ganciclovir, and a total of 2 (22.2%) people died.

The retrospective analysis also revealed that the most common symptoms were fever, abdominal pain, and diarrhea. The endoscopic examination revealed mostly ulceration, while imaging findings showed dilated intestines. M. Paparoupa et al. [ 10 ] and Dinesh et al. [ 5 ] reported cases of mechanical obstruction caused by fibrotic stenosis, thickening and edema of the bowel wall. In the present case and in the remaining cases, the location of the obstructive lesion was not identified, and paralytic ileus caused by toxic megacolon or Ogilvie syndrome was considered. The most common sites involved are the sigmoid colon and rectum. Based on the results of our study, we believe that CMV colitis should increase the rare clinical presentation of intestinal obstruction, even in a population with normal immunity. For patients diagnosed as CMV colitis with normal immunity, clinicians should observe abdominal symptoms and signs in clinical practice, and be alert for acute intestinal obstruction. Similarly, the presence of CMV should be reasonably suspected in patients with intestinal obstruction. Analysis showed that conservative treatments, such as ganciclovir and placement of obstruction catheters, were usually effective for CMV colitis presenting with intestinal obstruction, without the need for surgery.

It is believed that CMV latent infection exists in early myeloid cells, particularly CD34 + hematopoietic stem cells, which can be reactivated to infect parenchymal cells of various organs [ 11 ]. Viremia is crucial for pathogenesis, and there is a threshold relationship between the viral load controlled by the body's immunity and the occurrence of end-organ invasion [ 12 ]. Therefore, virus reactivation and corresponding diseases can easily occur when immunity is inhibited or damaged. However, immunocompetent people are not always unaffected. A retrospective analysis conducted by Yoon et al. [ 2 ] revealed that the majority of immunocompetent patients diagnosed with CMV gastroenteritis were elderly (74.4%) and had underlying chronic conditions (79.1%), which is consistent with our study. Immunity is affected by both aging and the basal state, so it is reasonable to assume that CMV disease may be rare in truly immunocompetent young patients. The patient's infection occurred after COVID-19, prompting us to further explore the interaction between these two viruses. An increased incidence of herpes virus reactivation has been observed in patients with COVID-19 [ 13 ]. In addition to being associated with inflammatory responses and steroid use, SARS-CoV-2 infection results in a reduction in lymphocytes and upregulation of T-cell apoptotic processes [ 14 , 15 ]. The ACE-2 receptor of SARS-CoV-2 entering cells is highly expressed in gastrointestinal epithelial cells. The immune regulation of the lung-gut axis indirectly affects gastrointestinal endothelial cells through pulmonary infection and is susceptible to CMV [ 16 ]. These are all proposed as possible mechanisms of CMV reactivation after SARS-CoV-2 infection. The specific mechanisms of virus-immune system interactions require further investigation and validation in large cohorts.

Cytomegalovirus disease involving the digestive tract can occur in immunocompetent hosts. Aside from abdominal pain, it can also manifest as intestinal obstruction, and generally, conservative treatment is effective. Early recognition of CMV colitis presenting with intestinal obstruction helps to avoid unnecessary disease prolongation and improves prognosis. The reactivation of cytomegalovirus is associated with inflammation in healthy individuals, and novel coronavirus coinfection is considered to be one of the potential contributing factors.

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Abbreviations

• Cytomegalovirus

Computed tomography

Metagenomic next-generation sequencing

Hematoxylin–eosin

Immunohistochemical

Normal range

Zuhair M, et al. Estimation of the worldwide seroprevalence of cytomegalovirus: a systematic review and meta-analysis. Rev Med Virol. 2019;29(3):e2034. https://doi.org/10.1002/rmv.2034 .

Article   PubMed   Google Scholar  

Yoon J, et al. Endoscopic features and clinical outcomes of cytomegalovirus gastroenterocolitis in immunocompetent patients. Sci Rep. 2021;11(1):6284. https://doi.org/10.1038/s41598-021-85845-8 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Machens A, Bloechle C, Achilles EG, Bause HW, Izbicki JR. Toxic megacolon caused by cytomegalovirus colitis in a multiply injured patient. J Trauma Acute Care Surg. 1996;40(4):644.

Article   CAS   Google Scholar  

Lin Y-H, Yeh C-J, Chen Y-J, Chang M-C, Su I-H, Cheng H-T. Recurrent cytomegalovirus colitis with megacolon in an immunocompetent elderly man. J Med Virol. 2010;82(4):638–41. https://doi.org/10.1002/jmv.21712 .

Dinesh BV, Selvaraju K, Kumar S, Thota S. Cytomegalovirus-induced colonic stricture presenting as acute intestinal obstruction in an immunocompetent adult. BMJ Case Rep. 2013;2013:bcr2013200944. https://doi.org/10.1136/bcr-2013-200944

Article   PubMed   PubMed Central   Google Scholar  

Cho JH, Choi JH. Cytomegalovirus ileo-pancolitis presenting as toxic megacolon in an immunocompetent patient: a case report. World J Clin Cases. 2020;8(3):552–9. https://doi.org/10.12998/wjcc.v8.i3.552 .

Charatcharoenwitthaya P, Pausawasdi N, Pongpaibul A. Education and imaging: gastrointestinal: Ogilvie’s syndrome: a rare complication of cytomegalovirus infection in an immunocompetent patient. J Gastroenterol Hepatol. 2014;29(10):1752. https://doi.org/10.1111/jgh.12760 .

Article   CAS   PubMed   Google Scholar  

Kim BS, et al. Cytomegalovirus colitis induced segmental colonic hypoganglionosis in an immunocompetent patient: a case report. World J Clin Cases. 2021;9(20):5631–6. https://doi.org/10.12998/wjcc.v9.i20.5631 .

Lagarto M, Santos A, Freitas BD, Anastácio M, Jesus S. The overlooked agent: cytomegalovirus colitis in an immunocompetent patient. Cureus. 2023;15(3):e36926. https://doi.org/10.7759/cureus.36926 .

Paparoupa M, Schmidt V, Weckauf H, Ho H, Schuppert F. CMV colitis in immunocompetent patients: 2 cases of a diagnostic challenge. Case Rep Gastrointest Med. 2016;2016:e4035637. https://doi.org/10.1155/2016/4035637 .

Article   Google Scholar  

Human Cytomegalovirus | SpringerLink. Available: https://link.springer.com/book/10.1007/978-3-540-77349-8 . Accessed 29 Jul 2023.

Griffiths P, Baraniak I, Reeves M. The pathogenesis of human cytomegalovirus. J Pathol. 2015;235(2):288–97. https://doi.org/10.1002/path.4437 .

Shafiee A, et al. Reactivation of herpesviruses during COVID-19: a systematic review and meta-analysis. Rev Med Virol. 2023;33(3):e2437. https://doi.org/10.1002/rmv.2437 .

Amanati A, et al. Severe acute respiratory syndrome coronavirus-2 Alpha variant (B.1.1.7), original wild-type severe acute respiratory syndrome coronavirus 2, and cytomegalovirus co-infection in a young adult with acute lymphoblastic leukemia, case report, and review of the possible cytomegalovirus reactivation mechanisms. J Med Case Reports. 2023;17(1):66. https://doi.org/10.1186/s13256-022-03750-8 .

Jeannet R, Daix T, Formento R, Feuillard J, François B. Severe COVID-19 is associated with deep and sustained multifaceted cellular immunosuppression. Intensive Care Med. 2020;46(9):1769–71. https://doi.org/10.1007/s00134-020-06127-x .

Carll WC, Rady MY, Salomao MA, Patel B, Singh VP, Sen A. Cytomegalovirus haemorrhagic enterocolitis associated with severe infection with COVID-19. BMJ Open Gastroenterol. 2021;8(1):e000556. https://doi.org/10.1136/bmjgast-2020-000556 .

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Acknowledgements

The authors thank the patient for his consent to publish this report. We thank the reviewers for their helpful comments on this paper.

This work was supported by the National High Level Hospital Clinical Research Funding (serial number 2022-PUMCH-B-109).

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Jiongshan Ge and Yan Li contributed equally to this work.

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Emergency Department, The State Key Laboratory for Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China

Jiongshan Ge, Yan Li, Di Shi, Jiaxin Wei & Jihai Liu

Pathology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, No.1 Shuaifuyuan Wangfujing Dongcheng Districtg, Beijing, 100730, China

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JS. G. drafted the manuscript, Y.L. collected the patient’s information, JH. L., D. S., and JX. W. edited the manuscript, and J. W. provided pathological pictures. All the authors have read and approved the final manuscript.

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Supplementary Information

Additional file 1: supplementary figure 1..

(A, B): Abdominal computed tomography. (A) The distended transverse colon. (B) Thickening of the rectal and sigmoid colon wall with peripheral inflammatory exudation.

Additional file 2: Supplementary Figure 2.

(A, B, C, D): The first colonoscopy and three months later, sigmoid colon and rectum. (A, B) 17 days after being hospitalized. Thickening and edema of the intestinal wall, a smaller intestinal cavity, and deep ulcers were observed. (C, D) 3 months after discharge. A narrow intestinal cavity and inflammatory polyps are visible, but the ulcer has improved.

Additional file 3: Supplementary Table 1.

Clinical characteristics of 9 cases of CMV enteritis with intestinal obstruction.

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Ge, J., Li, Y., Shi, D. et al. Cytomegalovirus colitis as intestinal obstruction in an immunocompetent adolescent: a case report and literature review. BMC Infect Dis 24 , 365 (2024). https://doi.org/10.1186/s12879-024-09255-7

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Anti-synthetase syndrome in a child with pneumomediastinum: a case report and literature review

• Jieqiong Lin 1 ,
• Yaowen Li 1 ,
• Qimeng Fan 2 ,
• Longwei Sun 1 ,
• Weisheng Sun 3 ,
• Xin Zhao 4 &
• Hongwu Zeng 1  

BMC Pulmonary Medicine volume  24 , Article number:  158 ( 2024 ) Cite this article

Metrics details

Anti-synthetase syndrome (ASS) is a group of rare clinical subtypes within inflammatory myopathies, predominantly affecting adult females. Instances of critical illness associated with ASS in children are even rarer.

Case presentation

We report the case of a 7-year-old boy finally diagnosed with ASS, combined with pneumomediastinum. He presented with intermittent fever persisting for 12 days, paroxysmal cough for 11 days, chest pain, and shortness of breath for 4 days, prompting admission to our hospital. Pre-admission chest CT revealed diffuse pneumomediastinum, subcutaneous pneumatosis in the neck and bilateral chest wall, consolidation, atelectasis, and reticular nodular shadowing in both lungs, as well as pericardial effusion and bilateral pleural effusions. Laboratory tests revealed a positive result for serum MP immunoglobulin M (MP-IgM) and MP immunoglobulin G (MP-IgG). The patient was initially diagnosed with mycoplasma pneumoniae (MP) infection, and following 3 days of antibiotic treatment, the patient's tachypnea worsened. Positive results in muscle enzyme antibody tests included anti–PL-12 antibody IgG, anti–Jo-1 antibody IgG, and anti–RO-52 antibody IgG. Ultrasonography detected moderate effusions in the right shoulder, bilateral elbow, and knee joints. Corticosteroids pulse therapy was initiated on the 27th day following disease onset, and continued for 3 days, followed by sequential therapy for an additional 12 days. The child was discharged on the 43rd day, and subsequent follow-up revealed a significant improvement in consolidation and interstitial lesions in both lungs.

Conclusions

ASS in children may combine with rapidly progressive interstitial lung disease (RPILD) and pneumomediastinum. It is crucial to promptly identify concurrent immunologic abnormalities during the outbreak of MP, particularly when the disease exhibits rapid progression with ineffective conventional antibiotic therapy.

Peer Review reports

Anti-synthetase syndrome (ASS) is an autoimmune disorder characterized by inflammatory myopathies, arthritis, and cutaneous manifestations such as Raynaud’s phenomenon and Mechanic’s hands, along with interstitial lung disease (ILD) [ 1 , 2 ]. ASS is one of the most prevalent subtypes of idiopathic inflammatory myopathies (IIMs), with distinctive serological markers being anti-tRNA synthetase antibodies (ARSs), including anti–Jo-1-ARS, anti–PL-7, anti–PL-12, anti-EJ, anti-KS, anti-Zo, anti-Tyr/YRS, and anti-OJ antibodies. Among these, anti–Jo-1-ARS is the most frequently observed in ASS patients [ 3 ].

When the lungs are affected, ASS manifests as nonspecific interstitial pneumonia characterized by diffuse ground-glass opacities and peripheral consolidation. Additional features encompass linear opacities, a honeycomb pattern, and traction bronchiectasis [ 4 ]. Pathological observations have revealed varying degrees of inflammation and fibrosis in the lung interstitium. Microscopically, this is characterized by infiltration of lymphocytes and plasma cells in the alveolar septa, which comprises collagen fibers exhibiting varying degrees of fibrosis mixed with chronic inflammation [ 5 ].

This study presents the case of an ASS child complicated with pneumomediastinum. The report underscores the importance for clinicians to pay attention to immunologic abnormalities when encountering a general infection that rapidly progresses to multi-system abnormalities during the outbreak of MP. Additionally, we conducted a literature review on ASS combined with pneumomediastinum, with the aim of enhancing understanding of ASS during infected states and preventing delays in treatment.

A 7-year-old male was admitted to our hospital exhibiting intermittent fever persisting for 12 days (with a peak temperature of 39.0 °C), paroxysmal cough ongoing for 11 days, and chest pain along with shortness of breath for the past 4 days. Before admission, the patient had undergone antibiotic treatment at other medical facilities, however, it proved ineffective. At the time of admission to our hospital, his body temperature was 36.9℃, respiratory rate was 65 breaths/min, pulse rate was 64 beats/min, and oxygen saturation was 98.0% with mask oxygenation. The patient had obvious symptoms of hypoxia, including tachypnea, three-concave sign, rough and decreased respiratory sounds in both lungs. There were rales in the left lung. Subcutaneous crepitation was detected in the neck. No hemorrhages or rashes were observed on the skin and mucous membranes throughout the body. The patient exhibited normal muscle strength and tension. There was no reported history of abnormal development, allergies, surgery, trauma, family medical background, or chronic infectious diseases.

Chest radiography conducted prior to admission revealed diffuse consolidation of both lungs, pneumomediastinum, and subcutaneous emphysema. To further elucidate the extent of pneumomediastinum and characterize the lung lesions, a chest CT examination was performed on the patient. Chest CT disclosed subcutaneous pneumatosis in the neck and bilateral chest wall, pneumomediastinum, interstitial emphysema in both lungs, diffuse consolidation, reticular nodular shadowing in both lungs, atelectasis in the upper lobes of both lungs, and in the lower lobe of the left lung, in addition to pericardial effusion and bilateral pleural effusions. Laboratory tests revealed a positive result for serum MP immunoglobulin M (MP-IgM) and immunoglobulin G (MP-IgG). Metagenomic next-generation sequencing (mNGS) of bronchoalveolar lavage fluid indicated the presence of MP, Human gammaherpesvirus 4, and human metapneumovirus (Table  1 ). Tests for Streptococcus pneumoniae and group A streptococcus antigens returned negative results. PCR results for EV71 + CA16 + enterovirus and COVID-19 nucleic acid were also negative. Other relevant laboratory tests are detailed in Table  2 . Noninvasive assisted ventilation was administered initially, followed by anti-infection medication (intravenous cefoperazone sulbactam and erythromycin) and anti-inflammation treatment (intravenous methylprednisolone, 2 mg/kg/day, b.i.d.).

On day 13 of illness, due to evident shortness of breath, the child was transferred to the PICU, where he underwent antibody testing to help identify autoimmune disease as CT indicated interstitial lesions in both lungs. The autoantibody profile, encompassing 11 items (serum), revealed anti–Jo-1 antibody (+ +). Myositis antibody spectrum analysis showed anti–PL-12 antibody IgG ( +), anti–Jo-1 antibody IgG ( +), and anti–RO-52 antibody IgG ( +). We did not perform tests on antibodies to melanoma differentiation-associated gene 5 (MDA5) because of restricted examination scope. Sputum culture showed no abnormalities.

On day 18, after a slight stabilization of his condition, the child was transferred to the Department of Respiratory Medicine. Although the child did not have obvious joint swelling or pain, based on the positive results of several myositis antibodies, he was considered to have an autoimmune disease, and was recommended to undergo a joint examination to confirm the joint involvement. Ultrasound revealed synovial bursa effusion in the right shoulder joint, bilateral elbow joints, and knee joints.

On day 26, following a multidisciplinary consultation and discussion, ASS was considered. Pulse treatment (methylprednisolone, 500 mg/day, intravenously guttae, q.d.), was administered for 3 days, followed by sequential oral prednisolone (30 mg/day, q.d.) on days 30–34, which was then reduced to 25 mg/day on day 35. On day 35, oral tacrolimus (1 mg, q12H) was added (Fig.  1 ).

Clinical treatment course of the patient

Chest radiographs were reexamined on day 42, revealing the absorption of pneumomediastinum, bilateral cervical and axillary subcutaneous pneumoperitoneum, reduction of lesions in both lungs, and nearly complete absorption of left pleural effusion. Following treatment, the child's condition stabilized, and he was discharged from the hospital. At the time of discharge, he showed no signs of fever, cough, shortness of breath, wheezing, or cyanosis, and the pneumomediastinum had resolved. One-week post-discharge, the chest CT scan revealed residual interstitial lesions and consolidation in both lungs, indicating improvement compared to the CT scan on day 18 of illness (Fig.  2 ). During a follow-up visit 1 month later, inflammatory indexes showed no abnormalities. The patient received oral administration of tacrolimus and prednisone acetate tablets, along with fluticasone propionate inhaler prescription. Regular follow-ups were scheduled in the 3rd, 4th, and 5th months to monitor the blood concentration of tacrolimus, adjust the tacrolimus dosage, lower the prednisone dosage, and undergo regular hospital admission for gammaglobulin transfusion (1 g/kg) for immunotherapy regulation.

Radiologic findings of the patient. A-C  On day 18 of illness, CT shows subcutaneous pneumatosis of the neck and bilateral chest wall, pneumomediastinum, consolidation, and reticular nodular shadow in both lungs, along with pericardial effusion and bilateral pleural effusion. D-E  On day 23, subcutaneous air is essentially absorbed, pneumomediastinum is reduced compared with earlier, and consolidation and interstitial lesions in both lungs are present. F-G  On day 30, pneumomediastinum is fully absorbed, and consolidation and pleural effusion are less pronounced than earlier. H-I  One week after discharge, CT shows reticular nodular shadow, and both lungs exhibit residual consolidation, which have significantly resolved

Pneumomediastinum, characterized by the entry of air into the mediastinum through connective tissue spaces within the pleura [ 6 , 7 ], can be asymptomatic with a small gas accumulation. However, sudden onset or a significant influx of air compressing the organs within the mediastinum can result in respiratory and circulatory disorders, and in severe cases, be life-threatening.

The current case represents the first report of anti-synthetase syndrome in a child combined with pneumomediastinum. Previous studies revealed the similar phenotype of ASS in juveniles and adults, although this subtype is much less frequent in childhood than in adulthood. Important features such as Raynaud phenomenon, mechanics hands and ILD seem to occur at a lower frequency in childhood-onset disease than in adult-onset disease [ 8 ].

Our retrospective analysis of ASS cases combined with pneumomediastinum, previously reported in adults (Table  3 ), strongly indicates a correlation of ASS with ILD and pulmonary infection [ 9 , 10 , 11 ]. This underscores the pivotal role of infection in precipitating severe complications of ASS-associated ILD. In our case report, pneumomediastinum was potentially associated with ASS-associated rapidly progressive ILD (RPILD), with infection being a crucial factor in its progression. Remarkably, the MP and other virus infection are not the trigger for the onset of ASS. The patient in this particular case had an underlying preexisting condition of ASS, which had not been previously identified.

Metagenomic next-generation sequencing (mNGS) of bronchoalveolar lavage fluid revealed the presence of MP, Human gammaherpesvirus 4, and human metapneumovirus. Notably, the number of sequences detected for MP was significantly higher than that for other pathogens. Considering the clinical manifestations in children, MP infection remains a significant factor to consider when explaining the rapid progression of interstitial lung disease; however, it is important not to exclude the possibility of infection with other viruses.

Numerous studies have confirmed that abnormalities in the immune mechanism play a significant role in the development of ASS-ILD, with a focus on the production of anti-synthesis enzyme antigen–antibody interactions [ 12 , 13 ]. In vitro experiments have shown the presence of histidyl-tRNA synthetase (anti–Jo-1)–reactive CD4 + T cells in bronchoalveolar lavage fluid, indicating immune activation against anti–Jo-1 antibody in the lungs of ASS patients [ 14 ]. Antigen stimulation triggers innate and adaptive immune responses, leading to the production of antibodies that can be transferred to various tissues in the body.

Pneumomediastinum and subcutaneous pneumatosis are commonly observed in IIM patients with ILD [ 5 , 7 ]. The mechanism underlying pneumomediastinum in IIMs remains unclear, with some scholars proposing that it may be induced by vasculitis and pulmonary fibrosis [ 7 , 15 ]. Vasculitis can lead to necrosis of the alveolar and bronchial walls, disrupting the mucosal barrier and allowing air to enter the mediastinum. Pulmonary fibrosis, on the other hand, may result in lung atelectasis near the mediastinum, forming pulmonary bullae; rupture of these bullae can puncture the pleura, enabling air to enter the mediastinum and causing pneumomediastinum. Moreover, rapidly progressing lung infections, such as MP, can cause mucosal damage to alveolar walls, resulting in pneumomediastinum and pneumothorax.

Approximately 33% [ 16 ] of IIM patients can develop RPILD. ASS, accounting for 7.8% of IIMs, is associated with ILD in > 90% of cases [ 17 ], and ILD significantly contributes to increased prevalence and mortality in these patients [ 17 , 18 ], and ASS patients with ILD often experience more severe disease with rapid progression. ILD associated with IIMs exhibit a high ICU admission rate of 26.7% and a mortality rate of 28.9% [ 16 ], emphasizing the importance of early diagnosis and aggressive treatment to prevent serious outcomes.

In the current case, the child did not exhibit significant manifestations of myositis; however, despite the absence of cutaneous features of connective tissue disease, myositis is not present in approximately 53% of ASS patients [ 2 ]. Positive results for anti–PL-12, anti–Jo-1, and anti–Ro-52 antibodies were reported in this case. Studies have shown that anti–Ro-52 antibodies in ASS patients are associated with RPILD [ 19 ], whereas anti–PL-12 antibodies are strongly associated with ILD development [ 20 ]. In a previous study, arthritis was the most common initial symptom in the anti–Jo-1 antibody-positive group [ 21 ], and in alignment with literature, our patient presented with multiple joint effusions. Additionally, this case highlights the importance of promptly considering the possibility of combined autoimmune-associated nonspecific ILD and, if necessary, conducting tests for IIM-associated antibodies when evaluating rapidly progressing infections with uncommon extrapulmonary complications.

The occurrence of ASS in children is uncommon, and when infection is present, the disease may progress rapidly or even lead to pneumomediastinum. In the context of an epidemic of MP, if a child demonstrates rapid progression and uncommon extrapulmonary complications, pediatricians should consider the possibility of immune-related diseases and promptly conduct tests for relevant antibodies.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Acharya S, Meador R, Plocharczyk E, Tiwari A. Gupta SS Isolated interstitial lung disease associated with anti-synthetase syndrome. QJM An International Journal of Medicine. 2022;115(6):408–9.

Article   CAS   PubMed   Google Scholar  

Bartoloni E, Gonzalez-Gay MA, Scirè C, Castaneda S, Gerli R, Lopez-Longo FJ, Martinez-Barrio J, Govoni M, Furini F, Pina T, et al. Clinical follow-up predictors of disease pattern change in anti-Jo1 positive anti-synthetase syndrome: Results from a multicenter, international and retrospective study. Autoimmun Rev. 2017;16(3):253–7.

Sun S, Chen Z, Zhang D, Xu W, Wu W, Sun F, Gu L, Chen J, Li J, Li T, et al. Description and Analysis of a Novel Subtype of the Anti-Synthetase Syndrome Characterized by Frequent Attacks of Fever and Systemic Inflammation in a Single-Center Cohort Study. Front Immunol. 2021;12:729602.

Alfraji N, Mazahir U, Chaudhri M, Miskoff J. Anti-synthetase syndrome: a rare and challenging diagnosis for bilateral ground-glass opacities—a case report with literature review. BMC Pulm Med. 2021;21(1):11.

Wu W, Guo L, Fu Y, Wang K, Zhang D, Xu W, Chen Z, Ye S. Interstitial Lung Disease in Anti-MDA5 Positive Dermatomyositis. Clin Rev Allergy Immunol. 2021;60(2):293–304.

Li C. Liang Me, Jiang H, Zhao J, Wu C, Wang Q, Zhang L, Zhao Y: The long-term prognosis of pneumomediastinum associated with dermatomyositis: a two-centre retrospective cohort study. Rheumatology. 2021;60(5):2288–95.

Le Goff B, Chérin P, Cantagrel A, Gayraud M, Hachulla E, Laborde F, Papo T, Sibilia J, Zabraniecki L, Ravaud P, et al. Pneumomediastinum in interstitial lung disease associated with dermatomyositis and polymyositis. Arthritis Care Res. 2008;61(1):108–18.

Article   Google Scholar  

Papadopoulou C, Chew C, Wilkinson MGL, McCann L, Wedderburn LR. Juvenile idiopathic inflammatory myositis: an update on pathophysiology and clinical care. Nat Rev Rheumatol. 2023;19(6):343–62.

Article   PubMed   PubMed Central   Google Scholar  

Jhajj AS, Shun Yeung JH, To F, Tsay GJ. Spontaneous Pneumomediastinum due to Anti-Melanoma Differentiation-Associated Protein 5 Requiring a Bilateral Lung Transplant. Case Reports in Rheumatology. 2021;2021:1–4.

Saint-Georges F, Mulliez P, Lebas D, Modiano P, Bisch D. Pneumomediastinum complicating the anti-synthetase syndrome. Rev Mal Respir. 2005;22(6 Pt 1):1031–34.

Vinicki JP, Pellet SC, Raimondi A, Dubinsky D, Nasswetter G. Antisynthetase syndrome with subcutaneous emphysema and pneumomediastinum. J Clin Rheumatol. 2014;20(7):401–2.

Article   PubMed   Google Scholar  

Adams RA, Fernandes-Cerqueira C, Notarnicola A, Mertsching E, Xu Z, Lo W-S, Ogilvie K, Chiang KP, Ampudia J, Rosengren S, et al. Serum-circulating His-tRNA synthetase inhibits organ-targeted immune responses. Cell Mol Immunol. 2019;18(6):1463–75.

Joosse BA, Jackson JH, Cisneros A, Santhin AB, Smith SA, Moore DJ, Crofford LJ, Wilfong EM, Bonami RH. High-Throughput Detection of Autoantigen-Specific B Cells Among Distinct Functional Subsets in Autoimmune Donors. Front Immunol. 2021;12:685718.

Galindo-Feria AS, Albrecht I, Fernandes-Cerqueira C, Notarnicola A, James EA, Herrath J, Dastmalchi M, Sandalova T, Rönnblom L, Jakobsson PJ, et al. Proinflammatory Histidyl-Transfer RNA Synthetase-Specific CD4+ T Cells in the Blood and Lungs of Patients With Idiopathic Inflammatory Myopathies. Arthritis & Rheumatology. 2019;72(1):179–91.

Gonçalves TA, Parente DB, Barreto MM. Pneumomediastinum and pneumorrhachis as complications of dermatomyositis. J Bras Pneumol. 2021;47(6):e20210352.

Abu-Rumeileh S, Marrani E, Maniscalco V, Maccora I, Pagnini I, Mastrolia MV, Rouster-Stevens K, Simonini G. Lung involvement in juvenile idiopathic inflammatory myopathy: A systematic review. Autoimmun Rev. 2023;22(10):103416.

Zhang D, Wang H, Zhou X, Yang J, Liu Y, Wang W, Jiang P, Fan B. Clinical characteristics and prognostic analysis of idiopathic inflammatory myopathy with positive anti‐aminoacyl‐tRNA synthetase antibodies: A single center experience. Immun Inflamm Dis. 2023;11(11):e1085.

Sawal N, Mukhopadhyay S, Rayancha S, Moore A, Garcha P, Kumar A, Kaul V. A narrative review of interstitial lung disease in anti-synthetase syndrome: a clinical approach. J Thorac Dis. 2021;13(9):5556–71.

Sodsri T, Petnak T, Ngamjanyaporn P. Clinical Characteristics of Anti-Synthetase Syndrome and Variables Associated with Interstitial Lung Disease and Mortality: A Retrospective Cohort Study. J Clin Med. 2023;12(21):6849.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Pinal-Fernandez I, Casal-Dominguez M, Huapaya JA, Albayda J, Paik JJ, Johnson C, Silhan L, Christopher-Stine L, Mammen AL, Danoff SK. A longitudinal cohort study of the anti-synthetase syndrome: increased severity of interstitial lung disease in black patients and patients with anti-PL7 and anti-PL12 autoantibodies. Rheumatology. 2017;56(6):999–1007.

Tang HS, Tang IYK, Ho RTC, Young JKY, Lai BTL, Chung JYK, Yung AKM, Cheung CCL, Lee PML, So H: Clinical heterogeneity and prognostic factors of anti-synthetase syndrome: a multi-centred retrospective cohort study. Rheumatology 2023:kead671.

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This work was supported by the Sciences and Technology Project of Shenzhen (Grant No. JCYJ20220530155805012), the Sanming Project of Medicine in Shenzhen (Grant No. SZSM202011005), Guangdong High-level Hospital Construction Fund (No. ynkt2022-zz38).

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Jieqiong Lin, Yaowen Li, Longwei Sun & Hongwu Zeng

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Shantou University Medical College, Shantou, Guangdong Province, China

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Jieqiong Lin collected the clinical data and wrote the original draft. Yaowen Li, Longwei Sun collected the clinical data and reviewed the manuscript. Weisheng Sun prepared the chest CT figures. Qimeng Fan, Xin Zhao prepared the clinical data. Hongwu Zeng reviewed the manuscript. All authors revised and approved the final manuscript.

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Lin, J., Li, Y., Fan, Q. et al. Anti-synthetase syndrome in a child with pneumomediastinum: a case report and literature review. BMC Pulm Med 24 , 158 (2024). https://doi.org/10.1186/s12890-024-02984-0

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• Published: 17 May 2021

Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries

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Health systems resilience is key to learning lessons from country responses to crises such as coronavirus disease 2019 (COVID-19). In this perspective, we review COVID-19 responses in 28 countries using a new health systems resilience framework. Through a combination of literature review, national government submissions and interviews with experts, we conducted a comparative analysis of national responses. We report on domains addressing governance and financing, health workforce, medical products and technologies, public health functions, health service delivery and community engagement to prevent and mitigate the spread of COVID-19. We then synthesize four salient elements that underlie highly effective national responses and offer recommendations toward strengthening health systems resilience globally.

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COVID-19 has caused an unprecedented global crisis, including millions of lives lost, public health systems in shock and economic and social disruption, disproportionately affecting the most vulnerable. As of April 2021, there are over 140 million confirmed cases and over three million COVID-19 deaths globally 1 . While vaccination has commenced in numerous countries, new outbreaks and variants continue to emerge. At the same time, the global distribution of vaccines is marred by challenges of equity on top of logistical complications. Millions more are therefore still at risk of dying, facing significant morbidity or losing their livelihoods given the uncertain economic outlook.

The pandemic has challenged local, national, regional and global capacities to prepare and respond. The various national strategies taken to control viral transmission are widely debated 2 , 3 . However, the relative success of these strategies depends largely on how an existing health system is organized, governed and financed across all levels in a coordinated manner 4 . The pandemic has exposed the limitations of many health systems, including some that have been previously classified as high performing and resilient 5 . A comprehensive analysis of the resilience of health systems during the pandemic can therefore pinpoint important lessons and help strengthen countries’ preparedness, response and approach to future health challenges.

While resilience is a core concept in disaster risk reduction, its application to health systems is relatively new. It has been defined broadly as institutions’ and health actors’ capacities to prepare for, recover from and absorb shocks, while maintaining core functions and serving the ongoing and acute care needs of their communities 6 , 7 . During a crisis, a resilient health system is able to effectively adapt in response to dynamic situations and reduce vulnerability across and beyond the system. Experience from previous epidemics, such as Ebola, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome, emphasized the links between resilience and thwarting new outbreak transmission 8 .

Health systems resilience literature stresses that efforts should focus not only on absorbing unforeseen shocks precipitated by emerging health needs, but also on ensuring continuity in health improvement, sustaining gains in systems functioning and fostering people centeredness, while delivering high-quality care 9 , 10 . As COVID-19 has overwhelmed health systems worldwide, debates around resilience have become more urgent, and there is a need to better understand the elements of national responses through a resilience lens 11 , 12 . Thus, in this perspective, we use an expanded health systems resilience framework centered on community engagement to examine 28 national responses to COVID-19. This analysis provides insights into the policies countries implemented and how these were implemented to tackle the pandemic.

Conceptual framework

Our conceptual framework (Fig. 1 ) is grounded in the World Health Organization’s (WHO) health systems framework 13 . We develop the framework elements by adding public health functions, including testing, contact tracing, disease surveillance and non-pharmaceutical public health interventions, which often operate separately from health service delivery. Yet, they are critical both to pandemic responses and to ongoing population health. Similarly, health information systems are vital functions for both public health and health systems as, ideally, they should be integrated to capture data at individual, health system and population levels.

The scheme illustrates the components of the resilient health systems framework we developed based on the WHO’s health systems building blocks framework. The five elements of resilient health systems are centered around community engagement as core to all elements of health systems resilience.

We centered our analysis on community engagement as core to all elements of health systems resilience (see Box 1 for more information on the analytical approach). To serve communities in a more equitable manner and promote healthy societies, resilience must be developed with these communities and according to their needs. There can be no health systems resilience without community engagement across domains 14 . We also acknowledge the critical role of coordination with non-health sectors as essential to providing necessary supports to address the social determinants of health. Underpinning these elements are health equity and outcomes. Resilient health systems should aim to generate positive physical and mental health outcomes for all, including vulnerable and marginalized groups. In many countries, COVID-19 mortality rates have been disproportionately higher among older populations, minority ethnic groups, socioeconomically deprived populations and low-wage and migrant workers, emphasizing the interconnectedness between equity and health outcomes 15 .

Box 1 Analytical approach

The analysis presented in this review is based on a purposive selection of countries including positive and negative outliers in relation to reported COVID-19 deaths per capita among highly populous countries, as well as a selection of countries in the middle ground from different regions and with widely varying health systems and economic status. Figure 2 provides an overview of countries in our review. Countries were selected according to the recorded number of deaths attributed to COVID-19 per 100,000 inhabitants on 6 November 2020. Given the dynamic and continuously changing situation, the ranking of positive and negative outliers in terms of death per capita may have changed during the pandemic. The analysis is thus limited to this specific time period.

Five complementary methods were adopted to analyze national responses to COVID-19:

Literature review: using standardized methods, we identified peer-reviewed papers and public reports that examined national and subnational policy responses and extracted data for each country on five dimensions comprising 62 items. The dimensions and items were identified through a review of 14 existent frameworks.

Semi-structured interviews and national government submissions : to supplement the literature review, we asked the selected countries and country experts a set of questions related to the measures implemented to contain COVID-19 in their respective countries. A total of 45 interviews and written submissions were provided. Semi-structured interviews with COVID-19 national experts at the policy, operational and academic levels were recorded and transcribed in full. All interviews were coded through an inductive approach and thematic analysis, using QSR NVivo 12 software, drawing on techniques of the constant comparison method.

In-depth case studies of 6 countries to validate the data from the 28 countries.

Expert validation of country-specific data with country experts. Experts in countries were provided with the specific data for each of their respective countries to validate the data.

Expert validation through roundtable discussions with country experts. A total of 35 national and international experts in COVID-19 policies participated in two roundtable discussions.

COVID-19 responses in 28 countries

Using our framework, we organized our results beginning with domains often viewed as external to health, which are nevertheless central determinants of health systems resilience—governance, finance, collaboration across sectors and community engagement—before exploring domains more closely associated with traditional views of health and health systems—health service delivery, health workforce, medical products and technologies and public health functions. We offer illustrative examples of selected countries for each domain in Tables 1 – 6 . We analyzed 28 countries based on a purposive selection, including positive and negative outliers in relation to reported COVID-19 deaths per capita among highly populous countries, as well as a selection of countries in the middle ground (as of 6 November 2020). Figure 2 provides an overview of countries in our review.

The map presents an overview of countries selected according to the recorded number of deaths attributed to COVID-19 per 100,000 inhabitants on 6 November 2020. Countries are listed according to region and in alphabetical order.

Governance, finance and collaboration across sectors

COVID-19 has made policymakers and the wider public acutely aware of the relationship between health systems, domestic economies and governance. Government decisions determine healthcare infrastructures, regulations and guidelines, defining access to medication and treatment, the provision of health coverage and the financing of these. Government responses to COVID-19, in the immediate term, have meant the difference between lockdown or business as usual, and have eroded or increased public trust. In the longer term, they have shaped national choices regarding private healthcare or universal health coverage (UHC) and strengthened or impoverished social safety nets that underpin health and well-being.

Overall, COVID-19 responses saw health policy moving beyond the remit of Ministries of Health and in doing so, draw on expertise from other ministries, particularly during the early response. Countries took whole-of-government approaches to strengthen health systems in response to COVID-19, particularly those with experience of other health-related disasters, such as Ebola. These decisions were, in most countries, made by translating evidence-based research into policies that preserve health system capacity, while protecting both public health and livelihoods. As such, most countries established temporary COVID-19 advisory groups to inform government decisions. However, in the majority of countries, the views represented on these committees were largely biomedical. More information on national responses from a governance and leadership perspective is available (V.H., A.-S.J., R. Neill, S.W. and M. Jamieson, unpublished data).

The COVID-19 response requires testing, treatment and vaccines to be financed with either a portion or all of these costs coming from public funds, and depends on healthcare infrastructures, workforce and supplies to provide much-needed surge capacity within health systems. Additionally, fiscal support measures, including relief packages aiming at helping businesses stay viable, protect jobs or provide financial aid to low-income households and the unemployed have been taken by many countries. These policies support people to adhere to public health guidance, with the aim of preventing infections, in turn mitigating the strain on the health system resulting from the need to deliver high-intensity COVID-19 care. To further enhance the reach of health services, many countries reviewed took specific actions to mitigate potential financial and physical barriers to care, such as covering part or all of the costs of COVID-19 care, and funding the establishment of testing and treatment centers in communities 16 . Importantly, the outcomes resulting from financial expenditures on health and well-being are only as good as the structures that support them. Thus, they require governance expertise across levels, sectors and domains and depend on a system’s ability to reach (vulnerable) populations.

Community engagement

Deep engagement with local communities is central to resilient health systems as a way to inform service delivery, decision-making and governance and to meet the needs of communities before, during and after crises. Community engagement strategies, such as building partnerships with local leaders and working alongside community members to tailor messages and campaigns are crucial during public health emergencies 17 . The range of non-pharmaceutical public health interventions employed in response to COVID-19, such as mask wearing and social distancing, rely on shared values and a sense of social responsibility within communities to break chains of viral transmission 18 .

Several countries reviewed engaged networks of community health workers (CHWs) to encourage active community participation in COVID-19 responses. Their roles range from creating awareness through door-to-door visits, supporting contact tracing efforts, maintaining essential health services, providing necessary medication to patients without COVID-19, surveillance or monitoring adherence to quarantine measures and assessing mental well-being 19 . They are also key to identifying and referring patients who face barriers to accessing healthcare services. For example, Thailand deployed over 1 million CHWs to disseminate and amplify messages widely in communities. Singapore deployed volunteers to educate seniors and help distribute daily necessities. Liberia further empowered community leaders by providing orientation on COVID-19 epidemiology to support containment efforts. However, many of these efforts depended on volunteers.

During early response efforts, a few countries conducted surveys to understand public sentiment regarding evolving measures. Japan conducted a survey in April 2020 to understand compliance with social distancing measures, using the results to inform response strategies. Governments also started multilingual hotlines to ensure comprehensive access to COVID-19 information. Other countries used social media platforms to engage communities. For example, the #TakeResponsibility campaign in Nigeria called on citizens to join forces and be proactive in taking greater individual and collective responsibility in controlling the spread of COVID-19 20 .

Health service delivery

Health systems globally have employed three common approaches to rapidly scale up health system infrastructure, namely by constructing new treatment facilities, converting public venues and reconfiguring existing medical facilities to provide care for patients with COVID-19. Thus, some of the health systems reviewed invested significant resources into rapidly creating dedicated field facilities. For example, in early 2020, China established two specialty field hospitals in under 2 weeks 21 . Where field hospitals were set up to house patients with COVID-19, countries often drew on their armed forces and military field hospital models, or adapted existing large public facilities. However, most health systems relied on a less resource-intensive approach that modified traditional healthcare facilities into dedicated COVID-19 care centers 22 . Other health systems relied on home care for patients with mild to moderate COVID-19, with facilities available if patients were unable to safely self-isolate within their homes. Additionally, the majority of reviewed countries canceled elective surgeries in an effort to ensure system capacity for COVID-19 care.

In many health systems, primary-care providers are the frontline of the health system providing continuous, coordinated and people-centered care. Primary care is an important point of COVID-19 triage, as well as the point at which most routine and acute care services are provided within communities 23 . In many of the countries reviewed, primary-care providers rapidly adopted and scaled up digital technology or telehealth services to provide ongoing and acute care while also triaging and referring persons with symptoms of COVID-19 to onward care 24 . Additionally, some countries complemented digital technology with proactive deployment of existing and new community health resources 25 . Community-based approaches developed with deep knowledge of local contexts are crucial to pandemic response and health systems resilience, particularly given the disproportionate impact of the pandemic on vulnerable groups 15 , 26 . While outside the reach of the health system in many countries, there have been extensive outbreaks in long-term care homes with devastating impacts on the health and well-being of high-risk older adults, long-term care patients and their families 27 . In response, most countries reviewed prioritized long-term care facilities and older adults for testing, surveillance and vaccine distribution, although often not until there had been high rates of mortality in these settings.

Health workforce

Resilient health systems manage crises by having an adequate, trained and willing workforce. Yet, in many countries, COVID-19 has spread quickly among health workers as they have been the most exposed to the virus, with data indicating that they have been disproportionately affected by the pandemic 28 . Health workforce challenges during COVID-19 include low staffing levels (particularly among nurses) and uneven geographical distribution, shortages of adequate personal protective equipment (PPE), limited testing capacity, insufficient training, social discrimination and attacks and poor mental health 29 .

As cases surged globally, most reviewed countries reallocated healthcare professionals, including primary-care workers, to emergency care wards, intensive care units (ICUs) and diagnosis and surveillance activities. Several recruitment strategies were implemented to increase the healthcare workforce. Retired, student or nonpracticing medical and paramedical professionals were asked to volunteer for healthcare tasks. For example, medical and nursing students were recruited and allowed to perform supervised work in different COVID-19 response capacities in countries such as Germany, Russia, Spain, the United Kingdom and Vietnam. Given these new roles or expanded job scopes, there was an immediate need for rapid and high-quality pandemic-related training of frontline healthcare workers, which was accomplished through virtual training courses in many countries.

Further measures were taken by countries to maintain, protect and support their healthcare workers in light of the physical and psychological strain of the pandemic. In some countries (for example, Japan, Mozambique, Singapore and South Korea), healthcare professionals were supported by measures such as organization of shifts to avoid extended hours without rest, leaves from duty for mental and physical recovery, accommodation near their workplaces to protect their families, and childcare. Additionally, most countries reported giving some form of financial support to their health workers, such as monetary incentives, bonuses, insurance, tax benefits, overtime pay, meal allowances, classification of their infections as an occupational disease or injury and declaring cause of death as work related. Several countries reported making psychological support available for health workers, such as counseling or trauma support, to maintain well-being and morale. Frontline staff and their families were especially vulnerable and were targeted for psychological interventions. Moreover, some countries launched social media campaigns that encourage people to show their pride, admiration and gratitude for healthcare workers to promote solidarity.

Medical products and technologies

High-quality prevention, diagnosis and management of COVID-19 require the ongoing development, production and sustained distribution of mass quantities of medical products and technologies. However, overreliance on a few countries for production, competition among countries and supply chain disruptions have caused global supply shortages. Some countries reviewed had national or regional stockpiles of PPE, including masks, gloves, face shields and gowns, which were used as a buffer while awaiting imported supplies or scale up of domestic production. Singapore, for example, drew from experience responding to SARS and preserved a national stockpile of medical products for up to 6 months 30 . To replenish stockpiles in Japan, medical product manufacturers were urged to boost production output, resulting in the tripling of production volume as factories operated 24 h a day 31 .

Governments also worked beyond the typical health sectors and developed guidelines and specifications for non-health sectors to supplement the existing medical product manufacturing lines. In India, automotive manufacturers were repurposed to produce low-cost ventilators and PPE 32 . Beyond industry, communities in some countries mobilized to bolster medical product supplies. Several countries had also relied on purchasing consortia, like the UN COVID-19 Supply Chain System and Africa Medical Supplies Platform, donations from development partners or grants and loans from other countries and international financial entities (that is, The World Bank and Asian Development Bank) to secure medical supplies 33 , 34 , 35 , 36 , 37 . Vaccine procurement is also an essential part of the medical supply chain, and countries have either made advance-purchase agreements or participated in the COVAX facility to ensure prompt access to the vaccine for their populations, although concerns remain about equitable access to vaccines in short supply.

In response to increased demand driven by widespread community transmission, countries enacted laws to prevent hoarding and exploitative pricing, as well as policies prohibiting export of medical supplies, while relaxing import licensing requirements and tariffs 38 . Within health facilities, measures including rational-use guidelines, per WHO recommendations, and postponement of nonemergency medical procedures helped stretch existing medical inventories 39 . Although supply chains began to stabilize during 2020, many points of care globally faced uncertain stocks and reports of counterfeit medical essentials highlighting the need for secure supply pipelines. Platforms that assist in monitoring logistics networks are integral in ensuring a steady and rapid flow of medical products and technologies, promoting transparency and ensuring better management of supply chains.

Public health functions

Public health interventions embedded within communities, such as testing, contact tracing, quarantine or self-isolation, and surveillance are crucial functions to break chains of transmission 40 . However, in many health systems, public health and health service delivery systems are siloed: their coordination is limited or ineffective, and they have separate referral processes and reporting systems, all of which serve to undermine health systems resilience 41 . Testing and contact tracing are a case in point that clearly illustrates why public health and health systems must act together in a coordinated manner.

Diagnostic tests to identify whether a person is, or has been, infected are foundational to infectious disease responses to pinpoint locations of spread, and provide care and treatment if it exists. Testing strategies are broadly classified as passive or proactive. Many of the countries reviewed relied on passive testing strategies, where symptomatic individuals self-present to a healthcare facility for testing after meeting certain criteria. However, some countries adopted proactive testing strategies characterized by programs tailored to the unique needs of specific populations as an important tool toward breaking chains of transmission and offering a clearer epidemiological picture 42 , 43 . Additionally, many countries rapidly decentralized testing capacity by strengthening or developing new laboratory networks.

Proactive testing must be accompanied by comprehensive contact tracing in partnership with communities. Contact tracing is the systematic process of following up with individuals who may have been exposed to COVID-19 44 . It can be characterized as either forward, aiming to find ‘downstream’ individuals who have been in contact with a person with COVID-19, or backwards, aiming to find an ‘upstream’ source of infection 45 . While most countries reviewed conducted forward contact tracing, Japan conducted backwards contact tracing measures aimed at identifying and ‘busting’ clusters by working with individuals to trace 14 d before symptom onset 46 . Contact tracing, particularly backwards tracing, is labor and time intensive and may be stigmatizing if not done with community engagement and consideration of at-risk and vulnerable groups 47 . The majority of countries reviewed introduced digital contact tracing tools. Even when fully operational, they may not be accessible, acceptable or feasible for use among those with limited access to, or concerns in using, adequate technology such as migrants, refugees or those experiencing homelessness, among others 48 .

Once cases and contacts are identified, self-isolation and quarantine measures are crucial to prevent onwards transmission and identify emergent cases. All countries reported on quarantine and isolation protocols. While necessary to outbreak management, unless done in coordination with communities, quarantine measures can have negative impacts on mental health and well-being, become a source of stigma and be deployed at the significant cost of human rights 49 . Some countries have implemented policies to provide social and economic assistance to those who must self-isolate or quarantine. Social supports range from services that ensure food and necessities during quarantine to dedicated quarantine or isolation facilities (for example, converted hotels, public facilities or purpose-built quarantine hospitals). Such self-isolation supports are recognized as integral to mitigating transmission, particularly among younger people and those working in high-exposure occupations, living in overcrowded housing or without a home 50 . However, to avoid negative unintended consequences, such facilities must be operationalized with a human rights focus 51 .

These efforts are enhanced by surveillance, including testing in areas or settings with outbreaks, to rapidly limit community circulation 52 . Given the high transmissibility of severe acute respiratory syndrome coronavirus 2, surveillance needs to be geographically comprehensive to provide accurate depictions of disease burden and epidemiology to prevent and mitigate community transmission 53 , 54 , 55 . As recommended by WHO guidelines, nearly all countries have adapted existing surveillance system infrastructure to collect information on COVID-19 cases 55 . However, surveillance based on case reporting may underestimate the epidemiological characteristics of COVID-19, given that stigma or other barriers may limit healthcare seeking, particularly in vulnerable populations 56 , 57 . Therefore, New Zealand, Sweden and the United States have additionally deployed syndromic surveillance, which monitors cases that meet the clinical definition of COVID-19 without confirmation by testing. By implementing active surveillance approaches, countries have expanded surveillance coverage from healthcare settings into communities, such as through primary care, thereby strengthening epidemiological surveillance among vulnerable populations.

Timely sharing of case-based data between public health and healthcare sectors is key to early detection of outbreaks, identification of changes in epidemiological trends and planning of health services 58 . This was facilitated by the use of innovative digital technology. For example, the China CDC launched a web-based infectious disease reporting system that allows real-time reporting of confirmed and suspected COVID-19 cases by healthcare providers 59 , 60 . Similar real-time surveillance and information systems are also used in Fiji, India, Japan and Vietnam.

Assessing health systems resilience is vital in helping policymakers plan for sustainable recovery and strengthen systems to better prepare and respond to current and future crises. Using an adapted and improved resilience framework, our review highlights many parallels in the measures implemented by countries in response to COVID-19. The similarities across countries with divergent health outcomes makes clear that there is no one silver bullet toward a resilient health system. Nevertheless, there are a number of characteristics of well-performing countries across the resilience determinants that stand out. These are summarized as four elements of resilience that are featured in highly effective country responses. These elements draw on the concept that resilient health systems are systems that: (1) activate comprehensive responses, which are responses that consider and address health and well-being as intertwined with social and economic considerations; (2) adapt capacity within and beyond the health system to meet the needs of communities; (3) preserve functions and resources within and beyond the health system to maintain pandemic-related and non-related routine and acute care; and (4) reduce vulnerability to catastrophic losses in communities, both in terms of health and well-being, as well as individual or household finances; all while continually learning, monitoring and adjusting in light of emerging evidence or the evolving epidemiological situation (Fig. 3 ).

The framework presented expands upon and applies the determinants of health systems resilience framework to identify four resilience elements characteristic of highly effective country responses to COVID-19.

High-performing countries

High-performing countries activated comprehensive responses across the determinants’ domains, including through whole-of-government approaches and the creation of multi-ministry task forces, to ensure adequate translation of evidence into policy and practices that preserve health system capacity, while protecting public health and livelihoods. Specific measures taken include training health workers, bolstering public health functions (including offering designated isolation facilities, either for all or for those unable to safely self-isolate at home) and preparing for new technologies and medicines through purchase agreements, while also engaging communities through routine communications on the epidemiological situation and emergent policies.

These countries also learned from emerging evidence and adapted the capacity of their health system in response to the evolving epidemiological situation. This was achieved by increasing capacity in hospitals, through construction of makeshift hospitals or repurposing of existing health facilities or civic spaces. The health workforce in high-performing countries was expanded through reallocation and recruitment and supported through financial and social supports.

These countries took action to preserve health system functions and resources through purchasing consortia and rational-use guidelines to maximize available material resources such as PPE, as well as investing in domestic research, development and production of medical supplies, test kits and vaccines. Additionally, these countries protected health and well-being more broadly by ensuring health system functioning for non-COVID-19-related health services. High-performing countries supported primary care and CHWs to conduct COVID-19 screening, assessment and/or referral, while providing ongoing routine and acute care in communities.

High-performing countries also sought to reduce vulnerability across the resilience determinants by providing financial relief and social supports to complement proactive and robust testing and contact tracing in partnership with communities to ensure public health measures and safety net supports reached all groups.

Building resilient health systems

While some countries have demonstrated elements of resilience, as we highlight above, progress is limited in developing resilient health systems overall. Our review highlights six areas requiring urgent action to build resilient health systems globally.

First, COVID-19 responses provide a clear illustration of the importance of governance supported by scientific evidence and leadership willing to learn and adjust course for successful health systems that protect health and well-being. Enhancing resilience to future disease outbreaks requires longer-term work to create high-quality healthcare systems and build community trust. Our review emphasizes that governments are well advised to address COVID-19, and any future disease outbreak, through a whole-of-government approach that incorporates all sectors, engages relevant actors across all levels, including community and local authorities, and is based on strong and clear coordination that extends beyond early-stage emergency management 61 . Crucial to health systems resilience is that governance must consider the intersections of gender, racialization and human rights, and their impact on health and well-being before, during and after crises 62 , 63 , 64 . Urging governments to adopt such an approach, which COVID-19 has made clear is essential, is not a new proposal. Yet, our review highlights a lack of uniform appreciation or adoption of such an approach by countries.

Second, health systems need appropriate financing, not only to prepare for new pandemics, but also to ensure that at all times, all people have access to the health services they need, when and where they need them, without financial hardship, regardless of ability to pay 65 . This is the foundation of UHC. While many countries have provided subsidized COVID-19 testing and treatment, more must be done to ensure people are not pushed into poverty due to out-of-pocket spending on health. Investing in UHC not only protects people from health threats but also mitigates the social and economic burdens that have characterized COVID-19. Countries will have to revisit the thresholds of health expenditure that they are willing to invest to build resilient health systems, promote population health and protect communities against financial risk.

Third, while country capacities varied, the pandemic has demonstrated a need to invest in improving both the quantity and quality of health workers to better prepare for and respond to future pandemics. Our review highlights that resilient health systems are those that not only invest in pandemic-related planning and training of health workers, but also ensure their physical, mental and economic protection in the workplace and beyond. Emphasis should also be placed on community mobilization where adequately trained and supported CHWs are equipped to play substantial roles in outbreak response and community engagement, much as they have played a crucial role in tuberculosis and HIV/AIDS response efforts globally for decades 66 .

Fourth, in terms of access to medicines and products, the pandemic has made visible, yet again, the clearly identified and thoroughly debated challenges to global supply chains for medicines and products. These challenges range from limited manufacturing capacities to financing to equity in access. The early experience of COVAX, with some high-income countries bypassing the initiative, has demonstrated the glaring limitations in the current system.

Fifth, health service delivery, including non-COVID-19-related health services, has been directly threatened, and often compromised, at all levels by the demands of the pandemic, even in traditionally high-performing health systems. Our review emphasizes that bolstering system capacity requires strong and well-funded primary care, with a skilled and protected workforce, to ensure that high-quality care is delivered in communities, with strengthened linkages to public health systems. Similarly, the long-term care sector, and care for older adults, must be prioritized and better integrated into health service delivery and public health functions. This must be underpinned by a renewed commitment to UHC to ensure high-quality care for all.

Finally, public health functions, such as testing and contact tracing, that are delivered in coordination with the health service system, are cornerstones for successful COVID-19 responses. These approaches often depend on innovative digital technologies, which bear their own challenges, including the potential to exacerbate inequalities and be the vehicle for human rights violations 67 , 68 , 69 , 70 . As such, future investments in these technologies requires a more holistic approach—one that engages communities, particularly the most vulnerable—that takes into account the potential risks and considers how health systems can minimize harms from their use 71 .

Importantly, our analysis of country responses points toward foundational debates on how we understand and think about resilient health systems. Health system resilience as a concept must expand beyond technical and biomedical knowledge and actions, to engage with the broader social, economic and political factors in society. Such comprehensive understanding of resilience requires a systems approach and should be guided by equity concerns, which include concerns for gender, human rights and racialization in health and healthcare 12 , 72 . Further, resilience cannot be achieved solely through unidirectional and top-down approaches by governments and other entities. Resilience requires community engagement as much as regulations and hospital capacity. Community engagement and its interlinkage with community resilience is fundamental to managing not only health threats but also other threats, such as climate and environmental change 73 . Importantly, health systems resilience requires countries worldwide to be open to exchange of knowledge and expertise from regions such as Asia and Africa, which have effectively mobilized CHWs and communities to extend the reach, capacity and quality of their health systems.

Our findings and recommendations are not new, and there have been prior incremental moves to expand what constitutes, influences and governs health and healthcare. COVID-19 demands dynamic systemic transformation. The pandemic has fundamentally challenged health systems and the communities they serve globally. The effect of a major shock represented by the pandemic is to manifest the points where the system is weakest, and to demonstrate the interdependencies of a range of health, social and economic structures. While the evidence of system failures has come at a huge cost in human and monetary terms, it has also pointed to what needs to change. With over 3 million global deaths and pervasive social and economic costs, the pandemic must serve as a call for transformation and investment toward resilience and people centeredness, beginning with health systems. COVID-19 provides a renewed prospect for solidarity, both within and between countries. It also serves as a reminder that health is more than healthcare and that a whole-of-government approach to health and well-being is needed to create healthy populations able to collectively prevent and respond to crises, leaving no one behind.

World Health Organization. WHO Coronavirus Disease (COVID-19) Dashboard. https://covid19.who.int (2021).

Glover, R. E. et al. A framework for identifying and mitigating the equity harms of COVID-19 policy interventions. J. Clin. Epidemiol. 128 , 35–48 (2020).

Article   Google Scholar  

Baker, M. G., Wilson, N. & Blakely, T. Elimination could be the optimal response strategy for COVID-19 and other emerging pandemic diseases. BMJ 371 , m4907 (2020).

Etienne, C. F. et al. COVID-19: transformative actions for more equitable, resilient, sustainable societies and health systems in the Americas. BMJ Glob. Health 5 , e003509 (2020).

El Bcheraoui, C., Weishaar, H., Pozo-Martin, F. & Hanefeld, J. Assessing COVID-19 through the lens of health systems’ preparedness: time for a change. Global Health 16 , 112 (2020).

Kruk, M. E., Myers, M., Varpilah, S. T. & Dahn, B. T. What is a resilient health system? Lessons from Ebola. Lancet 385 , 1910–1912 (2015).

United Nations System Chief Executives Board for Coordination (CEB). United Nations plan of action on disaster risk reduction for resilience . https://www.preventionweb.net/files/49076_unplanofaction.pdf (2016).

Nuzzo, B. et al. What makes health systems resilient against infectious disease outbreaks and natural hazards? Results from a scoping review. BMC Public Health 19 , 1310 (2019).

Haldane, V., Ong, S. E., Chuah, F. L. & Legido-Quigley, H. Health systems resilience: meaningful construct or catchphrase? Lancet 389 , 1513 (2017).

Legido-Quigley, H. & Asgari, N. Resilient and people-centred health systems: progress, challenges and future directions in Asia (World Health Organization, 2018).

Legido-Quigley, H. et al. Are high-performing health systems resilient against the COVID-19 epidemic? Lancet 395 , 848–850 (2020).

Article   CAS   Google Scholar  

Haldane, V. & Morgan, G. T. From resilient to transilient health systems: the deep transformation of health systems in response to the COVID-19 pandemic. Health Policy Plan. https://doi.org/10.1093/heapol/czaa169 (2020).

World Health Organization. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies (2010).

Barker, K. M. et al. Community engagement for health system resilience: evidence from Liberia’s Ebola epidemic. Health Policy Plan. 35 , 416–423 (2020).

Shadmi, E. et al. Health equity and COVID-19: global perspectives. Int. J. Equity Health 19 , 1–16 (2020).

Monaghesh, E. & Hajizadeh, A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health 20 , 1193 (2020).

Gilmore, B. et al. Community engagement for COVID-19 prevention and control: a rapid evidence synthesis. BMJ Glob. Health 5 , e003188 (2020).

Bonell, C. et al. Harnessing behavioural science in public health campaigns to maintain ‘social distancing’ in response to the COVID-19 pandemic: key principles. J. Epidemiol. Community Health 74 , 617–619 (2020).

PubMed   PubMed Central   Google Scholar  

Ballard, M. et al. Prioritising the role of community health workers in the COVID-19 response. BMJ Glob. Health 5 , e002550 (2020).

Nigeria Centre for Disease Control. NCDC and UNICEF launch Chatbot to combat COVID-19 misinformation in Nigeria. https://ncdc.gov.ng/news/272/ncdc-and-unicef-launch-chatbot-to-combat-covid-19-misinformation-in-nigeria (2020).

Luo, H., Liu, J., Li, C., Chen, K. & Zhang, M. Ultra-rapid delivery of specialty field hospitals to combat COVID-19: lessons learned from the Leishenshan Hospital project in Wuhan. Autom. Constr. 119 , 103345 (2020).

Her, M. Repurposing and reshaping of hospitals during the COVID-19 outbreak in South Korea. One Health 10 , 100137 (2020).

World Health Organization. Coronavirus disease (COVID-19) technical guidance: patient management. http://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/patient-management (2020).

Ministry of Health New Zealand. COVID-19: advice for all health professionals. https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-information-health-professionals/covid-19-advice-all-health-professionals (2020).

Haldane, V. et al. National primary care responses to COVID-19: a rapid review of the literature. BMJ Open 10 , e041622 (2020).

World Health Organization Western Pacific. COVID-19: vulnerable and high risk groups. http://www.who.int/westernpacific/emergencies/covid-19/information/high-risk-groups (2020).

McMichael, T. M. et al. Epidemiology of COVID-19 in a long-term care facility in King County, Washington. N. Engl. J. Med. 382 , 2005–2011 (2020).

Bandyopadhyay, S. et al. Infection and mortality of healthcare workers worldwide from COVID-19: a systematic review. BMJ Glob. Health 5 , e003097(2020).

World Health Organization. Health workforce policy and management in the context of the COVID-19 pandemic response (2020).

Chua, A. Q. et al. Health system resilience in managing the COVID-19 pandemic: lessons from Singapore. BMJ Glob. Health 5 , e003317 (2020).

Ministry of Economy, T. and I. Current status of production and supply of face masks, antiseptics and toilet paper. https://www.meti.go.jp/english/covid-19/mask.html (2020).

Mukherjee, S. Maruti Suzuki to help produce ventilators, masks and protective equipment to fight against COVID-19 (2020).

World Bank. 100 Countries Get Support in Response to COVID-19 (2020).

World Bank. World Bank group’s operational response to COVID-19 (coronavirus)–projects list (2020).

World Health Organization. COVID-19 supply chain system: requesting and receiving supplies. http://www.who.int/publications/m/item/covid-19-supply-chain-system-requesting-and-receiving-supplies (2020).

ABOUT US. Africa Medical Supplies Platform. https://amsp.africa/about-us/

World Health Organization. UK Gives £1.3 million to fight COVID-19 in Uganda. https://www.afro.who.int/news/uk-gives-ps13-million-fight-covid-19-uganda (2020).

International Trade Center. COVID-19 temporary trade measures. https://www.macmap.org/covid19 (2020).

World Health Organization. Rational use of personal protective equipment for coronavirus disease (COVID-19) and considerations during severe shortages. https://www.who.int/publications/i/item/rational-use-of-personal-protective-equipment-for-coronavirus-disease-(covid-19)-and-considerations-during-severe-shortages (2020).

Koo, D., Felix, K., Dankwa-Mullan, I., Miller, T. & Waalen, J. A call for action on primary care and public health integration. Am. J. Public Health 102 , S307–S309 (2012).

Nishtar, S. The mixed health systems syndrome. Bull. World Health Organ. 88 , 74–75 (2010).

Veillard, J., Campbell, J., Mohpal, A. & Evans, T. Testing, testing, testing: an essential strategy for public health, vaccine deployment and economic reactivation during COVID-19. https://blogs.worldbank.org/latinamerica/testing-testing-testing-essential-strategy-public-health-vaccine-deployment-and/ (World Bank Blogs, 2020).

The World Bank. Population-level, national testing strategies for COVID-19: Latin America & the Caribbean. https://www.worldbank.org/en/region/lac/brief/population-level-national-testing-strategies-for-covid-19-latin-america-and-the-caribbean (2020).

World Health Organization. Contact tracing in the context of COVID-19. https://www.who.int/publications/i/item/contact-tracing-in-the-context-of-covid-19 (2020).

Endo, A. et al. Implication of backward contact tracing in the presence of overdispersed transmission in COVID-19 outbreaks. Wellcome Open Res . 5 , 239 (2020).

Lewis, D. Why many countries failed at COVID contact-tracing—but some got it right . Nature 588 , 384–387 (2020).

Megnin-Viggars, O., Carter, P., Melendez-Torres, G. J., Weston, D. & Rubin, G. J. Facilitators and barriers to engagement with contact tracing during infectious disease outbreaks: a rapid review of the evidence. PLoS ONE 15 , e0241473 (2020).

Klenk, M. & Duijf, H. Ethics of digital contact tracing and COVID-19: who is (not) free to go? Ethics Inf. Technol. https://doi.org/10.1007/s10676-020-09544-0 (2020).

Brooks, S. K. et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 395 , 912–920 (2020).

Cevik, M., Baral, S., Crozier, A. & Cassell, J. Support for self-isolation is critical in COVID-19 response. BMJ 372 , 224 (2021).

Social Science in Humanitarian Action. Key considerations: quarantine in the context of COVID-19. https://opendocs.ids.ac.uk/opendocs/bitstream/handle/20.500.12413/15133/SSHAP%20COVID-19%20Key%20Considerations%20Quarantine.pdf?sequence=24&isAllowed=y (2020).

Pung, R. et al. Investigation of three clusters of COVID-19 in Singapore: implications for surveillance and response measures. Lancet 395 , 1039–1046 (2020).

Hao, X. et al. Reconstruction of the full transmission dynamics of COVID-19 in Wuhan. Nature 584 , 420–424 (2020).

Hu, B., Guo, H., Zhou, P. & Shi, Z.-L. Characteristics of SARS-CoV-2 and COVID-19. Nat. Rev. Microbiol . 19 , 141–154 (2021).

World Health Organization. Public health surveillance for COVID-19: interim guidance (2020).

Chiolero, A., Santschi, V. & Paccaud, F. Public health surveillance with electronic medical records: at risk of surveillance bias and overdiagnosis. Eur. J. Public Health 23 , 350–351 (2013).

Alwan, N. A. Surveillance is underestimating the burden of the COVID-19 pandemic. Lancet 396 , e24 (2020).

Jajosky, R. A. & Groseclose, S. L. Evaluation of reporting timeliness of public health surveillance systems for infectious diseases. BMC Public Health 4 , 1–9 (2004).

Khan, M. S., Wu, S., Wang, X. & Coker, R. Optimising routine surveillance systems for informing tuberculosis control policies in China. Health Policy Plan. 32 , i12–i14 (2017).

China CDC. The launch of infectious disease reporting system for COVID-19 (2020).

WHO regional office for Europe. Strengthening the health system response to COVID-19: recommendations for the WHO European region (2020).

Davies, S. E. & Bennett, B. A gendered human rights analysis of Ebola and Zika: locating gender in global health emergencies; a gendered human rights analysis of Ebola and Zika: locating gender in global health emergencies. Int. Aff. 92 , 1041–1060 (2016).

Harman, S. Ebola, gender and conspicuously invisible women in global health governance. Third World Q 37 , 524–541 (2016).

Wenham, C., Smith, J. & Morgan, R., Gender and COVID-19 Working Group. COVID-19: the gendered impacts of the outbreak. Lancet 395 , 846–848 (2020).

World Health Organization. Universal health coverage (UHC). https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc) (2019).

Bhutta, Z. A., Lassi, Z., Pariyo, G. & Huicho, L. Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: a systematic review, country case studies, and recommendations for integration into national health systems. https://www.who.int/workforcealliance/knowledge/publications/alliance/Global_CHW_web.pdf (2010).

Keshet, Y. Fear of panoptic surveillance: using digital technology to control the COVID-19 epidemic. Isr. J. Health Policy Res. 9 , 67 (2020).

Enter the cyborgs: health and human rights in the digital age. Health Hum. Rights https://www.hhrjournal.org/2020/12/editorial-enter-the-cyborgs-health-and-human-rights-in-the-digital-age/ (2020).

Technology, health, and human rights: a cautionary tale for the post-pandemic world. Health Hum. Rights https://www.hhrjournal.org/2020/12/viewpoint-technology-health-and-human-rights-a-cautionary-tale-for-the-post-pandemic-world/ (2020).

Analyzing the human rights impact of increased digital public health surveillance during the COVID-19 crisis. Health Hum. Rights https://www.hhrjournal.org/2020/12/analyzing-the-human-rights-impact-of-increased-digital-public-health-surveillance-during-the-covid-19-crisis/ (2020).

Lal, A., Erondu, N. A., Heymann, D. L., Gitahi, G. & Yates, R. Fragmented health systems in COVID-19: rectifying the misalignment between global health security and universal health coverage. Lancet 397 , 61–67 (2021).

Baum, F. et al. Explaining COVID-19 performance: what factors might predict national responses? BMJ 372 , n91 (2021).

Ebi, K. L. & Semenza, J. C. Community-based adaptation to the health impacts of climate change. Am. J. Prev. Med. 35 , 501–507 (2008).

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Acknowledgements

Data for this review were collected under the auspices of the Independent Panel for Pandemic Preparedness and Response. The analysis of this paper is separate from the Independent Panel’s Final Report and has been facilitated by the Independent Panel Secretariat. The Secretariat of the Independent Panel for Pandemic Preparedness and Response is independent and impartial. The views expressed in this work are solely that of the authors and do not represent the views of the Independent Panel for Pandemic Preparedness and Response.

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These authors contributed equally: Victoria Haldane, Chuan De Foo, Salma M. Abdalla, Anne-Sophie Jung.

Authors and Affiliations

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

Victoria Haldane

Saw Swee Hock School of Public Health, Singapore, Singapore

Chuan De Foo, Melisa Tan, Shishi Wu, Alvin Chua, Monica Verma, Pami Shrestha, See Mieng Tan & Helena Legido-Quigley

School of Public Health, Boston University, Boston, MA, USA

Salma M. Abdalla

The Independent Panel for Pandemic Preparedness and Response Secretariat, Geneva, Switzerland

Salma M. Abdalla, Sudhvir Singh, Michael Bartos, Shunsuke Mabuchi, Mathias Bonk, Christine McNab, George K. Werner, Raj Panjabi, Anders Nordström & Helena Legido-Quigley

London School of Hygiene and Tropical Medicine, London, UK

Anne-Sophie Jung, Tristana Perez & Helena Legido-Quigley

Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand

Sudhvir Singh

School of Sociology, Australian National University, Canberra, New South Wales, Australia

Michael Bartos

Berlin Institute of Global Health, Berlin, Germany

Mathias Bonk

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Contributions

V.H., C.D.F., S.A., A.-S.J. and H.L.-Q. conceived and designed this Review. V.H., C.D.F., S.A., A.-S.J., M.M.J.T., S.W., A.C., M.V., P.S., S.M.T. and H.L.-Q. collected the data. V.H., C.D.F., S.A., A.-S.J., M.M.J.T., S.W., S.S. and H.L.-Q. analyzed the data and drafted the manuscript with input from all authors. All authors contributed to revision of the manuscript.

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Correspondence to Helena Legido-Quigley .

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Haldane, V., De Foo, C., Abdalla, S.M. et al. Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries. Nat Med 27 , 964–980 (2021). https://doi.org/10.1038/s41591-021-01381-y

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DOI : https://doi.org/10.1038/s41591-021-01381-y

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A Review of Coronavirus Disease-2019 (COVID-19)

Tanu singhal.

Department of Pediatrics and Infectious Disease, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India

There is a new public health crises threatening the world with the emergence and spread of 2019 novel coronavirus (2019-nCoV) or the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The virus originated in bats and was transmitted to humans through yet unknown intermediary animals in Wuhan, Hubei province, China in December 2019. There have been around 96,000 reported cases of coronavirus disease 2019 (COVID-2019) and 3300 reported deaths to date (05/03/2020). The disease is transmitted by inhalation or contact with infected droplets and the incubation period ranges from 2 to 14 d. The symptoms are usually fever, cough, sore throat, breathlessness, fatigue, malaise among others. The disease is mild in most people; in some (usually the elderly and those with comorbidities), it may progress to pneumonia, acute respiratory distress syndrome (ARDS) and multi organ dysfunction. Many people are asymptomatic. The case fatality rate is estimated to range from 2 to 3%. Diagnosis is by demonstration of the virus in respiratory secretions by special molecular tests. Common laboratory findings include normal/ low white cell counts with elevated C-reactive protein (CRP). The computerized tomographic chest scan is usually abnormal even in those with no symptoms or mild disease. Treatment is essentially supportive; role of antiviral agents is yet to be established. Prevention entails home isolation of suspected cases and those with mild illnesses and strict infection control measures at hospitals that include contact and droplet precautions. The virus spreads faster than its two ancestors the SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV), but has lower fatality. The global impact of this new epidemic is yet uncertain.

Introduction

The 2019 novel coronavirus (2019-nCoV) or the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) as it is now called, is rapidly spreading from its origin in Wuhan City of Hubei Province of China to the rest of the world [ 1 ]. Till 05/03/2020 around 96,000 cases of coronavirus disease 2019 (COVID-19) and 3300 deaths have been reported [ 2 ]. India has reported 29 cases till date. Fortunately so far, children have been infrequently affected with no deaths. But the future course of this virus is unknown. This article gives a bird’s eye view about this new virus. Since knowledge about this virus is rapidly evolving, readers are urged to update themselves regularly.

Coronaviruses are enveloped positive sense RNA viruses ranging from 60 nm to 140 nm in diameter with spike like projections on its surface giving it a crown like appearance under the electron microscope; hence the name coronavirus [ 3 ]. Four corona viruses namely HKU1, NL63, 229E and OC43 have been in circulation in humans, and generally cause mild respiratory disease.

There have been two events in the past two decades wherein crossover of animal betacorona viruses to humans has resulted in severe disease. The first such instance was in 2002–2003 when a new coronavirus of the β genera and with origin in bats crossed over to humans via the intermediary host of palm civet cats in the Guangdong province of China. This virus, designated as severe acute respiratory syndrome coronavirus affected 8422 people mostly in China and Hong Kong and caused 916 deaths (mortality rate 11%) before being contained [ 4 ]. Almost a decade later in 2012, the Middle East respiratory syndrome coronavirus (MERS-CoV), also of bat origin, emerged in Saudi Arabia with dromedary camels as the intermediate host and affected 2494 people and caused 858 deaths (fatality rate 34%) [ 5 ].

Origin and Spread of COVID-19 [ 1 , 2 , 6 ]

In December 2019, adults in Wuhan, capital city of Hubei province and a major transportation hub of China started presenting to local hospitals with severe pneumonia of unknown cause. Many of the initial cases had a common exposure to the Huanan wholesale seafood market that also traded live animals. The surveillance system (put into place after the SARS outbreak) was activated and respiratory samples of patients were sent to reference labs for etiologic investigations. On December 31st 2019, China notified the outbreak to the World Health Organization and on 1st January the Huanan sea food market was closed. On 7th January the virus was identified as a coronavirus that had >95% homology with the bat coronavirus and > 70% similarity with the SARS- CoV. Environmental samples from the Huanan sea food market also tested positive, signifying that the virus originated from there [ 7 ]. The number of cases started increasing exponentially, some of which did not have exposure to the live animal market, suggestive of the fact that human-to-human transmission was occurring [ 8 ]. The first fatal case was reported on 11th Jan 2020. The massive migration of Chinese during the Chinese New Year fuelled the epidemic. Cases in other provinces of China, other countries (Thailand, Japan and South Korea in quick succession) were reported in people who were returning from Wuhan. Transmission to healthcare workers caring for patients was described on 20th Jan, 2020. By 23rd January, the 11 million population of Wuhan was placed under lock down with restrictions of entry and exit from the region. Soon this lock down was extended to other cities of Hubei province. Cases of COVID-19 in countries outside China were reported in those with no history of travel to China suggesting that local human-to-human transmission was occurring in these countries [ 9 ]. Airports in different countries including India put in screening mechanisms to detect symptomatic people returning from China and placed them in isolation and testing them for COVID-19. Soon it was apparent that the infection could be transmitted from asymptomatic people and also before onset of symptoms. Therefore, countries including India who evacuated their citizens from Wuhan through special flights or had travellers returning from China, placed all people symptomatic or otherwise in isolation for 14 d and tested them for the virus.

Cases continued to increase exponentially and modelling studies reported an epidemic doubling time of 1.8 d [ 10 ]. In fact on the 12th of February, China changed its definition of confirmed cases to include patients with negative/ pending molecular tests but with clinical, radiologic and epidemiologic features of COVID-19 leading to an increase in cases by 15,000 in a single day [ 6 ]. As of 05/03/2020 96,000 cases worldwide (80,000 in China) and 87 other countries and 1 international conveyance (696, in the cruise ship Diamond Princess parked off the coast of Japan) have been reported [ 2 ]. It is important to note that while the number of new cases has reduced in China lately, they have increased exponentially in other countries including South Korea, Italy and Iran. Of those infected, 20% are in critical condition, 25% have recovered, and 3310 (3013 in China and 297 in other countries) have died [ 2 ]. India, which had reported only 3 cases till 2/3/2020, has also seen a sudden spurt in cases. By 5/3/2020, 29 cases had been reported; mostly in Delhi, Jaipur and Agra in Italian tourists and their contacts. One case was reported in an Indian who traveled back from Vienna and exposed a large number of school children in a birthday party at a city hotel. Many of the contacts of these cases have been quarantined.

These numbers are possibly an underestimate of the infected and dead due to limitations of surveillance and testing. Though the SARS-CoV-2 originated from bats, the intermediary animal through which it crossed over to humans is uncertain. Pangolins and snakes are the current suspects.

Epidemiology and Pathogenesis [ 10 , 11 ]

All ages are susceptible. Infection is transmitted through large droplets generated during coughing and sneezing by symptomatic patients but can also occur from asymptomatic people and before onset of symptoms [ 9 ]. Studies have shown higher viral loads in the nasal cavity as compared to the throat with no difference in viral burden between symptomatic and asymptomatic people [ 12 ]. Patients can be infectious for as long as the symptoms last and even on clinical recovery. Some people may act as super spreaders; a UK citizen who attended a conference in Singapore infected 11 other people while staying in a resort in the French Alps and upon return to the UK [ 6 ]. These infected droplets can spread 1–2 m and deposit on surfaces. The virus can remain viable on surfaces for days in favourable atmospheric conditions but are destroyed in less than a minute by common disinfectants like sodium hypochlorite, hydrogen peroxide etc. [ 13 ]. Infection is acquired either by inhalation of these droplets or touching surfaces contaminated by them and then touching the nose, mouth and eyes. The virus is also present in the stool and contamination of the water supply and subsequent transmission via aerosolization/feco oral route is also hypothesized [ 6 ]. As per current information, transplacental transmission from pregnant women to their fetus has not been described [ 14 ]. However, neonatal disease due to post natal transmission is described [ 14 ]. The incubation period varies from 2 to 14 d [median 5 d]. Studies have identified angiotensin receptor 2 (ACE 2 ) as the receptor through which the virus enters the respiratory mucosa [ 11 ].

The basic case reproduction rate (BCR) is estimated to range from 2 to 6.47 in various modelling studies [ 11 ]. In comparison, the BCR of SARS was 2 and 1.3 for pandemic flu H1N1 2009 [ 2 ].

Clinical Features [ 8 , 15 – 18 ]

The clinical features of COVID-19 are varied, ranging from asymptomatic state to acute respiratory distress syndrome and multi organ dysfunction. The common clinical features include fever (not in all), cough, sore throat, headache, fatigue, headache, myalgia and breathlessness. Conjunctivitis has also been described. Thus, they are indistinguishable from other respiratory infections. In a subset of patients, by the end of the first week the disease can progress to pneumonia, respiratory failure and death. This progression is associated with extreme rise in inflammatory cytokines including IL2, IL7, IL10, GCSF, IP10, MCP1, MIP1A, and TNFα [ 15 ]. The median time from onset of symptoms to dyspnea was 5 d, hospitalization 7 d and acute respiratory distress syndrome (ARDS) 8 d. The need for intensive care admission was in 25–30% of affected patients in published series. Complications witnessed included acute lung injury, ARDS, shock and acute kidney injury. Recovery started in the 2nd or 3rd wk. The median duration of hospital stay in those who recovered was 10 d. Adverse outcomes and death are more common in the elderly and those with underlying co-morbidities (50–75% of fatal cases). Fatality rate in hospitalized adult patients ranged from 4 to 11%. The overall case fatality rate is estimated to range between 2 and 3% [ 2 ].

Interestingly, disease in patients outside Hubei province has been reported to be milder than those from Wuhan [ 17 ]. Similarly, the severity and case fatality rate in patients outside China has been reported to be milder [ 6 ]. This may either be due to selection bias wherein the cases reporting from Wuhan included only the severe cases or due to predisposition of the Asian population to the virus due to higher expression of ACE 2 receptors on the respiratory mucosa [ 11 ].

Disease in neonates, infants and children has been also reported to be significantly milder than their adult counterparts. In a series of 34 children admitted to a hospital in Shenzhen, China between January 19th and February 7th, there were 14 males and 20 females. The median age was 8 y 11 mo and in 28 children the infection was linked to a family member and 26 children had history of travel/residence to Hubei province in China. All the patients were either asymptomatic (9%) or had mild disease. No severe or critical cases were seen. The most common symptoms were fever (50%) and cough (38%). All patients recovered with symptomatic therapy and there were no deaths. One case of severe pneumonia and multiorgan dysfunction in a child has also been reported [ 19 ]. Similarly the neonatal cases that have been reported have been mild [ 20 ].

Diagnosis [ 21 ]

A suspect case is defined as one with fever, sore throat and cough who has history of travel to China or other areas of persistent local transmission or contact with patients with similar travel history or those with confirmed COVID-19 infection. However cases may be asymptomatic or even without fever. A confirmed case is a suspect case with a positive molecular test.

Specific diagnosis is by specific molecular tests on respiratory samples (throat swab/ nasopharyngeal swab/ sputum/ endotracheal aspirates and bronchoalveolar lavage). Virus may also be detected in the stool and in severe cases, the blood. It must be remembered that the multiplex PCR panels currently available do not include the COVID-19. Commercial tests are also not available at present. In a suspect case in India, the appropriate sample has to be sent to designated reference labs in India or the National Institute of Virology in Pune. As the epidemic progresses, commercial tests will become available.

Other laboratory investigations are usually non specific. The white cell count is usually normal or low. There may be lymphopenia; a lymphocyte count <1000 has been associated with severe disease. The platelet count is usually normal or mildly low. The CRP and ESR are generally elevated but procalcitonin levels are usually normal. A high procalcitonin level may indicate a bacterial co-infection. The ALT/AST, prothrombin time, creatinine, D-dimer, CPK and LDH may be elevated and high levels are associated with severe disease.

The chest X-ray (CXR) usually shows bilateral infiltrates but may be normal in early disease. The CT is more sensitive and specific. CT imaging generally shows infiltrates, ground glass opacities and sub segmental consolidation. It is also abnormal in asymptomatic patients/ patients with no clinical evidence of lower respiratory tract involvement. In fact, abnormal CT scans have been used to diagnose COVID-19 in suspect cases with negative molecular diagnosis; many of these patients had positive molecular tests on repeat testing [ 22 ].

Differential Diagnosis [ 21 ]

The differential diagnosis includes all types of respiratory viral infections [influenza, parainfluenza, respiratory syncytial virus (RSV), adenovirus, human metapneumovirus, non COVID-19 coronavirus], atypical organisms (mycoplasma, chlamydia) and bacterial infections. It is not possible to differentiate COVID-19 from these infections clinically or through routine lab tests. Therefore travel history becomes important. However, as the epidemic spreads, the travel history will become irrelevant.

Treatment [ 21 , 23 ]

Treatment is essentially supportive and symptomatic.

The first step is to ensure adequate isolation (discussed later) to prevent transmission to other contacts, patients and healthcare workers. Mild illness should be managed at home with counseling about danger signs. The usual principles are maintaining hydration and nutrition and controlling fever and cough. Routine use of antibiotics and antivirals such as oseltamivir should be avoided in confirmed cases. In hypoxic patients, provision of oxygen through nasal prongs, face mask, high flow nasal cannula (HFNC) or non-invasive ventilation is indicated. Mechanical ventilation and even extra corporeal membrane oxygen support may be needed. Renal replacement therapy may be needed in some. Antibiotics and antifungals are required if co-infections are suspected or proven. The role of corticosteroids is unproven; while current international consensus and WHO advocate against their use, Chinese guidelines do recommend short term therapy with low-to-moderate dose corticosteroids in COVID-19 ARDS [ 24 , 25 ]. Detailed guidelines for critical care management for COVID-19 have been published by the WHO [ 26 ]. There is, as of now, no approved treatment for COVID-19. Antiviral drugs such as ribavirin, lopinavir-ritonavir have been used based on the experience with SARS and MERS. In a historical control study in patients with SARS, patients treated with lopinavir-ritonavir with ribavirin had better outcomes as compared to those given ribavirin alone [ 15 ].

In the case series of 99 hospitalized patients with COVID-19 infection from Wuhan, oxygen was given to 76%, non-invasive ventilation in 13%, mechanical ventilation in 4%, extracorporeal membrane oxygenation (ECMO) in 3%, continuous renal replacement therapy (CRRT) in 9%, antibiotics in 71%, antifungals in 15%, glucocorticoids in 19% and intravenous immunoglobulin therapy in 27% [ 15 ]. Antiviral therapy consisting of oseltamivir, ganciclovir and lopinavir-ritonavir was given to 75% of the patients. The duration of non-invasive ventilation was 4–22 d [median 9 d] and mechanical ventilation for 3–20 d [median 17 d]. In the case series of children discussed earlier, all children recovered with basic treatment and did not need intensive care [ 17 ].

There is anecdotal experience with use of remdeswir, a broad spectrum anti RNA drug developed for Ebola in management of COVID-19 [ 27 ]. More evidence is needed before these drugs are recommended. Other drugs proposed for therapy are arbidol (an antiviral drug available in Russia and China), intravenous immunoglobulin, interferons, chloroquine and plasma of patients recovered from COVID-19 [ 21 , 28 , 29 ]. Additionally, recommendations about using traditional Chinese herbs find place in the Chinese guidelines [ 21 ].

Prevention [ 21 , 30 ]

Since at this time there are no approved treatments for this infection, prevention is crucial. Several properties of this virus make prevention difficult namely, non-specific features of the disease, the infectivity even before onset of symptoms in the incubation period, transmission from asymptomatic people, long incubation period, tropism for mucosal surfaces such as the conjunctiva, prolonged duration of the illness and transmission even after clinical recovery.

Isolation of confirmed or suspected cases with mild illness at home is recommended. The ventilation at home should be good with sunlight to allow for destruction of virus. Patients should be asked to wear a simple surgical mask and practice cough hygiene. Caregivers should be asked to wear a surgical mask when in the same room as patient and use hand hygiene every 15–20 min.

The greatest risk in COVID-19 is transmission to healthcare workers. In the SARS outbreak of 2002, 21% of those affected were healthcare workers [ 31 ]. Till date, almost 1500 healthcare workers in China have been infected with 6 deaths. The doctor who first warned about the virus has died too. It is important to protect healthcare workers to ensure continuity of care and to prevent transmission of infection to other patients. While COVID-19 transmits as a droplet pathogen and is placed in Category B of infectious agents (highly pathogenic H5N1 and SARS), by the China National Health Commission, infection control measures recommended are those for category A agents (cholera, plague). Patients should be placed in separate rooms or cohorted together. Negative pressure rooms are not generally needed. The rooms and surfaces and equipment should undergo regular decontamination preferably with sodium hypochlorite. Healthcare workers should be provided with fit tested N95 respirators and protective suits and goggles. Airborne transmission precautions should be taken during aerosol generating procedures such as intubation, suction and tracheostomies. All contacts including healthcare workers should be monitored for development of symptoms of COVID-19. Patients can be discharged from isolation once they are afebrile for atleast 3 d and have two consecutive negative molecular tests at 1 d sampling interval. This recommendation is different from pandemic flu where patients were asked to resume work/school once afebrile for 24 h or by day 7 of illness. Negative molecular tests were not a prerequisite for discharge.

At the community level, people should be asked to avoid crowded areas and postpone non-essential travel to places with ongoing transmission. They should be asked to practice cough hygiene by coughing in sleeve/ tissue rather than hands and practice hand hygiene frequently every 15–20 min. Patients with respiratory symptoms should be asked to use surgical masks. The use of mask by healthy people in public places has not shown to protect against respiratory viral infections and is currently not recommended by WHO. However, in China, the public has been asked to wear masks in public and especially in crowded places and large scale gatherings are prohibited (entertainment parks etc). China is also considering introducing legislation to prohibit selling and trading of wild animals [ 32 ].

The international response has been dramatic. Initially, there were massive travel restrictions to China and people returning from China/ evacuated from China are being evaluated for clinical symptoms, isolated and tested for COVID-19 for 2 wks even if asymptomatic. However, now with rapid world wide spread of the virus these travel restrictions have extended to other countries. Whether these efforts will lead to slowing of viral spread is not known.

A candidate vaccine is under development.

Practice Points from an Indian Perspective

At the time of writing this article, the risk of coronavirus in India is extremely low. But that may change in the next few weeks. Hence the following is recommended:

• Healthcare providers should take travel history of all patients with respiratory symptoms, and any international travel in the past 2 wks as well as contact with sick people who have travelled internationally.
• They should set up a system of triage of patients with respiratory illness in the outpatient department and give them a simple surgical mask to wear. They should use surgical masks themselves while examining such patients and practice hand hygiene frequently.
• Suspected cases should be referred to government designated centres for isolation and testing (in Mumbai, at this time, it is Kasturba hospital). Commercial kits for testing are not yet available in India.
• Patients admitted with severe pneumonia and acute respiratory distress syndrome should be evaluated for travel history and placed under contact and droplet isolation. Regular decontamination of surfaces should be done. They should be tested for etiology using multiplex PCR panels if logistics permit and if no pathogen is identified, refer the samples for testing for SARS-CoV-2.
• All clinicians should keep themselves updated about recent developments including global spread of the disease.
• Non-essential international travel should be avoided at this time.
• People should stop spreading myths and false information about the disease and try to allay panic and anxiety of the public.

Conclusions

This new virus outbreak has challenged the economic, medical and public health infrastructure of China and to some extent, of other countries especially, its neighbours. Time alone will tell how the virus will impact our lives here in India. More so, future outbreaks of viruses and pathogens of zoonotic origin are likely to continue. Therefore, apart from curbing this outbreak, efforts should be made to devise comprehensive measures to prevent future outbreaks of zoonotic origin.

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