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Impacto de la llegada de la enfermedad por Coronavirus 2019 (COVID-19) a la Amazonía Colombia: una mirada desde la iniciativa One Health y la importancia de la integración entre la salud ambiental, animal y humana
Abstract
Durante el curso de evolución de la Enfermedad por Coronavirus 2019 (COVID-19), causada por el coronavirus del síndrome respiratorio agudo severo tipo 2 (SARS-CoV-2), esta pandemia, declarada así por la Organización Mundial de la Salud (OMS), se ha dado una relativamente rápida expansión del virus y la enfermedad en múltiples territorios (1-3).
Originalmente emergido en Wuhan, China, esta enfermedad se extendió en corto tiempo al resto de ese país, luego a otras naciones de Asia, Europa y Norte América, especialmente Estados Unidos. Pero como era de esperar, llegaría también a otros continentes, como África y América Latina (3-7).
En América Latina, esta pandemia llegó el 25 de febrero de 2020, por Brasil procedente de Italia, como sucedió posteriormente con muchos otros países en la región (8-10). Entre estos países, por supuesto también se encuentra Colombia, que a la fecha (30 de mayo de 2020), cuenta ya más de 26 mil casos, con 853 fallecidos (11, 12). El primer caso llegó a Bogotá, el segundo a Buga, Valle del Cauca (8). Y se empezó a extender rápidamente por todo el territorio nacional, afectando ya a 34 departamentos y distritos.
Lamentablemente, entre los departamentos más afectados, se encuentra Amazonas. A la fecha contando ya con 1.799 casos, lo cual representa 6.74% del total de casos nacional, pero significando una tasa de incidencia de 22.561 casos por millón de habitantes, es decir 2.256,1 casos/100.00 habitantes (2,25 casos por cada 100 habitantes), lo cual lo posiciona como el 1° departamento del país en incidencia (11). Esto significa además, 20,39 veces mayor incidencia en Amazonas que en Bogotá, la capital del país, que tiene una incidencia de 1.106 casos por millón de habitantes (110,6 casos/100.00 habitantes o 0,11 casos por cada 100 habitantes) (Figura 1).
Más allá de ello, el departamento de Amazonas, e incluso Leticia, su capital, tienen un gran vulnerabilidad social, que incluye entre otras cosas, una proporción muy elevada de pobreza multidimensional, en múltiples sectores de la capital departamental, incluso por encima del 50% (Figura 2). Además con una proporción considerable de población a riesgo por edad (sujetos mayores de 60 años de edad) (Figura 3), y un número limitado de centros médicos (Figura 4).
Esta zona es además compleja, por ubicarse en una triple frontera, con Brasil y Perú (Figura 2), con población indígena en los tres territorios, dispersa, más allá de las zonas urbanas, y con gran biodiversidad, incluyendo abundante fauna silvestre. Más aún Amazonas, es uno de los cinco departamentos de Colombia aún huérfanos de Unidades de Cuidado Intensivo (UCI). Los otros son Guainía, Guaviare, y Vichada. En Arauca hay cuatro camas de UCI. Ello representa un problema particular que limita la atención de pacientes críticos, que en COVID-19 pueden llegar a ser de 10 a 30% (13), dependiendo de los factores de riesgo. Así las cosas, si bien, mucho otros departamentos parece que no llegarán a colapsar sus UCI (9), como han mostrado algunos análisis, dada su capacidad de camas, y el número de casos que se han presentado. No es esa la situación en Amazonas y en general en la región Amazónica de Colombia.
Con todo esto, se plantea además que el COVID-19, trágicamente, también está devastando comunidades indígenas frágiles en la región Pan-Amazónica, incluyendo Brasil, Colombia, Perú, y probablemente Venezuela, Ecuador, Bolivia y Paraguay, poniendo en riesgo culturas enteras y grupos de población (14).
Finalmente, en una zona, fuertemente afectada en los últimos años por el cambio climático, la minería ilegal, y la deforestación, entre otros factores que debilitan la salud ambiental de la región (15), y que se asocian con mayor interacción con la fauna silvestre en nichos ecológicos previamente no invadidos por el ser humano, ecotonos o zonas de transición, donde se puede incrementar el riesgo de zoonosis. En tal sentido, el SARS-CoV-2 es en esencia un virus de origen zoonótico, que parte de murciélagos, pero adicionalmente con otros hospedadores intermediarios que pueden estar involucrados, como el pangolín. Además de ello, la evidencia es creciente en indicar el riesgo de transmisión del ser humano infectado hacia diferentes animales, felinos domésticos y salvajes, en cautiverio, así como visones y también perros, entre otros, lo cual en zonas de mayor interacción humano-animal, generan aún más preocupación (2, 16-19).
La llegada del COVID-19 a la Amazonía colombiana está teniendo un gran impacto que demanda gran consciencia en todos los sectores, sanitario y no sanitario, en la investigación y en la sociedad. En ello la mirada desde la iniciativa de One Health o Una Salud, que busca integrar la salud ambiental, animal y humana, es clave, dado que tienen gran relación en esta zoonosis viral (2). El trabajo en equipo multidisciplinario en la prevención y control de esta y otras zoonosis virales, será clave para mitigar el impacto de las mismas (5, 20-22).
This study aimed at revealing the economic and social implications of Covid-19 on the Saudi Community and developing scientific and practical solutions to control and minimize these implications. The study sample consisted of (1238) male and female Saudi citizens and the descriptive analytical method was used to achieve the objectives of the study. The result showed that the economic and social implications of Covid-19 were highly effective (average: 3.56). Social implications came first with an average of (3.78), economic implications came next with an average of (3.35). The study also showed statistically significant differences at the level of significance of (a = 0.05) in all variables (gender, social, status, age, educational level, level of income and the nature of work). Differences are attributed to the economic and social implications of Covid-19. The study the economic and social implications of Covid-19 on the Saudi community.
Coronavirus disease 2019 (COVID-19), has spread over 210 countries and territories beyond China shortly. On February 29, 2020, the World Health Organization (WHO) denoted it in a high-risk category, and on March 11, 2020, this virus was designated pandemic, after its declaration being a Public Health International Emergency on January 30, 2020. World over high efforts are being made to counter and contain this virus. The COVID-19 outbreak once again proves the potential of the animal-human interface to act as the primary source of emerging zoonotic diseases. Even though the circumstantial evidence suggests the possibility of an initial zoonotic emergence, it is too early to confirm the role of intermediate hosts such as snakes, pangolins, turtles, and other wild animals in the origin of SARS-CoV-2, in addition to bats, the natural hosts of multiple coronaviruses such as SARS-CoV and MERS-CoV. The lessons learned from past episodes of MERS-CoV and SARS-CoV are being exploited to retort this virus. Best efforts are being taken up by worldwide nations to implement effective diagnosis, strict vigilance, heightened surveillance, and monitoring, along with adopting appropriate preventive and control strategies. Identifying the possible zoonotic emergence and the exact mechanism responsible for its initial transmission will help us to design and implement appropriate preventive barriers against the further transmission of SARS-CoV-2. This review discusses in brief about the COVID-19/SARS-CoV-2 with a particular focus on the role of animals, the veterinary and associated zoonotic links along with prevention and control strategies based on One-health approaches.
Background:
COVID-19 pandemics is a challenge for public health and infectious diseases clinicians, especially for the therapeutical approach that is not yet adequately defined. Amid this situation, investigational agents are being used, including chloroquine. We report here the clinical features and therapeutic course of the first reported patient with confirmed COVID-19 pneumonia that recovered in Colombia, after the use of chloroquine and clarithromycin.
Case presentation:
A 34-year-old male, returning from Spain, presented with complaints of fever, and cough, and class-II obesity, being hospitalized. The respiratory viruses and bacteria tested by FilmArray® PCR were negative. Two days later, clarithromycin was started because the patient was suspected as community-acquired pneumonia. At the third day, the rRT-PCR confirmed the SARS-CoV-2 infection. A day later, chloroquine was started because of that. His chest computed tomography was performed and showed bilateral multifocal ground-glass opacities with consolidation, which suggested viral pneumonia as a differential diagnosis. Progressively his clinical condition improved and at day 9, patient rRT-PCR for SARS-CoV-2 became negative. The patient was discharged and isolated at home per 14 days.
Conclusions:
Our patient improved significantly. This and other COVID-19 cases are urgently demanding results from clinical trials that support evidence-based therapeutical approaches to this pandemic and the clinical management of patients, especially those at critical care.
Introduction
An epidemic of Coronavirus Disease 2019 (COVID-19) began in December 2019 in China leading to a Public Health Emergency of International Concern (PHEIC). Clinical, laboratory, and imaging features have been partially characterized in some observational studies. No systematic reviews on COVID-19 have been published to date.
Methods
We performed a systematic literature review with meta-analysis, using three databases to assess clinical, laboratory, imaging features, and outcomes of COVID-19 confirmed cases. Observational studies and also case reports, were included, and analyzed separately. We performed a random-effects model meta-analysis to calculate the pooled prevalence and 95% confidence interval (95%CI).
Results
660 articles were retrieved for the time frame (1/1/2020-2/23/2020). After screening, 27 articles were selected for full-text assessment, 19 being finally included for qualitative and quantitative analyses. Additionally, 39 case report articles were included and analyzed separately. For 656 patients, fever (88.7%, 95%CI 84.5–92.9%), cough (57.6%, 40.8–74.4%) and dyspnea (45.6%, 10.9–80.4%) were the most prevalent manifestations. Among the patients, 20.3% (95%CI 10.0–30.6%) required intensive care unit (ICU), 32.8% presented with acute respiratory distress syndrome (ARDS) (95%CI 13.7–51.8), 6.2% (95%CI 3.1–9.3) with shock. Some 13.9% (95%CI 6.2–21.5%) of hospitalized patients had fatal outcomes (case fatality rate, CFR).
Conclusion
COVID-19 brings a huge burden to healthcare facilities, especially in patients with comorbidities. ICU was required for approximately 20% of polymorbid, COVID-19 infected patients and hospitalization was associated with a CFR of over 13%. As this virus spreads globally, countries need to urgently prepare human resources, infrastructure and facilities to treat severe COVID-19.
In the past decades, several new diseases have emerged in new geographical areas, with pathogens including Ebola, Zika, Nipah, and coronaviruses (CoV). Recently, a new type of viral infection has emerged in Wuhan City, China, and initial genomic sequencing data of this virus does not match with previously sequenced CoVs, suggesting a novel CoV strain (2019-nCoV), which has now been termed as severe acute respiratory syndrome CoV-2 (SARS-CoV-2). Although CoV disease 2019 (COVID-19) is suspected to originate from an animal host (zoonotic origin) followed by human-to-human transmission, the possibility of other routes such as food-borne transmission should not be ruled out. Compared to diseases caused by previously known human CoVs, COVID-19 shows a less severe pathogenesis but higher transmission competence, as is evident from the continuously increasing number of confirmed cases. Compared to other emerging viruses such as Ebola virus, avian H7N9, SARS-CoV, or MERS-CoV, SARS-CoV-2 has shown relatively low pathogenicity and moderate transmissibility Codon usage studies suggest that this novel virus may have been transferred from an animal source such as bats. Early diagnosis by real-time PCR and next-generation sequencing has facilitated the identification of the pathogen at an early stage. Since no antiviral drug or vaccine exists to treat or prevent SARS-CoV-2, potential therapeutic strategies that are currently being evaluated predominantly stem from previous experience with treating SARS-CoV, MERS-CoV, and other emerging viral diseases. In this review, we address epidemiological, diagnostic, clinical, and therapeutic aspects, including perspectives of vaccines and preventive measures that have already been globally recommended.
Los coronavirus (CoV) en sentido amplio son un grupo de virus de ARN de cadena simple con envoltura. Estos pertenecen a la subfamilia Orthocoronavirinae, familia Coronaviridae, en el orden Nidovirales. Se clasifican en cuatro géneros: alfa, beta, gamma y Deltacoronavirus. Los dos primeros pueden infectar al ser humano (1,2). Los CoV son agentes patógenos que pueden ser transmitidos a los animales y al hombre; tienen una distribución mundial (3-5).
La infección por CoV en animales particularmente en bovinos, cerdos, perros, entre otros, es conocida desde hace muchas décadas; estos al infectarse pueden presentar diarrea; de modo especial las aves desarrollan compromiso respiratorio semejante a una bronquitis. Los coronavirus, singularmente los de tipo beta, son zoonóticos es por ello que una completa vigilancia epidemiológica debería incluir también a los animales ya que son hospedadores susceptibles (6). Lo último hace parte de las iniciativas de “One Health”, que promueve y fomenta el estudio integrado de la salud humana, animal y ambiental (7).
En estas patologías virales el papel de la cadena de transmisión animal-humano es de importancia, pero, como se ha observado con varios virus del género Betacoronavirus, también se da una transferencia entre humanos (1,8).
En los humanos los CoV pueden originar diferentes enfermedades, desde resfriados frecuentes, hasta otras más graves como el síndrome respiratorio agudo grave (causado por el SRAG-CoV) y el síndrome respiratorio del oriente medio (causado por el MERS-CoV) (Figura 1). El SARS fue identificado por primera vez a finales del 2002 en Guangzhou (Guangdong, China), cuando provocó 8.422 casos y 916 muertes en 29 países de los cincos continentes, por consiguiente, se denominó la primera pandemia del siglo xxi (2,9,10).
Revisamos aquí el origen, características del brote y la epidemiología del nuevo Coronavirus (2019nCoV) responsable de una nueva enfermedad por coronavirus
(COVID-19). Una rápida respuesta de las autoridades de salud mundiales está en marcha y se ha hecho un llamado urgente para colaboración científica internacional. Las lecciones aprendidas de brotes previos con agentes virales similares han aumentado las capacidades para contener y controlar estas amenazas recurrentes a la salud global.
Zoonotic diseases have shaped the life of human beings during centuries. Particularly the
dynamics and changes over time make the difference in the occurrence, emergence and re-emergence of such conditions. Pathogen transmission from a vertebrate animal to a human, also known as zoonotic spillover, represents a global public health burden, which while associated with multiple outbreaks, still remains a poorly understood phenomenon [1]. Zoonotic spillover requires a blend of several factors to ignite, including the ecological, epidemiological and behavioral determinants of pathogen exposure, and the within human intrinsic factors that affect susceptibility to infection, as well as nutritional and cultural
factors, associated with foodborne zoonotic diseases [1, 2]. Coronaviruses (CoV) have been previously on the spotlight of this discussion [(3, 4]. They can infect the respiratory, gastrointestinal, hepatic and central nervous system tracts of man, cattle, birds, bats, rodents and various other wild animals (Figure 1) [5, 6]. Coronaviruses, like influenza viruses, circulate in nature in various animal species. Alpha-coronaviruses and beta-coronaviruses can infect mammals and gamma-coronaviruses and delta-coronaviruses tend to infect birds, but some of them can also be transmitted to mammals [5]. These zoonotic viruses, were not considered to be highly pathogenic to humans until the outbreak
of severe acute respiratory syndrome (SARS-CoV) in 2002 and 2003 in Guangdong province, China, as the coronaviruses that circulated before that time in humans mostly caused mild infections in immunocompetent people. Ten years after SARS, another highly pathogenic coronavirus, Middle East respiratory syndrome coronavirus (MERSCoV)
emerged in Middle Eastern countries [7].
Over the last three months, the pandemic of Coronavirus Disease 2019 (COVID-19) has caused significant concern in the world due to its rapid spreading [1, 2]. Since February 25, 2020, it has also comprised the Latin America and the Caribbean region [3]. However, there is still limited evidence of the full spectrum and impact of COVID-19 in certain population groups, including pregnant women [4]. No case reports on COVID-19 from Central America are yet available in scientific journals, including its occurrence during pregnancy.
On March 9, 2020, a 41-year-old female, who was 31 weeks pregnant, with gestational hypertension and hypothyroidism, presented to the Hospital Escuela of Tegucigalpa, Honduras, with intermittent fever, dry cough, headache and myalgias for three days. She had a history of travelling in Madrid, Spain, she lived for the last six months there and returned to Honduras on March 4. Her neighbours in Madrid were diagnosed with COVID-19. Therefore, given the patient’s travel history and fever, a nasopharyngeal aspirate sample was collected and tested following WHO guidelines for real-time RT-PCR at the National Virology Laboratory of Tegucigalpa, following the protocol Charité, Berlin, Germany [5]. The results were positive, and then she went into isolation at the hospital.
On admission, the physical examination revealed a body temperature of 36.0°C, high blood pressure (130/100 mmHg), normal pulse, and normal respiratory rate. She presented bilateral conjunctival hyperemia. Lung auscultation revealed no alterations. An obstetric ultrasound revealed a fetus with a dysplastic and multicystic right kidney with no other alterations. On March 9, 2020, she was referred to the National Cardiopulmonary Institute of Tegucigalpa, for follow-up. After four days of hospitalization, she is currently stable, remaining under observation.
According to previous reports for SARS in pregnancy in Hong Kong, SARS-CoV infection could be associated with poor pregnancy outcomes, including critical maternal illness, spontaneous abortion, or maternal death, preterm birth [6, 7]. In this case, her clinical presentation showed no significant alterations related to COVID-19, as has also been reported recently in a case in China [6].
So far, there is currently no evidence for intrauterine infection caused by vertical transmission in women who develop COVID-19 pneumonia in late pregnancy [4]. Nevertheless, this implies the need to further assessment, with rRT-PCR, after delivery, as we expect to perform in a few weeks in this case. Pregnant women are particularly susceptible to respiratory pathogens and severe pneumonia because of their physiological adaptive changes (e.g., diaphragm elevation, increased oxygen consumption, and oedema of respiratory tract mucosa) and immunosuppressive state. With the increase of the pandemic in Latin America, a region with high fecundity rates, we should expect to see more cases of COVID-19 among pregnant women that need to be studied in detail to understand better its clinical impact.
Over the past weeks the spread of the Coronavirus Disease 2019 (COVID-19), caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) [1], has been steady in Asia and other regions in the world. Latin America was an exception until February 25, 2020, when the Brazilian Ministry of Health, confirmed the first case.
This first case was a Brazilian man, 61 years-old, who traveled from February 9 to 20, 2020, to Lombardy, northern Italy, where a significant outbreak is ongoing. He arrived home on February 21, 2020, and was attended at the Hospital Albert Einstein in São Paulo, Brazil. At this institution, an initial real-time RT-PCR was positive for SARS-CoV-2 and then confirmed by the National Reference Laboratory at the Instituto Adolfo Lutz using the real-time RT-PCR protocol developed by the Institute of Virology at Charité in Berlin, Germany [2]. The established protocol also included now, as part of the Sao Paulo State Health Secretary, to include metagenomics and immunohistochemistry with PCR, as part of the response plan to COVID-19 outbreak in the city [3]. The patient presented with fever, dry cough, sore throat, and coryza. So far, as of February 27, the patient is well, with mild signs. He received standard precautionary care, and in the meantime, he is isolated at home [4]. Local health authorities are carrying out the identification and tracing of contacts at home, at the hospital, and on the flight. For now, other cases are under investigation in São Paulo, and other cities in Latin America. In addition to the Sao Paulo State Health Secretary, the Brazilian Society for Infectious Diseases have developed technical recommendations [4].
Coronaviruses can cause severe diseases in humans and animals, as has been stated recently by Biscayart et al. [1]. China has experienced several viral outbreaks in the last three decades; avian influenza outbreak in 1997, severe acute respiratory syndrome (SARS) in 2003 [2], and severe fever with thrombocytopenia syndrome (SFTS) in 2010 [3]. In China, yet another pathogenic human coronavirus outbreak was reported in the city of Wuhan. Wuhan is an urban town located in the central part of China. It is one of the significant transportations and business hubs. In 2018, the city comprised of a population of approximately 11.9 million, and one of the seventh most populous Chinese city [1,4].
On December 12, 2019, the Wuhan Municipal Health Commission (WMHC) reported 27 individuals infected by a new coronavirus designated 2019-novel coronavirus (2019-nCoV) by the World Health Organization (WHO). Of the reported cases, seven were critically ill and had a history of exposure with the Seafood Wholesale Market.
According to recent scientific evidence, Brazil's wildfires are linked to deforestation. The blazes are surging in a pattern typical of forest clearing, along the edges of the agricultural frontiers (Fig. 1). Historical data shows the pattern of events: chainsaws or excavators open the way, then the wildfires, and these are followed by livestock, monoculture, or other forms of economic activity [1]. By August 24th, 2019, Brazil's National Institute for Space Research (INPE) had counted more than 76,000 wildfire spots in the Brazilian Amazon, compared with 22,000 in the same period last year. The Global wildfire Emissions Database project, which includes scientists from NASA's Goddard Space Flight Center in Greenbelt, Maryland; the University of California, Irvine; and Vrije University in Amsterdam, sees the same trend, although the numbers are slightly higher [1]. The situation, especially ecologically, is critical. Brazil contains about 60% of the Amazon, the largest rainforest in the world. Several million plants, animal and insect species live in the Amazon, in addition to dwellers, and the Amazon acts as an enormous carbon sink that helps to cool global temperatures, of utmost importance in the context of climate change and global warming [2]. Forest wildfires (Fig. 1), in this scenario, release this stored carbon, causing a major impact on health. For example, high air pollution immediately. The long-term impact is more considerable and challenging to estimate. The effects will be determined by the type of change in the ecosystem (landscape, fauna, flora, environment) [3,4]. During the period August 16th-17th, 2019, a group of international experts held a meeting on Zoonoses and One Health, in Pereira, Colombia, under the auspices and networking of the Colombian Association of Infectious Diseases and its Committee on Tropical Medicine, Zoonoses and Travel Medicine. This group has analyzed the situation in Brazil and set a position regarding the potential impact of the 2019 Amazon wildfires (Fig. 1) on vector-borne and zoonotic emerging diseases.
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