Journal of Dental Research and Dental Prospects

Review Article Volume 01 Issue 01

Epidemiology of Covid–19: An epidemic into a pandemic

Akila Ganesh M.D.S., (PhD)
Professor and Head, Department of Public Health Dentistry, Faculty of Dental Sciences, Sri Ramachandra Institute of Higher Education and
Research, Porur, Chennai. ORCID ID: 0000 0003 1557 8000
*Corresponding Author: Akila Ganesh M.D.S., Professor and Head, Department of Public Health Dentistry, Faculty of Dental Sciences, Sri

Ramachandra Institute of Higher Education and Research, Porur, Chennai. ORCID ID: 0000 0003 1557 8000
Received date: 13 January 2022; Accepted date: 27 January 2022; Published date: 31 January 2022
Citation: Ganesh A (2022) Epidemiology of Covid–19: An epidemic into a pandemic. Journal of Dental Research and Dental
Prospects 01(01): https://doi.org/10.38207/JDRDP/2022/JAN010101
Copyright: © 2022 Akila Ganesh. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract
The 2019 novel coronavirus epidemic has transformed into a pandemic and has become an ongoing global health threat. The SARS-CoV-2
infection is still spreading, and this virus poses a serious threat to public health, though joint prevention and quarantine mechanisms have been
confirmed to be enacted globally. There is limited support for many of its key epidemiologic features, including the incubation period, which
has important implications for surveillance and control activities. Human to human transmission has been reported to occur primarily via direct
or indirect contact through respiratory droplets or secretions. WHO reported a mean incubation period of 6.4 days and a case fatality rate of 6.3
%. Increased severity of cases is reported in males, the elderly, and in presence of co-morbidities. There are no reports of vertical transmission
from mother to child. Health care workers as well as families of cases and health care workers are at increased risk. WHO in a recent report has
stated that there is no evidence of immunity to secondary infection in COVID 19 patients. The viral load of SARS-CoV-2 might be a useful
marker for assessing disease severity and prognosis. The importance of hand hygiene and social distancing play a vital role in halting the spread
of this pandemic. Various bodies including the WHO and US Centers for Disease Control and Prevention (CDC) are issuing continued advice
and education on preventing the further spread of COVID-19.
Keywords: COVID 19, epidemiology, challenges, prevention

Introduction
Background
Coronaviruses have been reported as causes of mild and moderate International Committee on Taxonomy of Viruses (ICTV) named this
respiratory infections for over 50 years [1] These viruses can also novel coronavirus as Severe Acute Respiratory Syndrome Corona
cause enteric, hepatic, and neurologic diseases.[2,3] They are large, Virus -2 (SARS CoV-2). [9] Emergence of 2019-nCoV has attracted
enveloped, positive-strand RNA viruses that can be divided into 4 global attention, and the WHO has declared the COVID-19 a Public
genera, a, b, d, and g, of which a and b coronaviruses are known to Health Emergency of International Concern (PHEIC).[10] COVID 19
infect humans, which are called Human Corona Viruses(HCoVs).[3] outbreak was declared a pandemic by WHO on March 12, 2020.
Four HCoVs (HCoV 229E, NL63, OC43, and HKU1) are endemic The epidemic, now transformed into a pandemic has become an
globally and account for 10 % to 30 % of upper respiratory tract ongoing global health threat. The SARS-CoV-2 infection is still
infections in adults. [4] Coronaviruses were found in 30 % of acute spreading, and this virus poses a serious threat to public health, though
respiratory tract infections of children under 6 years of age [5]. Monto joint prevention and quarantine mechanisms have been confirmed to
and Lim [6] also reported a 29 % infection rate with HCV OC43 in be enacted globally. Due to a lack of specific antiviral treatments and
children below 5 years who had a 29 % infection rate with HCV pressure of clinical treatment, thousands of severe cases are dying
OC43. every day worldwide. [11] There is limited support for many of its
The epidemic of the 2019 novel coronavirus has expanded from key epidemiologic features, including the incubation period, which
Wuhan throughout China to a growing number of countries. The has important implications for surveillance and control activities.
impact of an epidemic depends on the number of persons infected, the
infection’s transmissibility, and the spectrum of clinical severity.[7] Transmissibility of the infection
On January 7, 2020, the World Health Organization (WHO) named it Understanding transmissibility remains crucial for predicting the
the 2019 novel Corona Virus (2019-nCoV). On February 11, 2020, course of the pandemic and the likelihood of sustained
the WHO named the illness associated with 2019-nCoV as the 2019 transmission.[12] It is highly likely that the human-to-human
novel Corona Virus Disease (COVID-19). [8] On the same day, the

Citation: Ganesh A (2022) Epidemiology of Covid–19: An epidemic into a pandemic. Journal of Dental Research and Dental Prospects 01(01): https://doi.org/10.38207/JDRDP/2022/JAN010101
 Journal of Dental Research and Dental Prospects
transmissibility of 2019-nCoV is sufficient to support sustained to 6.7 days. [11,15,19] The time from onset of symptoms to

human transmission unless effective control measures are hospitalization (and isolation) ranged between 0 and 10 days with a

implemented.[13] Initial thoughts were that patients were presumed mean of 3.7 days. The mean number of days to hospitalization was

to be infected in hospitals due to nosocomial infection and hence it 2.5 days for cases imported from China, but 4.6 days for those

was concluded that the COVID-19 is not a super spreader virus infected in Europe.[24]

(spread by one patient too many others), but later it was reported that
many patients were getting infected at various locations throughout Case fatality rate

the hospital through unknown mechanisms.[14] As interventions are gradually implemented and calibrated during the

Human to human transmission has been reported to occur primarily course of an outbreak, early estimates of the Case-Fatality Ratio

via direct or indirect contact through respiratory droplets or secretions (CFR) provide crucial information for policymakers to decide the

spread by coughing or sneezing from an infected individual. [11,15] intensity, timing, and duration of interventions. However, the

Strong evidence of human-to-human transmission in this emerging assessment of epidemiologic characteristics, including the CFR,

acute respiratory tract infection has also been reported in various during the course of an outbreak tends to be affected by right

studies in China by Dong et al,[16] Li et al [17] and Lee et al. [18] censoring and ascertainment bias. [25,26]
CFR is multifactorial and is strongly influenced by a number of

Incubation period factors, including age, gender, comorbidities, availability of health

The incubation period can facilitate several important public health care facilities, etc. It was found to be increased in the elderly,

activities for infectious diseases, including active monitoring, especially over 80 years, and ranged from 14.8 % to 27 %. [11,27-29]

surveillance, control, and modeling. [19] Our current understanding Research in China [30] reported increased CFR in males when

of the incubation period for COVID-19 is limited. WHO did an early compared to females. Patients with underlying comorbidities showed

analysis [20] on confirmed cases in Chinese provinces outside poor prognosis and increased CFR ranging from 5.6 % to 10.5 %

Wuhan, and reported a mean incubation period of 6.4 days with a [11,27,31] to as alarming as 50 % in critically ill patients. [32,33] The

range of 2.1 to 11.1 days. Another analysis [21] based on 158 total CFR was 2.3 % of 44,672 confirmed cases in China.[27] The

confirmed cases outside Wuhan estimated a median incubation period overall fatality rate of persons with confirmed COVID-19 in the

of 5.0 days with a range of 2 to 14 days. These estimates are generally Italian population, was reported as 7.2 %.[34] This rate is higher than

consistent with estimates from confirmed cases in China [17] (mean that observed in other countries.[8] Thus, the overall older age

incubation period, 5.2 days) and from clinical reports of a familial distribution in Italy relative to that in China may explain, in part, the

cluster of COVID-19 in which symptom onset occurred 3 to 6 days higher average CFR in Italy.[35]

after assumed exposure in Wuhan.[22] As for healthcare workers, the CFR was approximately 0.17 % of 3019

Jin et al [23] reported the incubation period from 1 to 14 days, mostly cases.[27] A study by Mc Michael et al [36], reported a CFR of

3–7 days. However, the mean incubation period ranged from 5.2 days 33.7 % for hospital residents and 6.2 % for hospital visitors.

Epidemiological triad
The epidemiological triad of COVID-19 is illustrated in Figure 1.

Figure 1: Epidemiological Triad of COVID 19

Citation: Ganesh A (2022) Epidemiology of Covid–19: An epidemic into a pandemic. Journal of Dental Research and Dental Prospects 01(01): https://doi.org/10.38207/JDRDP/2022/JAN010101
 Journal of Dental Research and Dental Prospects

Host factors
Age higher severity in older age groups were reported in Wuhan [28] and
In a study reported by Fan et al [37], in China, the youngest patient United States. [29,48] Although the majority of reported COVID-19
was 20 months of age; the oldest was 94 years of age. This suggests cases in China were mild (81 %), approximately 80 % of deaths
the wide age range of the infection. A general pattern has been occurred among adults aged ≥ 60 years; with the highest percentage
reported from multiple countries that COVID-positive children have of severe outcomes among persons aged ≥ 85 years. Similar to reports
a milder form of the disease.[16,38] This could be attributed to the from other countries [8,33,43,49,50], this finding suggests that the
various reasons: children have well cared at home, composition and risk for serious disease and death from COVID-19 is higher in older
functional responses of the developing immune system,[39] the age groups. These results suggest that vigorous efforts should be made
decreased prevalence of comorbidities in children, presence of other to protect and reduce transmission and symptom progression in
simultaneous viruses in the mucosa of the lungs and airways & levels vulnerable populations including both elderly people and young
of antibodies to the virus due to more frequent respiratory tract children.
infections. These antibodies limit the growth of SARS-CoV2, by the
direct virus to virus interactions and competition. Another thought Gender
suggests that it is probably due to the differences in the expression of Results of various studies [2,16] have reported that there are no major
the Angiotensin-Converting Enzyme (ACE) 2 receptor necessary for differences in the gender distribution. However, a male predilection
the virus binding and infection. Treatment with ACE inhibitors or was reported by Bailek et al - CDC COVID 19 Response Team [40]
angiotensin receptor blockers induces expression of ACE 2. Since the among children and adults and by Bhatraju et al [51] in Seattle in the
therapies are more common in adults, it has accounted for the milder US. Similar results were reported by Lauer et al [19] in Hubei
form of the disease in children.[38] Province, China, Wang et al, [44] Guan et al, [33] Li et al,[17] Chen
In children up to 15 years of age, the median age was reported as 7 et al [52], and Zhou et al [47] in the Wuhan outbreak. (Table 1) Spiteri
years, with an age range from 1 day to 18 years, suggesting that all et al [24] reported that the proportion of male cases was higher in
ages of childhood are prone to COVID 19 infection.[16] However, Europe (66 %) when compared with those acquired in China (57 %).
increased vulnerability of infants to COVID 19 infection was reported Fan et al [37] reported that the distribution of illness by gender did not
by Dong et al [16] and in a report by Bialek et al - US Centers for differ significantly, but female patients predominated slightly. Similar
Disease Control and Prevention (CDC) COVID 19 Response Team results were reported by Pan et al, [45] and Shi et al [46] in Wuhan,
[40] in which infants accounted for the highest percentage (15 %–62 China. Mc Michael et al [36] in Washington and Spiteri et al [24]
%) of hospitalization among pediatric patients with COVID-19. reported a predominant female predilection (Table 1). Though
Similarly, the highest rate of cases among children and adolescents females had a higher rate of confirmed cases compared with males,
was reported in infants by the WHO-China Joint Commission [41] males were more likely to have a severe or critical illness. This is
and by Wang et al. [42] consistent with previous reports from China [53,54] suggesting a
Various studies have reported varied median age ranges: ranging from higher crude fatality rate among men compared with women and
42 years to 72 years, [17,19,24,33,36,43-47] (Table 1). China CDC another study in critically ill patients demonstrating that more men
data [27] showed that more than 85 % of patients were mainly were affected (67 %) than women (33 %).[55]
concentrated at the age range of 30–79 years.[11] Similar results of

Table 1: Age and gender distribution of COVID 19 cases

AUTHOR/ LOCATION OF AGE DISTRIBUTION (years) GENDER DISTRIBUTION (%)
YEAR STUDY Median Range Males Females
Dong, et al [16] China 7 1day -18yrs No major gender differences
Li et al, [17] Wuhan, China 59 15 - 89 56 44
Lauer, et al [19] Hubei Province, 44.5 34 - 55.5 60 40
China
Spiteri, et al [24] Europe 42 2 - 81 34 66
Guan, et al [33] China 47 35 -58 58 42
Mc Michael, et al Washington, USA 72 21 -100 33 67
[36]
Bialek, et al [40] USA 11 0 – 17 57 43
18 – 64 53 47

Citation: Ganesh A (2022) Epidemiology of Covid–19: An epidemic into a pandemic. Journal of Dental Research and Dental Prospects 01(01): https://doi.org/10.38207/JDRDP/2022/JAN010101
 Journal of Dental Research and Dental Prospects
Wang, et al [44] Wuhan, China 56 54 46
Pan, et al [45] Wuhan, China 56.7 0 - 103 48 52
Shi, et al [46] Wuhan, China 64 21 - 95 49 51
Zhou, et al [47] Wuhan, China 56 18 - 87 Majority
Bhatraju, et al [51] Seattle, USA 64 23 -97 63 37
Chen, et al [52] Wuhan, China 55.5 21 - 82 68 32

Table 2: Comparison of COVID 19, Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS)

Severe Acute
Corona Virus Disease Middle East Respiratory
Characteristics Respiratory Syndrome
2019 (COVID 19) Syndrome (MERS)
(SARS)

Mean Generation time

8.4 8.4 10.7
(days)

Mean 6.4 5 6
Incubation Period
(days) 5
Range 2.1-11.1 2 - 14
2 -14
Increased severity in presence of
Present Present Present
co morbidities

Case to case variation Greater Greater Greater

Risk in Pregnant women Not reported Increased Increased

Case-fatality rate 6.9 %, 9.6 % 34 %,

Virulence Less More More

Viremia Less than 1 week First week Lesser duration

Peak respiratory viral shedding 2nd week 2nd week Longer duration

Persistent stool viral shedding longer Beyond second week Lesser

Increased severity with age Present Present Present

Virus RNA in respiratory

20 days 4 weeks 3 weeks
specimens

Occupation
Persons who are in close contact with patients or sub clinically hygiene, longer duty hours, and those in contact with patients had a
symptomatic infected persons are part of the high-risk population, higher risk of COVID-19.
who are mostly healthcare workers and the family members of
patients and health care workers.[56] Pregnancy
The rate of cases in Health Care Workers (HCWs) was substantially Research on pregnant COVID-19 patients in China,[59] indicates
higher than in the general population initially, indicating a high risk pregnant women are also susceptible to SARS-CoV-2. However, no
of nosocomial infection. However, it quickly decreased in the later evidence of vertical transmission was reported. Many other studies
periods, after increasing awareness of and wider use of personal [59-61] globally have also not reported clinical or serologic evidence
protective equipment, proper training, adequate hospital-level suggestive of vertical transmission of SARS-CoV-2. In a study [15]
prevention and management, and support.[57] conducted on COVID 19 positive women in their third trimester, there
A study [58] conducted among health care professionals reported that was no evidence that there is a transmission from mother to child.
the high-risk department group had 2.13 times higher risk of Personal habits
developing COVID-19 compared with the general department group. Smoking has been reported as a susceptible factor by Jia et al62 and in
HCWs working in the high-risk departments, with suboptimal hand a report by the National Health Commission.[56]

Citation: Ganesh A (2022) Epidemiology of Covid–19: An epidemic into a pandemic. Journal of Dental Research and Dental Prospects 01(01): https://doi.org/10.38207/JDRDP/2022/JAN010101
 Journal of Dental Research and Dental Prospects

Agent factors
Virulence COVID-19 tend to have a high viral load and a long virus-shedding
Virulence is the proportion of clinical cases resulting in severe clinical period. This suggests that the viral load of SARS-CoV-2 might be a
manifestations and resulting sequelae. CFR is one way of measuring useful marker for assessing disease severity and prognosis.[63]
virulence. Overall CFR was 6.9 % according to the WHO situation Nutrient agents
report as of April 28, 2020.[8] Obesity, caused due to lack of intake of a balanced diet has been
Viral load reported as a susceptible factor by Jia et al [62] and in a report by the
The mean viral load of severe cases was around 60 times higher than National Health Commission.[56]
that of mild cases, suggesting that higher viral loads might be
associated with severe clinical outcomes. Patients with severe

Environmental Factors
diseases at Penn State University, that COVID-19 is more seasonal.
Comorbidity
It becomes more active in winter and spreads faster in cold and dry
Comorbidities were present in nearly 50 % of patients, with
air. The virus has basically zero infectivity during summer as it
hypertension being the most common comorbidity [36], followed by
cannot usually withstand high temperatures. Contrarily, disease
diabetes [51], coronary heart disease. [22,47] and cerebrovascular
expert Amesh Adalja disagrees with McGraw, arguing that the
disease.[46] A meta-analysis by Yang et al,[64] also reported that
evidence suggests it is not seasonal.39 Hence, there is a need for
the most prevalent comorbidities were hypertension, diabetes
further research in this perspective.
mellitus, cardiovascular diseases, and respiratory diseases. Yang’s
study [64] also reported that these comorbidities were more likely
Geographic variations
detected in severe patients. Another meta-analysis by Emami et
Studies have reported that in remote, mountainous, rural, or hard-
al,[65] showed that hypertension, cardiovascular diseases, diabetes
to- reach areas, the spread of COVID -19 has been restricted or
mellitus, smoking, chronic obstructive pulmonary disease,
slowed down. Studies have also reported that the outbreaks
malignancy, and chronic kidney disease were the most frequently
occurred faster (hotspots) in developed populated cities at the high
detected underlying diseases among hospitalized patients. Data from
end of economic, medical, and cultural development.[37]
China [50] have indicated that particularly those with serious
underlying health conditions, are at higher risk for severe COVID-
Secondary infections
19–associated illness and death. Similar results were reported by
Cyclic patterns of recurrence in 2 to 3 years were reported by
Guan et al,[33] Guo et al,[43] Chen et al [52], and Jia et al. [62]
American studies [5,6] in infections caused by HCV 229E and
Similarly, in a recent report,[44] 25 % and 58.3 % of patients who
HCV OC43. Re-infections with HCVs were common.
were critically ill with COVID-19 had underlying heart diseases and
Furthermore, we found HCVs in secretions taken from
hypertension, respectively.
consecutive acute infections more than 3 months apart. WHO in a
recent report has stated that there is no evidence that coronavirus
Confined location
patients are immune to secondary infections. [8]
Evidence indicating that COVID-19 transmission is facilitated in
confined settings was reported by Mizumoto et al [66,67] in a cruise
Challenges for control of COVID 19
ship in Japan where a large cluster of confirmed cases was reported.
COVID-19 outbreak poses challenges for curtailing global spread
This finding indicates the high transmissibility of COVID-19 in
and maintaining global health. Implementation of collective
enclosed spaces.
infection control measures has been useful. However, these
measures should be executed in a sagacious manner while
Climate
considering their cost- efficiency. It is required to continue the
American studies [5,6] have reported that epidemics occur
collective infection control measures though there may be a
duringthe winter and early spring, with the peak period varying by
prolongation of the epidemic period. Public health perspectives to
several months. A study in the United Kingdom [68] reported that
control the pandemic
HCV infection in adults occurred throughout the year with major
The first pillar for interventions is to preserve the healthcare
peaks of infection during the summer and winter. Similar results
system by protecting health care workers and preventing hospital
were reported in a study by Isaac et al. [5]
outbreaks. There is a growing need for providing advice on the
Scientists report that the new coronavirus is most likely to become a
proper management of COVID-19 patients so that they receive the
seasonal respiratory disease based on its current infectivity and
most appropriate treatment and avoid overtreatment. The trust
lethality. It has been reported by McGraw, a professor of infectious

Citation: Ganesh A (2022) Epidemiology of Covid–19: An epidemic into a pandemic. Journal of Dental Research and Dental Prospects 01(01): https://doi.org/10.38207/JDRDP/2022/JAN010101
 Journal of Dental Research and Dental Prospects
between people and institutions must be maintained by respecting curative treatment, the best practice to reduce the impact of
temporary individual restrictive measures. Any antagonism COVID-19 is prevention. Contact transmission is one of the main
between countries and their governments must be carefully routes of the SARS-CoV-2. Hand hygiene through hand washing
avoided.[31] is considered the most important prevention measure for
Because the risk for death from COVID-19 is probably associated healthcare-associated infections, as it significantly reduces the
with hampering the healthcare system, especially with the lack of residual viruses. Several types of research have highlighted the
appropriate drug interventions or vaccines, enhanced public health importance of hand hygiene after contacting or caring for COVID-
interventions like social distancing measures, quarantine, effective 19 patients. [69,70] While the majority of transmission has
infection control in healthcare settings, improved hygienic measures occurred in community settings, super- spreading events in
in the general population and an increase in healthcare system healthcare settings have already been described.[71] Various
capacity, should be implemented to rapidly contain the pandemic. bodies including the WHO and US CDC are issuing continued
advice and education on preventing the further spread of COVID-
Prevention
19.
Prevention is better than cure! With the limited awareness of

Conclusion
The rapidly evolving nature of the COVID-2019 pandemic,
The pandemic potential of COVID 19 is still spreading. Hence
altering statistics, and constant results of new research findings
regular updates on the disease pathogenicity, transmissibility, risk
represent a major limitation to the present review.
factors, and treatment modalities must be precisely monitored.

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