PERCEPTION OF MASS MEDIA AS TOOLS FOR SENSITIZING RURAL DWELLERS ABOUT INFECTIOUS EPIDEMIC A CASE STUDY OF CORONA VIRUS IN NIGERIA

CHAPTER TWO

REVIEW OF RELATED LITERATURE

2.1 Communication for Development (C4D)

Communication is crucial to human development. In the past centuries, communication was used to promote trade and commerce as a development index. From the Babylonian clay tablet and the Egyptian Papyri which were used for communication, to the Greeks‘ town criers who used to announce the arrival of merchant ships with cargoes of wines, spice, and metals as well as the French‘s town criers who would blow the bugle, gather the people and offer samples of products (Russell et. al, 1988:3), today, the use of communication is not limited to trade and commerce. It has been extended across sectors: health, politics, governance, agriculture, and other areas of livelihood. Communication as a process is developed for multiple applications: marketing communication, corporate communication, public information, and development communication, among others.

Development Communication is a critical success factor for human development process in any community. It is a system of human communication linked to a society's planned transformation from a state no longer desirable to that which propels socio- economic growth that engenders equitable unfolding of individual potentials. Where human development is the purpose, effective communication with the target group must be at the core of activities. Development communication, according to Servaes (2008:15), is the sharing of knowledge aimed at reaching a consensus for action that takes into account the interests, needs and capacities of all concerned. The focus on Development Communication became stronger and greater attention was paid to communication tools and messaging that could trigger and galvanise development in the society. This led to the emergence of Communication for Development (C4D) which sometimes, is used interchangeably with Development Communication.

Article 6 of the United Nations General Assembly Resolution 51/172 of 1997, states that Communication for development stresses the needto support two-way communication systems that enable dialogue and that allow communities to speak out, express their aspirations and concerns and participate in the decisions that relate to their development.‖ Since 1997, other definitions that looked at C4D from broader perspectives have been advanced. The Rome Consensus from the World Congress on Communication for Development (2006:2) defined C4D as:

A social process based on dialogue using a broad range of tools and methods. It is also about seeking change at different levels, including listening, building trust, sharing knowledge and skills, building policies, debating and learning for sustained and meaningful change. It is not public relations or corporate communication.

2.1.1 Health Communication

Health communication is a unit within the larger communication spectrum. It simply means any human communication that deals with health issues and directed to specific individuals, community or the public. It is the dissemination of health-related information, ideas and values from an identified source through a channel to a receiver and with in-built capacity for feedback. In other words, Health communication is the use of communication strategies to improve the health of individuals and wellbeing of communities. According to O‘Sullivan, et al. (2003:4), health communication is the―collaboratively designed, implemented, and evaluated communication strategies will help achieve the goal of improving health in a significant and lasting way by empowering people to change their behaviour and by facilitating social change.‖ Communication in health can be defined in much the same way as communication has generally been defined: a transactional process. The main difference in communicating health is that the focus is not a general one but one specific to health information (Corcoran: 2007:8).

Health Communication encompasses the study and use of communication strategies to inform and influence individual and community decisions that enhance health. It links the domains of communication and health and is increasingly recognized as a necessary element of efforts to improve personal and public health. The art and technique of informing, influencing, and motivating individual, institutional, and public audiences about important health issues (Healthy People: 2010). No doubt, Health Communication is a strategic component of public health and general health care services. Acknowledging this, Berry (2010) observes that effective communication is now generally acknowledged to be central to effective healthcare. It is no longer seen as an add-on extra; rather it is recognised by many as being at the heart of patient care – as playing a pivotal role.

Health Communication goes beyond being a process of disseminating health information. It is a solution to the problem of seeming disconnect between the target audience and the message due to the channel through which the Health Communication message is deployed. For Communication practitioners, it is important not only to look at the content of the information provided to adolescents on reproductive health but also its channels, sources, uses, perceptions, among others (Bashir and Gapsiso, 2008:61). In health communication, just as in strategic communication, the channels of communication should align with the target audience. The channels should be reach the primary target audience. Health Communication‘s target audience which might be a geographical location or a defined group of people, must be studied and well understood in terms of their profile, lifestyle, language, beliefs and media preference.

As noted by Nwodu (2008:3), one of the purposes of health communication message ―is to encourage the seemingly super sexually active youths to abstain from pre- marital sex and by so doing, avoid contracting sexually transmitted diseases (including the most dreaded HIV/AIDS pandemic)…‖ The US Department of Health and Human Services further acknowledges the outcomes of a Health Communication to be the ability of individuals and community groups to make decisions about the health of their work place and their community. The Department submits that:

Health communication is critical for people's exposure to, search for, and use of health information; individuals' ability to reduce or eliminate unhealthy behaviours and adopt healthy behaviours; and individuals' and community groups' ability to make decisions about the health of their workplace, their community, and our society (Healthy People, 2010:1).

However, it is important to note that the desired outcomes of health communication cannot materialise if the medium of health communication is not credible enough to build trust and understanding amongst the target audience. This probably accounts for Mitchel‘s (2014:1) opinion that health care providers must continuously work to understand the needs of their community and share important health information with a culturally appropriate strategy. Culturally appropriate strategy also extends to culturally appropriate medium of communication.

This recognises that every group has some cultural norms and beliefs it holds dearly and any communication process that negates such beliefs and norms will not elicit desired feedback from the group. This brings to the fore, the issue of conventional radio with its elitist perspectives and community radio, believed to be people-oriented and culturally appropriate to address a public health challenge like HIV disease that thrives on the misconception about its existence and spread.

2.1.3 Effective Health Communication

The goal of every communication process is for the message to reach the target audience and for the target audience‘ attitude and behaviour to correlate with the communicator‘s desired response. Communication is regarded as effective if the feedback from the receiver aligns with the sender‘s desired response. In the context of communication targeting the rural communities, the message and the messenger must be such that conform with community norms, needs and aspirations. It is when this strategic alignment is achieved that communication can be said to be efficient and effective. Effective health communication is ―generally acknowledged to be central to effective healthcare. It is no longer seen as an add-on extra; rather it is recognised by many as being at the heart of patient care – as playing a pivotal role‖ (Berry, 2007:3).

Within the context of health communication, Oosterman, and Jop de Vrieze (March 2008:10) observe that:

To achieve effective communication, a culturally sensitive approach is required. Cultural sensitivity can be achieved by a combination of insight in the actual situation, up to date and reliable information about the health problem and knowledge of attractive and effective communication methods considering the subject and target group.

Because community radio is broadcasting at the grassroots level and speaking the same dialects with the people, its programming process is required to be culturally appropriate and its broadcasts, culturally sensitive. One of the major reasons for this is that its programme design, production and presentation are supposed to be done collaboratively with community members.

Active participation of beneficiaries and stakeholders in the communication is a critical success factor of any communication initiative. O‘Sullivan et al. (2003:4) believe health communicators have come to realize that collaboratively designed, implemented, and evaluated health communication strategies will help achieve the goal of improving health in a significant and lasting way by empowering people to change their behaviour and by facilitating social change. Sound communication strategies provide coherence for a health program‘s activities and enhance the health program‘s power to succeed.

For a health communication initiative to be a success, health message dissemination should follow certain criteria. These include accurate and culturally appropriate message; accessible channels that can deliver maximum reach at the lowest cost and a strong feedback mechanism. In its quest for achieving an impactful health communication programme, the United States Office of Disease Prevention and Health Promotion identified the following criteria as the critical success factors:

Accuracy: The content is valid and without errors of fact, interpretation, or judgment.

Availability: The content (whether targeted message or other information) is delivered or placed where the audience can access it. Placement varies according to the audience, message complexity, and purpose, ranging from interpersonal and social networks to billboards and mass transit signs to prime-time TV or radio, to public kiosks (print or electronic), to the Internet.

Balance: Where appropriate, the content presents the benefits and risks of potential actions or recognizes different and valid perspectives on the issue.

Consistency: The content remains internally consistent over time and also is consistent with information from other sources (the latter is a problem when other widely available content is not accurate or reliable).

Cultural Competence: The design, implementation, and evaluation process that accounts for special issues for select population groups (for example, ethnic, racial, and linguistic) and also educational levels and disability.

Evidence-based: Relevant scientific evidence that has undergone comprehensive review and rigorous analysis to formulate practice guidelines, performance measures, review criteria, and technology assessments for tele-health applications.

2.1.4 Challenges of Health Communication

In the sub-Sahara, a greater percentage of the population lives in the rural areas where there are no electricity, good roads and potable water. The Human Development Report (2014:3) indicated that three-quarters of the world‘s poor live in rural areas, where agricultural workers suffer the highest prevalence of poverty. Approximately two-thirds of the population of sub-Saharan Africa still live in rural areas and rely largely on near subsistence agriculture or traditional pastoralism for their livelihoods (United Nations: 2006). These infrastructural challenges also have ripple effects on other services, including public health delivery. Ilo and Adeyemi (2010:2), agreed that rural communities were seriously marginalized in terms of the requirements for development such as education, health care, and leisure activities.‘ As a result, communications within the public health sector often encounter challenges.

According to UNICEF, ‗Reaching people with information in remote areas remains a challenge in Mozambique, where over half the population is illiterate and more than 55 per cent of households do not own a radio. In this context, interpersonal communication, community radio, drama and music are among the most effective forms of communication for development.‘ In terms of channels of communicating health information, especially in a rural Sub-Saharan Africa that is hard to reach and where most amenities are non-existent,

‗availability‘ and ‗reach‘ are very critical. The situation in the rural areas, which constitute the larger part of sub-Saharan Africa, requires a medium that is readily available to the people and capable of reaching the largest number of the population. This reality, probably, has propelled the penetration of radio broadcasting, especially community radio and its use for development interventions in the sub-region.

In acknowledging the role of community radio in development, Al-Hassan et al (2011:2) notes:

Community radio, to a large extent, if effectively organized, performs three main significant functions at the grass root level for rural development. Firstly, it promotes issues of agriculture, gender equality, education, trade and commerce, disaster, weather, natural calamities, poverty and social problems. Community radio is usually for the people, run by the people and owned by the people. Secondly, it enhances the capacities of local people to work together to tackle a range of social problems, including poverty and exclusion through radio. Lastly, it contributes to nurturing of the creative talents of the community and providing a forum for a diversity of opinions and information.

The above, of course, comes with some challenges including electricity, technical, administrative, and semantics. The transmitter and other equipment at the community radio are powered by electricity and so many community radio stations are in communities not connected to the national grid of public power supply. This places a huge financial burden of maintaining an alternative power source on the radio station that is required to be not- for-profit, for and by the community. Technical problems at community radio stations are not swiftly resolved due to lack of capacity and often, technician would have to come from the city to help. In the implementation of the strategic framework for health communication, especially in the rural sub-Saharan Africa, there are some socio-cultural and semantic challenges. Corcoran (2007:7) citing Pechmann and Reibling (2000), notes that using words from complex medical technology or abbreviating key terms can confuse messages and exclude the target audience, whereas using repetition has been positively found to influence communication.

As a health practitioner, the communication method will alter the importance of additional factors such as lexical content and body language (Corcoran: 2007). The goal of health communication is to ensure health literacy which will in turn lead to well-being of the people. Therefore, lexical and semantic issues must be addressed ab initio to avoid creating fatal gap in the dissemination of life-saving messages. The use of medical terms or professional jargons during communication with the generality of the people be they in urban or rural areas must be discouraged.

There are occasions when some health-related messages are at variance with certain cultural norms in the target communities. Instances include some misconceptions about HIV/AIDS: In Somalia, it is seen as a non-Islamic, foreigner‘s disease (Wheeler, 2003:5). In sub-Saharan Africa Flanagan (2001), Meel (2003) and Groce (2004) acknowledge the prevalence of the myth that having sex with a virgin cures HIV infection. In some parts of Ghana, being a hugely religious society, there is a misconception that the infection is a punishment for sin.

It is imperative, in designing and implementing a Health Communication strategy, to mainstream the culture of target community and the social behaviour of target population into the communication plan. The UK government Choosing health: making healthy choices easier white paper (DOH, 2004) identifies one fundamental and important problem with health messages: that it is not a lack of information in health, but that it is inconsistent, uncoordinated and out of step‘ (DOH, 2004: 21) with the way the population live their lives. This suggests perhaps that despite efforts from health practitioners, some messages are not as effective as they could be (Corcoran, 2007: 5).poor communication can lead to psychological damage, physical harm, litigation or, at worst, death.‘

2.1.5 Benefits of Health Communication

Despite the challenges of health communication, there are several benefits that development workers could leverage on to achieve greater impact. Effective health communication improves the health of individuals and the community through increased access to information that improves healthy living. The Office of Disease Prevention and Health Promotion in the U.S. Department of Health and Human Services notes that:

By strategically combining health IT tools and effective health communication processes, there is the potential to improve health care quality and safety; increase the efficiency of health care and public health service delivery; improve the public health information infrastructure; support care in the community and at home. Also, it facilitates clinical and consumer decision-making and build health skills and knowledge.

Building health skills and knowledge leads to attitudinal and behavioural changes which are the desired outcomes of effective health communication. Achalu, et. al., (2015:746) in their discussion observe that:

Health communication assists the individual in passing from the state of awareness and interest to the final stage of decision-making and adoption of the new idea or programme. The expansion of communication channels and health issues on public agenda increase competition for people‘s time and attention. Now people have more opportunities to select information based on their personal interests and preferences.

Information is knowledge and knowledge is not only power but health. Health information and knowledge provide choices and greater opportunities to resolves health issues.

According to the National Cancer Institute of the United States, health communication can Increase the intended audience‘s knowledge and awareness of a health issue, problem, or solution; influence perceptions, beliefs, and attitudes that may change social norms; prompt action; demonstrate or illustrate healthy skills; reinforce knowledge, attitudes, or behaviour; show the benefit of behaviour change; advocate a position on a health issue or policy; increase demand or support for health services; refute myths and misconceptions; and strengthen organizational relationships (Making Health Communication Programs Work, 2001:3).

The above contexts of health promotion and disease prevention are quite instructive and reflective of the purpose of Corona virus communication, especially in rural sub-Sahara.

The goal of a health communication process should be to first increase the level of awareness, highlight healthy behaviour and its benefits with a view to stimulating the adoption of such a healthy behaviour as demonstrated in the communication. Rim-Rukeh and Ogbemi (2008:29) argue that health communication can contribute to all aspects of disease prevention and health promotion. Health communication is broad. It involves public health information, strategic communication, health education, among others. It goes beyond communication through the mass media to include even communication between medical doctors and their patients. To appropriate the full benefits of health communication, the message, the messenger and the channel must be culturally sensitive and appropriate. The communication process must be participatory and engaging to amplify the voices of the affected and others in the community. Rim-Rukeh and Ogbemi (2008:34-35) in their study of environmental sanitation in Woji community in Port Harcourt Nigeria, propose that a beneficial health communication process must have accurate content and target audience; reach the target audience and be consistent over time, as well as be culturally relevant.

This is reinforced by Communication For Social Change (CFSC) which focuses on using communication to empower people, with an emphasis on: Social and political contexts; Amplifying voices of those most affected; Enabling people most affected to use communication to shape the health/development agenda; Internally driven change; Understanding and helping to shape empowered communication environments (UNAIDS:

2.2 THE CORONA VIRUS DISEASE 2019

At the end of 2019, a series of pneumonia cases of unknown cause emerged in Wuhan (Hubei, China). A few weeks later, in January 2020, deep sequencing analysis from lower respiratory tract samples identified a novel virus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as causative agent for that observed pneumonia cluster. On February 11th, 2020, the World Health Organization (WHO) Director-General, Dr. Tedros Adhanom Ghebreyesus, named the disease caused by the SARS-CoV-2 as “COVID-19”, and by March 11th, 2020 when the number of countries involved was 114, with more than 118,000 cases and over 4000 deaths, the WHO declared the pandemic status. Corona Virus Disease 2019 (COVID-19) is an RNA virus, with a typical crown-like appearance under an electron microscope due to the presence of glycoprotein spikes on its envelope. It is not the first time that a coronavirus causing an epidemic has been a significant global health threat: in November 2019, an outbreak of coronaviruses (CoVs) with severe acute respiratory syndrome (SARS)-CoV started in the Chinese province of Guangdong and again, in September 2012 the Middle East respiratory syndrome (MERS)-Co V appeared. There are four genera of CoVs: (I) α-coronavirus (alphaCoV), (II) β-coronavirus (betaCoV) probably present in bats and rodents, while (III) δ-coronavirus (deltaCoV), and (IV) γ-coronavirus (gammaCoV) probably represent avian species. The virus has a natural and zoonotic origin: two scenarios that can plausibly explain the origin of SARS-CoV2 are:

(i) natural selection in an animal host before zoonotic transfer; and (ii) natural selection in humans following zoonotic transfer [5,6]. Clinical features and risk factors are highly variable, making the clinical severity range from asymptomatic to fatal. Understanding of COVID-19 is on-going. This review aims to summarize early findings on the epidemiology, clinical features, diagnosis, management, and prevention of COVID-19.

2.2.1 Epidemiology

The COVID-19 epidemic expanded in early December from Wuhan, China’s 7th most populous city, throughout China and was then exported to a growing number of countries. The first confirmed case of COVID-19 outside China was diagnosed on 13th January 2020 in Bangkok (Thailand). On the 2nd of March 2020, 67 territories outside mainland China had reported 8565 confirmed cases of COVID-19 with 132 deaths, as well as significant community transmission occurring in several countries worldwide, including Iran and Italy and it was declared a global pandemic by the WHO on the 11th of March 2020. The number of confirmed cases is constantly increasing worldwide and after Asian and European regions, a steep increase in cases is currently (31 March 2020) being observed in low-income countries. It is problematic to quantify the exact size of this pandemia as it would necessary to count all cases including not only severe and symptomatic cases but also mild ones [11]. Unfortunately, to date, there is not a global and standard response to the pandemia and each country is facing the crisis based on their own possibilities, expertise and hypotheses. Thus, there are different criteria for testing, hospitalisation and estimating of cases making it difficult to calculate the number of people affected by epidemic. Based on the data we have so far, the estimated case fatality ratio among medically attended patients is approximately 2%, but, also in this case, a true ratio may not be known for some time.

Today, 31st of March 2020, based on the WHO reports, we have globally 693,224 confirmed cases and 33,106 deaths, distributed as follows: Western Pacific Region 103,775 cases and 3649 deaths, European Region 392,757 cases and 29,962 deaths, South East Asia Region 4084 cases and 158 deaths, Eastern Mediterranean Region 46,329 cases and 2813 deaths, Region of the Americas 142,081 cases and 2457 deaths and in the Africa region 3486 cases and 60 deaths.

2.2.2 Pathophysiology and Clinical Manifestation

To address the pathogenetic mechanisms of SARS-CoV-2, its viral structure and genome must be considered. Coronaviruses are enveloped positive strand RNA viruses with the largest known RNA genomes—30–32 kb—with a 5j-cap structure and 3j-poly-A tail. Starting from the viral RNA, the synthesis of polyprotein 1a/1ab (pp1a/pp1ab) in the host is realized. The transcription works through the replication-transcription complex (RCT) organized in double-membrane vesicles and via the synthesis of subgenomic RNAs (sgRNAs) sequences. Of note, transcription termination occurs at transcription regulatory sequences, located between the so-called open reading frames (ORFs) that work as templates for the production of subgenomic mRNAs. In the atypical CoV genome, at least six ORFs can be present. Among these, a frameshift between ORF1a and ORF1b guides the production of both pp1a and pp1ab polypeptides that are processed by virally encoded chymotrypsin-like protease (3CLpro) or main protease (Mpro), as well as one or two papain-like proteases for producing 16 non-structural proteins (nsps). Apart from ORF1a and ORF1b, other ORFs encode for structural proteins, including spike, membrane, envelope, and nucleocapsid proteins and accessory proteic chains. Different CoVs present special structural and accessory proteins translated by dedicated sgRNAs. Pathophysiology and virulence mechanisms of CoVs, and therefore also of SARS-CoV-2 have links to the function of the nsps and structural proteins. For instance, research has underlined that nsps are able to block the host innate immune response. Among the functions of the structural proteins, the envelope has a crucial role in virus pathogenicity as it promotes viral assembly and release.

The pathogenic mechanism that produces pneumonia seems to be particularly complex. The data so far available seem to indicate that the viral infection is capable of producing an excessive immune reaction in the host. In some cases, a reaction takes place, which as a whole is labelled a “cytokine storm”. The effect is extensive tissue damage. The protagonist of this storm is interleukin 6 (IL-6). IL-6 is produced by activated leukocytes and acts on a large number of cells and tissues. It is able to promote the differentiation of B lymphocytes, promotes the growth of some categories of cells, and inhibits the growth of others. It also stimulates the production of acute phase proteins and plays an important role in thermoregulation, in bone maintenance and in the functionality of the central nervous system. Although the main role played by IL-6 is pro-inflammatory, it can also have anti-inflammatory effects. In turn, IL-6 increases during inflammatory diseases, infections, autoimmune disorders, cardiovascular diseases and some types of cancer. It is also implicated into the pathogenesis of the cytokine release syndrome (CRS) that is an acute systemic inflammatory syndrome characterized by fever and multiple organ dysfunction.

The virus might pass through the mucous membranes, especially nasal and larynx mucosa, then enters the lungs through the respiratory tract. Then the virus would attack the targeting organs that express angiotensin converting enzyme 2 (ACE2), such as the lungs, heart, renal system and gastrointestinal tract. The virus begins a second attack, causing the patient’s condition to aggravate around 7 to 14 days after onset. B lymphocyte reduction may occur early in the disease, which may affect antibody production in the patient. Besides, the inflammatory factors associated with diseases mainly containing IL-6 were significantly increased, which also contributed to the aggravation of the disease around 2 to 10 days after onset.

The clinical spectrum of COVID-19 varies from asymptomatic or paucisymptomatic forms to clinical conditions characterized by severe respiratory failure that necessitates mechanical ventilation and support in an intensive care unit (ICU), to multiorgan and systemic manifestations in terms of sepsis, septic shock, and multiple organ dysfunction syndromes (MODS). Asymptomatic infections have also been described, but their frequency is unknown. The main symptoms are reported in Table 1. Pneumonia appears to be the most frequent serious manifestation of infection, characterized primarily by fever, cough, dyspnea, and bilateral infiltrates on chest imaging. There are no specific clinical features that can yet reliably distinguish COVID-19 from other viral respiratory infections. Other, less common symptoms have included headaches, sore throat, and rhinorrhea. In addition to respiratory symptoms, gastrointestinal symptoms (e.g., nausea and diarrhea) have also been reported, and in some patients they may be the presenting complaint. Respiratory droplet transmission is the main route and it can also be transmitted through person-to-person contacts by asymptomatic carriers.

Main COVID-19-associated symptoms.

Fever

Cough

Dyspnea

Headach

Sore throat

Rhinorrhea

Chest CT in patients with COVID-19 most commonly demonstrates ground-glass opacification with or without consolidative abnormalities, consistent with viral pneumonia. Chest CT abnormalities are more likely to be bilateral, have a peripheral distribution, and involve the lower lobes. Less common findings include pleural thickening, pleural effusion, and lymphadenopathy. Chest CT may be helpful in making the diagnosis, but no finding can completely rule in or rule out the possibility of COVID-19. The possibility of COVID-19 should be considered primarily in patients with new onset fever and/or respiratory tract symptoms (e.g., cough, dyspnea). It should also be considered in patients with severe lower respiratory tract illness without any clear cause. Although these syndromes can occur with other viral respiratory illnesses, the likelihood of COVID-19 is increased if the patient [26]:

1. resides in or has travelled within the prior 14 days to a location where there is community transmission of SARS-CoV-2 (i.e., large numbers of cases that cannot be linked to specific transmission chains);

(2) has had close contact with a confirmed or suspected case of COVID-19 in the prior 14 days, including through work in health care settings. Close contact includes being within approximately six feet (about two meters) of a patient for a prolonged period of time while not wearing personal protective equipment or having direct contact with infectious secretions while not wearing personal protective equipment.

The period from the onset of COVID-19 symptoms to death ranges from 6 to 41 days with a median of 14 days. This period is dependent on the age of the patient and status of the patient’s immune system. It was shorter among patients >70-years old compared with those under the age of 70 years. The most common symptoms at onset of COVID-19 illness are fever, cough, and fatigue, while other symptoms include sputum production, headache, haemoptysis, diarrhoea, dyspnoea, and lymphopenia.

The WHO has reported an incubation period for COVID-19 between 2 and 10 days. However, some literature suggests that the incubation period can last longer than two weeks and it is possible that a very long incubation period could reflect double exposure. Many studies support a 14-day medical observation period for people exposed to the pathogen. The severity of the clinical picture seems to be correlated with age (>70 years), comorbidities such as: diabetes, chronic obstructive pulmonary disease (COPD), hypertension, obesity and male sex but currently no scientifically valid explanations have been developed.

2.2.4 Diagnosis

For patients with suspected infection, the following diagnosis techniques are utilised: performing real-time fluorescence (RT-PCR) to detect the positive nucleic acid of SARS-CoV-2 in sputum, throat swabs, and secretions of the lower respiratory tract samples. In patients with COVID-19, the white blood cell count can vary. Leukopenia, leukocytosis, and lymphopenia have been reported, although lymphopenia appears most common . Elevated lactate dehydrogenase and ferritin levels are common, and elevated aminotransferase levels have also been described. On admission, many patients with pneumonia have normal serum procalcitonin levels; however, in those requiring ICU care, they are more likely to be elevated. High D-dimer levels and more severe lymphopenia have been associated with mortality. Imaging findings—Chest computed tomography (CT) in patients with COVID-19 most commonly demonstrates ground-glass opacification with or without consolidative abnormalities, consistent with viral pneumonia. Others study have suggested that chest CT abnormalities are more likely to be bilateral, have a peripheral distribution, and involve the lower lobes. Less common findings include pleural thickening, pleural effusion, and lymphadenopathy [23–25]. Chest CT may be helpful in making the diagnosis, but no finding can completely rule in or rule out the possibility of COVID-19.

An oropharyngeal swab can be collected but is not essential; if collected, it should be placed in the same container as the nasopharyngeal specimen. An oropharyngeal swab is an acceptable alternative if nasopharyngeal swabs are unavailable. Expectorated sputum should be collected from patients with productive cough; induction of sputum is not recommended. A lower respiratory tract aspirate or bronchoalveolar lavage should be collected from patients who are intubated. Data from this study suggested that viral RNA levels are higher and more frequently detected in nasal compared with oral specimens, although only eight nasal swabs were tested. SARS-CoV-2 RNA is detected by reverse-transcription polymerase chain reaction (RT-PCR). A positive test for SARS-CoV-2 generally confirms the diagnosis of COVID-19, although false-positive tests are possible. If initial testing is negative but the suspicion for COVID-19 remains, the WHO recommends resampling and testing from multiple respiratory tract sites. The accuracy and predictive values of SARS-CoV-2 testing have not been systematically evaluated. Negative RT-PCR tests on oropharyngeal swabs despite CT findings suggestive of viral pneumonia have been reported in some patients who ultimately tested positive for SARS-CoV-2. Serologic tests, once generally available, should be able to identify patients who have either current or previous infection but a negative PCR test. Coinfection with SARS-CoV-2 and other respiratory viruses, including influenza, has been reported, and this may impact management decisions.

2.2.5 Management

There is no specific antiviral treatment recommended for COVID-19, and no vaccine is currently available. The treatment is symptomatic, and oxygen therapy represents the major treatment intervention for patients with severe infection. Mechanical ventilation may be necessary in cases of respiratory failure refractory to oxygen therapy, whereas hemodynamic support is essential for managing septic shock. Different strategies can be used depending on the severity of the patient and local epidemiology. Home management is appropriate for asymptomatic or paucisintomatic patients. They need a daily assessment of body temperature, blood pressure, oxygen saturation and respiratory symptoms for about 14 days. Management of such patients should focus on prevention of transmission to others and monitoring for clinical status with prompt hospitalization if needed. Outpatients with COVID-19 should stay at home and try to separate themselves from other people in the household. They should wear a face mask when in the same room (or vehicle) as other people and when presenting to health care settings. Disinfection of frequently touched surfaces is also important. The optimal duration of home isolation is uncertain, but in consideration of incubation time around 14 days without symptoms (fever, dyspnoea, others) are considered sufficient to end home isolation.

Some patients with suspected or documented COVID-19 have severe disease that warrants hospital care. Management of such patients consists of ensuring appropriate infection control, and supportive care. Patients with severe disease often need oxygenation support. High-flow oxygen and noninvasive positive pressure ventilation have been used. Some patients may develop acute respiratory distress syndrome and warrant intubation with mechanical ventilation; extracorporeal membrane oxygenation may be indicated in patients with refractory hypoxia.

A number of investigational agents are being explored for antiviral treatment of COVID-19, and enrolment in clinical trials should be discussed with patients or their proxies. Certain investigational agents have been described in observational studies or are being used anecdotally based on in vitro or extrapolated evidence. It is important to emphasize that there are no controlled data supporting the use of any of these agents, and their efficacy for COVID-19 is unknown.

Remdesivir is a novel nucleotide analogue that has activity against SARS-CoV-2 in vitro and related coronaviruses (including SARS and MERS-CoV) both in vitro and in animal studies. The compassionate use of remdesivir through an investigational new drug application has been described in various studies. Any clinical impact of remdesivir on COVID-19 remains unknown.

Chloroquine and hydroxychloroquine have antiviral activity in vitro, as well as anti-inflammatory activities. They act on interference with the cellular receptor ACE2, on impairment of acidificationof endosomes and on activity against many pro-inflammatory cytokines (e.g., IL-1 and IL-6) [46,47]. Other experiments have shown that azithromycin in combination with hydroxychloroquine appeared to have additional benefit, but there are methodologic concerns about the control groups for the study, and the biologic basis for using azithromycin in this setting is unclear [48].Despite the limited clinical data, given the relative safety of short-term use of hydroxychloroquine (with or without azithromycin), the lack of known effective interventions, and the in vitro antiviral activity, some clinicians think it is reasonable to use one or both of these agents in hospitalized patients with severe or risk for severe infection, particularly if they are not eligible for other clinical trials. The possibility of drug toxicity (including QT interval (QTc) prolongation and retinal toxicity) should be considered prior to using hydroxychloroquine, particularly in individuals who may be more susceptible to these effects including epilepsy, porphyria, myasthenia gravis, and retinal pathology—glucose-6-phosphate dehydrogenase (G6PD) deficiency.

Tocilizumab is a recombinant humanized monoclonal antibody which binds to the interleukin-6 (IL-6) receptor and blocks it from functioning. It is used for patients with severe COVID-19 and elevated IL-6 levels; the agent is being evaluated in a clinical trial [50].

Lopinavir-ritonavir appears to have little to no role in the treatment of SARS-CoV-2 infection. This combined protease inhibitor, which has primarily been used for HIV infection, has in vitro activity against the SARS-CoV and appears to have some activity against MERS-CoV in animal studies. However, there was no difference in time to clinical improvement or mortality at 28 days in a randomized trial of 199 patients with severe COVID-19 given lopinavir-ritonavir (400/100 mg) twice daily for 14 days in addition to standard care versus those who received standard of care alone. Moreover, limited evidence are available for baraticinib, a numb-associated kinase (NAK) inhibitor, with a particularly high affinity for the kinase AAK1, a pivotal regulator of clathrin-mediated endocytosis, anakinra, an anti IL-1, used in some UTI settings in Lombardy, Italy, and faviparavir a RNA-dependent RNA-polymerase inhibitor.

Support oxygen therapy with high-flow nasal oxygen (HFNO) should be used only in selected patients with hypoxemic respiratory failure. Compared with standard oxygen therapy, HFNO reduces the need for intubation. Patients with hypercapnia, hemodynamic instability, multiorgan failure, or abnormal mental status should generally not receive HFNO, although emerging data suggest that HFNO may be safe in patients with mild-moderate and non-worsening hypercapnia. Non-invasive ventilation (NIV) patients treated with either HFNO or NIV should be closely monitored for clinical deterioration. Mechanical ventilation is the main supportive treatment for critically ill patients. In positive patients with a D-Dimer value four times higher than the normal limit, and without anticoagulant contraindications, ananticoagulation therapy isrecommended. The French

Medicines Agency on its official page, warns of thepossible harmful effectsof nonsteroidal anti-inflammatory drugs (NSAIDs). The European Medicines Agency (EMA), for its part, undertakes to carry out an investigation in this regard and collect data but is not reluctant to advise against its use, however, it is advisable to prudently take paracetamol in the first instance.

Interestingly, there is hypothesis of the link between angiotensin converting enzyme (ACE) inhibitors and COVID-19. Indeed, SARS-CoV-2 uses ACE receptor 2 for entry into target and in animal experiments both lisinopril and losartan can significantly increase mRNA expression of cardiac ACE2. If this were the case, we might be able to reduce the risk of fatal COVID-19 courses in many patients by temporarily replacing these drugs. Existing literature strongly recommends that healthy patients continue therapy, and in hospitalized patients to modify ACE-I/ARB with other therapy (calcium channel blockers).

2.2.6 Prevention

Prevention is, so far, the best practice in order to reduce the impact of COVID-19 considering the lack of effective treatment. At the moment, there is no vaccine available and the best prevention is to avoid exposure to the virus. In order to achieve this goal, the main measures are the following:

1. to use face masks;
2. to cover coughs and sneezes with tissues;
3. to wash hands regularly with soap or disinfection with hand sanitiser containing at least 60% alcohol;
4. to avoid contact with infected people;
5. to maintain an appropriate distance from people; and

(6) to refrain from touching eyes, nose, and mouth with unwashed hands (Table 3). Interestingly, the WHO issued detailed guidelines including: (I) Regularly and thoroughly clean your hands with an alcohol-based hand rub or wash them with soap and water; (II) Avoid touching eyes, nose and mouth; (III) Practice respiratory hygiene covering your mouth and nose with your bent elbow or tissue when you cough or sneeze;

(IV) If you have fever, cough and difficulty breathing, seek medical care early; (V) Stay informed and

follow advice given by your healthcare provider; (VI) Maintain at least 1 m (3 feet) distance between yourself and anyone who is coughing or sneezing. In particular, regarding the use of face mask, health care workers are recommended to use particulate respirators such as those certified N95 or Filtering FacePiece 2 (FFP2) when performing aerosol-generating procedures and to use medical masks while providing any care to suspected or confirmed cases. Moreover, while an individual without respiratory symptoms is not required to wear a medical mask when in public, people with respiratory symptoms are advised to use medical masks both in health care and home care settings.

<!--td {border: 1px solid #cccccc;}br {mso-data-placement:same-cell;}-->PERCEPTION OF MASS MEDIA AS TOOLS FOR SENSITIZING RURAL DWELLERS ABOUT INFECTIOUS EPIDEMIC A CASE STUDY OF CORONA VIRUS IN NIGERIA

2.2.7 Future Perspective

The COVID-19 outbreak is proving to be an unprecedented disaster, especially in the most afflicted countries including China, Italy, Iran and USA in all aspects, especially health, social and economic. It is too early to forecast any realistic scenario, but it will have a strong impact worldwide. If high income countries, especially those already affected by the outbreak, seem to face a catastrophic perspective, in low-income countries there seem to be two possible scenarios. In particular, in the worst-case scenario, when the COVID-19 outbreaks, the majority of countries will be unprepared, with low resources allocated for affording the viral emergency and the consequences will be catastrophic. In the best case scenario, similarly to the global outbreak of the SARS-CoV in 2003, also the COVID-19 will not affect Africa or South America on a large scale suggesting that respiratory viruses spread more effectively in the winter and, therefore, the southern hemisphere will be affected later in the year, if at all. To this could contribute also the climate-specific cultural differences (living more outdoors than indoors), the effect of UV light on the survival of the virus on surfaces, immunological differences of the population (innate immunity), preexposure with coronaviruses, or the higher temperatures. This data was also indirectly supported by Chin and colleagues that artificially reproduced different environmental conditions in order to study the virus survival capacity. In addition to this hopeful low impact, if the prevention measures will be implemented, we could register a lower incidence of hygiene-linked diseases that still represent leading causes of death