Background: Since the beginning of the coronavirus disease 2019 (COVID-19) epidemic in Iran, the control and management of the epidemic were headed by the National Headquarter for the Control of COVID-19 Epidemic through setting up different scientific committees, including the COVID-19 National Epidemiology Committee. The present study reviews the missions, structures, achievements, and challenges of the Epidemiology Committee.Study design: A rapid reviewMethods: All relevant reports, documents, guidelines, published literature, and surveillance data related to the establishment, visions, missions, roles, activities, and outputs of the COVID-19 Epidemiology Committee were critically reviewed in this study.Results: The efforts of the committee’s working groups may have impacted improvements in data registration/usage, provincial data quality at provincial levels, and perception of the epidemic situation in the provinces. The committees have also played role in informing the policies in different stages of the epidemic through routine or problem-based data/evidence analyses, epidemic investigations, and mathematical modeling.Conclusions: The structure and experience gained by the committee can be used in similar situations within and outside the country. To further improve the impacts of our activities, it is essential to have effective interaction, collaboration, and data flow between the committee and a broad range of organizations within and outside the Ministry of Health and Medical Education. Iran was among the first countries infected with the virus after the epidemic in Wuhan, China . The primary cases in Iran were identified and reported on 19 February 2020 in Qom . Soon after that, many more cases were identified in other provinces of the country, with some provinces being highly affected in the early phase of the epidemic, including Tehran, Gilan, Mazandaran, Qom, and Golestan .Since the beginning of 2020, the coronavirus disease 2019 (COVID-19) pandemic has affected more than 200 countries worldwide, with millions of infections and thousands of mortalities .Since the start of the epidemic, Iran has adopted a wide range of control policies in order to mitigate the rate of epidemic spread. One of the key efforts involved the establishment of the National Headquarter for the Control of COVID-19 Epidemic (NHCCE). The Supreme National Security Council assigned headquarters as the principal entity responsible for the development and communication of COVID-19 mitigation policies. The council appointed Iran’s minister of health as the leader of the NHCCE  After the establishment of the NHCCE, different scientific committees were formed by the NHCCE leader in order to provide scientific support for mitigation policies in each area. The COVID-19 National Epidemiology Committee, as one of these scientific committees, was formed in February 2020 in the Ministry of Health and Medical Education (MoHME). This study reviews the missions, objectives, structures, achievements, and challenges of the National COVID-19 Epidemiology Committee in Iran by October 2020.. It has been discussed that countries that have had and used their previous experiences in dealing with emerging infections, such as China and South Korea, have been better able to efficiently respond to the COVID-19 pandemic . Notably, some countries without previous experience also acted successfully in responding to the epidemic. The experience of these countries is of high value and needs to be disseminated in more detail. Some of the known lessons from New Zealand’s pandemic response include rapid science-based risk assessment linked to early decisive government action, implementation of interventions at various levels , provision of empathic leadership, and effective communication of key messages to the public by the prime minister . For the experiences to be re-usable, it is necessary to have them published. In many countries, different health sectors/committees/disciplines have initiated publishing their experiences and lessons learned from responding to the COVID-19 pandemic .Learning from experiences has been widely recommended by leadership scholars  This review aimed to convey the experience gained by the COVID-19 Epidemiology Committee in Iran, including the lessons learned by all its achievements and shortcomings/barriers, to help leaders better organize similar activities in the future. The mission is to compile the results of local and international epidemiological studies, mathematical models, and expert opinions in order to promote evidence-oriented policymaking. To achieve this goal, the committee has the following objectives:The investigation of the current status and prediction of the trend of COVID-19 in the country The investigation of the epidemiological models of COVID-19 in the country and the world Leading the epidemic investigations of COVID-19 at national and subnational levels A review of the documents and findings of studies published in high-standard scientific journals about COVID-19  The current study critically reviewed all relevant reports, documents, guidelines, published literature, and surveillance data related to the establishment, visions, missions, roles, activities, and outputs of the COVID-19 Epidemiology Committee in Iran. A. Intrasectoral collaborators A diverse group of multidisciplinary intrasectoral collaborators is deemed necessary to accomplish the missions of the committee. Therefore, the committee collaborates with the following entities as its major intrasectoral collaborators:The NHCCE Vice-Chancellor of Health Affairs, MoHME, Iran Vice-Chancellor in Treatment Affairs, MoHME, Iran Deputy of Research and Technology, MoHME, Iran Food and Drug Organization, MoHME, Iran Deputy of Nursing, MoHME, Iran Statistics and Information Technology Center, MoHME, Iran National Diagnostic Laboratory Network, Pasteur Institute of Iran Medical Sciences universities  B. Intersectoral collaboratorsWorld Health Organization Country Office, Iran Iranian Academy of Medical Sciences, Iran Research Center of the Islamic Consultative Assembly, Iran Sharif University of Technology, Iran  In order to achieve its missions, a wide range of expertise formed the core members of the COVID-19 Epidemiology Committee. The composition brings together scientific and/or executive managers/members in various health-related fields, either in the MoHME or medical universities. This has provided a more comprehensive perspective of the epidemic features. Such diversity has also facilitated the intersectoral communication and information flow with the areas at the disposal of committee members. In addition to its core members, the committee has a close working relationship with more than 100 colleagues. These colleagues mainly collaborate within one or more working groups of the committee.A diverse set of working groups was formed in order to aid the committee to achieve its objectives. The description of each working group and its main tasks, outputs, and achievements are provided below. Description and objectives: The objectives of the COVID-19 Surveillance Data Management Core Group include compiling, organizing, cleaning, and analyzing COVID-19 surveillance data. The National COVID-19 data are deposited in some independent databases , which contain the clinical data of hospitalized suspected and confirmed COVID-19 cases, and SIB portal, which contains outpatients’ data and screening information. The working group manages data cleaning and analysis, the main results of which are communicated with policymakers to inform decision processes. The working group also uses the data to monitor the accuracy of surveillance data collection, registration, and flow from the local settings  to upper levels within the MoHME. Feedback is provided to the working entities whenever needed.Outputs and impacts: The work performed in this group has improved data registration of hospitals and medical universities. The results of these analyses have also informed the preliminary case definition and clinical management guidelines for COVID-19 in Iran and many decisions processed to control the epidemic in the country. B. Provincial Epidemiology SubcommitteeDescription and objectives: This working group was formed to facilitate the provision of high-resolution perspectives on the epidemiological features of COVID-19 within each province. To this end, provincial COVID-19 epidemiology committees were formed in each province. The committees were responsible for leading province-level outbreak investigation, contact tracing, epidemiological data gathering, and surveillance data cleaning and analysis. The committees were responsible for providing weekly reports about the epidemiological profile of the province to the National Epidemiology Committee. Feedbacks were provided whenever needed. The National COVID-19 Epidemiology Committee also facilitated logistic issues faced by the provincial committees.Outputs and impacts: During the early months of the epidemic, investigations were weekly prepared by provincial committees and dispatched to the COVID-19 Epidemiology Committee. Subsequently, the reports were sent once a month. These reports are now the premise of provincial determination and intervention measures. C. Analysis of Provincial Epidemic TrendsDescription and objectives: This working group aimed to determine the epidemic trend of COVID-19 in different provinces of Iran. Accordingly, since the beginning of the epidemic and based on the rate of COVID-19 cumulative incidence, the provinces of Iran are classified into three categories, namely high-, medium-, and low-incidence provinces. The provinces can move between these categories over time given their epidemic status. The trend of daily confirmed cases and mortalities are analyzed every 7 days. In each analysis, the changes in the number of confirmed and mortality cases within the past 5 days are calculated by averaging the numbers in a specified day and a day before and after that. Given the trend of morbidity and mortality, the provincial trend is inferred as upward, downward, or stable. These analyses show if a province approaches a new epidemic pick or has passed one. Provinces with controversial data can also be detected in these analyses, where the source of controversy can then be identified.Outputs and impacts: The factsheets published by this working group provided the policymakers at the MoHME and medical universities with information about the possible course of the epidemic in different provinces. These analyses can detect incompatibility in the data of the provinces. In such cases, the feedback was immediately provided for the province, which has ultimately improved the reporting quality of the provinces. D. National Daily Situation Reports for COVID-19Description and objectives: The National Daily Situation Reports for COVID-19 working group was formed to provide national COVID-19 situation reports for a broad audience of caring individuals within and outside the country. The national COVID-19 surveillance data is being analyzed, validated, and aggregated. The data sources for daily reports mainly include the MCMC and HIS databases (for inpatients) as well as the SIB portal (for outpatients). The reports contain basic epidemiological features of confirmed and mortality cases, including the national daily trend of infection, mortality, and recovery, age and gender distributions, prevalence of different comorbidities, and trends of case fatality rate and intensive care unit admission.Outputs and impacts: By 20 October 2020, 62 daily situation reports have been released by the National Epidemiology Committee both in Persian and English, some of which have provided basic information required for policymaking either in the clinical or public health settings (access to daily situation reports ). E. Model-Based Analyses and Forecast of COVID-19 TrendDescription and objectives: To inform the decision, the modeling working group was responsible for the development of simulation-based analyses to respond to the questions coming up over the course of the epidemic. For this purpose, the first modeling report forecasted the possible number of COVID-19 infections, hospitalizations, and mortalities in the whole country and Tehran  using compartmental dynamic models. The first modeling report was the estimation of the number of medical equipment required under different levels of social distancing. The results were used to inform policies and practices at the moment. The models were developed based on a domestic model in collaboration with Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran, and using an international developed model  in collaboration with the University of Oxford, England. Other models that are developed upon emerging practical questions include the prediction of the effects of closing schools and universities, holy shrines, and other nonpharmaceutical interventions on the number of COVID-19 infections, hospitalizations, and mortalities. Moreover, some reports on the burden of disease and economic impact of the epidemic were prepared (access to daily situation reports ).Outputs and impacts: Eight policy reports (seven based on domestic models and one based on the CoMo model) were delivered to the MoHME, evaluating the effect of interventions or predicting future trends. F. Evidence Mapping and SummarizationDescription and objectives: The mission of this working group is the improvement of the current research awareness by providing the audiences with a summary report of the high-quality evidence in Persian. Major activities include the provision of summary research and journal watches in Persian. To this end, scientific information and research results of COVID-19 from various international and domestic credible sources, including scientific journals, related organizations, news agencies, and research centers, are collected by a group of 20 students and health experts every day. The topics cover various aspects of COVID-19. The summarization task is performed using a standard “data extraction” template. The template contains different headings that should be filled, including “main results”, “key message of the study”, “study title”, “article publication date”, “journal name”, “target audiences”, “study samples”, “conclusions”, and “lessons to be learned”. These summaries are utilized by a wide range of audiences, including policymakers, managers, therapists, and the general population.Similar to the reports of other working groups, the above-mentioned documents are also uploaded regularly on the official website of the COVID-19 Epidemiology Committee. These materials are also distributed within a broad network of audiences either in hard copy or electronic formats. Outputs and impacts: Within the 4 months, more than 850 evidence summaries have been uploaded, receiving more than 200,000 website views by the target audiences. The process takes about 2-3 h every day. G. Documentation Core GroupDescription and objectives: The objectives of this working group were to share Iran experiences for the control of the COVID-19 pandemic that can be used in future emergencies, document efforts/ interventions, success stories, challenges, innovations, and suggestions for the better management of emergencies by the chancellor of universities, all relevant sectors, and senior management within MoHME. In addition to its core members, this working group enjoyed the collaboration and engagement of a focal point from each of the universities of medical sciences and health services and a focal point from 28 relevant departments within MoHME. This working group interviewed around 30 heads of the organization and deputy ministers from other sectors that were documented in one of the below-published documents.Outputs and impacts: To date, four documents have been published that are summarized below. In addition, two others are on the way . 1. Islamic Republic of Iran actions in prevention, diagnosis, and management of COVID-19 that is published in 150 copies in 88 pages and shared on different websites. The document summarizes MoHME policies, strategies, and action points during the first 2 months of the pandemic in 6 main sections, namely governance, action points, international and public relations, emergency unit and Red Crescent actions, provision of medicines and personal protective equipment, and medical education, research, and students affairs. 2. “The First-Line Care Providers” that is published in 100 copies in 70 pages. Considering substantial efforts of the care providers, namely community health workers at rural health houses, family experts at urban health posts, nurses and midwives at hospitals, and emergency and laboratory experts, it was decided to document some examples of dedicated and sacrificed efforts of these first-line care providers in the current review. 3. Intersectoral Collaboration and Partnership is published in 200 copies in 164 pages and shared on different websites. In this study, the researchers identified a few relevant questions related to each sector and made an appointment with the head of the organization/deputy ministers in different sectors. The members of the documentation committee were divided into three main groups and met the highest authority within the relevant sectors. The main interventions, challenges, innovations, and suggestions for improvement in emergency management were also among the key questions raised in these interviews. 4. Preparedness and Response for the Control of COVID-19 (in English) in Islamic Republic of Iran that is published in 200 copies in 82 pages and shared on different websites in addition to shared hard copies to all United Nation agencies and foreign embassies located in Tehran. To share the policies, strategies and main interventions of Iran in controlling the COVID-19 pandemic and in line with Global World Health Organization guidelines for emergency preparedness and response, this document is prepared in partnership and coordination with the relevant departments within MoHME. The main contents of the document include epidemiological studies, health governance, policies and strategies for the prevention, diagnosis, and treatment of COVID-19, screening standards, implementation of health protocols, use of the Primary Health Care (PHC) network in national screening, community engagement and empowerment, international collaboration and partnership, summary of nursing, midwifery, and emergency units, and Red Crescent Society and environmental health protocols and standards. The field and scope of the work in the Epidemiology Committee have a strong inter/intra-organizational character. To convert COVID-19-relevant data and information into policy, it is required to have effective communication, collaboration, and data/information flow between the committee and a wide range of sectors/organizations within and outside MoHME. To date, one of the main challenges has been effective and timely coordination between the committee and these sectors. The COVID-19 surveillance data are deposited in more than one database, with different databases covering part of the data, such as laboratory, outpatient, and inpatient data. Combining the aforementioned databases poses important challenges in data cleaning, data verification, and linkage of different databases. On the other hand, while putting the stress on COVID-19 data registration in the local settings has led to the completeness of the data, it has also had important side effects. Firstly, the efforts have already posed a heavy workload to the local staff, leading to occupational burnout in some staff. Secondly, emphasizing the diagnosis and data registration of COVID-19 has overshadowed the surveillance of other respiratory infections, especially influenza. Finally, the infection of some of the committee’s key members with COVID-19 during the early phases of the epidemic diminished the workforce that could actively collaborate with the committee to fulfill its missions. This challenge highlighted the necessity of protection against infection for those involved in critical positions during the epidemics. The structure and the experience gained by the committee can be used in similar situations within and outside the country. To further improve the impacts of our activities, it is essential to have effective interaction, collaboration, and data flow between the committee and a broad range of organizations within and outside the MoHME. We would like to thank all the colleagues in the working groups of the Epidemiology committee who contributed to the defined activities, and helped the committee to achieve its goals. Aliakbar Haghdoost holds the position of the Deputy Minister of Education in MoHME and Mohammad Mehdi Gouya holds the position of the head of Iran’s Center for Disease Control and Prevention in MoHME. The rest of the authors declare that there is no conflict of interest. The authors received no funding for this study.Activities: Data curing, modeling, outbreak analysis, evidence mapping, and documentation.The compilation of coronavirus disease 2019-related data from different sources remains a challenge.Rapid committee formation helped in keeping pace with the epidemic growth rate.


This obituary highlights a number of contributions by Professor Jan Beneken (1934–2021) to modeling of human physiology and pharmacology and to simulation-based training. European modeling and simulation pioneer Professor Jan Beneken, born in Arnhem, The Netherlands on 20 March 1934, passed away in Eindhoven, The Netherlands, on 23 September 2021. This obituary focusses on the impact of Dr. Beneken on simulation-based training, established via his groundbreaking research on modeling of human physiology and pharmacology, via his mentorship of the team at the University of Florida that invented the Human Patient Simulator, and via the recent Jan Beneken conferences.Dr. Beneken obtained his electrical engineering degree from the University of Delft, The Netherlands, in 1958, and his PhD in mathematics and natural sciences from the University of Utrecht, The Netherlands, in 1965. After working for the Netherlands Organization for Applied Scientific Research, he became a full-time professor of Medical Electrical Engineering at the Technical University, Eindhoven, The Netherlands, and served in that function from 1973 until 1995. He was the dean of the Faculty of Electrical Engineering from 1993 until 1995. He was the first president of the COMAC-BME, a coordinating committee of the European Commission for the research area Biomedical Engineering, from 1982 until 1990. He was a co-founder of the European Society for Engineering and Medicine (ESEM), and one of the founders of the journal Technology in Healthcare [His 1965 PhD thesis  presentsDrs. Beneken and Joachim (Nik) Gravenstein acted as mentors to the team at the University of Florida that invented the Human Patient Simulator between 1988 and 1994 , 7. TogeTwo Jan Beneken conferences on modeling and simulation of human physiology took place in Eindhoven, The Netherlands, in 2013, and in Nijmegen, The Netherlands, in 2015. These conferences brought together several generations of Dutch and some other European modelers. Dr. Beneken was actively involved in the organization of the conferences and a stimulating presence during the debates. In 2017, the conference was held at the University of Twente, Enschede, The Netherlands, and with Dr. Beneken’s assent renamed to Applied Modeling in Acute Care (AMAC). The broader international coverage of the conferences was confirmed in 2019, when the conference was held in Canberra, Australia. The keynote lecture was given by Nobel prize winner Dr. Brian Schmidt, and Dr. Debra Nestel, Editor in Chief of Advances in Simulation at the time, presented a plenary lecture. Dr. Beneken pre-recorded a brief overview of his career and presented the Jan Beneken award to a promising young modeling researcher from the Australian National University  Via his research on modeling of human physiology and pharmacology, his mentorship of the team that invented the Human Patient Simulator, and his active participation in the conferences that bear his name, Professor Jan Beneken (1934-2021) made decisive contributions to simulation-based training in Europe and beyond.


Objective: This study aimed to examine the effectiveness of containment strategies and mitigation strategies to provide a reference for controlling the ongoing global spread of the pandemic.Methods: We extracted publicly available data from various official websites between January 1 and December 31, 2020, summarized the strategies implemented in China, South Korea, Singapore, the United States, the United Kingdom, and France, and assessed the effectiveness of the prevention and control measures adopted by these countries with the daily new cases and mortality rate per 100,000 population.Results: China, South Korea, and Singapore adopted containment strategies, which maintained a proactive approach by identifying and managing cases, tracking and isolating close contacts. China and Singapore had a similar epidemic curve and the new daily cases. As of December 31, 2020, the new daily cases of China and Singapore were below 100 with the mortality rates per 100,000 population of 0.3 and 0.5, respectively. But the new daily case of South Korea was as high as 1,029, with a mortality rate per 100,000 population of 1.8. In contrast, the United States, the United Kingdom, and France responded with mitigation strategies that focus on treating severe cases and those with underlying conditions. They had similar epidemic curves and mortality rates per 100,000 population. The United States had up to 234,133 new confirmed cases per day, and the mortality rate per 100,000 population was 107, while the United Kingdom had 56,029 new confirmed cases per day and the mortality rate per 100,000 population was 108, and France had 20,042 new cases per day, with a mortality rate per 100,000 population of 99.Conclusions: China, Korea, and Singapore, which implemented strict containment measures, had significant outbreak control. Meanwhile, the successful practices in China, Singapore, and South Korea show that the containment strategies were practices that work especially at the individual level identifying and managing the infected patients and their close contacts. In the United States, the United Kingdom, and France, which implemented the mitigation policies, the effect of epidemic prevention and control was not significant that the epidemic continued or even increased epidemic relatively quickly. The coronavirus disease 2019 (COVID-19) is continuing to spread worldwide. As of Feb 23, 2021, the COVID-19 outbreak has caused 112,222,860 confirmed cases and 2,483,930 death cases. The number of new cases outside China exceeded 290,000, the total of confirmed cases was more than 110 million, and the total number of death cases was more than 2.47 million  outbreak in 2015 and the severe acute respiratory syndrome (SARS) outbreak in 2003, respectively, in responding to COVID-19. Based on the three core principles of openness, transparency, and creative innovation, South Korea was able to effectively implement the strategy of 3Ts of testing, tracing, and treatment . HoweverCompared with China, South Korea, and Singapore, where the COVID-19 infections occurred earlier, the United States, the United Kingdom, and France seemed slow to respond to the COVID-19 outbreak and preferred to adopt mitigation strategies. The aggressive measures of the US federal government could date back to a national emergency declaration on March 13, 2020. Since then, the United States has adopted a combination of “containment” and “mitigation” strategies, with multiple channels and means of response and increasing support for prevention and control.The government did not take more measures to control the COVID-19 epidemic before mid-March, 2020. However, the British government began implementing the mitigation strategies based on the theory of “herd immunity” until the outbreak in Italy and Spain were nearly out of control in March due to the confirmed cases of Italy was exceeded 5,000 per day, and total deaths exceeded 1,000; and the confirmed cases of Spain was nearly 10,000 per day, and total deaths exceeded 1,000 , 13. SubAs shown in Whether in the new confirmed cases per day, or the mortality rate per 100,000 population, the difference is significantly remarkable between China, South Korea, and Singapore, which implemented the containment strategies, and the United States, the United Kingdom, and France, which took the mitigation strategies. There are differences in healthcare workers, health systems, health authority model, political systems, and cultural customs among China, South Korea, Singapore, the United States, the United Kingdom, and France, so their prevention and control strategies combat the COVID-19 outbreak differ. China, South Korea, and Singapore have maintained a proactive approach in responding to the COVID-19 outbreak by identifying and managing cases, tracking and isolating close contacts, and strictly restricting or controlling population movement when feasible and appropriate. Although no large-scale embargoes were implemented in Singapore and South Korea, and the outbreak rebounded in South Korea, these three countries have adopted a containment strategy based on the nature of prevention and control policies. In contrast, the United States, the United Kingdom, and France have implemented nationwide lockdown; however, these three countries focus on treating the severe cases and those with underlying conditions, and they have implemented measures that are essentially mitigation strategies.China's experience with SARS exposed weaknesses in the public health system and prompted a rethink of epidemic prevention policies. The government subsequently invested 6.8 billion RMB (US$850 million) to establish a new three-level network of disease control and prevention systems . MeanwhiSimilar to China, after the SARS epidemic in 2003, Singapore invested a lot of resources in improving its epidemic prevention system, establishing an interdepartmental working group pre-planning system that can be activated immediately when it encounters a public health crisis and operates in a whole-of-government manner. It has also established a public health system that includes community general clinics, public hospitals, and the National Centre for Infectious Diseases , 22. SinSouth Korea experienced a public health crisis caused by MERS in 2015, which exposed a weakness in the national health disaster response system. Since then, improvements have been made at all levels and throughout the public and private health sectors to protect society from the threat of emerging infectious diseases , 24. AftThe United States is a wealthy country and has a well-developed healthcare system, but it has relatively poor health status and healthcare coverage and does not provide its population with the best and most equitable healthcare treatment. The US insurance system is primarily based on private employers, and individual coverage is voluntary . Based oThe United Kingdom has a well-established and respected universal healthcare system (NHS) that invests heavily in public health, but the shortage of personal protective equipment (PPE) and the deaths of healthcare workers in the early phases of pandemic posed a significant risk to the patients and healthcare workers . MeanwhiFrance benefits from its universal health insurance system, relatively large number of healthcare professionals and hospital beds, but the French system is complex, and the notoriously weak coordination between the different parts of the care system makes it more difficult for primary and social care providers and hospitals to mount a joint response. In addition, France experienced months-long protests and strikes by healthcare workers before the COVID-19 outbreak coming . In factThis study found that each country has implemented a series of non-pharmaceutical interventions at four levels of the epidemic: containment and surveillance, healthcare, border control, and community and society, but the effectiveness of the prevention and control measures were different among these six countries. China, South Korea, and Singapore, due to their experience with previous MERS and SARS epidemics, responding quickly, implementing strict interventions, and control the spread of the epidemic to keep the daily new cases and mortality rate per 100,000 population low. However, there are differences in the group behaviors of social people, such as community closure, home isolation, and social behavior self-discipline. In China, when a COVID-19 case was confirmed in a region, the community was immediately put under strict control or even lockdown, and large-scale nucleic acid testing of residents in the community, as well as tracing and home quarantine of close contacts. In addition, criminal detention will be imposed on those who conceal their travel and hinder the prevention and control of the epidemic. Also, people must wear masks to take public transports or to enter public places.In Singapore, mask-wearing continues to be mandatory in public transport and all public places . In addiIn contrast, the United States, the United Kingdom, and France, due to their lenient approach at the beginning of the epidemic, made the subsequent fight against the epidemic more difficult. Although a series of non-pharmaceutical interventions were implemented, and these countries have initiated vaccination programs for COVID-19, the results seem to be less than satisfactory. Of course, there are some reasons why implementing a strict containment strategy is simply not possible in the United States, the United Kingdom, and France. There are at least two reasons for this. The primary reason is that these are homes of intense liberal democratic norms, and the government cannot simply impose any type of lockdown. In Sweden, it is even constitutionally forbidden to impose lockdown unless there is a war . There wThis study compared prevention and control strategies among China, Singapore, South Korea, the United States, the United Kingdom, and France, and examined the effectiveness of containment strategies and mitigation strategies. However, this study also has limitations that need to be considered. Other studies should be developed in order to confirm what has been achieved. Such as we can further work on the population-based epidemiological studies, respectively, in these six countries to improve non-pharmaceutical interventions.Based on this study it seems that China, Korea, and Singapore, which implemented strict containment measures, had significant outbreak control. In the United States, the United Kingdom, and France, which implemented mitigation policies, the effect of epidemic prevention and control was not significant that the epidemic continued or even increased relatively quickly. However, until the vaccine is globally available and effective, countries still need to address the current COVID-19 epidemic with non-pharmacological measures to avoid further damage. Meanwhile, the successful practices in China, Singapore, and South Korea show that containment strategies were practices that work especially at the individual level identifying and managing infected patients and their close contacts.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.HC and GS conceived the paper and study guarantors. HC, YZ, XW, MY, and JJ collected the data. HC drafted the manuscript. LS, YZ, XW, MY, and JJ revised the manuscript. GS contributed to the critical revision of the manuscript for important intellectual content and approved the final version of the manuscript. All authors have read and approved the final manuscript.This work was supported by the National Social Science Fund of China (no. 16BGL184).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Disruptive behavior creates a dysfunctional culture that has a negative impact on work relations and influences the quality of care and safety of the patient. The objective of the present work is to provide the best methodological quality scientific evidence available on disruptive behavior at a hospital, the aspect associated with the safety of the patient, and its impact on quality of care. For this, we included studies that addressed the prevalence of disruptive behaviors observed in the area of hospital health and its professionals. The selection, eligibility, data extraction and evaluation of the risk of bias stages were conducted by two researchers, and any discrepancies were solved by a third researcher. The data presented show that disruptive behaviors are frequently observed in the daily life of health professionals, and compromise the quality of care, the safety of the patient, and can lead to adverse effects. The results presented indicate that the appearance of disruptive behaviors compromises the quality of care, the safety of the patient, and the appearance of adverse effects, and can also affect the physical and mental health of the health professionals. PROSPERO registration number: CRD42021248798. Although no clear consensus exists about the definition of disruptive behavior, authors agree that it creates a dysfunctional culture that has a negative impact on work relations, making difficult interpersonal communication and influencing the quality of care and safety of the patient ,5,6,7,8.According to Meneses et al. , the maiIn 2008, the Joint Commission International (JCAHO) considered disruptive behavior as threatening, inappropriate behavior, which has a deconstructive effect on the culture of safety, and for this reason, considered it as a Sentinel Event Alert 40, indicating the importance of preventing, managing, and controlling these behaviors among health professionals, including the managing board of the organization. It proposes eleven institutional strategies, highlighting effective and affective leadership and communication. It states that it is the responsibility of the institution to control a hostile environment and provide a proactive culture for safer care, aside from underlining the increase in healthcare costs .Disruptive behaviors are perceived by health professionals as predictors of adverse events (53%), negative impacts with damage to health care (73%), and a contributor to mortality (25%) . In thisHicks et al.  found a Therefore, the objective of the present systematic review is to provide the scientific evidence with the best methodological quality, on disruptive behavior at a hospital, the aspects related to the associated safety of the patient, and its impact on the quality of care.This systematic review study was conducted based on the updated version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses  ,17. ThisThe eligibility criteria adopted in the review are related to the research questions: Which are the most frequent disruptive behaviors in the hospital environment and what are their impacts on the safety of the patient? Which are the triggers of these disruptive behaviors perceived by the health professionals?Therefore, the inclusion criteria were chosen to start with a condition, context, and population (CoCoPop) . Thus, tAs result, studies with non-resident students and studies conducted strictly with the administration of hospital institutions were excluded.Initially, various search strategies were tried in each database. Based on the greater sensitivity and specificity, a standardized search strategy was defined, after which two researchers performed the search independently. The search terms and descriptors .After the search was conducted in the databases, the article files were collected with the application Rayyan, with which an initial verification was performed to detect the presence of duplicate articles.During the selection phase, the titles and abstracts of the articles were read to evaluate their compliance with the eligibility criteria. Then, the complete text of the articles selected was read. Additionally, the references from these articles were examined to detect studies that could be potentially relevant. At all the stages, two reviewers were responsible for the reading of the articles, and when a divergence was observed, a third reviewer was consulted.The general information and methodology utilized were collected from each study: title, first author, year of publication, country, the objective of the study, type of disruptive behavior and its frequency, impact on the safety of the patient, and quality of attention, and lastly, type of measuring tools, data analysis, and main results.The JBI scale (Joanna Bridges Institute)  was utilThe general information and the methods applied in the study were extracted. We collected the name of the authors and year of publication, the size of the sample, the measurement instruments utilized in the evaluation of disruptive behaviors, and the main results presented in each study. There was high heterogeneity in the characteristics and size of the samples, in the results, and in the measurement instruments. For these reasons, quantitative synthesis of the data was not possible.The search in the different databases provided 233 articles, which were screened to evaluate their eligibility. Of these, two were eliminated because they were duplicates. After reading the titles and abstracts, and after reading the complete articles, 12 articles were selected for their systematic review ,29,30,31Of the 12 studies selected, five were conducted in the Unites States ,26,28,29As for the measurement instruments, high heterogeneity was observed. Different types of scales and questionnaires, validated and adapted to each studied population, were applied. Additionally, these were provided printed or virtually ,29,30,31The consequences of these disruptive behaviors are documented by health professionals. It was observed that its occurrence can compromise the quality of care, patient safety, and lead to adverse effects ,21,25,27In general, the high prevalence of disruptive behaviors and consequences on the quality and safety of the patient, as well as the physical and mental damage of the health professionals re-enforces the need to monitor these behaviors and actions oriented towards collaborative work .With respect to the evaluation of the methodological quality, some weaknesses were found in the evaluation of the exposure, the definition of the criteria to standardize the measurement of the condition, the identification of confounding factors, and the strategies to face these variables . However, some studies showed an excellent methodological quality ,26,27.The results presented in this systematic review indicate that the appearance of disruptive behaviors can compromise the quality of care, the safety of the patient, and can lead to adverse effects. In the studies included, it was observed that these behaviors can affect the physical and mental health of the health professionals, independently of their profession and length of employment.At present, the studies on this subject are mainly cross-sectional, through the use of a questionnaire, and are mainly focused on four broad dimensions that are associated with the safety of the patient and the quality of care, considering the possible adverse effects experienced during the process of care derived from the different disruptive behaviors. These dimensions are: Motives and prevalence of disruptive behavior in the health context where the individual factors, the environmental factors, the organizational factors, and the social factors, are relevant, with important correlations observed between abuse and gender, physical abuse and position, and physical abuse and level of education that have generated at least one observed disruptive behavior ,32,33; pWith respect to the social-labor variables, a study that analyzed the reports of the notifications observed more disruptive behaviors in the category “physicians” (81%) compared to 52% in the category “nursing”. It was observed that these behaviors result in stress (97%), job dissatisfaction and compromised patient safety (53%), quality of care (72%) and errors (70%) .Another study addressed 2821 nurses, who indicated the existence of a relationship between disruptive behavior and gender. Women indicated that they suffered more verbal and physical abuse than men [The main limitation of the study is related to the absence of clinical trial studies on disruptive behaviors associated with patient safety. Given the heterogeneity of the studies included in the systematic review, a meta-analysis was not possible. Therefore, the findings of this systematic review have led to an update in scientific knowledge in this area, and the results can be further utilized to facilitate decision-making and the implementation of new health policies.The results presented in this systematic review indicate that the appearance of disruptive behaviors compromises the quality of care in the hospital setting. These disruptive behaviors  lead to negative consequences, such as the safety of the patient, the appearance of adverse effects, and can also affect the physical and mental health of the health professionals, independently of their profession and the length of employment. Most importantly, it is hoped that these data can be used to develop organizational policies to enhance the workplace and positive patient outcomes within a healthy work environment.


Working the One health strategy in developing countries is a challenge, due to structural weaknesses or deprivation of financial, human, and material resources. Brazil has policies and programs that would allow continuous and systematic monitoring of human, animal, and environmental health, recommending strategies for control and prevention. For animals, there are components of the Epidemiological Surveillance of zoonosis and Animal Health Programs. To guarantee food safety, there are Health Surveillance services and support of the Agropecuary Defense in the inspection of these products, productive environments, and their inputs. Environmental Surveillance Services monitor water and air quality, which may influence health. For human health, these and other services related to Health Surveillance, such as Worker Health and Epidemiological Surveillance, which has a training program responsible for forming professionals groups to respond effectively to emergencies in public health are available. Therefore, Brazil has instruments that may allow integrated planning and intervention based on the One Health initiative. However, the consolidation of this faces several challenges, such as insufficient resources, professional alienation, and lack of the recognition of the importance of animal and environmental health for the maintenance of human and planetary well-being. This culminates in disarticulation, lack of communication, and integration between organizations. Thus, efforts to share attributions and responsibilities must be consolidated, overcoming the verticality of the actions, promoting efficiency and effectiveness. Finally, this perspective aims to describe the government instruments that constitute potential national efforts and the challenges for the consolidation of the One Health initiative in Brazil. One Health is an integrative and cooperative health initiative, with a transdisciplinary approach to health promotion and surveillance at the local, regional, national or global level, aiming to achieve optimal health conditions, given the recognition of the interconnection and interdependence between human, animals, and the environment , 2.Historically, the perspective that environmental health affects humans has existed since the classical era. Hippocrates stated that biological and environmental conditions affect human health . Afterwath century, pathologist Robert Virchow coined the term “zoonosis,” to name diseases transmitted from animals to humans, based on his observations with helminths, believing that there is no separation between animal and human health , World Health Organization (WHO), Food and Agriculture Organization of the United Nations (FAO), and the World Organization for Animal Health (OIE) have recently established a cooperation to promote the perspective of One Health, encouraging the implementation of government policies and programs guided by it –11.To this end, the Global Health Security Agenda (GHSA) was signed in 2014 with more than 64 nations and international non-governmental organizations supporting the collaborative approach. This will accelerate the consolidation and compliance of the requirements from the OIE Terrestrial and Aquatic Animal Health Codes, the WHO International Health Regulations (IHR), and other global health regulations for planetary health , 12, 13.Despite the increase in rhetoric and support for the One Health model, it is difficult to find authentic examples of multidisciplinary or multi-sectoral efforts that transcend traditional public, animal, and environmental health “silos” , 14.The ability to face threats to public and animal health effectively and efficiently requires effort and proper planning. A prerequisite for this is the training and capacitation of the public and private health sectors. However, this, within the One Health strategy, remains a challenge, especially for developing countries. This stems from competing priorities, insufficient and fragmented funding, with a lack of integration and communication between sectors , 15.Some positive international experiences in this path have been reported, such as the One Health Workforce (OHW) project by the United States Agency for International Development (USAID). This aims to build partnerships with institutions and leaders in Africa and Southeast Asia to assist in the identification of technical, collaborative, and organizational characteristics, important for the development of the workforce in alignment with the goals established in the GHSA and by the Joint External Evaluation– International Health Regulations (JEE – IHR) , 17.In Latin America, the incorporation of the One Health strategy into government plans is timid and the integration of animal, environmental and human programs and sectors is insignificant –11.In Brazil, the One Health concept itself requires recognition by health professionals and is not acknowledged by important entities such as the Federal Council of Medicine. As an effect, the power of interventions and control strategies over the environmental causes of diseases is limited, and these activities are often restricted to veterinary professionals. On the other hand, public policies for Health Surveillance (HS) have allowed the gradual insertion of One Health supportive efforts in health practices, however with little integration between their organizations , 17, 18.An adequate surveillance system, with a strong laboratory network, is the key component of any disease prevention and control strategy. To develop an effective One Health implementation plan, it is necessary to reexamine how the existing systems are structured, resourced, and managed. These analyzes would contribute to the development and sustainability of the synergy between human, animal, and environmental health initiatives –14, 19.Thus, this perspective article aims to present the potential, successes and challenges of government health strategies, programs and policies in Brazil, from One Health point of view. The present discussion is based on the analysis of the official documents, legislation and health informational systems.One of the most important aspects of pathogen control at the human, animal, and environmental interface is the development of appropriate scientific-based Surveillance and Risk Management policies that respect transboundary regulations , 14, 19.In Brazil, there is a complex system for monitoring human, animal, and environmental health conditions, based on the Health Surveillance System (HSS) and in the use of epidemiology as a planning tool. This system is supported by organizations such as the Ministério da Agricultura Pecuária e Abastecimento- MAPA  and the Sistema Único de Saúde- SUS  and its respective policies, programs, regulations, and health information systems as summarized in Brazil's health system emerged due to an organizational restructuring and popular social movements. With the implementation of this universal and integral system, normative actions created for stimulation of the HSS, brought with it the redefinition of health practices, allowing their greater integration with epidemiology. This surveillance system is based on four main pillars, focused mainly on conditions that affect human health, namely: Epidemiological, Sanitary, Environmental and Occupational Health Surveillance Systems –15, 50.The National Environmental Health Surveillance System performs continuous and systematic monitoring of environmental conditions that may interfere with human and animal health such as water, soil, air, biological factors and vectors, environmental disasters, and accidents with contaminants. The operational instruments to make this viable are VIGIÁGUA , VIGIPEQ , VIGISOLO , VIGIAR , and VIGIDESASTRES  , 46–48.The Epidemiological (ES) component of the Surveillance System is responsible for systematic monitoring of adverse health events, and control measures proposition, consolidated by the National ES System and its sub-areas, allowing significant advances in the capacity to respond to health problems. ES monitors communicable and non-communicable diseases and other health problems, such as accidents, violence, and a strategic area, that performs Zoonosis Surveillance, recognizing the importance of the animal-human bond. The latter is responsible for monitoring the progress of animal diseases and accidents with venomous animals. The recognition of the importance of zoonotic diseases by the health system is extremely relevant; both for management and for the health care itself, since, on average 60–80% of human diseases are of animal origin , 51–53.In the context of ES, Brazil also has a Training program in Applied Epidemiology to the Services of the Unified Health System- EpiSUS, part of the Department of Surveillance of Communicable Diseases of the Health Surveillance System. This program counts with multidisciplinary teams, aiming to enhance the ability to respond to public health emergencies and encourage the exchange of professionals and experiences at national and international levels, to improve the national technical capacity in field epidemiology, becoming an international reference in this field , 53–57.The Occupational Health Surveillance, part of HSS, monitors occupational risk factors and determinants of human health conditions that are related to the production and labor processes, as well as the ones related to the work environment , 54–57.The Sanitary Surveillance System, coordinated by ANVISA, the national agency for Sanitary Surveillance, works in the regulation, control, and inspection of goods, products, and environments that are directly or indirectly related to health conditions, from production to consumption. It is recognized as a set of integrated institutional, administrative, programmatic, and social strategies, guided by public policies that aim the elimination, reduction, or prevention of individual and collective health risks, based on comprehensive services and actions that are essential to the health defense and promotion. This breadth of activities justifies the fact that these actions are developed as a democratic and participatory exercise and in an articulated way, to guarantee the quality of products, services, and environments, fundamental aspects for global health. Therefore, the Sanitary Surveillance is not restricted to purely technical actions, but its driving axes are actions aimed at the strengthening of the society and citizenship to promote health and preventing risks, damages or injuries , 55, 58.Also responsible for One Health, regarding animal health, food safety, trade and transit of products of animal and vegetable origin are the programs subjected to MAPA, the institution responsible for the National Agropecuary Defense , 57, 58.The Agropecuary Defense relates to all stages of agricultural and livestock production, since the registration and inspection of agricultural inputs; production, industrialization, inspection and trade of products and by-products of animal and vegetable origin; besides acting in the import and export of inputs and products, as well as in the transit of these products and animals. In this way, it would not only promote and protect animal, human and environmental health but also help to increase economic incentives by promoting security and adding value to agricultural products , 59–63.Also subject to the National Agricultural Defense services, are the Animal Health Programs, namely: National Equine Health Program, National Poultry Health Program, National Program for the Control and Eradication of Brucellosis and Tuberculosis, National Goat and Sheep Health Program, National Herbivore Rabies Control Program, National Apiculture Health Program, National Program for the Eradication and Prevention of Foot-and-Mouth Disease, coordinated by MAPA , 61–64.These programs aim to prevent, control, or eradicate diseases of public health importance or that may threaten international trade, ensuring animal health through health education activities; epidemiological studies; the inspection of breeding establishments, fiscalization of agricultural events and animal transit, notifying the occurrence of these diseases, in addition to guaranteeing the competitive value of the products in the international market , 61–64.Furthermore, an operational instrument for Agropecuary Defense is VIGIAGRO, MAPA's instance that regulates the flow of animals, products, and agricultural inputs in frontiers, to ensure their safety and quality, preventing or minimizing potential risks to the One health , 64–66.In this construct, the programs and services presented have the potential for the insertion of the multidisciplinary and integrative approach of One Health, with intra and intersectoral collaboration Tis approach is appropriate to the current context of growing concerns about the consequences of the interactions between humans, animals, and the environment, in a productive framework based on capitalist ideals , 67–69.The importance of the policies and operationalization referred in this perspective article is acknowledged, but several challenges are found for the consolidation of its potential, the main ones being the disarticulation, the verticality of the actions, and the overlapping of attributions –5.The central goals of the One Health model include altering the organization's work from a vertical and hierarchical approach to a horizontal and integrated one, in addition to moving from individual “silos” to a transdisciplinary functioning , 2, 14.The difficulties in achieving these goals and in the integration between the spheres that work animal, human, and environmental health start in the professional training of those who work in these fields. Few individuals enter the workforce with crosscutting skills to thrive in transdisciplinary or multi-sectoral teams , 15.The increase in the number and distribution of qualified personnel has proved to be one of the main limitations in most developing regions. This limitation, added to the financial, structural, and bureaucratic constraint faced by this sector, prevents it from satisfactorily exercising its potential, putting global health at risk .The need and benefits of an integrated surveillance system to better understand the emergence and epidemiology of diseases have been demonstrated. This should count with a health care notification system and a comprehensive national database including environmental monitoring, human and animal health diagnostic systems, essential components of an integrated surveillance system, and for the implementation of One Health –15, 61.Brazil has all these components, but they do not articulate or communicate. Even more, they sometimes overlap their attributions and compete for authority and hierarchy. The information produced by different organizations, rarely crosses that 'silo' that produced them, even though it could support health actions as a whole, producing and using information and communication in a shared way, to better instrumentalize the intervention .For example, information on the incidence and prevalence of work-related illnesses could be used to modify production processes, minimizing the risks and potential damage. The occurrence of water and foodborne diseases could contribute to the improvement of the performance of Agropecuary Defense, among others. Just as, information about environmental health can be useful to guide all production processes, to help understanding the epidemiology and natural history of diseases, allowing the intervention in their origins. This would promote cheaper, more assertive, and definitive solutions to health problems and demands, making individuals, animals, and the environment healthier, more productive, and sustainable –15.While some progress has been done, there is a need for continued investment and political commitment to address the persistent challenges in public health. As it can be seen in the The One Health initiatives are of complex consolidation from both a political, technical, and sanitary perspective , 14, 15.The lack of articulation and use of health information for planning interventions can be evidenced with a contemporary example. The COVID-19 pandemic and the recent worsening of it at the national level in early 2021 are the results of a lack of planning and intervention by governmental health spheres that have proved inefficient and non-resolute. Instead of applying the information, fees, numbers to equip their infrastructure and instruct their professionals, the highest governmental spheres have chosen to hide and fragment the health information consolidated by the Epidemiological Surveillance Systems and not apply it for planning and structuring measures to mitigate the health crisis –72.The integration and articulation between health actions, organizations, and policies would promote greater effectiveness and efficiency of health interventions, promoting global health and expanding the response capacity. However, there are still restrict limits to the autonomy of federal entities in Brazil, perpetuating an excess of verticality in programs and decisions, which makes it difficult to move toward the integration of surveillance systems in the perspective of democratizing the health practices , 59, 73.The action of these entities and services should be in the sense of sharing attributions and responsibilities, without leaving behind the technical specification of each of the areas. This would imply new roles, as well as new dynamics, relationships, and innovative practices at all levels, which denotes the complexity and challenge of its implementation , 73, 74.Thus, it is proposed to work, from the One Health approach, in an articulated and integrated set of actions, which assume specific configurations according to the environmental, animal, and human health situation of each territory, transcending the institutionalized spaces of the health services system, the verticality, and hierarchy of agencies and programs. Thus, seeking a dialogue between “cause control,” “risk control” and “damage control” through the redefinition of the object, the means of work, activities, and technical and social relations , 13, 15.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The authors contributed equally to all phases of the manuscript construction and revision.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


It has been 5 months since the COVID-19 outbroke in Wuhan, China, at the end of 2019. Despite the small sigh of relief in China, the situation seems to be growing more intense in the rest of the world, as the number of cases of confirmed SARS-CoV-2 infection continues to increase. What is truly worrying is the condition of healthcare professionals. On March 25th, the number of medical personnel with confirmed infection had reached nearly 6,500 in Spain, representing almost 14% of the country's total cases, while in Italy, there was about 7,400, nearly one-tenth of its total cases , including masks, gowns, gloves, and eye protection. As far as we know, however, surging demand for PPE has become a major issue in different areas that has given rise to an interregional scramble for medical resources, potentially intensifying the stress of the disadvantaged areas Durkee, . The shoThe COVID-19 pandemic is a global issue that no one can face alone. During the height of the epidemic, the Chinese government made every effort to curb outbreaks, mobilizing nationwide resources to support the fierce battle in Hubei, specifically in Wuhan (Chinese Center for Disease Control and Prevention, Meanwhile, Guangdong, the most crowded province in China with a population of 115.21 million (Statistics Bureau of Guangdong Province, The government acted quickly. Guangdong launched the first level response to major public health emergencies in late January (Health Commission of Guangdong Province, Health workers have been getting the attention they deserve. A series of comprehensive, supportive policies for frontline medical staff, issued on February by the Guangdong government (Xinkuaibao, In response to the shortage of PPEs, the government called for a strengthening of the coordination of the production, supply, and distribution of medical supplies, ensuring the supply of important materials and giving priority to the needs of frontline medical staff and patients. They also established an online reporting system for inventory based on a comprehensive investigation of the stock and consumption; in addition, they established a system for the coordination of allocating supplies at the provincial and municipal levels to resolve the urgent shortages through centralized mobilization and emergency allocation (Southern Metropolis Daily, The joint effort of the government and the public showed to be effective on flattening the curve in the province with over one hundred million people: by May 1st, the total number of confirmed infections in Guangdong was 1,588, with only eight cases of death (Health Commission of Guangdong Province, According to our experience in the past 4 months, it is vitally important to consider how to wisely collect and manage the medical resources during this challenging time, and it is crucial that available resources are made full use of wherever they are needed. It can be an option to address the shortages of medical supplies and workforces by facilitating international collaboration and interregional exchange or share of resources, experiences, and ideas, if possible.Strategies regarding how to protect and preserve the healthcare workforces should be developed, with careful consideration of the roles for older personnel (Buerhaus et al., In addition, offering accessible mental health services under the direction of expert psychotherapists or psychiatrists for workers in need should be considered. Such measures include but are not limited to: providing a safe, undisturbed space for rest and expressing concerns and emotions; helping to deal with negative feelings potentially associated with an unusual amount of deaths and critical patients; and providing information about how to identify and cope with the mental issues of patients or themselves, such as irritability, serious anxiety, or panic attacks.All in all, it is crucial to ensure accessible resources work at their full capacity and to protect and support healthcare workers, in order to sustain the normal function of health systems all over the world in this crisis. Hopefully, more collaboration and coordination will help us bring the war to an early end.YH, MW, and BZ have contributed to the conception, editing, and revision of the manuscript, approve the final version to be published, and agree to be accountable for all aspects of the work.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Oral cancer represents a worldwide public health problem, being among the most prevalent, associated with high morbidity and mortality rates. This systematic review aimed to review the causes of the delayed diagnosis of oral cancer mainly in the elderly, in developed and developing countries. Search strategy was developed for MEDLINE databases (via PubMed), EMBASE, Web of Science, SCOPUS, and LILACS and for grey literature , without language or period restrictions. The risk of bias was assessed using instruments from the Joanna Briggs Institute and the quality of evidence according to the GRADE system. The search resulted in 14,473 records, of which only 13 met the eligibility criteria. The total sample was 1,705 participants, with a predominance of males. All studies included reported causes of delayed diagnosis of oral cancer related to the patient and five also reported causes related to health professionals. The scarce knowledge of the population was pointed out as the main cause of delayed diagnosis of this cancer. Regarding the risk of bias, ten studies were classified as low risk and three, as moderate risk. The quality of the evidence was very low for the outcome related to delayed diagnosis of oral cancer. Wide dissemination of information on oral cancer is needed, especially for the elderly, such as its initial signs and symptoms, in developed and developing countries. Further studies should be conducted to better understand the causes of delayed diagnosis of oral cancer in countries with different socioeconomic statuses. Key words:Delayed diagnosis, mouth neoplasms, oral neoplasm, aged. Oral cancer is among the ten most prevalent types of cancer in the world, associated with high mortality and morbidity rates, representing a worldwide public health problem. This cancer is more frequent in men aged over 40 years and has multifactorial etiology, resulting from the interaction of several risk factors, being the main ones smoking and excessive consumption of alcoholic beverages . In the These projections show the importance of knowing the characteristics of oral cancer, enabling the promotion of preventive actions and early diagnosis . These aThe stages of tumors are classified according to the Classification System of Malignant Tumors (TNM) recommended by the International Union for Cancer Control (UCC). They receive graduations based on the anatomical extension of the disease, usually from T0 to T4, from N0 to N3, and from M0 to M1. The first one (T), respectively, consider the characteristics of the primary tumor, the second (N) the characteristics of the lymph nodes of the lymphatic drainage chains of the organ in which the tumor is located, and the M the presence or absence of distant metastases. T3 or T4 classifications represent advanced stages of cancer , which a- Protocol and registerThis review was reported according to the items of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) . A study- Eligibility criteriaThe acronym PECOS  was used to formulate the research question of this systematic review, the population was defined as the elderly, the exposure as oral cancer, the primary outcome as causes of delay, and the study design as observational ones. Therefore, the following question was established: "Is there a difference in the causes of the delayed diagnosis of oral cancer mainly in the elderly in developed and developing countries?"The inclusion criteria consisted of observational studies, without language or period restriction, which evaluated the diagnosis of oral cancer in the elderly. The following exclusion criteria were applied: 1) studies that did not include participants aged 60 years or older; 2) studies that did not evaluate the causes of late diagnosis; 3) studies that did not report data related to the causes of late diagnosis only for oral cancer; 4) studies that performed evaluations only to the treatment of oral cancer. Furthermore, experimental studies, reviews, letters, abstracts, opinion articles, case reports, case series, and book chapters were excluded.This review was conducted to verify the causes of the delayed diagnosis, especially in the elderly, due to the high incidence of oral cancer in this population and the frequent presence of unfavorable systemic conditions, which hinder the diagnosis, treatment and cure of this disease . Given tFinally, the criteria proposed by the United Nations Development Programme (UNDP) of the United Nations (UN) was adopted to classify developed and developing countries. These criteria are based on the degree of wealth, level of industrialization and development, Gross Domestic Product (GDP), per capita income, and the Human Development Index (HDI), which represents a comparative measure of countries regarding wealth, literacy, education, life expectancy and birth expectancy .- Search strategyThe literature search was conducted by two independent researchers [AMCL and CSLDP], at MEDLINE databases (via PubMed), EMBASE, Web of Science, SCOPUS and LILACS, and in the gray literature .With the collaboration of a librarian, a search strategy was set up for PubMed and adapted to the other databases. The strategy adopted sought to rescue as many studies as possible related to the subject. For this, the descriptors indexed in the Health Science Descriptors (DeCS) and in the Medical Subject Headings (Mesh Terms) were used, with the Boolean operators AND and OR, as described in - Selection of the studiesThe reference manager, Mendeley® Desktop, was used to remove duplicate records and organize primary studies.The study selection process was carried out in two phases and independently by two reviewers [AMCL and CSLDP]. In the first phase, the two reviewers used Rayyan software (Qatar Computing Research Institute) to exclude studies that did not meet the eligibility criteria . In the - Data extraction and qualitative synthesisThe information of the selected studies was collected by the first reviewer [AMCL] and confirmed by the second reviewer [CSLDP]. The data collected were: author, year of publication, country of study, type of study, general sample, participants’ age, sample loss, form of data collection, and reported causes for the delayed diagnosis of oral cancer.- Assessment of methodological qualityThe methodological quality was evaluated using checklists for analytical cross-sectional and qualitative studies from Joanna Briggs Institute ,14. IndeThe evaluation of methodological heterogeneity among the eligible studies was evaluated regarding the study design, the sample , quality of measurements and results. Finally, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to classify the quality of evidence for the outcome related to the delayed diagnosis of oral cancer, according to the following criteria: risk of bias, inconsistency, indirect evidence, inaccuracy or publication bias. Based on the GRADE criteria, for each serious concern, a level of evidence was lowered and non-randomized clinical studies started with a low classification .Initially, 13,708 records were identified from the electronic databases and gray literature. After excluding duplicates, 9,284 were analyzed with the reading of titles and abstracts, and 71 articles were selected for full reading. After that, 59 articles were excluded because they did not meet the eligibility criteria, resulting in 12 articles included. A search update was carried out in May 2021, where 764 records were identified. After excluding duplicates, 626 studies were analyzed with the reading of titles and abstracts, selecting 01 article for full reading, which was included, resulting in 13 articles included in this review (Fig. All studies reported causes of delayed diagnosis of oral cancer related to the patient and 5 also reported causes of delayed diagnosis related to health professionals. Among the causes of delay related to the patient, the lack of knowledge about oral cancer, its risk factors and the signs and symptoms of the disease were reported in all studies. These aspects are due to the difficulty of visualization and identification of the initial lesions, neglect of the signs and initial symptoms due to absence of pain, without impairment of function, leading the participants to consider the symptoms as normal and something secondary. Hope for spontaneous cure, self-medication, fear of diagnosis and coping with the disease, financial restrictions and difficulty in accessing specialized professionals were also reported ,17-28.The causes of delay related to professionals were reported in only five studies, four of them conducted in developing countries -20 and o- Characteristics of the studiesOf the included studies, 13 were observational, four retrospective and two qualitative, published between 1994 and 2020 . Of thes- Methodological qualityMost of the included studies presented a low risk of bias in their evaluation. Of the 11 observational studies, eight presented low risk of bias and three moderate risk Fig. . For theThe results of this systematic review indicate that the population's lack of knowledge about the signs and symptoms of oral cancer and the devaluation of self-care are extremely related to the delayed diagnosis of this cancer.The sample studies performed their analyzes considering the elderly population along with other age groups, with no reporting of categorizations. A higher prevalence of participants aged ≥ 60 years was identified in the sample, resulting in the hypothesis of greater delay in the diagnosis of oral cancer in this population. Regarding gender in the incidence of oral cancer, the prevalence of males in the sample corroborates other primary studies not included in this review and data from the World Health Organization . This diThe studies conducted in developed and developing countries included in this review identified the difficulty of visualization and/or identification of oral lesions and the absence of symptoms of the initial lesions as the main cause in the delayed diagnosis of oral cancer related to the patient ,17-28. Tet al. [2006] (In developing countries, fear of diagnosis and negative coping with the disease were also reported as causes of patient delay, probably related to the negative belief of the population that a cancer diagnosis is a death sentence ,18,24. S. 2006]  in the U  in the et al. [2016] (In developed countries, the population has greater access to health services when compared to developing countries, which does not always happen when it comes to a specialized service. As reported in the study by Ligier . [2016] , which c. [2016] , the popAlthough it has not been reported in the studies included in this review, some authors associate the presence of comorbidities with the delay in the diagnosis of oral cancer. This suggests that patients already debilitated, due to the presence of other diseases, especially those dependent or bedridden, ignore or deny new oral symptoms . The impWith the severity of the pandemic, anxiety and the population’s fear of becoming infected with COVID-19 has led patients to underestimate the signs and symptoms of other serious diseases, which may lead to delays in the diagnosis of oral cancer . Thus, tet al. [2003] (Among the included studies that evaluated the causes of the delayed diagnosis of oral cancer related to professionals in developing countries, the difficulty in recognizing oral cancer lesions early, incorrect diagnosis, and wrong treatments were prevalent. These causes were also reported in the study by Onizawa . 2003] , perform. [2003] ,17-20.03 , perfThe early diagnosis of oral cancer contributes to the implementation of appropriate treatment in early stages of disease evolution, with less invasive surgeries, faster convalescence and better patient survival . On the The methodological quality analysis showed that most studies presented a low risk of bias. However, there was a high methodological heterogeneity among the included studies, related to the use of several instruments to analyze the delayed diagnosis and the inclusion of a wide age group, which hindered summarizing and comparing the results, limiting this review. Some studies did not present the clinical staging of tumors through the TNM System, information relevant to the classification of late diagnosis of oral cancer. Moreover, the possible loss of information in retrospective studies and the lack of studies conducted simultaneously in developed and developing countries, adopting the same methodology, hindering comparing more accurately and analyzing the results carefully. The low level of awareness and knowledge about oral cancer by the population and health professionals shows the need for actions aimed at health education with an emphasis on prevention and early diagnosis of oral cancer, to reduce the high mortality and morbidity rates and, consequently, improve the survival of the population, especially the elderly. The causes of oral cancer delayed diagnosis in countries with different socioeconomic statuses need further clarification.Despite the lack of methodological standardization, the causes of delayed oral cancer diagnosis were related to the scarce knowledge of patients and health professionals in developed and developing countries. A proposal for a future study is to investigate, in addition to the causes that hinder early diagnosis in the elderly, the reasons for abandonment and/or non-oral cancer treatment.


Cognitive linguistics is a branch of linguistics. Based on the theory of the second generation of cognitive science and experiential philosophy, it was born on the basis of opposing the transformational generative grammar of mainstream linguistics and began to take shape from the late 1980s to the 1990s. Cognitive linguistics involves artificial intelligence, linguistics, psychology, systems theory, and other disciplines. Aiming at the innate view held by generative linguistics, it proposes that the creation, learning and application of language must be explained through human cognition, because cognitive ability is the foundation of human knowledge.As a relatively new research paradigm in linguistic studies, Cognitive Linguistics has made a lot of remarkable achievements both in theory and in practice in the past 40 years. It has been widely used and become a multidisciplinary, interdisciplinary, and transdisciplinary school of linguistics. Cognitive Linguistics is closely related to psycholinguistics and systemic functional linguistics. It is based on cognitive science, and the research of cognitive linguistics is to use cognitive psychology and linguistic theory to study the relationship between representation, concept, and language structure. Psycholinguistics is based on psychology, it involves language memory, phonological perception, language learning, and so on. Compared with Systemic Functional Linguistics, Cognitive Linguistics focuses more on the internal factors of the speaker, that is, the psychological mechanism and the generation and exchange of meaning in the cognitive process. Systemic Functional Linguistics focuses on the social communication of language, and studies language from the social function and use situation of language.The Routledge Handbook of cognitive linguistics gives a comprehensive introduction to cognitive linguistics. It covers the key areas of cognitive linguistics and contains a wide range of perspectives and methods in this area .The first part of the book covers basic theories and hypotheses. This is the most important chapter in which readers can understand the basic concepts and historical developments of cognitive linguistics, including cognitive semantics, frame semantics, natural semantic metalanguage, along with cognitive grammar, construction grammar, and word grammar.Part 2 collects the most popular topics in cognitive linguisticsis, mainly about cognitive pragmatics, cognitive poetics, metaphor, metonymy, humor, construal, iconicity, and image schemas, categorization, embodiment, motivation, constructionalization, intersubjectivity, grounding, multimodality, and linguistic synaesthesia, and so on. This chapter presents the most mainstream research of cognitive linguistics for researchers.Part 3 of the book focuses on relationships and interfaces between cognitive linguistics and other areas, including figurative language, gesture, signed languages, cultural linguistics, language acquisition and pedagogy, linguistic typology, digital lexicography, and translation studies. It shows the integration of cognitive linguistics and other research fields or disciplines.For students and young researchers, the last chapter should not be missed. Studies in this chapter look to new horizons in cognitive linguistics, presenting a series of approaches to social, diachronic, neuroscientific, biological, ecological, multimodal, and quantitative studies. Following the pace of these studies, we can further explore and develop the research of cognitive linguistics.In sum, this book introduces the latest development of cognitive linguistics and predicts its future development. It makes a rational analysis of the criticisms of other schools on cognitive linguistics, and puts forward the direction of improvement and efforts. The book has its own characteristics compared with other books on cognitive linguistics. Some books in this area only introduce or summarize the results of previous studies. Researchers in this book not only analyze the previous theories in detail and systematically, but also express their own views and point out the development direction of cognitive linguistics.Cognitive linguistics is not a single language theory, but represents a research paradigm. It holds that people's daily experience is regarded as the basis of language use, and it focuses on explaining the inseparable relationship between language and general cognitive ability. Although these linguistic theories are different, their basic assumptions about language are almost the same. They all agree with the basic viewpoints, but differ in the specific linguistic phenomena discussed and concerned.Unfortunately, most of the articles in this book are still using traditional western research frameworks, methods and corpus, so its interpretation tends to have certain western contextual background and characteristics. Studies of Cognitive Linguistics still has a long way to go in China. Looking forward to the development of cognitive linguistics, Chinese scholars should make full use of the advantages of Chinese, Chinese dialects and the diversity of minority languages in China, fully describe and compare the similarities and differences of these languages and dialects and their causes, so as to provide unique and richer evidence for revealing the influence of language on cognitive style and cultural development. At the same time, through the theory of cognitive linguistics, we can deeply explore the cognitive style and cultural background behind Chinese grammar, truly reveal the characteristics of Chinese grammar and pragmatics, and make contributions to the theory of general linguistics.Throughout the development of Cognitive Linguistics in the past 40 years, it has achieved remarkable achievements both in theory and practice. With the development of cognitive linguistics, the core concepts of category theory, metaphor/metonymy theory, cognitive semantics, and construction grammar have made great progress. At the same time, it also integrates with other disciplines, such as neurolinguistics, psycholinguistics, sociolinguistics and philosophy, and promotes each other's development. In addition, how to use the theory to better understand the process of second language acquisition and effectively carry out language teaching activities has become the focus of scholars' discussion in recent years. But at the same time, this book, as well as Cognitive Linguistics, is still worthy of improvement. Studies in this book, as well as many other Cognitive Linguistic studies, often focused on introspective research methods and restricts itself to oral language studies, many theoretical hypotheses are put forward but fewer empirical studies have been done. Individual differences and social factors in language are often ignored.The Routledge Handbook of Cognitive Linguistics still provides the most up-to-date research on Cognitive Linguistics. The book describes a systematic research paradigm and comprehensively interpret Cognitive Linguistic studies from an international perspective. It offers a starting point of studies in this area, and provides new frameworks for analyzing and interpreting languages. This book will be a vital resource and a very thought-provoking reference for all students and researchers working in this area.However, YY has written the book review. QS was YY's colleague, he helped to examine and modify the review. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In developing countries, low levels of awareness, cost and organizational constraints on access to specialized care contribute to inadequate patient help-seeking behavior. As much as 95% of cancer patients in developing countries are diagnosed at late to end stage disease. Consequently, treatment outcome is dismally poor and a vicious cycle sets in, with public mystification of cancer and the admonishment of cancer medicine as a futile effort, all, to the further detriment of patient help-seeking behavior and treatment engagement. The situation spirals down, when the practice of cancer medicine is not gratifying to the medical practitioner and does not appeal as a medical specialty to those in training. The future of cancer medicine in developing countries thus hinges on the demystification of cancer through positive information, coupled to an effective organization that allows for the optimal use of available resources, facilitates access to specialized care and promotes the flow of knowledge and technology amongst various stakeholders. This paper strives to make a cogent argument and highlight the capital importance of information and communication technologies in organizing and leveraging scarce resources for cancer education, research and practice in developing countries. Developing countries currently bear fifty-percent of the global cancer burden and, are projected to bear sixty-percent by the year 2020 . The risIn the wake of an overwhelming cancer case-incidence, an already over-extended healthcare system gives way. Presently, because of low levels of awareness and the cost and organizational constraints on access to specialized care as much as 95% of cancer patients in developing countries are diagnosed at late or end stage disease -8. ConseBy contrast, with existing knowledge and technology, the concerted action of governments, non-governmental organizations and healthcare systems in developed countries can prevent a third of cancers, provide treatment to another third and palliative care to those in need . While tHistorically, the sharing advantage of nascent technologies has spurred leaps and bounds in human development. This is evident in the telescoping timelines of human development milestones, from a ten thousandth year lapse for the onset of the agricultural revolution, to a four hundredth year lapse for the scientific revolution and then a one hundredth year lapse for the industrial revolution. In order, the information revolution heralds an unsurpassed leap in national, international and global development, by granting access to knowledge, cognitive tools and organizational support and permitting a greater fraction of the global community to actualize their human potentials and participate in a global intelligent network.By virtue of its sharing advantage (portability and affordability), developing countries have in recent times, known an excess of 263% growth in telecommunications and Internet connectivity ,21. The Knowledge, positive information and advocacy are cornerstones of cancer survivorship ,26. In dInformation engenders research and research engenders information. To this end, the Internet would not only serve the informational and educational purposes, but would inherently result in the digitization of data, procedures and processes and set up the quintessence of a rigorous and viable research enterprise: speed, control, accountability, cost-containment and patient-provider engagement and satisfaction ,30.Optimal cancer patient care is multidisciplinary and at its bare minimum, calls for the timely and concerted opinion and action of the patient; the primary care physician; the pathologist; the medical oncologist; the radiation oncologist and the surgical oncologist . In the The strength of ICTs should be harnessed to engage a south-south and north-south dynamic. While laudable efforts are being made towards building the cancer control capacity of developing countries, by transfering technology from developed countries ,33, the The author is a UICC fellow and member of the UICC expert review panel, focusing on the area of cancer information and education.


The Internet is changing how people receive health information and health care. All who use the Internet for health-related purposes must join together to create an environment of trusted relationships to assure high quality information and services; protect privacy; and enhance the value of the Internet for both consumers and providers of health information, products, and services. The goal of the e-Health Code of Ethics is to ensure that people worldwide can confidently and with full understanding of known risks realise the potential of the Internet in managing their own health and the health of those in their care. The final e-Health Code of Ethics, presented in this paper, has been prepared as a result of the "e-Health Ethics Summit," which convened in Washington DC on 31 January 2000 - 2 February 2000. The summit, organized by the Internet Healthcare Coalition and hosted by the World Health Organisation/Pan-American Health Organisation (WHO/PAHO), was attended by a panel of about 50 invited experts from all over the world and produced the foundation for a draft code, which was released 18 February [Note: Abstract, keywords, acknowledgements and references have been added by the editor and are not part of the final Code. All people who use the Internet for health-related purposes-patients, health care professionals and administrators, researchers, those who create or sell health products or services, and other stakeholders-must join together to create a safe environment and enhance the value of the Internet for meeting health care needs.Because health information, products, and services have the potential both to improve health and to do harm, organisations and individuals that provide health information on the Internet have obligations to be trustworthy, provide high quality content, protect users' privacy, and adhere to standards of best practices for online commerce and online professional services in health care.People who use Internet health sites and services share a responsibility to help assure the value and integrity of the health Internet by exercising judgment in using sites, products, and services, and by providing meaningful feedback about online health information, products, and services.Health information includes information for staying well, preventing and managing disease, and making other decisions related to health and health care.It includes information for making decisions about health products and health services.It may be in the form of data, text, audio, and/or video.It may involve enhancements through programming and interactivity.Health products include drugs, medical devices, and other goods used to diagnose and treat illnesses or injuries or to maintain health. Health products include both drugs and medical devices subject to regulatory approval by agencies such as the U.S. Food and Drug Administration or U.K. Medicines Control Agency and vitamin, herbal, or other nutritional supplements and other products not subject to such regulatory oversight.Health services include specific, personal medical care or advice; management of medical records; communication between health care providers and/or patients and health plans or insurers, or health care facilities regarding treatment decisions, claims, billing for services, etc.; and other services provided to support health care.Health services also include listserves, bulletin boards, chat rooms, and other online venues for the exchange of health information.Like health information, health services may be in the form of data, text, audio, and/or video, and may involve enhancements through programming and interactivity.Anyone who uses the Internet for health-related reasons has a right to expect that organisations and individuals who provide health information, products or services online will uphold the following guiding principles: