Knowledge, and practice towards infection control

measures for the novel corona virus among nurses

working at isolation department

By: Omima Muhammed Elgnedy

DEPARTMENT: Community Health Nursing

INSTITUTION: Academy of Graduate Studies – Misurata
 :Over view of the study
............................................................................................................. Introduction

.Statement of the problem………………………………………………………….3

Objectives of the Study.........................................................................................5

Significance of the study...............................................................................5

REVIEW OF RELATED LITERATURE

Definition of the covid 19………………………………………..6

Patient-Centered Precautions …………………………………………6

Equipment centered precautions………………………………………7

personal protective Equipment ........................................................................................... 7

Transporting patient outside .................................................................................................9

Aerosol
generating .....................................................................................................................10

Decontamination standred..........................................................................11

METHODOLOGY 3

Research design.............................................................................................................18

Subject and Respondents of the Study..........................................................................18

Data-gathering Instrument.............................................................................................18

Validity of the data-gathering Instrument......................................................................19

Statistical Tools..............................................................................................................19

TIMELINE……………………………………………………………………………21

REFERENCE……………………………………………………………………….22
 INTODUCTION
The rapidly unfolding coronavirus disease 2019 (COVID-19) pandemic has
disrupted life globally. The novel coronavirus (nCOV, later called SARS-CoV-2)
originated from an unknown source in Wuhan, China. Unlike previous coronavirus
outbreaks [4], this highly contagious zoonotic virus from an as-yet-unconfirmed
animal origin.]
evolved from a local flu-related severe acute respiratory syndrome] to a pandemic
threatening the lives of millions within a few weeks. COVID-19 has thrown global
public health into turmoil by severely straining many nations’ healthcare systems. The
epicenter rapidly moved from China to Iran and then through Europe and the US over
a span of nine weeks].
As it spread through social contact , billions were forced into lockdown to minimize
the transmission rate. Lockdowns were necessary since researchers need time to
develop a vaccine or effective treatment as in preceding pandemics including SARS
and MARS [1-3].
from an as-yet-unconfirmed animal origin [10,11] evolved from a local flu-related
severe acute respiratory syndrome [4,8, ,] to a pandemic threatening the lives of
millions within a few weeks. COVID-19 has thrown global public health into
turmoil by severely straining many nations’ healthcare systems.

The epicenter rapidly moved from China to Iran and then through Europe and the
US over a span of nine weeks [11]. As it spread through social contact [5,6],
billions were forced into lockdown to minimize the transmission rate [4].
Lockdowns were necessary since researchers need time to develop a vaccine or
effective treatment as in preceding pandemics including SARS and MARS [4,7,8].
No imminent solution for COVID-19 is likely in the immediate future [9].

The first-world healthcare system has failed to provide medical care for the
rapidly increasing number of infected patients, let alone developing or
underdeveloped nations [2,1]. In the majority of the cases, the leadership and
bureaucracy in different countries seemed indecisive, inefficient, unprepared, and
unable to contain the contagion. For the first time in history, the active
participation of every single person on earth, in the form of testing, isolation,
contact tracing, social distancing, staying at home, self-quarantining, improving
personal hygiene, and using personal protective equipment such as masks and
gloves, has become critical to contain COVID-19, prevent healthcare workers
from becoming overwhelmed, and give researchers time to develop treatment
strategies [5].

Hundreds of millions have sacrificed their autonomy, health, job, business,

recreation, and education. However, ensuring voluntary participation in COVID-
 19 prevention strategies has posed challenges in different countries due to varying
levels of knowledge, attitudes, and practices. Accordingly, the design and success
of anti-contagion initiatives depend on macro- and micro-level understanding of
respective regions and within each country.

:Objectives of the study

The purpose of the present study is to assess knowledge ,practice toward infection control of
various corona covide19 from nurses in isolation department in National Hospital during the
year of 2020 until2021

:Specifically, this study sought answers to the following

?How well do nurses know how to avoid infection with covid 19 in isolation centers .1

2.How nurses protect herselfe and others from covid 19?

3.Are face maskeffective in protecting against covid 19?

:Significance of the study

The present study examined the effects of the system of measures during their
implementation 2020 . Before and after the intervention, nursing attendants, were
evaluated in terms of theoretical knowledge of nosocomial infection control, hand
hygiene implementation, use of personal protective equipment, and disinfection and
sterilization effectiveness. All evaluation procedures were administered by an
infection control team of 26 members (four were full-time and had a nursing,
epidemiology, and statistics background). The research was approved by the Ethics
.)Committee of the isolation awram Hospital of misurata (approval number 2020-19)

Theoretical knowledge of nosocomial infection was tested via authorized software .1

Based on the sheet of hand hygiene compliance issued by WHO (10), hand .2
hygiene compliance was examined in staff without examinees' knowledge to
eliminate the “Hawthorne effect” (11). The compliance rate was obtained with actual
times of hand washing divided by hand hygiene opportunities and multiplied by
100%. The accuracy of hand hygiene in staff was also observed and recorded by
.infection control inspectors (11)
Based on the Technique Standard for Isolation in Hospital the accuracy of personal .3
protection implementation was assessed

The Regulation of Disinfection Technique in Healthcare Settings -was used as the .4

standard to evaluate the quality of sterilization

REVIEW OF RELATED LITERATURE

Difination Abuot Covid 19

Being a member of the Coronaviridae family, the novel coronavirus (2019-nCoV) is a
nonsegmented, enveloped, positive-sense, single-strand ribonucleic acid virus [5, 6].

This virus has a significant capability to infect humans through an interaction between
the viral S protein and the angiotensin-converting enzyme 2 receptors on human
respiratory endothelial cells [3]. It spread rapidly inside China and transmitted to
other countries [4, 7].

As early as 45 days after the first notice, more than 60,000 cases were reported
worldwide, with 1,525 mortalities, providing the preliminary estimation of a 2%
mortality rate [4, 8–11]. By March 11, 2020, WHO officially announced COVID-19
as a pandemic, declaring a worldwide health emergency state [12]. As of this report
on May 14, 2020, the number of cases worldwide has reached 4,258,666 in more than
216 countries with 294,190 deaths, which estimates the mortality rate of 6.9% [11].
These numbers highlight the significant virulence of the novel coronavirus.

Two previous outbreaks of coronavirus, severe acute respiratory syndrome (SARS)

and Middle East respiratory syndrome (MERS) coronavirus, which had high mortality
of 11% and 30%, respectively, have alarmed the medical community to the potential
of these respiratory infections [5, 13].

Despite their high mortality, comparing the number of cases and countries affected
by the epidemics demonstrates that the transmission rate of those viruses was
significantly lower than that of the novel coronavirus (2019-nCoV); MERS affected a
total of 2,500 cases in 27 countries, and SARS infected 8,422 cases in 29 countries
[5, 11]. This highlights the increased risks of disease exposure and transmission to
front-line health-care professionals in treating the patients and the importance of
taking necessary precautions and safety measures to protect the health-care personnel
during the current pandemic [10, 11].

How to Stay Safe while Providing Critical Patient Care

The novel coronavirus (2019-nCoV) is highly contagious, and the main route of
transmission is believed to be respiratory droplets. The virus can stay active for
several hours to days on multiple surfaces under artificial conditions, and touching the
face or the mucosal surfaces of the body with contaminated hands could probably lead
to infection. While the highest risk of transmission via droplets is within 3 feet (91.44 
cm) of the source, they can contaminate up to 6 feet (183 cm) [5]

According to the latest WHO and Center for Disease Control and Prevention (CDC)
guidelines and considering the ongoing research on the subject, the necessary
precautionary recommendations fall under three main categories: patient-centered
.precautions, provider-centered precautions, and equipment-centered precautions

specific precautions. Some of the patient-centered and provider-centered precautions

may also be useful and overlap with the operation room precautions

 Patient-Centered Precautions

All patients should be screened for relevant symptoms. Patients who meet the criteria
for a person under investigation (PUI) require isolation and additional precautions to
provide triage and care.

To minimize the risk of cross-infection, patients with different infection risks should
be separated by space where possible or by time otherwise [2]. Additionally,
procedures on PUI should be separated by place and time from other patients [2].

The transfer of PUIs should be kept at a minimum. Utilizing portable radiology

equipment in this setting proved to be a very effective safety measure in the SARS
epidemic [5, 10, 2,  3]. For complicated cases in which patient transfer is inevitable,
assigning dedicated procedural rooms and predetermined transport routes and
performing a cleaning protocol according to infectious disease control protocol
afterward will greatly minimize the risk of cross-contamination. It is important that
the COVID-19 patients wear a surgical mask during the transfer and, if possible,
during the procedures which require direct provider contact.

Provider-Centered Precautions

Based on the experience of the Covid 19 epidemic, it is clear that the risk of virus
transmission to the providers is significantly reduced by using droplet and contact
precautions [11, 5]. The current evidence suggests asymptomatic transmission even
through the incubation period [2]. This highlights the importance of the use of
minimum personal protective equipment (PPE) for all staff during all procedures,
preferably everywhere or, at least, at the involved centers.

The latest recommendations of WHO include respiratory protection with a standard

face mask for the health-care providers while interacting with all patients, unless
aerosol-generating procedures are performed [5, , 8]. Additionally, CDC recommends
strict airborne precaution using an N95 mask or higher when in close contact with a
confirmed COVID-19 case, or a PUI [5]. Furthermore, necessary PPE includes a
disposable (if resources are limited, autoclavable) fluid-resistant isolation gown,
disposable gloves with the emphasis of coverage over gown cuffs, protective goggles,
and, if available, a face shield [9]. Recent studies also reported the possibility of
transmission via ocular surface mucosa, which highlights the importance of ocular
protection wear such as glasses or face shields as well [1, 3].

Rapid spread of COVID-19 pandemic highlights the importance of the awareness and
effective measures to prevent transmission of microorganisms, particularly highly
resistant microorganisms. Therefore, it is important to be mindful of general infection
prevention protocols, such as hand hygiene for everyone including patients and
health-care providers. In addition, lessons learned from the present outbreak
management of COVID-19 call for a continuing quality improvement program in
place for the infection prevention and control to prepare for potential outbreaks in the
future.

Equipment-Centered Precautions

The use of portable imaging devices is highly recommended specifically for the
confirmed COVID-19 patients, as well as the PUI. These devices should be carefully
disinfected before and after the procedures.

All the routinely used equipment including CT and magnetic resonance imaging
(MRI) machines, ultrasound transducers, blood pressure monitoring cuffs, pulse
oximeters, and reading room mice, keyboard, monitors, and surfaces, as well as
interventional radiology suite equipment, should be disinfected following every
COVID-19 suspect encounter, if in contact <2 m of the patient, which should be
avoided whenever possible [5].

CDC recommendations include washing with soap and water on the possible surfaces
and equipment or alternatively use of at least intermediate-level disinfectants such as
ethyl alcohol, isopropyl alcohol, and iodophor germicidal detergent solution [5]. It is
important to note that ethanol solutions should contain at least 70% ethanol for
surfaces and at least 60% ethanol for hand sanitizers, according to CDC guidelines
[3]. Education of the staff on the decontamination protocols plays an important role to
prevent cross-contaminations in these settings [4].

Tissue and fluid specimens are considered infectious and must be transported in leak-
proof biohazard bags by trained personnel to ensure safe handling practices and spill
decontamination procedures [11]. Disinfection of the room and medical equipment
must be performed after procedures on these patients as well [9].

While portable procedure performance is preferred, specific and dedicated procedure

rooms should be dedicated to the PUIs or confirmed COVID-19 patients, and these
rooms should be separated from other procedure rooms [8]. The procedure rooms
should be vigorously disinfected following each procedure on a suspected patient. If
possible, performing the procedure on COVID-19 patients or PUIs should be
scheduled as the last case of the day to minimize the risk of cross-contamination.

Procedure personnel should be limited to the minimum required for safe and effective
performance, in order to minimize exposure risk to the personnel. The procedure team
should plan to stay for the entire procedure from start to finish (i.e., no breaks or
substitute personnel). Medical doctor coverage should be limited to a single person in
order to keep the risk of infection and losing manpower to a minimum unless case
complexity requires multiple doctors.

No nonessential personnel (e.g., medical students) should scrub into cases during the
COVID-19 outbreak. For medical teams covering multiple hospitals, assigning
different sites to each subteam will minimize the cross-contamination risk [1, 2]. In
the case of intrahospital transmission, segregation of staff into independent teams will
be needed to prevent a shutdown of the entire service should there be a need for
quarantine [9]. The assigned role of each member of the provider team should be clear
to minimize confusion during the probable overflow hours, which will require more
detailed protocols than usual.

It is helpful to have a second technician and registered nurse (RN) available to get
supplies or medications for a COVID-19 case to prevent procedural personnel from
leaving the room during the procedure. This may include assigning a second on-call
technician for the same reason and particularly for more complicated cases. The RN
should predict and prepare extra sets of medications for the suspicious case, and
unused medications may be returned after the conclusion of each procedure following
disinfection protocol.

Personal Protective Equipment

HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2
infection should adhere to Standard Precautions and use a NIOSH-approved N95 or
equivalent or higher-level respirator (or facemask if a respirator is not available),
gown, gloves, and eye protection.

When available, respirators (instead of facemasks) are preferred; they should be

prioritized for situations where respiratory protection is most important and the care
of patients with pathogens requiring Airborne Precautions (e.g., tuberculosis, measles,
varicella). Information about the recommended duration of Transmission-Based
Precautions is available in the Interim Guidance for Discontinuation of Transmission-
Based Precautions and Disposition of Hospitalized Patients with COVID-19
 Hand Hygiene
1. HCP should perform hand hygiene before and after all patient contact, contact
with potentially infectious material, and before putting on and after removing
PPE, including gloves. Hand hygiene after removing PPE is particularly important
to remove any pathogens that might have been transferred to bare hands during
the removal process.

2.HCP should perform hand hygiene by using ABHS with 60-95%

alcohol or washing hands with soap and water for at least 20 seconds.
If hands are visibly soiled, use soap and water before returning to
ABHS.

3.Healthcare facilities should ensure that hand hygiene supplies are readily available
to all personnel in every care location.

 Personal Protective Equipment Training

HCP must receive training on and demonstrate an understanding of:

1. when to use PPE

2. what PPE is necessary

3. how to properly don, use, and doff PPE in a manner to prevent self-

contamination

4. how to properly dispose of or disinfect and maintain PPE

5. the limitations of PPE.

Any reusable PPE must be properly cleaned, decontaminated, and maintained

after and between uses. Facilities should have policies and procedures describing a
recommended sequence for safely donning and doffing PPE.

The PPE recommended when caring for a patient with suspected or confirmed
COVID-19 includes the following:

 Respirator or Facemask

1. Put on an N95 respirator (or equivalent or higher-level respirator) or

facemask (if a respirator is not available) before entry into the patient room
 or care area, if not already wearing one as part of extended use strategies
to optimize PPE supply. Other respirators include other disposable filtering
facepiece respirators, powered air purifying respirators (PAPRs), or
elastomeric respirators.

2. N95 respirators or respirators that offer a higher level of protection

should be used instead of a facemask when performing or present for an
aerosol generating procedure. See appendix for respirator definition.

3. Disposable respirators and facemasks should be removed and discarded

after exiting the patient’s room or care area and closing the door unless
implementing extended use or reuse. Perform hand hygiene after removing
the respirator or facemask.

4. If reusable respirators (e.g., powered air-purifying respirators

[PAPRs] or elastomeric respirators) are used, they should also be
removed after exiting the patient’s room or care area. They must be
cleaned and disinfected according to manufacturer’s reprocessing
instructions prior to re-use.

5. When the supply chain is restored, facilities with a respiratory

protection program should return to use of respirators for patients with
suspected or confirmed Covid 19 infection. Those that do not currently
have a respiratory protection program, but care for patients with pathogens
for which a respirator is recommended, should implement a respiratory
protection program.

 Eye Protection

1. Put on eye protection (i.e., goggles or a face shield that covers the front
and sides of the face) upon entry to the patient room or care area, if not
already wearing as part of extended use strategies to optimize PPE supply.

2. Protective eyewear (e.g., safety glasses, trauma glasses) with

gaps between glasses and the face likely do not protect eyes from
all splashes and sprays.

3. Ensure that eye protection is compatible with the respirator so there is

not interference with proper positioning of the eye protection or with the
fit or seal of the respirator.

4. Remove eye protection after leaving the patient room or care area,
unless implementing extended use.

5. Reusable eye protection (e.g., goggles) must be cleaned and disinfected

according to manufacturer’s reprocessing instructions prior to re-use.
Disposable eye protection should be discarded after use unless following
protocols for extended use or reuse.
  Gloves

1. Put on clean, non-sterile gloves upon entry into the patient room or care
area.

2. Change gloves if they become torn or heavily contaminated.

3. Remove and discard gloves before leaving the patient room or care area,
and immediately perform hand hygiene.

4. Double gloving is not recommended when providing care to patients

with suspected or confirmed Covid 19 infection.

 Gowns

1. Put on a clean isolation gown upon entry into the patient room or area.
Change the gown if it becomes soiled. Remove and discard the gown in a
dedicated container for waste or linen before leaving the patient room or
care area. Disposable gowns should be discarded after use. Reusable (i.e.,
washable or cloth) gowns should be laundered after each use.

2. In general, HCP caring for patients with suspected or confirmed Covid

19 infection should not wear more than one isolation gown at a time.

Transporting patients outside the isolation room 

Patients with confirmed or suspected COVID-19 should wear a medical mask if being
transported out of the room (eg, for studies that cannot be performed in the room). If a
portable tent system with high-efficiency particulate air (HEPA) filtration is used to
transport patients with COVID-19, the patient does not need to wear a mask, but
HCWs transporting the patient should wear PPE in case of a failure of the powered
HEPA filtration.

Aerosol-generating procedures/treatments:

In patients with COVID-19, aerosol-generating procedures and treatments should be

avoided when possible to reduce the potential risk of transmission to HCWs.

1. Some procedures performed on patients with suspected or confirmed Covid 19

infection could generate infectious aerosols. Procedures that pose such risk
should be performed cautiously and avoided if possible.
 2. If performed, the following should occur:
o HCP in the room should wear an N95 or equivalent or higher-level
respirator, eye protection, gloves, and a gown.
o The number of HCP present during the procedure should be limited to
only those essential for patient care and procedure support. Visitors
should not be present for the procedure.
o AGPs should take place in an AIIR, if possible.

Clean and disinfect procedure room surfaces promptly as described in the section
on environmental infection control below

●Aerosol-generating procedures 

In patients with COVID-19, aerosol-generating procedures assumed to be

associated with an increased risk of infection typically include (listed
alphabetically):
•Bronchoscopy (including mini bronchoalveolar lavage)
•Cardiopulmonary resuscitation
•Filter changes on the ventilator
•High-flow oxygen
•Manual ventilation before intubation
•Nasal endoscopy
•Open suctioning of airways
•Tracheal intubation and extubation
•Tracheotomy
•Upper endoscopy (including transesophageal echocardiogram)
•Swallowing evaluation
•Chest physiotherapy

Patients with prior COVID-19

Some patients have recovered from COVID-19 and have met initial criteria for
discontinuation of precautions but are subsequently rehospitalized. Precautions for
such patients depend on the interval since the prior illness.
●If the onset of prior illness (or the initial positive test in those who were
asymptomatic) was within three months, we use the following approach, which
is consistent with CDC guidelines [11]

•Patients who are asymptomatic

If the patient has no symptoms consistent with COVID-19, repeat SARS-
CoV-2 testing is not recommended, and enhanced infection control
precautions specific for COVID-19 are not required. This means that health
care centers should not perform routine screening of asymptomatic patients
who had past infection with SARS-CoV-2 within the last three months.
Similarly, quarantine is not required for such patients if they had a new
exposure [10].
 •Patients with symptoms
If the patient has symptoms consistent with COVID-19, we use infection
control precautions for patients with suspected COVID-19 pending the
initial evaluation. If another etiology (eg, influenza, bacterial infection,
heart failure) is not identified, the decision to continue these precautions
must be determined on a case-by-case basis in conjunction with an infection
prevention specialist. Although the risk of reinfection within the first three
months of infection is unlikely, rare cases of probable reinfection with
SARS-CoV-2 several months after the initial onset of symptoms have been
documented

The CDC has developed investigative criteria for identifying reinfection in patients

who develop signs and symptoms of SARS-CoV-2 after their initial infection [7]

Patients who are NOT suspected of having COVID-19

When there is ongoing community transmission of SARS-CoV-2, enhanced infection

control precautions should be used when caring for patients who are not suspected of
having COVID-19 [3,4,5], even those who had a negative test for SARS-CoV-2 upon
entry into the health care setting. These precautions include the use of:
1. A medical mask (eg, surgical mask) when providing routine care for patients;
this provides protection for the HCW and is also used for source control
A respirator, rather than a medical mask, should be used for aerosol-generating
procedures and surgical procedures that generate potentially infectious aerosols
or involve anatomic regions where viral loads might be higher, such as the nose,
throat, oropharynx, and respiratory tract. If the respirator has an exhalation valve
or vent, a medical mask should be placed on top of it since these types of
respirators are not sufficient for source control.
2. Face or eye protection (goggles or face shields), in addition to a mask or
respirator. Universal use of eye or face protection has been implemented in many
institutions and is particularly important when caring for patients who are unable
to reliably use a mask and when performing aerosol-generating procedures.
HCWs who use a full face shield should be reminded that face shields alone do
not provide adequate respiratory protection or source control.
3. Gloves and gowns in addition to masks and face or eye protection when
evaluating patients with an undiagnosed respiratory infection or when contact
precautions are warranted.

The CDC and WHO have highlighted several methods for

decontamination of respirators when supplies are critically low (crisis
standards These include:

●Ultraviolet light
Decontamination with ultraviolet (UV) light was evaluated in the context of the
H1N1 influenza pandemic; in experimental models, UV irradiation was observed
to reduce H1N1 influenza viability on N95 respirator surfaces at doses below the
 threshold observed to impair the integrity of the respirator [7.5]. Coronaviruses
can also be inactivated by UV irradiation, but comparable studies have not been
performed with SARS-CoV-2, and the dose needed to inactivate the virus on a
respirator surface is unknown. Nebraska Medicine has implemented
a protocol for UV irradiation of N95 respirators in the context of the COVID-19
pandemic based on the dose generally needed to inactivate other single-stranded
RNA viruses on surfaces [6].

●Hydrogen peroxide vapor

Duke University Health System and others are using hydrogen peroxide vapor
for N95 decontamination [7]. Hydrogen peroxide vapor has been observed to
inactivate other non-coronavirus single-stranded RNA viruses on environmental
surfaces [8, ]. In one report, there were no effects on filtration efficiency or
quantitative fit testing when N95 respirators were decontaminated with 59%
vaporized hydrogen peroxide [5]. In the United States, The US Food and Drug
Administration granted an emergency use authorization for use of low-
temperature vaporous hydrogen peroxide sterilizers, used for medical
instruments, to decontaminate N95 respirators [8.9].

●Moist heat
Moist heat has been observed to reduce the concentration of H1N1 influenza
virus on N95 respirator surfaces [4]. In this study, moist heat was applied by
preparing a container with 1 L of tap water in the bottom and a dry horizontal
rack above the water; the container was sealed and warmed in an oven to
65°C/150°F for at least three hours; it was then opened, the respirator placed on
the rack, and the container resealed and placed back in the oven for an additional
30 minutes. No residual H1N1 infectivity was found. The optimal time and
temperature to inactivate SARS-CoV-2 are uncertain; several studies observed
inactivation of SARS-CoV after 30 to 60 minutes at 60°C/140°F [5].

 Environmental disinfection

To help reduce the spread of COVID-19, environmental infection control procedures

should be implemented [3,4,8]. In United States health care settings, the CDC states
routine cleaning and disinfection procedures are appropriate for SARS-CoV-2 [3].
Products approved by the Environmental Protection Agency (EPA) for emerging viral
pathogens should be used; a list of EPA-registered products can be found here.
Specific guidance on environmental measures, including those used in the home
setting, is available on the CDC and WHO websites.
Many hospitals have implemented enhanced environmental cleaning and disinfection
protocols for rooms used by patients with known or suspected COVID-19 and for
areas used by HCWs caring for such patients to prevent secondary transmission from
fomites. As an example, adjunctive disinfection methods, such as ultraviolet (UV)
light and hydrogen peroxide vapor, are used in some facilities to disinfect the rooms
that have housed or been used for aerosol-generating procedures on patients with
COVID-19.

Workers should be fit tested and trained to wear N95 respirators and face shields (or
PAPRs) when cleaning patient rooms that are or have been occupied by persons with
known or suspected COVID-19 or have been used for aerosol-generating procedures
on patients with COVID-19. Environmental services workers can use droplet and
contact precautions, plus eye protection (surgical mask, face shield or goggles, gown,
and gloves) when cleaning areas used by HCWs who are caring for COVID-19
patients.
The importance of environmental disinfection was illustrated in a study from
Singapore, in which viral RNA was detected on nearly all surfaces tested (handles,
light switches, bed and handrails, interior doors and windows, toilet bowl, sink basin)
in the airborne infection isolation room of a patient with symptomatic mild COVID-
19 prior to routine cleaning [9].
Viral RNA was not detected on similar surfaces in the rooms of two other
symptomatic patients following routine cleaning (with sodium dichloroisocyanurate).
Of note, viral RNA detection does not necessarily indicate the presence of infectious
virus. The role of environmental contamination in transmission of SARS-CoV-2 is
discussed elsewhere.
 METHADOLOGY

The study employed the descriptive research design mainly because the present

investigation is descriptive in nature. The main purpose of the study will be assess the

knowledge ,practice of control infection from nurses in isolation hospital in misurata

.during 2020year

Descriptive research, is used to describe characteristics of a population or

phenomenon being studied. It does not answer questions about how/when/why the

characteristics occurred. Rather it addresses the question (What are the characteristics

of the population or situation being studied?). Descriptive research is also called

.Statistical research

The main goal of this type of research is to describe the data and characteristics

about what is being studied. The idea behind this type of research is to study

.frequencies average, and other statistical calculation

Descriptive research studies assist the researcher to discover new meaning

describing what exists determining the frequency with which

something occurs and categorizing information

:Objectives of the study

The purpose of the present study is to assess knowledge ,practice toward infection control of

various corona coved 19 from nurses in isolation department in National Hospital during the
year of 2020 until 2021

:Specifically, this study sought answers to the following

?How well do nurses know how to avoid infection with covid 19 in isolation centers .1
2.How nurses protect herselfe and others from covid 19?

.?Are face maskeffective in protecting against covid 19.3

:Data-gathering instrument
The research instrument used in the study will a self-made questionnaire. The

questionnaire will be developed and formulated by the researcher with the help of his adviser

.by questionnaire

:Validity of the instrument

The questionnaire is presented to the research adviser and the research teacher for

their suggestions and corrections. Each item or issue included in the questionnaire will

based on the literature review. The relevant suggestions and corrections are included in the

.final copy of the questionnaire

:Statistical tools
Gathered data were classified, tabulated and analyzed using Microsoft Office Excel

Statistical data were interpreted using descriptive statistics employing the following

Frequency distribution will used for the respondents’ profile to determine the total

number of the respondents who answered for each specific category. The following formula

computes the frequency distribution

.Percentage is a hundred times the proportion

The data collected for the present study was organized, summarized,
:tabulated and presented in the following sequence

.Part I: General Characteristics of the Studied Nurses (table 1)

Part II: Distribution of Nurses` Knowledge Regarding Infection Control Measures in

.isolation department . (Table2-6)

Part III: PART III: Distribution of Nurses` Compliance with Infection Control
.Measures in isolation department. (Table 7-9)
PART V: Relation between Nurses` knowledge, Practice & Their General
.Characteristics

.Part I: General Characteristics of the Studied Sample

Table 1: Frequency distribution among the studied sample
according to their general characteristics (n=51)
% frequency general characteristics
Age (years)
3.9 2 20<
19.6 10 21-25
76.5 39 or more 26-30

4.8 ± 27.8 Mean ± SD

Educational level
84.3 43 Diploma nurse

11.8 6 Technical nurse

3.9 2 Bachelor nurse

Years of experience
9.8 5 Year 1>

5.9 3 Year 2-5

84.3 43 Years 6>

Training course
76.5 39 Yes

23.5 12 No

Place of residence
52.9 27 Rural
47.1 24 Urban

Periodic check up
15.7 8 Yes

84.3 43 No
Table 1 show that the higher percentage of nurses (76.5%) in the study group
was in the age group between 26-30 or more with a mean age of 27.8± 4.8, only 3.9%
of them below 20. Meanwhile, majority of them had secondary level of education
(diploma), only two had bachelor nurse (84.3%, 3.9% respectively) %). Moreover,
most of them hadn`t a periodical examination before and during work, hadn`t any
training course and were living in rural areas (84.3%, 76.5%, 52.9% respectively

Table (2): Frequency distribution among the studied sample's

knowledge concerning infection control measures in icu isolation
.department

Knowledge items Incorrect Correct

No % No %

 Definition of infection 51 100 _ _

 Infection cycle 47 92.2 4 7.8

 Hospital acquired infection 41 80.4 10 19.6

due to hospitalization
 Health team as a cause of 44 86.3 7 13.7
infection in delivery room
 Fever as an enough sign for 26 51 25 49
infection
 Long hospitalization increase 45 88.2 6 11.8
incidence of hospital
acquired infection
 Infection can be prevented 46 90.2 5 9.8
through infection prevention
measures

Table 2 showed knowledge deficit of the study sample regarding all items
about infection. However, as much as 100.0% of the study group did obtain
satisfactory knowledge about the definition of infection, its Infection cycle, Infection
can be prevented through infection prevention measures, Long hospitalization
increase incidence of hospital acquired infection, Health team as a cause of infection
in delivery, Hospital acquired infection due to hospitalization, and fever as an enough
.sign for infection (92.2%, 90.2% 88.2% 86.3%, 80.4% and 55.0% respectively)

Table (3): Frequency distribution among the studied sample `s

knowledge regarding hand hygiene &wearing protective clothes in
.isolation department (n=51)
Protective measures Incorrect Correct
No % No %
Hand washing
Hand washing is an 50 98 1 2
essential procedure for
infection control
Hand washing 33 64.7 18 35.5
techniques

Wearing protective clothes

Types of protective 49 96.1 2 3.9
clothes
Purpose of wearing 50 98 1 2
protective gown
Purpose of wearing 49 96.1 2 3.9
sterile gloves

Table 3.displays the results of nurses` knowledge regarding protective measures in

isolation department. The Correct answer for hand washing is an essential procedure
for infection control only mentioned by 2%of them, 35.5%of them were known hand
washing techniques. Regarding wearing protective clothes most of them had incorrect
answer for Purpose of wearing protective gown, Types of protective clothes, and
Purpose of wearing sterile gloves (98%, 96.1, and96.1%respectively)
Table (4): Frequency distribution among the studied sample `s
knowledge regarding equipment processing in icu isolation (n=51)

Equipment handling & Correct Incorrect

processing procedure No % No %
• Disinfection
• Definition of 33 64.7 18 35.3
disinfection
• Types of preparation 25 49 26 51
of disinfection
solutions
• Disinfection by using 29 56.9 22 43.1
cidex
• Disinfection solution 5 9.8 46 9.2
is enough to kill
viruses
• Sterilization
• Definition of 45 88.2 6 11.8
sterilization
• Sterilization 49 94.1 2 3.9
technique using steam
• Equipment 48 94.1 3 5.9
preparation for
sterilization by
autoclave
• Dry heat sterilization 32 62.7 19 37.3
kill all viruses
• Solution used in 4 7.8 47 92.2
sterilization
Table 4 describes nurses` knowledge regarding equipment handling &processing in
icu isolation. It points to disinfection definition was correct in 64.7% near half
(49%)of them gave correct about types of preparation of disinfection solutions ,and
more than half 56% of the study sample were known that disinfection by using cidex.
While about 10% disinfection solution is enough to kill all viruses specially corona
virus. On the other hand, as much as 94.0% of the study group did acquire knowledge
about sterilization technique using steam and equipment preparation for sterilization
by autoclave, most of them 88.2 % define sterilization while less than ten percent
.7.8%of them were known solution used in sterilization
Table (5): Frequency distribution among the studied sample `s
knowledge regarding isolation & waste disposal in isolation
department (n=51)
Knowledge Items Correct Incorrect
No % No %
• Isolation
• Purpose of isolation 51 100 _ _
• Measures of isolation 50 98 1 2
• Precautions during 35 68.6 16 31.4
isolation
• Waste disposal
• Cleaning garbage 36 70.6 15 29.4
containers after
disposal of waste on a
regular basis and using
double bagging
• Assurance that medical 48 94.1 3 5.9
waste or sharps
allocated in its
container
• Necessary to have a 48 94.1 3 5.9
special container to
keep needles and sharp
instruments after use
• Aspirator material 39 76.5 12 23.5
between the region
clean and unclean
• Waste disposed bags 22 43.1 29 56.9
must be changed at the
end of the day

Concerning nurses` knowledge regarding isolation, its purpose, measures and

precautions & waste disposal in in icu isolation their knowledge were incorrect
(100%,98%and 68%respectively ). Moreover, 94%of them had correct knowledge
regarding assurance that medical waste or sharps allocated in its container and
necessity to have a special container to keep needles and sharp instruments after use.
cleaning garbage containers after disposal of waste on a regular basis and using
double bagging was correct knowledge by 70.6% of them while 43.1% of them had
.correct knowledge about waste disposed bags must be changed at the end of the day
Table (6): Frequency distribution among the studied sample `s
knowledge regarding standers of the infection control measures in
isolation department (n=51)

Infection control measures in Correct Incorrect

isolation department
No % No %

Good ventilation helping in 15 29.4 36 70.6

spreading infection
Sink founded near entrance of 1 2 50 98
isolation department
Drug preparation zone far from 11 21.6 40 78.4
patients` rooms
Microorganism planted plate 16 31.4 35 68.6
founded in isolation department

Table 6 demonstrates nurses` knowledge regarding infection control

measures in isolation department in the study group in all tested elements as such as
their knowledge were in correct sink founded near entrance of isolation room, Drug
preparation zone far from patients` rooms, Good ventilation helping in spreading
infection, and microorganism planted plate founded in isolation department (98.0%,
78%, 70.6% &68.6% respectively)
Table (7): Distribution among the studied sample according to total
knowledge score regarding infection control measures in isolation

department (n = 51)

.No %
Knowledge overall
<60 incorrect 37 72.5
≥60 correct 14 27.5
Total score
Min. – Max. 49.0 – 30.0
Mean ± SD. 4.89 ± 41.98
Percent score
Min. – Max. 85.96 – 52.63
Mean ± SD. 8.58 ± 73.65

PART III: Distribution of Nurses` Compliance with Infection Control

.Measures in isolation department
Table (8): Frequency distribution concerning studied sample `s
compliance with hand hygiene in isolation department (n=51)
Hand washing Comply Not comply
No % No %
• Hand washing procedure 23 45.1 28 54.4
• Running water -paper 22 43.1 29 56.9
towels
• Trash basket 11 21.6 40 78.4
• Procedure
• Stand in front of but 10 19.6 41 80.4
away from sink
• Turn on water using foot 1 2 50 98
paddle or faucet
• Adjust temperature 6 11.8 45 88.2
,running water
• Place a small amount of 24 47.1 27 52.9
soap
• Rub vigorously using 15 29.4 36 70.6
firm circular
• Wash your hand for at 22 43.1 29 56.9
least 10-15 seconds
• Clean under finger nails 5 9.8 46 90.2
• Rinse your hand under 23 45 28 54.2
running water, keep
finger pointed sound
• Re-soap your hand, 4 7.8 47 92.2
rewash and rerinse if
heavily contaminated

Table (8): demonstrates the nurses` compliance with infection control

measures in isolation department related to hand hygiene. Most of them were not
comply to hand hygiene,98%,92.2%&90% 88% respectively turn on water using
foot paddle or faucet , clean under finger nails and re-soap your hand, rewash , rerinse
.if heavily contaminated, and adjust temperature, running water
Distribution of the studied nurses according to level hand washing checklist
(n = 51)

No. %
Level Hand washing checklist
≥80 comply 3 5.9
<80 not comply 48 94.1
Total score
Min. – Max. 0.0 – 10.0
Mean ± SD. 3.25 ± 3.74
Percent score
Min. – Max. 0.0 – 83.33
Mean ± SD. 27.12 ± 31.13
Table (9): Frequency distribution concerning studied sample `s compliance with infection
control measures in isolation department related to wearing personal protective equipment
(n=51)
Comply Not comply
Protective equipment
No % No %

Gloving 50 98 1 2

Gowning 4 7.8 47 92.2

Masking 14 27.5 37 72.5

It is noticed from table 9 that nurses` compliance with infection control

measures in isolation department related to wearing personal protective equipment
was not comply regarding gowning and masking(92.2%&72.5% respectively ). Near
.all of them 98% showed comply in gloving
Table (10): Frequency distribution among the studied sample `s
compliance with equipment processing in delivery room (n=51)

Technique Comply Not comply

No % No %

Decontamination )1( 47 92.2 4 7.8

Cleaning )2( 3 5.9 48 94.1

High level disinfection by )3( - - 51 100

boiling

Sterilization )4(

By chemical)A( 3 5.9 48 94.1

Dry –heat sterilization)B( 3 5.9 48 94.1

Sterilization by autoclave)C( 48 94.1 3 5.9

Table (10): demonstrates the nurses` compliance with infection control

measures in isolation department related to equipment handling & processing. All of
them 100% not comply to high level disinfection by boiling ,Most of them 94% were
not comply to Cleaning, chemical, and dry heat sterilization ,while only 7.8%and
.5.9% respectively not comply to decontamination and sterilization by autoclave
Distribution of the studied nurses according to total compliance with infection
control measures in delivery room (n = 51)

% .No
Practice items overall
100.0 51 < 80 not comply
0.0 0 comply 80≥
Total score
107.0 – 0.0 .Min. – Max
18.66 ± 42.25 .Mean ± SD
Percent score
78.68 – 0.0 .Min. – Max
13.72 ± 31.07 .Mean ± SD
PART IV: Distribution of Nurses` Attitude Regarding
Compliance with Infection Control Measures in isolation department

Table (11): Frequency distribution according to studied

sample`s attitude regarding infection control measures in isolation
department(n=51)
Items Disagree Un certain Agree St.
deviation
No % No % No %
Feeling upset when 22 43.1 5 9.8 24 47.1 0.96
dealing with patients for
fear of infection
Feeling fear when case 17 33.3 8 15.7 26 51 0.91
is infected
Feeling upset and un 28 54.9 15 29.4 8 15.7 0.75
comfort from the mask
and glove work
Needle stick injuries 38 74.5 - - 13 25.5 0.88
normal in work
Thinking the use of 34 66.7 3 5.9 14 27.5 0.90
sterilization methods is
not important that
caution does not prevent
fate
Wearing protective 1 2 2 3.9 48 94.1 0.34
clothing for infection
control during
operations is one of the
important means to
reduce the spread of
infection
There is difficulty in 15 30 4 8 31 62 0.91
using the principles of
preventing infection
especially in the case of
emergency
It is necessary to follow 3 6 2 4 45 9 0.51
infection control
precautions (bib –
garbage – gloves )
during patient care
It is necessary to take - - 3 6 47 94 0.24
vaccination again viral
hepatitis
Thinking that exposure 1 2 2 3.9 48 94.1 0.34
 to blood and body fluids
displays the health team
of the infection
I am appalled when I 8 16 6 12 36 72 0.76
know that one of my
colleagues had become
infected where I think
it`s on the way to
When tearing gloves, 49 96.1 1 2 1 2 0.31
it`s not necessary to
have another
I don`t care when blood 43 87.8 2 4.1 4 8.2 0.58
or body fluids came on
my clothes and I don`t
change it
I don`t care when about 45 90 1 2 4 8 0.56
hand washing after
giving patient care
Table 10 shows nurses` attitude regarding infection control measures in
isolation department 94% of nurses had positive attitude regarding wearing protective
clothing for infection control during operations is one of the important means to
reduce the spread of infection, It is necessary to take vaccination again viral hepatitis
and thinking that exposure to blood and body fluids displays the health team of the
infection. Also majority of them had positive attitude for I am appalled when I know
that one of my colleagues had become infected where I think it`s on the way to and
There is difficulty in using the principles of preventing infection especially in the case
of emergency(72%and62%respectively). Near half of them 47% feeling upset when
dealing with patients for fear of infection and feeling fear when case is
infected51% .But only 2% of them had positive attitude regarding when tearing
.gloves, it`s not necessary to have another
 Distribution of the studied sample according to Attitude (n = 51)

% .No
Attitude overall
100.0 51 negative 60% <
0.0 0 positive 60≥
Total score
30.0 – 14.0 .Min. – Max
4.32 ± 21.64 .Mean ± SD
Percent score
57.14 – 0.0 .Min. – Max
15.42 ± 27.31 .Mean ± SD

PART V: Relation between Nurses` knowledge, Practice &

.Their General Characteristics

Table (11): Relation between studied sample`s knowledge &

their area of residence

Know ledged item Rural Urban X P-Value

No % No %
Definition of infection Correct - - - - - -

Incorrect 27 52.9 24 47.1

Infection cycle Correct 1 2 3 5.9 1.360 0.244

Incorrect 26 51 21 41.2

Hospital acquired infection due to hospitalization Correct 21 41.2 20 39.2 0.249 0.618
Incorrect 6 11.8 4 7.8
Health team as a cause of infection in delivery Correct 5 9.8 2 3.9 1.113 0.291
room
Incorrect 22 43.1 22 43.1

Fever as an enough sign for infection Correct 12 23.5 13 25.5 0.481 0.488

Incorrect 15 29.4 11 21.6

Long hospitalization increase incidence of hospitalCorrect 5 9.8 1 2 2.521 0.112

acquired infection
Incorrect 22 43.1 23 45.1

Infection can be prevented through infection prevention

Correct 4 7.8 1 2 1.629 0.202
measures
Incorrect 23 45.1 23 45.1

Table 11 describes no significant difference between the group's knowledge

about infection control measures & their area of residence as much as 100.0% of the
study group did obtain satisfactory knowledge about the definition of infection, its
.cycle, and Hospital acquired infection due to hospitalization
 Table (12): Relation between studied sample`s practice & their
general characteristics.

Personal character Not comply Comply X2 P-value

No % No %

Age in years <20 1 1.9 1 1.9 8.86 <0.05

21-25 7 13.7 3 5.9
26-30 or more 32 62.7 7 13.9
Educational qualification Diploma 40 78.5 3 5.8 9.41 <0.05
Technical 5 9.8 1 1.9
Bachelor 1 1.9 1 1.9
Years of experience >1 Year 4 7.9 1 1.9 8.63 <0.05
2-5 Year 2 4 1 1.9
>6 Years 41 80.5 2 3.8
Training course Yes 6 11.9 2 3.8 7.63 <0.05
No 41 80.5 2 3.8
Residence Rural 22 43.1 5 9.8 4.32 <0.05
Urban 20 39.2 4 7.9
nurses in age, educational level year of experience, training course,
Concerning relation between nurses` practice & their general characteristics, table 12
shows statistically significant (0.005*) among residence.,

Table (13): Relation between studied sample`s knowledge &

their general characteristics.

Personal character Incorrect Correct X2 P-value

No % No %
Age in years <20 1 1.9 1 1.9 15.56 <0.001
21-25 9 17.6 1 1.9
26-30 or more 37 72.9 2 3.8
Educational qualification Diploma 41 80.6 2 3.8 5.86 <0.05
Technical 5 9.9 1 1.9
Bachelor 1 1.9 1 1.9
Years of experience >1 Year 4 7.9 1 1.9 7.62 <0.05
2-5 Year 2 3.8 1 1.9
>6 Years 40 78.6 3 5.9
Training course Yes 6 11.9 2 3.8 13.65 <0.05
 No 40 78.4 3 5.9
Residence Rural 25 49.1 2 3.8 4.32 <0.05
Urban 21 41.2 3 5.9
Vaccination against viral hepatitis Yes 14 27.5 1 1.9 9.81 <0.05
No 34 62.7 4 7.9

Concerning relation between nurses` practice & their general characteristics,

table 13 shows statistically significant (0.005*) among nurses in age, educational
level year of experience, training course, residence, and their knowledge about
infection control measures. Increasing of general characteristic accompanied by
increasing knowledge.

Dissection:
To the best of our knowledge, this is the first study to assess the knowledge
and practice of COVID-19 infection control among in isolation departments in
misurata. The results of the present study indicated that there is a good knowledge of
infection control measures with patients with COVID-19 among isolation
departments. In addition, there was a significant association between HCWs’
profession and their knowledge of COVID-19 and good clinical practices of infection
control measures. The most common sources of COVID-19 information and
prevention policies were official media platforms and the websites of the
hospital/MOH.

The findings of the current study demonstrate that the majority of the
respondents knew the required infection control precautions needed during
radiological examinations of suspected and/or positive COVID-19 cases and when
using a portable unit.

We also analyzed the association between profession and HCWs’ knowledge

of COVID-19 infection control in clinical practice in isolation departments. The
results showed that the majority of nurses agreed that they knew about the types of
disinfectant used for the isolation department, . In our study, most of the surveyed
 HCWs were nurses worked in isolation department, their age ranged from 25 to 50
years old, and they had more than 10 years of experience in the field. These factors
could explain their sufficient knowledge of infection control. This is in line with the
findings from a previous study in misurata that indicated that age, specialty, and work
experience were significantly associated with infection control knowledge of MERS-
CoV among HCWs (Nour et al., 2015). Similarly, Ayinde et al (Ayinde et al., 2020)
and Giao et al (Giao et al., 2020) reported that profession was significantly associated
with nurses knowledge of COVID-19. This sufficient knowledge had a positive
impact on HCWs’ attitudes toward COVID-19 prevention .

The present study revealed good practices of infection control among nurses in
isolation department during the outbreak compared with other HCWs in the isolation
department. We found that the majority of the nurses reported wearing the
recommended PPE for each the patient’s infection status during this pandemic. This
good practice indicates their high level of knowledge about the appropriate use of
PPE such as isolation gowns, surgical masks, and gloves while exposure for patients
to protect against the new virus. These findings agree with those from a study in
China showing that professional categories and work experience significantly
influenced HCWs’ practices regarding COVID-19 (Zhou et al., 2020).

The results of our study also showed that most of the HCW professions agreed
that their nurses in isolation department followed the COVID-19 infection control
measures and precaution policies before and after each exam. These infection control
measures included screening each out-patient at the front room the isolation
department and performing a deep cleaning of all and workstations. These guidelines
were in line with recent recommendations for infection control of COVID-19 in
isolation departments (Kooraki et al., 2020; Mossa-Basha et al., 2020; Nasir et al.,
2020; Wan et al., 2020; Yu et al., 2020). Thus, the sufficient COVID-19 knowledge
and good practice of control measures by HCWs in isolation departments found in
this study are likely related to the protection-associated materials and policies of the
MOH that have aided the frontline HCWs.

The results of barriers of nursing noncompliance with infection control

measures. It points to emergency situation, lack of equipment & supplies, lack of
infection control measures, lack of periodical infection and control training course
.were the most barrier (37.5%,87.5%,75,&95%respectively)

TIMELINE
 The Research plan will be divided in the form of a series shown in table

Data Program The

12.12.2020 Prepare the questioner
4.12.2020-23.12.2020 Distribution of the questioner
12.1.2020 Prepare the introduction
6.2.2020 Literature reviw and methodology
2.3.2020 Printing the proposal

Budjet

Required materials & means Cost

The cost printing photos 400
Internet service subscribtion 100
Break fast for staff 250
Transporation 160
Total 910

REFRENCES
1. WHO. Novel Coronavirus-Japan (ex-China). https://www.who.int/csr/don/17-
january-2020-novel-coronavirus-japan-ex-china/en/. (Accessed on 1st Feb 2020).
2. Kommenda N, Levett, C and Levitt D. How the coronavirus spread across China
and the world–visual explainer, The
Guardian. https://www.theguardian.com/world/ng-interactive/2020/feb/11/how-novel-
coronavirus-spread-across-the-world-visualexplainer (Accessed on 27th March 2020).
3. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics
in Wuhan, China, of novel coronavirus–infected pneumonia. New England Journal of
Medicine. 2020. January 29. [PMC free article] [PubMed] [Google Scholar]
4. El Zowalaty ME, Järhult JD. From SARS to COVID-19: A previously unknown
SARSCoV-2 virus of pandemic potential infecting humans–Call for a One Health
approach. One Health. 2020. February 24:100124
10.1016/j.onehlt.2020.100124 [PMC free article] [PubMed] [CrossRef] [Google
Scholar]
5. MacIntyre CR. Global spread of COVID-19 and pandemic potential. Global
Biosecurity. 2020. February 26;1(3). [Google Scholar]
6. WMHC. Wuhan Municipal Health and Health Commission’s Briefing on the
Current Pneumonia Epidemic Situation in Our
City. http://wjw.wuhan.gov.cn/front/web/showDetail/2019123108989. (Accessed on
1st February 2020).
7. Zhang W, Du RH, Li B, Zheng XS, Yang XL, Hu B, et al. Molecular and
serological investigation of 2019-nCoV infected patients: implication of multiple
shedding routes. Emerging microbes & infections. 2020. January 1;9(1):386–9. [PMC
free article] [PubMed] [Google Scholar]
8. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients
infected with 2019 novel coronavirus in Wuhan, China. The Lancet. 2020. February
15;395(10223):497–506. [PMC free article] [PubMed] [Google Scholar]

9.X. Xu, P. Chen, J. Wang et al., “Evolution of the novel coronavirus from the
ongoing Wuhan outbreak and modeling of its spike protein for risk of human
transmission,” Science China Life Sciences, vol. 63, no. 3, pp. 457–460,
2015.View at: Publisher Site | Google Scholar

1o.H. Shi, X. Han, N. Jiang et al., “Radiological findings from 81 patients with
COVID-19 pneumonia in Wuhan, China: a descriptive study,” The Lancet
Infectious Diseases, vol. 20, no. 4, pp. 425–434, 2020.View at: Publisher
Site | Google Scholar

11.S. Kooraki, M. Hosseiny, L. Myers, and A. Gholamrezanezhad, “Coronavirus

outbreak: what the department of radiology should know,” Journal of the
American College of Radiology, vol. 17, no. 4, pp. 447–451, 2020.View
at: Publisher Site | Google Scholar
12. S. R. Weiss and J. L. Leibowitz, “Coronavirus pathogenesis,” in Advances in
Virus Research, vol. 81, pp. 85–164, Academic Press, Cambridge, MA, USA,
2019.