Relative Sensitivity of Common Target Genes For The Detection of SARS-Cov-2 In Real Time-PCR (preprint)

SARS-CoV-2(COVID-19) currently is the main cause of the severe acute respiratory disease and fatal outcomes in human beings worldwide. Several genes are used as targets for the detection of SARS-CoV-2, including the RDRP, N, and E genes. The present study aimed to determine the RDRP, N, and E genes expressions of SARS-CoV- 2 in clinical samples. For this purpose, 100 SARS-CoV-2 positive samples were collected from diagnostic laboratories of Mazandaran province, Iran. After RNA extraction, the real time RT-PCR assay was performed for differential gene expressions’ analysis of N, E, and RDRP. The CT values for N, RDRP, and E targets of 100 clinical samples for identifying SARS-CoV-2 were then evaluated using qRT-PCR. This result suggests N gene as a potential target for the detection of the SARS‐CoV‐2, since it was observed to be highly expressed in the nasopharyngeal or oropharynges of COVID-19 patients (P < 0.0001). Herein, we showed that SARS-CoV- 2 genes were differentially expressed in the host cells. Therefore, to reduce obtaining false negative results and to increase the sensitivity of the available diagnostic tests, the target genes should be carefully selected based on the most expressed genes in the cells.

IFI27 transcription is an early predictor for COVID-19 outcomes; a multi-cohort observational study (preprint)

Background. Robust biomarkers that predict disease outcomes amongst COVID19 patients are necessary for both patient triage and resource prioritisation. Numerous candidate biomarkers have been proposed for COVID19. However, at present, there is no consensus on the best diagnostic approach to predict outcomes in infected patients. Moreover, it is not clear whether such tools would apply to other potentially pandemic pathogens and therefore of use as stockpile for future pandemic preparedness. Methods. We conducted a multi cohort observational study to investigate the biology and the prognostic role of interferon alpha inducible protein 27 (IFI27) in COVID19 patients. Findings. We show that IFI27 is expressed in the respiratory tract of COVID19 patients and elevated IFI27 expression is associated with the presence of a high viral load. We further demonstrate that systemic host response, as measured by blood IFI27 expression, is associated with COVID19 severity. For clinical outcome prediction (e.g. respiratory failure), IFI27 expression displays a high positive (0.83) and negative (0.95) predictive value, outperforming all other known predictors of COVID19 severity. Furthermore, IFI27 is upregulated in the blood of infected patients in response to other respiratory viruses. For example, in the pandemic H1N1/09 swine influenza virus infection, IFI27 like genes were highly upregulated in the blood samples of severely infected patients. Interpretation. These data suggest that prognostic biomarkers targeting the family of IFI27 genes could potentially supplement conventional diagnostic tools in future virus pandemics, independent of whether such pandemics are caused by a coronavirus, an influenza virus or another as yet to be discovered respiratory virus.

Side Effects and Immunogenicity Following Administration of The Sputnik V COVID-19 Vaccine Among Health Care Workers; An Observational Study in Iran (preprint)

The Sputnik V COVID-19 vaccine, have shown excellent safety and efficacy against COVID-19 in phase 3 of the clinical trial. We provided independent evidence on side effects and immunogenicity following the administration of the Sputnik V COVID-19 in Iran. In this observational study, the healthcare workers who vaccinated with the Sputnik V COVID-19 vaccine within February and April 2021 were evaluated. Among a total of 13435 vaccinated healthcare workers, we received 3236 self-declaration reports of Sputnik V associated adverse events with the mean age 39.32±10.19 years old which 38.8% were men and 61.2% were women. The most common side effect was a pain in the injection site (56.9%), fatigue (50.9%), body pain (43.9%), headache (35.7%), fever (32.9%), joint pain (30.3%), chilling (29.8%) and drowsiness (20.3%). Side effects of the vaccine were significantly more frequent in females and younger individuals. Among a total of 238 participants, more than 90% after the first and second dose of vaccine had a detectable level of SARS-CoV-2 RBD antibody and SARS-CoV-2 neutralizing antibody. Although the overall the rate of adverse effects was higher than the interim results from randomized controlled trials, our findings support the manufacturer’s reports about the high humoral immunogenicity of vaccine against COVID-19.

Co-infection of SARS-CoV-2 with influenza among COVID-19 cases: A-meta analysis (preprint)

Background The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), that causes coronavirus disease 2019 (COVID-19) is a public health problem and may have co-infection with other pathogens such as influenza virus.Objective This study aims to assess the co-infection of SARS-CoV-2 with influenza among COVID-19 cases.Material and methods The all relevant studies were collected from international databases. For improving the quality of the present literature, the all studies were evaluated by two reviewers in order to confirm all of the studies have inclusion criteria. Finally, all articles with sufficient quality scores were included in meta-analysis. Assessment of heterogeneity among the studies of primary studies was performed using the statistic chi‐squared test (Cochran's Q) and I2 index. In this results, random or fixed effect model were used for determination of heterogeneity test. All statistical analyses were performed using Comprehensive Meta-Analysis (CMA), V.2 software.Results This meta- analysis included 9 primary studies investigating the co-infection of SARS-CoV-2 with influenza among COVID-19 cases. Pooled prevalence (95% confidence interval) of co-infection is shown that the prevalence of influenza A is higher than influenza B. 2.3(0.5-9.3) vs 0.1 (0.4-3.3). Using the fixed effect model the frequency of fever was (80.6% [95% CI 76.1–84.40, p < 0.153]) and it is shown that fever is the most prevalent symptom in patients.Conclusion Patients admitted to hospital with COVID-19 also infected with influenza virus. Thus, the current research provides a better understanding about the control and treatment of co-infection with SARS-CoV-2 and the influenza virus.

Emerging SARS-CoV-2 Genetic Variations and Mutations in the COVID-19 genomic sequence: A Systematic and Meta-analysis review (preprint)

Objectives Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of coronavirus disease 2019 (COVID-19). The high mutation rate of RNA viruses causes genetic variation, virus evolution and it is a strategy to escape the immune system. In the present study, all researches and evidence were extracted from the available online national databases. Two researchers randomly evaluated the assessment of the research sensitivity. Finally, after quality assessment and specific inclusion and exclusion criteria, the eligible articles were entered for meta-analysis. The heterogeneity between the results of studies was measured using test statistic (Cochran's Q) and I2 index. The forest plots illustrated the point and pooled estimates with 95% confidence intervals (crossed lines). All statistical analyses were performed using Comprehensive meta-Analysis V.2 software.This meta-analysis included 13 primary studies investigating the SARS-CoV-2 genetic variations and mutations in the COVID-19 genomic sequence. According to the pooled prevalence (95% confidence interval) of mutations, the spike gene variations showed the highest non-synonymous mutation frequency (16.4%, CI: 13.6, 16.6) and the Non-structural protein (NSP) genes possess the highest mutation frequency among total mutations (31.6%, CI: 21, 44.6). Genomic mutation analysis of SARS-CoV-2 strains may provide knowledge about different biological infrequent mutations and their relationships of viral transmission, pathogenicity, infectivity, and fatality rates between SARS-CoV-2 and human cells.

The Role of Vitamin D in The Age of COVID-19: A Systematic Review and Meta-Analysis Along with an Ecological Approach (preprint)

Background: Following emerge of a novel coronavirus from Wuhan, China, in December 2019, it has affected the whole world and after months of efforts by the medical communities, there is still no specific approach for prevention and treatment against the Coronavirus Disease 2019 (COVID-19). Evidence recommends that vitamin D might be an important supportive agent for the immune system, mainly in cytokine response regulation against COVID-19. Hence, we carried out a rapid systematic review and meta-analysis along with an ecological investigation in order to maximize the use of everything that exists about the role of vitamin D in the COVID-19. Methods: A systematic search was performed in PubMed, Scopus, Embase, Cochrane Library, Web of Science and Google Scholar (intitle) as well as preprint database of medRxiv, bioRxiv, Research Square, preprints.org, search engine of ScienceDirect and a rapid search through famous journals up to May 26, 2020. Studies focused on the role of vitamin D in confirmed COVID-19 patients were entered into the systematic review. Along with our main aim, to find the second objective: correlation of global vitamin D status and COVID-19 recovery and mortality we carried out a literature search in PubMed database to identify the national or regional studies reported the vitamin D status globally. CMA v. 2.2.064 and SPSS v.16 were used for data analysis. Results: Out of nine studies entered into our systematic review, six studies containing 3,822 participants entered into the meta-analysis. The meta-analysis indicated that 46.5% of COVID-19 patients were suffering from vitamin D deficiency (95% CI, 28.2%-65.8%) and in 43.3% of patients, levels of vitamin D were insufficient (95% CI, 27.4%-60.8%). In regard to our ecological investigation on 51 countries including 408,748 participants, analyses indicated no correlation between vitamin D levels and recovery rate (r= 0.041) as well as mortality rate (r=-0.073) globally. However, given latitude, a small reverse correlation between mortality rate and vitamin D status was observed throughout the globe (r= -0.177). In Asia, a medium direct correlation was observed for recovery rate (r= 0.317) and a significant reveres correlation for mortality rate (r= -0.700) with vitamin D status in such patients. In Europe, there were no correlations for both recovery (r= 0.040) and mortality rate (r= -0.035). In Middle East, the recovery rate (r= 0.267) and mortality rate (r= -0.217) showed a medium correlation. In North and Sought America, surprisingly, both recovery and mortality rate demonstrated a direct correlation respectively (r= 1.000, r=0.500). In Oceania, unexpectedly, recovery (r= -1.000) and mortality (r= -1.000) rates were in considerable reverse correlation with vitamin D levels. Conclusion: In this systematic review and meta-analysis with an ecological approach, we found a high percentage of COVID-19 patients who suffer from vitamin D deficiency or insufficiency. Much more important, our ecological investigation resulted in substantial direct and reverse correlations between recovery and mortality rates of COVID-19 patients with vitamin D status in different countries. Considering latitudes, a small reverse correlation between vitamin D status and mortality rate was found globally. It seems that populations with lower levels of vitamin D might be more susceptible to the novel coronavirus infection. Nevertheless, due to multiple limitations, if this study does not allow to quantify a value of the Vitamin D with full confidence, it allows at least to know what the Vitamin D might be and that it would be prudent to invest in this direction through comprehensive large randomized clinical trials.

Relationship Between Blood Group and Risk of Infection and Death in COVID-19: a live Meta-Analysis (preprint)

Introduction: The relationship between ABO blood group and the incidence of COVID-19 infection and death has been investigated in several studies. The reported results were controversial, so the objective of the present study is to assess the relationship between different blood groups and the onset and mortality of COVID-19 infection using meta-analysis method. Methods: We searched the databases using appropriate MeSH terms. We screened articles on the basis of titles, abstracts, and full texts and the articles that met the inclusion criteria were selected. Quality assessment was done with the Newcastle-Ottawa Scale checklist. The estimated frequency of COVID-19 infection and death in terms of ABO blood group and the overall estimate of the odd ratio between blood group with COVID-19 infection and death was done with 95% confidence interval. Results: The pooled frequency of blood groups A, B, O, and AB among COVID-19 infected individuals was estimated as 36.22%, 24.99%, 29.67%, and 9.29% respectively. The frequency of blood groups A, B, O, and AB among the dead cases due to COVID-19 infection was estimated as 40%, 23%, 29%, and 8% respectively. The odd ratio of COVID-19 infection for blood group A versus the other blood groups was estimated 1.16 (CI 95%: 1.02-1.33). The corresponding figures for blood groups O and AB versus other blood groups were estimated as 0.73 (CI 95%: 0.60-0.88) and 1.25(CI 95%: 0.84-1.86) respectively. Conclusion: This meta-analysis showed that individuals with blood group A are at higher risk for COVID-19 infection while those with blood group O are at lower risk. Although the odds ratio of death for AB blood group was non-significant, it was considerable.

Liver Function in Novel Coronavirus Disease (COVID-19): A Systematic Review and Meta-Analysis (preprint)

Introduction:The outbreak of new coronavirus has become a global public health challenge. Given a consequential liver function, and the high risk of death coming from liver disorders, the assessment of Novel Coronavirus Disease on liver function is importance. Hence, we carried out this meta-analysis to heightening insight into the occult features of COVID 19, which is likely to affect liver function. Method:This study was performed using databases of Web of Science, Scopus, and PubMed. We considered English cross-sectional and case-series papers, which reported available findings on the association between liver injury and COVID-19 infection. We used the STATA v.11 and random effect model for data analysis. Result:In this present meta-analysis, 52 papers, including 8,463 COVID-19 patients, were studied. The prevalence of increased liver enzymes among the patients, including Alanine aminotransferase, Aspartate aminotransferase, were 30% and 21% in non-severe patients, respectively, which were 38% and 48% in severe patients. The prevalence of increasing C-reactive protein, Lactate dehydrogenase, D-dimer, and Bilirubin were 55%, 39%, 28%, and 10% in non-severe patients respectively, which were 78%, 75%, 79% and 17% in sever patients.The prevalence of liver toxicity as a complication of COVID-19 was 20%.Also patients who have severe condition are 5.54, 4.22, 4.96, 4.13 and 4.34 times more likely to have elevated CRP, ALT, AST, LDH, D-dimer enzymes retrospectively. Conclusion:Elevation of some liver markers were higher in patients with severe COVID-19 infection. All to gather, we assumed that abnormal liver markers could act as a prognostic factor for a better survey of COVID-19.

Anxiety and Depression in Health Workers and General Population During COVID-19 Epidemic in IRAN: A Web-Based Cross-Sectional Study (preprint)

The COVID-19 outbreak has exerted a great deal of psychological pressure on Iranian health workers and the general population. In the present study, the prevalence of anxiety and depression symptoms along with the related variables in this epidemic were investigated.An online cross-sectional study was conducted for the general public and healthcare workers in IRAN using a questionnaire comprised of demographic questions and Hospital Anxiety and Depression Scale. Chi square test was used to compare categorical variables, and univariate and multivariate logistic regression models were conducted.Of the 2045 participants,1136 (65.6%) were considered to have moderate and severe anxiety symptoms, and 865(42.3%) had moderate and severe depression symptoms. Based on the logistic regression models, the prevalence of anxiety was higher in the females than in the males (OR=1.4, 95% CI: 1.123-1.643, P=.002); the prevalence of anxiety was significantly higher in those aged 30-39 years than in other age groups (OR=1.6, 95% CI: 1.123-2.320, P=0.001); furthermore, the prevalence of anxiety and depression was significantly higher in doctors and nurses compared with other occupations (OR=1.9, 95% CI: 1.367-2.491, P< 0.001) and(OR=1.5, 95% CI: 1.154-2.021, P=0.003). In addition, the prevalence of anxiety symptoms in the likely-infected COVID-19 group was higher than in the noninfected COVID-19 group (OR=1.35, 95% CI: 1.093-1.654, P=0.005).A majority of health workers and general population have anxiety and depression symptoms. These symptoms are more widespread in doctors and nurses in comparison to other occupations, and psychological interventions might be conducive to reducing the negative symptoms.

High Resolution Computed Tomography Finding in 552 Patients with Symptomatic COVID-19: First Report from North of Iran (preprint)

Purpose: Due to the emergence of the new Coronavirus-2019 and the lack of sufficient information about infected patients, this study was conducted to investigate the Chest High Resolution Computed Tomography (HRCT) findings of patients infected with the new Coronavirus 2019.Methods: This cross-sectional study was performed on COVID-19 patients referred to Medical Imaging Centers of Sari, Mazandaran, Iran, on March 2020 for Computed Tomography Scan (CT-Scan). Symptomatic patients were referred to the Medical Imaging Center for diagnosis confirmation through CT-scan. In addition to age and sex, HRCT findings were collected from the picture archiving and communication system (PACS) for further evaluations.Results: Out of 552 patients with mean age of 14.8 ± 51.2 years, the male/female ratio was 1.38 to 1. The most common expressive findings in patients were ground-glass opacity (GGO) (87.3%), peripheral distribution (82.4%) and posterior distribution (81.5%). The most conflicting findings in patients were pleural effusion (7.6%), peribronchovascular distribution (7.6%), and lymphadenopathy (5.1%). The peripheral distribution (p = 0.034), round opacities (p = 0.02), single lobe (p = 0.003) and pleural effusion (p = 0.037) were significantly in people under and over 50 years of age.Conclusion: In summary, the present study indicated that in addition to GGO, peripheral distribution findings could be a vital diagnostic choice in COVID-19 patients.

Hydroxychloroquine Versus COVID-19: A Rapid Systematic Review and Meta-Analysis (preprint)

Background: Coronavirus Disease 2019 (COVID-19) has become a major global issue with rising the number of infected individuals and mortality in recent months. Among all therapeutic approaches, arguments have raised about hydroxychloroquine (HCQ) efficacy in the treatment of COVID-19. We carried out a systematic review and meta-analysis overcome the controversies regarding the effectiveness of hydroxychloroquine in the treatment of COVID-19. Methods: A systematic search was performed in PubMed, Scopus, Embase, Cochrane Library, Web of Science, Google Scholar and medRxiv pre-print database using all available MeSH terms for COVID-19 and hydroxychloroquine up to July 19, 2020. Studies focused on the effectiveness of HCQ with/without azithromycin (AZM) in confirmed COVID-19 patients were entered into the study. Two researchers have independently evaluated quality assessment of the studies and abstracted data for data extraction. Extracted data were analyzed using CMA v. 2.2.064. Heterogeneity was assessed using the I-squared (I2) test, and fixed/random-effects model was used when appropriate for pooling of studies. Results: Out of 26 studies entered into our systematic review, 21 studies including 14 comparative studies with control group and seven observational studies containing 103,486 participants have entered into the meta-analysis. The results of the meta-analysis on comparative studies indicated no significant clinical effectiveness (negative in RT-PCR evaluation) for HCQ regimen in the treatment of COVID-19 in comparison to control group (RR: 1.03, 95% CI, 0.79-1.34). The same result was observed for the combination of HCQ+azithromycin (RR: 1.26, 95% CI, 0.91-1.74). No significant differences were found for both HCQ (RR: 0.92, 95% CI, 0.72-1.16) and HCQ+AZM (RR: 1.72, 95% CI, 0.86-3.42) mortality rate; however, mortality was affected by age differences according to meta-regression analysis (P<0.000001). No substantial difference was observed for disease exacerbation (RR: 1.23, 95% CI, 0.65-2.30) between HCQ group and controls. Also, radiological findings significantly improved in the HCQ group (OR: 0.32, 95% CI, 0.11-0.98). Odds of known HCQ adverse effects (diarrhea, vomiting, blurred vision, rash, headache, etc.) occurred in the HCQ regimen group was approximately 3.5 times of control group (OR: 3.40, 95% CI, 1.65-6.98), but no substantial differences were found regarding intubation odds between HCQ group and control group (OR: 2.11, 95% CI, 0.31-14.03). Meta-analysis indicated no significant prophylactic effects for HCQ (OR: 0.40, 95% CI, 0.04-3.65) Conclusion: This systematic review and meta-analysis showed no clinical benefits regarding HCQ treatment with/without azithromycin for COVID-19 patients. Although mortality rate was not significantly different between cases and controls, frequency of adverse effects was substantially higher in HCQ regimen group. However, due to that most of the studies were non-randomized and results were not homogenous, selection bias was unavoidable and further large randomized clinical trials following comprehensive meta-analysis should be taken into account in order to achieve more reliable findings. Also, it is worth mentioning that if this work does not allow to quantify a "value" of the HCQ, it allows at least to know what is not the HCQ and that it would be prudent not to continue investing in this direction.

Cardiovascular Diseases and COVID-19 Mortality and Intensive Care Unit Admission: A Systematic Review and Meta-analysis (preprint)

BackgroundHigh rate of cardiovascular disease (CVD) have been reported among patients with novel coronavirus disease (COVID-19). Meanwhile there were controversies among different studies about CVD burden in COVID-19 patients. Hence, we aimed to study CVD burden among COVID-19 patients, using a systematic review and meta-analysis. MethodsWe have systematically searched databases including PubMed, Embase, Cochrane Library, Scopus, Web of Science as well as medRxiv pre-print database. Hand searched was also conducted in journal websites and Google Scholar. Meta-analyses were carried out for Odds Ratio (OR) of mortality and Intensive Care Unit (ICU) admission for different CVDs. We have also performed a descriptive meta-analysis on different CVDs. ResultsFifty-six studies entered into meta-analysis for ICU admission and mortality outcome and 198 papers for descriptive outcomes, including 159,698 COVID-19 patients. Results of meta-analysis indicated that acute cardiac injury, (OR: 13.29, 95% CI 7.35-24.03), hypertension (OR: 2.60, 95% CI 2.11-3.19), heart Failure (OR: 6.72, 95% CI 3.34-13.52), arrhythmia (OR: 2.75, 95% CI 1.43-5.25), coronary artery disease (OR: 3.78, 95% CI 2.42-5.90), and cardiovascular disease (OR: 2.61, 95% CI 1.89-3.62) were significantly associated with mortality. Arrhythmia (OR: 7.03, 95% CI 2.79-17.69), acute cardiac injury (OR: 15.58, 95% CI 5.15-47.12), coronary heart disease (OR: 2.61, 95% CI 1.09-6.26), cardiovascular disease (OR: 3.11, 95% CI 1.59-6.09), and hypertension (OR: 1.95, 95% CI 1.41-2.68) were also significantly associated with ICU admission in COVID-19 patients. ConclusionFindings of this study revealed a high burden of CVDs among COVID-19 patients, which was significantly associated with mortality and ICU admission. Proper management of CVD patients with COVID-19 and monitoring COVID-19 patients for acute cardiac conditions is highly recommended to prevent mortality and critical situations. Graphical abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=143 SRC="FIGDIR/small/20062869v2_ufig1.gif" ALT="Figure 1"> View larger version (22K): org.highwire.dtl.DTLVardef@21e53corg.highwire.dtl.DTLVardef@150dcc6org.highwire.dtl.DTLVardef@1ce7f21org.highwire.dtl.DTLVardef@1fc5fd7_HPS_FORMAT_FIGEXP M_FIG C_FIG

Repurposing naproxen as a potential antiviral agent against SARS-CoV-2 (preprint)

The Outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in late 2019 in China and many other countries around the world necessitate immediate action to develop new drugs against the virus. Repurposing of existing drugs for new targets is a fast, safe and unexpansive approach for this goal. Studies have shown that naproxen could specifically interact with the RNA binding domain of nueclporteins of RNA viruses such as the influenza virus. Therefore, this study aimed to evaluate the binding properties of naproxen to the nucleocapsid protein of SARS-CoV-2. 3D structure of N and C terminal domains of SARS-CoV- 2 nucleocapsid were constructed and each were docked with naproxen and analyzed during 100 ns of molecular dynamics. The results showed that naproxen interacts with the N terminal domain of the nucleocapsid via two salt bridges with Arg 88 and 92 and a network of h-bonds. Molecular dynamics analysis was also revealed that all the coordinations of naproxen with N terminal domain were kept during 100 ns of simulation time. The results of this study provide insights how naproxen can specifically interact with the conserved RNA binding module of the nucleocapsid of SARS-CoV-2 that would inhibit the packaging of viral genome into capsid and virus assembly. Therefore we recommend evaluating the antiviral effects of naproxen against SARS-CoV-2 in in vitro studies and clinical trials.

Clinical and Paraclinical Characteristics of COVID-19 patients: A systematic review and meta-analysis (preprint)

Introduction: Recently, a new strain of coronaviruses, which originated from Wuhan City, Hubei Province, China has been identified. According to the high prevalence of new coronavirus, further investigation on the clinical and paraclinical features of this disease seems essential. Hence, we carried out this systematic review and meta-analysis to figure out the unknown features. Methods: This study was performed using databases of Web of Science, Scopus and PubMed. We considered English cross-sectional and case-series papers which reported clinical, radiological, and laboratory characteristics of patients with COVID-19. We used STATA v.11 and random effect model for data analysis. Results: In the present meta-analysis, 32 papers including 49504 COVID-19 patients were studied. The most common clinical symptoms were fever (84%), cough (65%) and fatigue (42%), respectively. The most common radiological and paraclinical features were bilateral pneumonia (61%), ground-glass opacity (50%), thrombocytopenia (36%) and lymphocytopenia (34%). The study also showed that the frequency of comorbidities and early symptoms was higher in critically severe patients. Moreover, we found the overall mortality rate of three percent. Conclusion: According to that there are many cases without Computed Tomography Scan findings or clear clinical symptoms, it is recommended to use other confirming methods such RNA sequencing in order to identification of suspicious undiagnosed patients. Moreover, while there is no access to clinical and paraclinical facilities in in public places such as airports and border crossings, it is recommended to consider factors such as fever, cough, sputum and fatigue.