International Journal of Healthcare Management

ISSN: 2047-9700 (Print) 2047-9719 (Online) Journal homepage: https://www.tandfonline.com/loi/yjhm20

Factors influencing the epidemiological

characteristics of pandemic COVID 19: A TISM
approach

S. Lakshmi Priyadarsini & M. Suresh

To cite this article: S. Lakshmi Priyadarsini & M. Suresh (2020): Factors influencing the
epidemiological characteristics of pandemic COVID 19: A TISM approach, International Journal of
Healthcare Management, DOI: 10.1080/20479700.2020.1755804

To link to this article: https://doi.org/10.1080/20479700.2020.1755804

Published online: 20 Apr 2020.

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INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT
https://doi.org/10.1080/20479700.2020.1755804

Factors influencing the epidemiological characteristics of pandemic COVID 19:

A TISM approach
a b
S. Lakshmi Priyadarsini and M. Suresh
a
Department of Zoology, Govt.Victoria College, Palakkad, India; bAmrita School of Business, Amrita Vishwa Vidyapeetham, Coimbatore,
India

ABSTRACT ARTICLE HISTORY

The COVID 19 is a pandemic having an epidemic nature influencing the human health and Received 4 April 2020
economy in a global level. The major limitation to overcome the issue is the lack of potential Accepted 7 April 2020
vaccines or effective medicines to treat or control the disease. Considering the shortness of
KEYWORDS
time to act, the purpose of the paper was to identify and categorise the climatic, socio- Virulency; COVID 19; novel
biological factors that influence the global super-spread of the epidemic using a theory Corona virus 2; SARS-CoV-2;
building approach, ‘Total Interpretive Structural Modelling’ (TISM). MICMAC analysis of the Viral immune response; social
identified factors, based on their interdependence categorized the triggering factors, air distancing; total interpretive
temperature, humidity, age, airflow and ventilation, responsible for the increased mortality structural modelling
rate of COVID 19 compared to SARS and MERS. So the model explains why the temperate
countries of similar climatic zones and aged people are more vulnerable. It also predicts the
susceptibility of countries based on their geographic locations and upcoming climatic
conditions which were found to be influential in sustaining longevity and aerosol spread of
the virus. Since many of these factors remain unaltered or out of human control, the linkage
factors identified in this paper; change in host behaviour and number of contacts can be
given priorities in order to overcome the situation. Furthermore, this is the first attempt
made to understand epidemiological characteristics of COVID 19 using TISM approach.

1. Introduction ematical modelling considering the potential factors

The novel Corona Virus Disease 2019 or COVID 19 is a
respiratory illness that can spread from person to person
causing flu like symptoms and in severe cases death. It
was found to be originated from Wuhan, Hubei,
China, in December 2019, and was recognized as a pan-
demic by the World Health Organization [1,2], spread-
ing to more than 190 countries and territories, resulting
near 74,816 deaths and 1,349,660 affected cases as on 7
April 2020 [3]. Since there is no vaccine or specific anti-
viral treatment for COVID-19 there are a number of
suggested strategies in the control like social distancing
[4] and personal hygiene practices. Even then, the pan-
demic has led to severe global socioeconomic disrup-
tion, [5] and discrimination to foreigners [6].
There are many factors that can contribute to the
increased mortality rates of COVID 19 and this research
considered the major factors which have significant
impact on the global death toll due to COVID 19, by
a TISM approach which is used for analysing inter-
relationship between the factors. There are several the-
ories suggesting the impact of environmental factors
like, temperature and humidity along with international
travel and lack of proper social consciousness for iso-
lation as causes of the global spread of COVID 19; but
still there are no reliable predictions based on math-
on the spread of this pandemic which was identified
as a research gap which needs to be filled with emer-
gency action as it may possibly give an insight to policy
makers in prioritizing factors in the defense against this
disease globally, which is the motivation for this paper.
The main objective of the paper has been converted into
the following Research Questions (RQ):
RQ1: What are the major factors that contribute to the
pandemic nature of COVID 19 and to the high death
toll?
RQ2: What are the relationships among these factors?
RQ3: Can these factors be ranked according to priority?
2. Literature review
Though the worldwide statistics of COVID 19 inci-
dents are projecting some triggering factors responsible
for the heightened increase in the reported mortality, a
comprehensive analysis to find out the interrelation-
ship among them in order to identify the key or trigger-
ing factors are the need of the hour. The factors
influencing the epidemiological characteristics of
COVID 19 are listed below with definitions and
references.

CONTACT M. Suresh m_suresh@cb.amrita.edu; drsureshcontact@gmail.com Department of Zoology, Govt.Victoria College, Palakkad-678001, Kerala,
India
© 2020 Informa UK Limited, trading as Taylor & Francis Group
2 S. Lakshmi Priyadarsini and M. Suresh
2.1. Virulency of novel Corona virus
Virus virulence is the disease causing capability of a virus
which depends on various factors like those allow it to
replicate and spread inside a host by modifying host
defenses, and breaking host cells and damaging tissues.
It is this infectious potential of a pathogen which deter-
mines the severity of symptoms [7]. There are different
types of Corona viruses reported over the years. Tissue
tropism varies with the type of corona virus ie, alpha
and beta corona viruses infect mammals; in contrast,
gamma and delta corona viruses infect birds and fish,
but some of them can also infect mammals [8]. The
new 2019 novel Corona virus-2 or SARS-CoV-2 is ident-
ified as beta corona virus [9]. Virus virulence is basically
due to its genes responsible for viral replication, genes
which help to escape from host immune system, those
which are involved in the transmissibility and genes cod-
ing toxic products in host cells. The current virus seems to
be very contagious and has quickly spread globally [10].
2.2. Host defense potential
It directly correlates with the disease defense potential
of an individual, specifically the innate and adaptive
immune responses against pathogens [11]. Humans
are generally and specifically immune to various
kinds of viruses [12,13]. During the initial phase of
Corona viral infection, the upper respiratory tract
will be infected and the host immune power is the
determining factor for disease progression [14]. A wea-
kened immune defense may fail to compete with the
viruses leading to lower respiratory tract infections,
which on that stage may worse at a faster rate leading
to lung fibrosis, shortness of breath and finally death.
Genome studies have reported that a protein called
nsp3 in the novel Corona Virus-2 causing COVID 19
is meant for blocking host innate immune response
and promoting cytokine expression [15,16]. The
Immune-compromised persons are in a highly suscep-
tible group as their host defense is very poor.
2.3. Underlying health conditions
People with underlying health conditions like high
Blood Pressure, diabetes, stroke, cardiac or kidney dis-
eases, aged individuals, and people with weakened
immune system face higher risks if COVID 19 like
infections happens to them [17,18]. If people are chal-
lenged with COVID 19 after a recent viral infection,
their defenses are already down and that could result
in increasingly poor prognosis for them from this
virus [19]. This is mainly because of low levels of
immune cells and high cytokine levels in body fluids.
Cytokine release syndrome (CRS) is an acute systemic
inflammatory syndrome characterized by fever and
multiple organ dysfunctions. In some cases viral
infections can illicit excessive immune reactions like
‘cytokine storm’ leading to tissue damage. This is
mainly mediated by a chemical interleukin 6 (IL-6)
produced by our immune cells. It was observed that
other than viral infections, IL-6 level will also increases
during cardiovascular diseases, infections, some forms
of cancers, inflammatory and autoimmune disorders
[20]. COVID 19 often leads to CRS if other systemic
health complications were previously present in a
patient, a major cause of death. That is the reason
why the people with underlying diseases are
requested to stay safe otherwise they may not be able
to cope with the excess IL-6 levels upon infection
which can lead to cytokine release syndrome (CRS)
and even death [14].
2.4. Host behaviour and number of contacts
Since the current pandemic can be spread by aerosol
transmission from person to person, with direct or
indirect contact [21], intentional and thoughtful acts
are the necessity of the time as Governments, commu-
nities, citizens, media, and other key influencers have
an important role to play in preventing and stopping
the pandemic which is highly influenced by host travel
and other host behaviours leading to direct contact and
spread of COVID 19 [22]. The WHO guidelines
restricting international travel from affected areas,
clinical or home isolations and other advices and rec-
ommendations are having prime importance as they
are meant to be strictly followed to reduce number of
direct contacts and the general risk of transmission of
this acute respiratory infection [1]. In addition to
this, behavioural differences like restricted stay in
indoors during winter can also have an effect on Cor-
ona viral spread [23].
2.5. Social distancing and community
consciousness
Social distancing is one category of non-pharma-
ceutical countermeasures (NPCs) aimed to minimize
physical contact between individuals and thereby to
reduce the possibility for new infections [22]. With
the rapidly escalating COVID-19 pandemic, govern-
ments in all countries have been urged by WHO to
regard control of the disease as a ‘top priority’ [1]. Pub-
lic health authorities and decision makers should raise
the community consciousness regarding the mode(s) of
transmission of the virus, need of community-level
social distancing measures and other guidance aimed
at minimizing the spread of COVID 19 with contain-
ment efforts like contact tracing. Social distancing
measures, and their early, coordinated and comprehen-
sive implementation and community consciousness are
effective in slowing the spread of the virus [24–26].

2.6. Age
The higher case-fatality rate of COVID-19 reported in
different countries suggests that it is more fatal in older
patients [27]. Statistical reports states that the case-
fatality rate in Italy and China appear very similar for
age groups 0–69 years, but rates are higher in Italy
among individuals aged 70–80 years or older [1].
The reasons for this susceptibility can be either
physical or social or both. Not only old ages compro-
mise immunity and self defense making them more
vulnerable to infectious diseases and acute respiratory
distress syndrome but also more likely to have health
conditions such as coronary, lung or kidney diseases,
diabetes which can contribute to their low immunity
levels. Stress can also cause people dying from heart
attacks who have COVID-19 [28].
Social isolation or mobility challenges are faced by the
elderly in many societies, which may worsen the scene
more than their weak immunity. In many countries,
elderly are more likely to be in nursing or retirement
home, or living with family in a more crowded situation
where there’s a greater risk of infection [29].
2.7. Atmospheric temperature
Winter is flu season in cold temperate countries
because of three reasons [30]. First, Influenza virus sur-
vive better in cold-dry weather with reduced ultraviolet
light. Second, the reduced innate immunity during
winter days due to low levels of vitamin D and melato-
nin. Third, in winter people tend to stay more in
indoors increasing opportunities for the virus to spread
among them. The COVID-19 broke out in the
countries reported were in their coldest months of
the year. Moreover, a reduction in COVID case reports
during warmer weather would provide ample time to
the health systems to cope with the influx of patients,
and for a potential vaccine to be developed. There is
a hypothesis of cold–to–common cold connection.
According to this, people when exposed to cold winter
will have diminished local immune response in the
nasal passage making them more susceptible for flu
like viruses [31]. There are scientific reports suggesting
a direct correlation between temperature and spacial
spread of COVID 19 around the globe. Upon coughs
or sneezes, respiratory droplets expelled from a
patient’s mouth can spread multiple metres and high
temperatures causes evaporation of these droplet nuclei
and may reduce infectivity [32–34].
2.8. Population density
By definition, population density is the number of
people living in an area per square kilometre [35]. The
relationship between high population density and
spread of epidemics has been reported earlier [36].
INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 3
Epidemic management heavily rely on a country’s
health capacity. For the management and control of
COVID-19, several measures have to be implemented,
like travel restrictions [37] and execution of strict
measures like rapid detection, prevention, and control.
Isolation of affected persons and follow up will be cum-
bersome if a majority of the population get affected [38].
Guidelines have been circulated by World Health
Organization in the COVID 19 context as emergency
non pharmaceutical measures to be taken in the verge
of a global spread of the pandemic COVID 19 [39].
2.9. Airflow and ventilation
Closed areas with low airflow and ventilation can
increase the risk of COVID 19 infection. As with
other respiratory pathogens, including flu and rhino-
virus, the transmission of Novel Corona Virus 2019
is believed to occur through respiratory droplets from
coughing and sneezing. Aerosol transmission is also
possible in case of protracted exposure to elevated
aerosol concentrations in closed spaces [2]. Analysis
of data related to the spread of SARS-CoV-2 in
China seems to indicate that close contact between
individuals is necessary. The spread, in fact, is primar-
ily limited to family members, healthcare professionals,
and other close contacts. But, individuals at high risks
like, aged individuals, people with respiratory diseases,
diabetes or immune-compromised persons if hap-
pened to get exposed to a closed space with multiple
individuals present, such as a meeting in a small
room, aeroplane, centralised A/C etc expose the person
to high risk of getting COVID 19 [40–43].
2.10. Personal hygiene practices
Importance of personal hygiene practices in public health
is well accepted and documented especially in health care
systems [44]. Minimizing personal contacts and hand
sanitization are mandatory to limit the community
spread of viral diseases, especially SARS-CoV-2 [2,44].
2.11. Humidity
Humidity is the concentration of water vapour present
in the air. The main route of transmission of SARS-
CoV-2 infection is presumed to be respiratory droplets.
However the virus is also detectable in other body
fluids and excreta [2]. The observation on low
COVID infections in Asian countries in tropical area
stability leads to the point that high temperature and
high relative humidity has a negative effect on the
spread of COVID 19. It was reported that the dried
virus on smooth surfaces retained its viability for
over 5 days at temperatures of 22–25°C and relative
humidity of 40–50%, that is, typical air-conditioned
environments. However, higher relative humidity
4 S. Lakshmi Priyadarsini and M. Suresh
(e.g. 38°C, and relative humidity of >95%) reduced the
viability of the virus. The better stability of Novel Cor-
ona Virus at low temperature and high humidity
environment may facilitate its transmission in air-con-
ditioned and temperate climatic environments [32,33].
3. Research methodology
TISM is a methodology used to understand the inter-
relationship between and among the factors that
affects the epidemiological characteristics of pandemic
COVID-19 around the globe. Many researchers have
used TISM approach for analysing factors relationships
in manufacturing and service industries [45–55].
The following steps were used [56–58] for the suc-
cessful application of the TISM model:
(1) Identification of the factors: The first step was to
identify the factors that influencing the epidemio-
logical characteristics of pandemic COVID-19
around the globe. This was identified through lit-
erature review and taking expert opinion on the
same. The factors are listed in Table 1.
(2) Establish interconnectedness between factors: To
arrive at the Initial Reachability Matrix (IRM),
contextual relationships between the factors have
to be established. For this study, 27 responses
were obtained from professors, scientists and
researchers of life science in India. The respon-
dents were selected on the basis of their scientific
research background specifically in biomedical
research as well as their capability in concluding
the current situation of pandemic COVID 19 on
the basis of their knowledge and observations.
Table 2 contains the IRM.
(3) Interpretation of relationship between factors: In
the TISM approach, this step answers the question
of ‘how’, and tries to understand how Factor 1
influences Factor 2.
(4) Developing the Final Reachability Matrix (FRM)
after checking for transitivity: A transitivity check
must be done before arriving at the FRM. Tran-
sitivity check must be done on all the entries with
Table 1. The selected factors influencing the epidemiological
characteristics of COVID-19.
Sl. no. Factors
1 Virulency of COVID 19 (F1)
2 Host defense potential (F2)
3 Underlying health conditions (F3)
4 Host behaviour and number of contacts (F4)
5 Social distancing and community consciousness
(F5)
6 Age (F6)
7 Air temperature (F7)
8 Population density (F8)
9 Airflow and ventilation (F9)
10 Personal hygiene practices (F10)
11 Humidity (F11)
‘0’ in the IRM. 1* signifies the presence of tran-
sitivity, and the lack of it means that the original
value of ‘0’ can be retained. 1* implies first level
transitivity wherein if A = B and B = C then A =
C. 1** implies second level transitivity wherein
if A = B, B = C, and C = D, then A = D. Table 3
contains the FRM.
(5) Partition of the factors from FRM into levels: The
FRM is divided into three categories, namely
reachability set, antecedent set and interaction
set. Beginning from level 1, factors of each level
are extracted by way of repeated iterations and
this process is continued until the partitioned
reachability matrix is arrived at.
(6) Designing the interaction matrix: Direct and sig-
nificant transitive links are used to design the
interaction matrix. It’s depicted in Table 4.
(7) Creating the digraph and the TISM model: The
digraph, also known as directed graph, was created
by using data from the interaction matrix and the
level partitions. In the digraph, factors at the top of
the model were called first level factors and sub-
sequent levels are ranked in ascending order.
Further, using the digraph and the interpretive
interaction matrix, the TISM model was devel-
oped. The TISM model is shown in Figure 1,
while the reasons behind the direct and the signifi-
cant transitive links were discussed in Section 4.1.
4. Results and discussions
4.1. Interpretation of TISM Di-graph
Figure 1 represented the graphical representation of
TISM analysis of the factors having an impact on the
epidemiological characteristics of COVID-19.
4.1.1. Level IV: Level four had three factors, factor
5, factor 6 and factor 8
Social distancing and community consciousness (F5)
had strong influence on Host behaviour and number
of contacts (F4); Strong recommendations from
WHO and European Centre for Disease Control
(ECDC) recommended early implementation of social
distancing measures to delay and to reduce the spread
and impacts of the pandemic COVID 19. As part of
References that, public consciousness has been raised to help to
[7–10] control people’s behaviour and to restrict local,
[11–16]
[17–20]
regional and international contacts. Social distancing
[1,21–23] and community consciousness (F5) was a key factor
[1,24– which had significant influence on personal hygiene
26,65]
[27–29,66] practices (F10) at level III. As per the expert opinion,
[30–34] the only measure could be taken in the individual
[35–39]
[2,40–43] level to reduce person to person transmission of corona
[2,44] viral infection was personal hygiene practices and
[2,32,33]
social isolation and that needed a strong public
 INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 5

Table 2. IRM for factors influencing the epidemiological characteristics of COVID-19.

F1 F2 F3 F4 F5 F6 F7 F8 F9 F10 F11
F1 1 0 0 0 0 0 0 0 0 0 0
F2 1 1 1 0 0 0 0 0 0 0 0
F3 1 1 1 0 0 0 0 0 0 0 0
F4 1 0 0 1 0 0 0 0 0 1 0
F5 1 0 0 1 1 0 0 0 0 1 0
F6 1 1 1 1 0 1 0 0 0 0 0
F7 1 1 1 0 0 0 1 0 1 0 1
F8 0 0 0 1 0 0 0 1 0 0 0
F9 1 1 1 0 0 0 1 0 1 0 1
F10 1 1 1 1 0 0 0 0 0 1 0
F11 1 1 0 0 0 0 1 0 1 0 1

Table 3. FRM for factors influencing the epidemiological characteristics of COVID-19.

F1 F2 F3 F4 F5 F6 F7 F8 F9 F10 F11
F1 1 0 0 0 0 0 0 0 0 0 0
F2 1 1 1 0 0 0 0 0 0 0 0
F3 1 1 1 0 0 0 0 0 0 0 0
F4 1 1* 1* 1 0 0 0 0 0 1 0
F5 1 1* 1* 1 1 0 0 0 0 1 0
F6 1 1 1 1 0 1 0 0 0 1* 0
F7 1 1 1 0 0 0 1 0 1 0 1
F8 1* 1** 1** 1 0 0 0 1 0 1* 0
F9 1 1 1 0 0 0 1 0 1 0 1
F10 1 1 1 1 0 0 0 0 0 1 0
F11 1 1 1* 0 0 0 1 0 1 0 1
*,**Represents transitive links.

consciousness across the globe. So by keeping strict
social distancing and proper health practices could
reduce the virulency and infectiousness of COVID 19
(F1) the level 1 factor.
The level IV factor, Age (F6) was found to have an
influence on Host defense potential (F2) a level II fac-
tor, as age is a determining factor for the immune per-
formance which had a direct correlation. As a result, as
age progresses, the individual may be more susceptible
to diseases especially those which are systemic in
nature (F3) which is on level II. Age and underlying
diseases were directly correlated to the host behaviour
and number of contacts (F4), a level III factor. The
reduced self defense could also increase the risks of
infection and could make people more prone to
COVID 19 like infections (F1), a level 1 factor. Thus
age was found to be a critical factor in determining
the viral infectivity and spread.
Population density (F8) on the level IV was ident-
ified as another triggering factor for the level 1 factor,
Virulency of COVID 19 (F1) by directly influencing
level III factor, host behaviour and number of con-
tacts (F4) as population density increases, number
of individual contacts could also be naturally high.
Thus, even the population density of a country is
very high exposing the people to higher risks of infec-
tion, the COVID 19 spread can be effectively mana-
ged by modifying individual behaviour, travel
patterns, personal hygiene and by reducing direct
contacts.
4.1.2. Level III: Level three had five factors, factor
7, factor 9, factor 11, factor 4 and factor 10
Air Temperature (F7) is a critical triggering factor
which regulates atmospheric humidity (F11) and low
temperatures which, in the temperate countries
restricts people indoors with reduced airflow and ven-
tilation (F9 at level IV). The indoor restrictions due to
low temperatures make people more susceptible to
infectious diseases and increase the chances of virus

Table 4. Interaction matrix of factors influencing the epidemiological characteristics of COVID-19.

F1 F2 F3 F4 F5 F6 F7 F8 F9 F10 F11
F1 1 0 0 0 0 0 0 0 0 0 0
F2 1 1 1 0 0 0 0 0 0 0 0
F3 1 1 1 0 0 0 0 0 0 0 0
F4 1 1a 1a 1 0 0 0 0 0 1 0
F5 1 0 0 1 1 0 0 0 0 1 0
F6 1 1 1 1 0 1 0 0 0 0 0
F7 1 1 1 0 0 0 1 0 1 0 1
a
F8 1 0 0 1 0 0 0 1 0 0 0
F9 1 1 1 0 0 0 1 0 1 0 1
F10 1 1 1 1 0 0 0 0 0 1 0
F11 1 1 1a 0 0 0 1 0 1 0 1
a
Represents significant transitive links.
6 S. Lakshmi Priyadarsini and M. Suresh
Figure 1. TISM model for factors influencing the epidemiological characteristics of COVID-19.
spread (F1) within members, thus ultimately influen-
cing level 1factor (F1). The current analysis justified
the increased reports of COVID 19 on temperate
countries as low temperature can increase humidity
in the air (F11) which reduce the host innate immune
responses (F2) and could also worsen underlying
health conditions (F3) especially respiratory illnesses
at level II. Similar relationships can be exhibited by
restricting people indoor in centralised air condition-
ing also; low and circulating Airflow and ventilation
(F9) could increase the indoor humidity (F11), which
pose the chance of fungal and microbial growth in
the interiors during winter seasons leading to increased
reports of flu like diseases. Studies on common cold
virus – Coronavirus 229E explained how experimental
aerosols could persist and retain viability for as long as
6 days at 20°C and 50% relative humidity, the con-
ditions representative of typical indoor environments.
Thus factor 9 and 11 were found to be triggering factors
for factors 2 and 3 at level II and indirectly influencing
the level 1 factor Virulency of COVID 19. In another
view, increased humidity in the atmosphere could
reduce the air temperature (F7) another key factor at
level IV and could indirectly influence the disease sus-
ceptibility of people in the temperate and high humid
areas of globe.
Host behaviour and number of contacts (F4) in level
III was found to be a linkage factor influencing per-
sonal hygiene practices (F10) a factor on the same
level, as personal hygiene practices are an outcome of
good host behaviours which is important in maintain-
ing good immune defense potential, self isolation if tra-
velled abroad or infected (F2) and systemic health (F3),
both at level III. So host behaviour was identified as a
linkage factor for health status through good hygiene
practices and also by reducing number of contacts,
finally determining the spread of COVID 19 infection
(F1), in the level 1.
4.1.3. Level II: Level two have two factors, which
are factor 2 and factor 3
The level II factors, Host defense potential (F2) and
Underlying Health conditions (F3) could have a
direct relation as the health status of an individual
is a product of his own immune capability. Those
individuals with compromised or weak immune sys-
tem and people with undergoing respiratory infec-
tions, coronary, kidney diseases or diabetes were
found to be highly susceptible to diseases and more
prone to epidemics like the novel corona viral infec-
tion. Thus, level II factors Host defense potential and
Underlying Health conditions were found to be
 INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 7

affecting factors of level 1, the infectivity of COVID Table 5. MICMAC rank for factors influencing epidemiological
19 (F1). characteristics of COVID-19.
Driving Driving power/ MICMAC
Factor power Dependence dependence rank
4.1.4. Level I: Level one has one factor, which is
F1 1 11 0.091 5
factor 1 F2 3 10 0.300 4
Virulency of COVID 19 (F1), which was related to the F3 3 10 0.300 4
F4 5 5 1.000 3
objective of this study did not influence any factor but F5 6 1 6.000 1
was influenced by all the factors used in this study. F6 6 1 6.000 1
F7 6 3 2.000 2
F8 6 1 6.000 1
F9 6 3 2.000 2
4.2. MICMAC analysis F10 5 5 1.000 3
F11 6 3 2.000 2
MICMAC involves classifying the factors into four
different zones, namely, driving factors, autonomous
factors, dependent factors and linkage factors [59– the top key factors. Also, factor 7 (Air temperature),
64]. The factors can be explained as below: factor 9 (Airflow and ventilation) and factor 11
(Humidity), the key factors.
(1) Autonomous factors (Zone-I): Factors that have Virulency of COVID 19, the factor that is ranked
weak dependence power and weak driving power fifth in the MICMAC analysis ranking. It means that
are known as autonomous factors. In this study, it has higher dependence on other factors. This is due
there were no autonomous factors. to the fact that the changes in other factors could
(2) Dependent factors (Zone-II): Factors that have bring about changes in the Virulency.
higher dependence on other factors but lesser driv-
ing power are known as dependence factors. In this
study factor 2 (Host defense potential), factor 3 5. Healthcare management implications
(Underlying health conditions) and factor 1 (Viru-
lency of COVID 19) were the dependent factors. COVID 19 is a global emergency; lack of proper medi-
These factors get influenced when there is change cines or vaccination makes it more dangerous as it is
in the other factors. rapidly spreading around the globe sacrificing thou-
(3) Linkage factors (Zone-III): Factors that have a sands of people. The recent super spread events of
strong dependence power and strong driving the new virus started in densely populated developing
power are known as linkage factors. They establish countries are anxiously looked by the governments
the connection between the dependence and the and health care system, as many of them have poor
driving factors. In this study factor 4 (Host behav- health care facilities which are not sufficient to cope
iour and number of contacts) and factor 10 (Per- up with the emergency needs of a pandemic spread
sonal hygiene practices) were identified as the to a mass population. In this scenario, the current
linkage factors. model could clearly identify factors which can be
(4) Driving or Independent factors (Zone-IV): Factors manipulated, like linkage factors, which are host
that have a strong driving power, but weak depen- behaviour and number of contacts and personal
dence power are known as driving factors or inde- hygiene practices. The effective and planed manipu-
pendent factors. In this study factor 5(Social lation of linkage factors identified, has shed light to
distancing and community consciousness), factor
6 (Age), factor 8 (Population density), factor 7
(Air temperature), factor 9 (Airflow and venti-
lation) and factor 11(Humidity) were the driving
or key factors.

As per the MICMAC analysis, the factors influen-

cing the epidemiological characteristics of COVID-19
were ranked [63] in Table 5.
Figure 2 represents the MICMAC graph. It rep-
resents the driving power – dependence diagram
based on the MICMAC analysis shown in Table 5.
Table 5 shows the ranking of the factors influencing
the epidemiological characteristics of COVID-19 based
on MICMAC analysis. According to the ranking, factor
5 (Social distancing and community consciousness), Figure 2. MICMAC graph representing driving power and
factor 6 (Age) and factor 8 (Population density) were dependence of the factors.
8 S. Lakshmi Priyadarsini and M. Suresh
the prospective areas to which governments and com-
munities can focus on to overcome the crisis. Thus, a
coordinated system of actions should be implemented
integrating medical centres and clinics along with
govt. agencies which are of paramount importance in
solving this problem.
6. Sustainability implications
The repeated exposures to epidemics have critical
impacts on social and economic sustainability, especially
in the context of a pandemic like the COVID 19. The
researcher’s use of the model helped them to identify
several factors which can act as triggers but, many of
them are out of human control, like climatic factors,
age and population density. So, for the sustainable con-
trol of the infection, timely action should be taken, by
considering the linkage factors projected by this
model. Thus, proper social consciousness regarding
the epidemic nature of the virus and wise utilization of
existing medical and allied resources, including man-
power in health care system is very important for the
sustainable control of the novel Corona Virus 2019.
7. Conclusion
The authors of this article evaluated the epidemiologi-
cal risk factors for the Novel Corona Virus 19 trans-
mission during the recent global outbreak. There are
several studies published in a short span of time,
suggesting the importance of selected factors like temp-
erature and stability of SARS-CoV-2 in air and signifi-
cance of social distancing measures. An integrative
analytical approach is essential to mathematically
model the inter relationship and dependency of factors
to prioritise them as time is a crucial factor in control-
ling community spread of COVID 19. This study has
identified 11 factors that influence the epidemic
characteristics of COVID 19 across the globe through
literature review and experts opinion. TISM approach
was used to list the factors influencing epidemic
characteristics of COVID 19 and to identify the links
between them. Factors were ranked according to their
order of importance and a hierarchy was established
using MICMAC analysis. The results from the study
suggest that changes in any individual factor men-
tioned in the study could directly or indirectly affect
the viral spread. Social distancing and community con-
sciousness, age, air temperature, airflow and venti-
lation, population density and humidity were
identified as the driving or key factors in this model.
These factors were independently and interdepen-
dently found to impose a strong impact on epidemic
characteristics of the SARS-CoV- 2. Host behaviour
and number of contacts and personal hygiene practices
were found to be the linkage factors between the above
named driving factors and the infectivity and epidemic
nature of the virus. So, effective management of linkage
factors can effectively control the COVID 19 spread
across the world irrespective of geographical or cli-
matic zones, age, population density, or strength of
health care system. Thus, the model is a guide to policy
makers of healthcare services and governments, which
precisely point out epidemiological factors of COVID
19 which are under human control and help them to
prioritise the emergency steps to be taken to implement
immediate action.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Notes on contributors
S. Lakshmi Priyadarsini is an immunology faculty in the
department of Zoology, Govt.Victoria College, Kerala,
India. She did her PhD in Biochemistry and post doctoral
research in Viral immunology from Emory Vaccine Centre,
Atlanta, USA acquired several publications in influenza viral
research, especially in pandemic H1N1 2009. Her contri-
butions to immunology has gained a nature communication
in 2016.
M. Suresh is an Associate Professor at Amrita School of
Business, Amrita Vishwa Vidyapeetham, Coimbatore,
India. He holds a PhD in Operations Management from
Indian Institute of Technology, Bombay, India and Master’s
in Industrial Engineering from PSG College of Technology,
Coimbatore, India. His research interests include issues
related to Healthcare Operations Management.
ORCID
S. Lakshmi Priyadarsini http://orcid.org/0000-0002-9840-
0998
M. Suresh http://orcid.org/0000-0002-3796-3623
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