Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is included in the Coronaviridae family, Betacoronavirus genus, Sarbecovirus subgenus, and 30 kb enveloped, non-segmented, (+) ssRNA. Each virus particle is 0.05 to 0.2 µm in diameter [1]. As the SARS-CoV-2 (COVID-19) continues to spread and evolve, World Health Organization (WHO) and partners are characterizing emerging variants of concern (VOCs) to evaluate increased transmissibility and other potential phenotypic impacts [2]. A total of 11 global rapid risk assessments have been undertaken for COVID-19, and additional assessments were conducted for specific events around the emergence of SARS-CoV-2 VOCs, alpha, beta, gamma, and delta [2]. Analysis of infection pattern of recent fourth wave (July 4~10, 2021) showed increased mutation (36.9%) and infection among acquaintances and colleagues of the same age group in Korea [3]. Although there is an interval of several months, the fourth wave appears in a similar pattern. According to WHO, the global number of new cases during July 5 to 11, 2021 was nearly three million, a 10% increase as compared to the previous week and with almost 56,000 new deaths in the past week; cumulative deaths have now surpassed four million [2].

Each country updated the COVID-19 response guidelines based on the Centers for Disease Control and Prevention (CDC) or WHO. The Korean government also released the 10th edition on May 17, 2021, reported the situation daily, and quarantine guidelines for the general public were emphasized [4]. Healthcare professionals who contact or care for COVID-19 patients work in a medical environment that is likely to be directly or indirectly exposed to patients or infectious substances. Medical personnel's failure to follow infection source guidelines increases the likelihood that they will become sources or mediators of the spread of COVID-19. Thus, mitigating and reducing these infection risks is essential to protecting their well-being and reducing the spread [5]. Therefore, it is necessary to focus on the role of nurses in the prevention and management of COVID-19 during this fourth wave.

Next, to end this pandemic, the world needs to achieve herd immunity and the safest way is through vaccines. Humans have relied on vaccines to reduce the death toll of infectious diseases. In total, 26.6% (3.73 billion) of the world population has received at least one dose of a COVID-19 vaccine, and 30.84 million vaccines are now administered each day globally. However, only 1.1% of people in low-income countries have received at least one dose [6]. The evidence on the efficacy and effectiveness of COVID-19 vaccines against emerging variants is limited; however, full vaccination offers high levels of protection against severe disease and death for all four VOCs [2]. Healthcare professionals are required to know the contraindications and possible side effects of each vaccine [6]. Misinformation about the types and side effects of the COVID-19 vaccine leads to the vaccination refusal.

Finally, the scientific basis for excluding vaccinated people from wearing masks and practicing social distancing is not clear yet. Therefore, it is necessary to provide accurate information with data from reputable institutions regarding post-vaccination quarantine guidelines. When coronavirus infections of Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) occurred, there was a lack of proper guidelines for nurses to respond to the general and special populations in Korea. However, now there are healthcare professionals who can manage the impacts of acute changes, especially for people at the highest risk from COVID-19.

Therefore, this review paper aimed to show the nursing practice guidelines for prevention and management of COVID-19, vaccination, and guidance for fully vaccinated people. For this, we composed general precautions targeted not only people residing in a community but all patients and health workers using reliable data and public documents.

Clinical nurses should be aware of the following management strategies in hospitals and other medical institutions, along with the general prevention and management strategies about COVID-19 prevention. Among the infection prevention and control (IPC) strategies required by medical institutions to prevent COVID-19 transmission are as follows

Vaccines are highly effective methods for controlling and eliminating vaccine-preventable diseases. They are one of the most cost-effective public health investments among the target groups [13]. Significant effort has been made to develop vaccine candidates using various approaches that encompass traditional live attenuated and inactivated vaccines and modern solutions using viral vectors, mRNA, DNA, single proteins, and virus-like particles as carriers [14, 15]. In 2020, new vaccine platforms—including mRNA vaccines and viral vector-based DNA vaccines—have been given emergency use authorization (EUA), leading to mass vaccinations worldwide.

As of March 23, 2021, the following four vaccines are listed for emergency use and approved by WHO: BNT162b2 (Pfizer-BioNTech; Pfizer Inc., New York, NY, USA; BioNTech, Mainz, Germany), mRNA-1273 (Moderna; Moderna, Cambridge, MA, USA), Ad26.COV2.S (Janssen; Johnson & Johnson, New Brunswick, NJ, USA), and AZD1222 (AstraZeneca; AstraZeneca, Cambridge, UK). These vaccines were evaluated for their immunogenicity and safety through phase 1/2 clinical studies. In the phase 3 clinical study, vaccine efficacy and adverse events were confirmed by comparing the vaccine and the control group. The efficacy of Pfizer-BioNTech, Moderna, Janssen, and AstraZeneca are 95% (95% credible interval [CI], 90.3%~97.6%), 94.1% (95% CI, 89.3%~96.8%), 66.9% (95% CI, 59.1%~73.4%), and 70.4% (95% CI, 54.8%~80.6%), respectively [16].

In late 2020, reports from the United Kingdom, Brazil, South Africa, and India confirmed the emergence of SARS-CoV-2 variants: B.1.1.7 (or alpha), AY.2 (or delta), P.1 (or gamma), B.1.351 (or beta), and B.1.617.2 AY.1 and AY.2 (or delta), respectively [17]. Regarding delta variant, in the UK, although data showed there was a higher risk of hospitalization compared with the alpha variant, two doses of vaccination were found to provide a high degree of protection, estimated at over 90% [18]. NVX-CoV2373 (Novavax, Gaithersburg, MD, USA) vaccine, which is scheduled to be introduced in Korea, is not yet authorized, but some studies [19, 20] have reported the efficacy. After a two-dose regimen administered 21 days apart was its, efficacy, which consists of 5 µg of a recombinant nanoparticle spike protein plus 50 µg of Matrix-M (Novavax) adjuvant, was 86.3% (95% CI, 71.3%~93.5%) against the alpha variant and 96.4% (95% CI, 73.8%~99.4%) against non-alpha strains in healthy patients who were over 18 years of age.

Pfizer-BioNTech, Moderna, Janssen, and AstraZeneca vaccines were confirmed as safe vaccines through clinical trials, and although serious adverse reactions were rarely reported, the benefit of continuing the vaccination was evaluated as greater than the risk. After the phase 3 clinical study, the Janssen vaccine was available with a single-dose schedule, and the remaining three vaccines were approved with a two-dose schedule. All four are administered intramuscularly, and the approved age is over 12 for Pfizer-BioNTech, and over 18 for Moderna, Janssen, and AstraZeneca vaccines [16, 21]. Any current U.S. Food and Drug Administration (USFDA)-authorized COVID-19 vaccine can be used when indicated; the Advisory Committee on Immunization Practices does not state a product preference. However, COVID-19 vaccines are not interchangeable. The need and timing for a booster dose for COVID-19 have not been established, and no additional doses are currently recommended. Any current USFDA-authorized COVID-19 vaccine can be administered to people with underlying medical conditions who have no contraindications to vaccination. However, myocarditis or pericarditis have occurred in some people (predominantly in males aged 12 to 29 years) following receipt of mRNA COVID-19 vaccines (Pfizer-BioNTech and Moderna), and Thrombosis with thrombocytopenia syndrome occurred primarily among women aged 18 to 49 years after Janssen [22] and AstraZeneca vaccination [23].

Vaccines need to maintain a cold chain from manufacturing to human inoculation because of the vulnerability of mRNA molecules. Pfizer-BioNTech and Moderna vaccines have low temperatures during storage and distribution, and long-term storage at refrigerated temperatures is impossible. Vaccine-related information is presented in Table 1. Also, since there are various types of COVID-19 vaccines and healthcare professionals are not familiar with them, nurses should know the contraindications and possible side effects of each vaccine and correct vaccination and prepare for anaphylaxis at the location (Table 2) [21].

Table 1
Current COVID-19 Vaccines with Emergency Use Authorization

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Table 2
Administration of Vaccine and Management of Anaphylaxis

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To control or eradicate COVID-19 successfully, a combination of several steps, including vaccination, surveillance of infected people, and reducing the susceptibility of infection, is required [24]. To be considered fully vaccinated, a person must have received the last dose 14 days ago if two doses are required or a dose 14 days ago if they received a single-dose vaccine, and they must be able to provide evidence of having received the full series of vaccines [25].

People are getting vaccinated despite the side effects to return to pre-COVID normal. However, that might be difficult without masks even if herd immunity is achieved. Since not all vaccinated people acquire a preventable level of immunity, people would have to adhere to a certain lifestyle with hygiene measures such as wearing masks and washing hands for a considerable period even if after vaccination [26, 27]. As nurses are responsible for protecting people from the pandemic, they should be able to provide guidelines for those who have completed the vaccination.

The role of nurses during COVID-19 has been strengthened and is still being emphasized. More than a year and a half after the outbreak in early 2020, it is necessary to look at the global trends in changes in nursing personnel. According to a report of International Council of Nurses (ICN) in July 2020, after the COVID-19 outbreak, nurses have fallen ill or died from the poor provision of PPE and have experienced work-related stress and exhaustion [34]. According to the March 2021 ICN report, the number of nurses quitting has increased worldwide at a rate of one in five. Among them, 90% reported that excessive workload, insufficient resources, exhaustion, and stress are causing them to quit, which is a “serious or extremely worrying” situation, and collective trauma for health workers is a serious problem [35].

Compliance with IPC guidelines by healthcare workers has become even more important. Wearing masks and face shields, using PPE such as gloves and gowns, separation from respiratory infections, and particularly rigorous cleaning procedures can be difficult and time-consuming. In a qualitative review by Cochrane [36], nurses stated that their numbers per patient should increase because the work fatigue while wearing using PPE is very high in stressful situations, and it would be difficult for them to follow the IPC guidelines of hospitals if unrealistic workloads continue. To overcome this situation, ICN introduced three phases of COVID-19 influence and policy response and presented major nurse staffing policy problems at each stage [34]. In the first phase, First wave of COVID-19 impact, the focus is on increasing the overall nurse workforce and shifting more of them to intensive care unit or coronary care unit (ICU/CCU). The successful first step allows the national health system to address intensive care challenges in patients with acute COVID-19 symptoms. The second phase is Transition phase, which covers a period beyond the first immediate impact phase of COVID-19, a time when the system must maintain its ability to meet future waves, including the relocation of nurses by the department. In phase 3, The “New Normal”, many countries need to improve public health and primary care delivery and achieve better integration with acute/hospital sectors to improve overall system responsiveness to COVID-19 or future epidemic outbreaks [34]. To attract new students to nursing programs and maintain existing nursing staff, recognition of nursing work, appropriate salaries, and awareness of a safe working environment are key. Investing in nursing staff and securing a solid foundation for nursing education and jobs is an essential step towards post-COVID-19 recovery and preparation for future pandemics [37]. The vast money spent on tackling COVID-19 and the deaths of countless nurses worldwide emphasizes the need for large investments to develop pandemic measures to protect and support nurses, which should be conducted at the government and the global level [38].

The curve of COVID-19 fluctuated and reached the fourth pandemic in July 2021. Since three waves, the focus has been on achieving herd immunity through vaccination while a lot of manpower is being used for quarantine. However, the fourth wave was not prevented, and it is likely to target the unvaccinated. While almost a quarter (24.7%) of the world population has received at least one dose of a vaccine against COVID-19, there are vast inequities in vaccine distribution and administration. The world should pay attention to the issue of inequality in vaccines.

Another thing to note is that each country has different infection control guidelines when fully vaccinated individuals have close contact with COVID-19 cases. Since major outbreaks of COVID-19 cases affects the entire society, we need to continue taking serious measures. WHO, CDC, and each country have been regularly posting response guidelines for COVID-19. Moreover, they provide information on infection control principles and vaccines that healthcare professionals should know. Nurses must recognize up-to-date information and guidelines of COVID-19 to take appropriate action to support and guide. Also, nursing researchers and educators try to identify the essence of nursing required by the COVID-19 era through various studies and find the basis for appropriate scientific nursing [39].

We examined guidelines for preventing and managing COVID-19 and accurate information related to vaccination and described quarantine measures even for those who completed vaccination. We recommend vaccination with self-quarantine to overcome this 4th COVID-19 pandemic. Also, there is need for large investments to protect and support nurses in future pandemic measures.