CMAAO Update 5^th February on 2019-nCoV

Kerala government declares coronavirus as a state disaster: Three primary cases in North, South and Central Kerala (Kasaragod district in north Kerala, Thrissur in central Kerala and Alappuzha in South Kerala)

Beware of Myths

1. It is safe to receive a letter or a package from China. People receiving packages from China are not at risk of contracting the new virus. Coronaviruses do not survive for a long period on objects like letters or packages.
2. There is no evidence that animals/pets such as dogs or cats can get infected with the new coronavirus. However, it is always in your best interests to wash your hands with soap and water after contact with pets. This protects you against various bacteria that can pass from pets to humans.
3. Vaccines against pneumonia, such as pneumococcal vaccine and Haemophilus influenza type B (Hib) vaccine, provide no protection against the new coronavirus.
4. There is no evidence that regularly rinsing the nose with saline protects people from infection with the new coronavirus.  Limited evidence suggests that regularly rinsing nose with saline can hasten recovery from the common cold. However, regularly rinsing the nose has not been shown to prevent respiratory infections.
5. There is no evidence that using mouthwash protects you from infection with the new coronavirus. Some brands of mouthwash can eliminate certain microbes for a few minutes in the saliva in your mouth. However, this does not protect you from the new coronavirus infection.
6. Sesame oil does not kill the new coronavirus. Certain chemical disinfectants can kill the 2019-nCoV on surfaces. These include bleach/chlorine-based disinfectants, either solvents, 75% ethanol, peracetic acid and chloroform. However, they have little to no impact on the virus if you put them on the skin or under your nose. It is dangerous to put these chemicals on the skin.
7. People of all ages can be infected by the new coronavirus. Older people, and people with pre-existing medical conditions (such as asthma, diabetes, heart disease) have increased odds of becoming severely ill with the virus.  People of all ages are advised to take steps to protect themselves from the virus, by following good hand hygiene and good respiratory hygiene.
8. Antibiotics do not work against viruses. The new coronavirus is a virus. Hence, antibiotics should not be used prevent or treat 2019-nCoV. Patients hospitalized for the 2019-nCoV may receive antibiotics as bacterial co-infection is possible.
9. There is no specific medicine yet recommended to prevent or treat the new coronavirus. Those infected with the virus must be given appropriate care to relieve and treat symptoms, and those with severe illness should receive optimized supportive care. Some specific treatments are being investigated, and will be tested through clinical trials.

Continue asking patients with suspected flu or diarrhea if they, or someone they have been in contact with, recently returned from coronavirus-affected area.

Coronavirus is a Public Health Emergency of International Concern  (It is mandatory to report to WHO human and animal cases) as person-to-person transmission in UK, USA, Germany, Japan, Taiwan and Vietnam and two deaths, one in the Philippines on Feb 2 (44 M) and 2^nd in Hong Kong (39 M),  outside of mainland China, have been confirmed.

The virus behaves like SARS with 2 % case fatality (15% of admitted cases),  time to death 14 days,  3-4 reproductive number R0, has its origin from bats, spreads through large droplets and predominantly from people having lower respiratory infections, and hence universal droplet precautions are the answer.

Status

The Novel Coronavirus (2019-nCoV) originating from Wuhan, China, has now spread to 28 countries and territories worldwide, with 24552 confirmed cases and 492 deaths (median age 45, range 2-74, predominantly males , deaths more in comorbid cases,  just like SARS, it mostly does not affect children 15 years of age or less).  There were 64 new deaths on 3^rd Feb. It is anticipated that one lac people are already infected.

Countries and territories that have confirmed cases: Thailand, Japan, Hong Kong, Singapore, Taiwan, Australia, Malaysia, Macau, Russia, France, the United States, South Korea, Germany, the United Arab Emirates, Canada, Britain, Vietnam, Italy, India, the Philippines, Nepal, Cambodia, Sri Lanka, Finland, Sweden and Spain.

Cases recorded in Thailand, Taiwan, Germany, Vietnam, Japan, France and the United States involved patients who had not been to China.

It’s not new

Every decade a zoonotic coronavirus seems to cross species and infect human populations. This decade has seen a virus, the 2019-nCoV, first identified in Wuhan, China, in persons exposed to a seafood or wet market in mid-December 2019.

CORONA: Crown or Coronary artery

The virus belongs to the corona virus family and has an RNA core. The term ‘corona’ stands for crown or the halo around the sun. The arteries that supply oxygen to the heart are also called coronary arteries, as the heart is considered the crown. When seen under an electron microscope, the virus appears round in shape with spikes poking out from its periphery.

The three deadly human respiratory coronaviruses so far -

1. Severe acute respiratory syndrome coronavirus [SARS-CoV]
2. Middle East respiratory syndrome coronavirus [MERS-CoV])
3. 2019-nCoV: The virus is 75-80% identical to the SARS-CoV

The virus

2019-nCoV is quite different from SARS-CoV to be considered a new human-infecting betacoronavirus. According to the structural analysis, 2019-nCoV might be able to bind to the angiotensin-converting enzyme 2 receptor in humans. This single-strand, positive-sense RNA genome ranges from 26 to 32 kilobases in length.

The case fatality is lower than SARS, MERS and EBOLA

2019-nCoV mortality rate is 2% (earlier thought to be 3%) compared to 34% for MERS, 10% for SARS (out of 5327 cases), 50% for Ebola, 30-40% for small pox, 10-15% for measles (developing countries), 2-5% in children and 15-30% in adults for polio, 5-10% for diphtheria, 4% in infants < 1yr, 1% in children < 4 years for whooping cough AND < 0.1-4 % for swine flu.

If Hubei province, where the epicenter of 2019-nCoV, Wuhan, is situated, is removed from the calculation, the national (China) mortality rate comes down to 0.3%. Within the Hubei province, the mortality rate is about 1% if the city of Wuhan is excluded (where it is 5.5%).

The case fatality rate with seasonal flu is <0.01% (1 death per 10,000 cases) 

Role of CMAAO and other Medical Associations

It is mandatory for all countries to be prepared for containment measures. This includes active surveillance measures, early detection, isolation and case management, tracking contacts and preventing the spread of the virus. It is important to share full data with WHO. It is a legal requirement that all countries share information with WHO under the IHR. 

If 2019-nCoV is detected in an animal (information about the species, tests, and epidemiological data), it must be reported to the World Organization for Animal Health (OIE) as an emerging disease.

All countries should emphasize on reducing human infection, and preventing secondary transmission and international spread.

Three is no travel or trade restriction based on the current information available.  All countries are required to inform WHO about any travel measures taken. Countries are cautioned against actions promoting stigma or discrimination, in line with the principles of Article 3 of the IHR.  

It’s Zoonotic but it is unlikely to spread through seafood in India

This new coronavirus is closely related to several bat coronaviruses. Bats seem to be the likely primary reservoir for the virus. While SARS-CoV was transmitted to humans from exotic animals in wet markets, MERS-CoV transmitted from camels. The ancestral hosts were probably bats; however.

The virus has been traced to snakes in China, so, it is unlikely to spread in India through sea food. Snakes often hunt for bats. According to reports, snakes were sold in the local seafood market in Wuhan, thus raising the likelihood that the 2019-nCoV might have moved from the host species, i.e., bats, to snakes and then to humans. It is still not understood as to how the virus could adapt to both the cold-blooded and warm-blooded hosts. 

It is more infectious to humans

 This new virus seems to grow better in primary human airway epithelial cells as compared to standard tissue-culture cells, unlike SARS-CoV or MERS-CoV. The 2019-nCoV will likely behave more like the SARS-CoV.

Human to Human infection

 SARS-CoV and MERS-CoV affect the intrapulmonary epithelial cells more than the upper airway cells. Transmission thus occurs primarily from patients with recognized illness and not from patients with mild, nonspecific signs. However NEJM has reported a case of 2019-nCoV infection acquired outside of Asia wherein transmission seems to have taken place during the incubation period in the index patient.

2019-nCoV seems to employ the same cellular receptor as SARS-CoV (human angiotensin-converting enzyme 2 [hACE2]). Transmission is expected to occur only after signs of lower respiratory tract disease develop.

The principal cause for breathlessness is the fact that this virus does not attack the throat alone. It attacks the lungs as well. Patients so far have not presented with a sore throat, because the 2019-nCoV attacks the intraepithelial cells of lung tissue.

A report of a small cluster of five cases indicated transmission from asymptomatic individuals during the incubation period; all patients in this cluster had mild illness. Another person got infected while using gown, but the eyes were not covered.

 It’s predominantly a large droplet infection

Transmission of 2019-nCoV probably occurs through large droplets and contact and less frequently by aerosols and fomites,. In lab, we need minimum BSL-3 (or BSL-4) facilities to prevent transmission. 

The incubation period

Up to 2 weeks, according to WHO, with mean being 5.5 days.

Symptoms

 According to a report published in the Lancet, one-third of the patients landed up in the intensive care unit; and around 15% of these succumbed to the infection. Almost all presented with fever, more than two-thirds had cough and nearly 50% had weakness or muscle ache. More than 50% had shortness of breath.

2019-nCoV presents with low white cell count and reduction in lymphocyte count, and raised liver transaminase levels.

Most infected patients experience milder symptoms, but about 1 in 5 people have severe illness, including pneumonia and respiratory failure.

nCoV: novel coronavirus; CDC: United States Centers for Disease Control and Prevention; NIOSH: National Institute for Occupational Safety and Health.

* Fever may be subjective or confirmed.

¶ CDC definition of close contact (any of following):

• Being within approximately 6 feet (2 meters) or within the room or care area of a 2019-nCoV case for a prolonged period of time while not wearing recommended personal protective equipment (gowns, gloves, NIOSH-certified disposable N95 respirator, eye protection); close contact can include caring for, living with, visiting, or sharing a health care waiting area or room with a 2019-nCoV case.
• Having direct contact with infectious secretions of a 2019-nCoV case while not wearing recommended personal protective equipment.

Δ Documentation of laboratory confirmation of 2019-nCoV may not be possible for travelers or persons caring for patients in other countries.◊ Includes any member of a cluster of patients with severe acute lower respiratory illness (eg, pneumonia, acute respiratory distress syndrome) of unknown etiology in whom 2019-nCoV is being considered that requires hospitalization. Evaluate such persons in consultation with state and local health departments irrespective of travel history.

 (Source: CDC)

Drugs

No proven antiviral treatment exists yet for the coronavirus. A combination of lopinavir and ritonavir exhibited some promise in patients with SARS, but this was only in the lab and not in humans. A randomized study is underway in Saudi Arabia in patients with MERS; a combination of lopinavir, ritonavir and recombinant interferon beta-1b versus placebo; the results are still awaited.

Scientists in Australia have reportedly developed a lab-grown version of coronavirus. The breakthrough would help researchers globally in their efforts to develop a vaccine and detection tests. 

Chloroquine, which has potent antiviral activity against the SARS-CoV, has been shown to have similar activity against HCoV-229E in cultured cells and against HCoV-OC43 both in cultured cells and in a mouse model. However, studies of efficacy in humans are lacking.

Thai doctors have used oseltamivir along with lopinavir and ritonavir, both HIV drugs. An experimental drug from Gilead Sciences Inc., called remdesevir, has shown encouraging results.

PVP-I mouthwashes and gargles are known to reduce viral load in the oral cavity and the oropharynx. The World Health Organization has included PVP-I in the list of essential medicines. It exhibits a high potency for virucidal activity against viruses of significant global concern, including hepatitis A and influenza, as well as the MERS and SARS coronaviruses.

Universal droplets precautions the answer

1. Quarantining for two weeks
2. Timely diagnosis
3. Strict adherence to universal precautions

• Wash your hands often with soap and water for at least 20 seconds. If soap and water are not available, use an alcohol-based hand sanitizer.
• Avoid touching your eyes, nose, and mouth with unwashed hands.
• Avoid close contact with people who are sick.
• Stay home when you are sick.
• Cover your cough or sneeze with a tissue, then throw the tissue in the trash.
• Clean and disinfect frequently touched objects and surfaces.

These are everyday habits that can help prevent the spread of several viruses!

Travel

1. Requires contact of ten minutes within a distance of six feet
2. The virus can remain alive on any surface for 3-12 hours
3. Chose a window seat and remain there to lower your chances of encountering an infectious disease.

Contagiousness: The reproduction number, referred to as R0 or “r naught” is the number of additional people that an infected person can infect.

A recent study has shown Ro as high as 4.08. This exceeds WHOs estimate of 1.4-2.5 made on January 23, and also exceeds recent estimates of 3.6 -4.0 and 2.24 - 3.58. Preliminary studies had estimated Ro as 1.5-3.5.  Going by this value, on average every case of the Novel Coronavirus would give rise to 3 to 4 new cases. An outbreak with a reproductive number of below 1 will gradually disappear. The Ro for common flu is 1.3 and for SARS it was 2.0.

Evacuation

US, Japan, India have evacuated their citizens trapped in China’s affected areas

Coronavirus: Mass Quarantine May Spark Irrational Fear, Anxiety, Stigma

Comparisons

• Every year, an estimated 290,000 to 650,000 people die across the globe due to complications from seasonal influenza (flu) viruses. This figure corresponds to 795 to 1,781 deaths in a day owing to seasonal flu.
• SARS (Nov 2002 - Jul 2003) was a coronavirus with its origin in Beijing, China. It spread to 29 countries, and infected 8,096 people with 774 deaths (fatality rate of 9.6%). SARS infected 5,237 people in mainland China. Going by this figure, Wuhan Coronavirus surpassed SARS on January 29, 2020, when Chinese officials confirmed 5,974 cases of 2019-nCoV. On January 30, 2020 the novel coronavirus cases surpassed even the 8,096 cases worldwide representing the final SARS count in 2003.
• MERS (2012) led to the death of 858 people out of the 2,494 infected cases (fatality rate of 34.4%).

PMO Suggestions

10^th January: I wrote an editorial: Coronavirus strain causing pneumonia in Wuhan, China

17^th Jan: India at threat of Coronavirus. Advisory should be issued (18^th Jan: Indian government issues travel advisory as Chinas mysterious Coronavirus spreads in other countries)

18th-20th Jan: Three countries meet, also discussed Coronavirus

22^nd Jan: Still not being declared to be a notifiable disease; N 95 to be included in the list of essential drugs and price-capped; Oseltamivir should also be price-capped; flights should have masks available for all passengers; not declaring flu-like symptoms while boarding or landing should be a punishable offence (23^rd Jan: India advisory to airports)

24^th Jan: Inter Ministerial Committee needs to be formed on Coronavirus (PMO took a meeting on 24^th evening)

25^th Jan: Indian government should pay for Indians affected with the virus in China

26^th Jan: Need of National Droplet Infection Control Program; Policy to ban export of face masks; policy to evacuate Indians from China’s affected areas; Time to collaborate on Nosode therapy

27^th Jan: History of anti-fever drugs at airports should be taken

28^th Jan: Do research on Nosodes 29^th Jan: Closure of live markets all over the world, India should take a lead30^th Jan: Paid flu leave, surgical mask at public places, N 95 for health care providers

31^st Jan: Respiratory hygiene advisory to schools, Pan-India task force to be made (Exports of masks banned on 31^st January by Indian Government)

1^st Feb: Disaster Budget is the need of the hour

3^rd Feb: 100 crore budget for Corona virus; Private labs to be recognized; one dedicated coronavirus National help line; MTNL BSNL to have a line of advisory in their bills; isolation wards to be single rooms or two beds separated with six feet distance; national insurance to cover cost of treatment,  suspend AI flights to China and Hong Kong [New Delhi, Feb 4 (IANS)  - Air India on Tuesday said that it will suspend flights to Hong Kong due to the outbreak of deadly coronavirus. The suspension will come into force from Friday until March 28. Earlier, Air India had cancelled its flight to Shanghai from January 31 to February 14.]

4th Feb: Kerala travel advisory needed [The Union Ministry of Health and Family Welfare issued a fresh travel advisory on Monday urging people to refrain from visiting China]

Confirmed Cases and Deaths by Country and Territory

(Affecting 28 countries and territories)

 Total Deaths of Novel Coronavirus (2019-nCoV)

Daily Deaths of Novel Coronavirus (2019-nCoV)

(Source: https://www.worldometers.info/coronavirus/coronavirus-death-toll/)

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA