CMAAO Update 7^th February on Coronavirus

Summary

Behaves like SARS with 2% case fatality (15% of admitted cases),  time to death 14 days,  time to pneumonia 9 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.

 Case Definition

1. Fever (subjective or confirmed)

OR signs/symptoms of lower respiratory illness (cough or shortness of breath)

PLUS, any person (including health care workers) who has had close contact with a laboratory-confirmed 2019-nCoV patient within 14 days of symptom onset.

   [Contact means: Being within about 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 may include caring for, living with, visiting, or sharing a health care waiting area or room with a 2019-nCoV case OR having direct contact with infectious secretions of a 2019-nCoV case while not wearing recommended personal protective equipment.]

4. Fever andsigns/symptoms of lower respiratory illness (cough or shortness of breath) PLUS  history of travel from Hubei Province, China within 14 days of symptom onset
5. Feverand signs/symptoms of lower respiratory illness (cough or shortness of breath) requiring hospitalization PLUS  history of travel from mainland China within 14 days of symptom onset.

Continue asking patients with suspected flu or diarrhea if they, or someone they have been in contact with, recently returned from coronavirus-affected area. [In US, in a confirmed case, 2019-nCoV RNA has been identified in a stool specimen collected on day 7 of the patient’s illness.]

 Take Home Messages

Delhi Help line number: +91-11-23978046

Virus: Single-strand, positive-sense RNA genome ranging from 26 to 32 kilobases in length.

Type: Beta corona virus

Family: Corona virus family. ‘Corona’ means crown or the halo around the sun. Heart is considered crown and hence the arteries that supply oxygen to the heart are also called coronary arteries. When seen under an electron microscope, the virus appears round in shape with spikes poking out from its periphery.

Link to ACE: 2019-nCoV might be able to bind to the angiotensin-converting enzyme 2 receptor in humans.

Origin: Wuhan, China December 2019

Spread: 28 countries and territories

Confirmed cases: 31481

Deaths: 638

New Cases: On Feb 5, 31 provincial-level regions on the Chinese mainland as well as the Xinjiang Production and Construction Corps reported 3,694 new cases (2,987 in Hubei province)

Suspected cases on 5^th:  5,328 new cases (3,230 in Hubei province)

Serious cases on 5^th: 640 new serious cases (564 in Hubei province)

Deaths on 5^th Feb:  73 (70 in Hubei province, 1 in Tianjin, 1 in Heilongjiang province and 1 in Guizhou province)

Deaths on 6^th Feb: 73

Discharged on 5^th:  261 cured (113 in Hubei province)

Freed from medical observation on 5^th:  21,365

Total cured: 1,153

Suspected cases: 24,702

Quarantine: 26,302 patients

Serious: 3,859 in serious condition

Close contacts:  282,813 people

Medical observation: 186,354

42 confirmed infections had been reported in the Hong Kong and Macao special administrative regions and Taiwan province: 21 in Hong Kong (1 death), 10 in Macao and 11 in Taiwan.

 Three deadly human respiratory coronaviruses: Severe acute respiratory syndrome coronavirus [SARS-CoV], Middle East respiratory syndrome coronavirus [MERS-CoV]) and 2019-nCoV: The virus is 75-80% identical to the SARS-CoV.

Emergency: It is a Public Health Emergency of International Concern (It is mandatory to report to WHO human and animal cases)

 Kerala: State public health emergency. Three primary cases in North, South and Central Kerala (Kasaragod district in north Kerala, Thrissur in central Kerala and Alappuzha in South Kerala). Four Karnataka districts bordering Kerala — Kodagu, Mangaluru, Chamarajanagar and Mysuru - have been put on high alert.

 Median age: 59 years (2-74 years)

 Male to female ratio: 56% male

 Link to Huanan Seafood Wholesale Market: 55% with onset before January 1, 2020 and 8.6% of the subsequent cases.

 Mean incubation period: 5.2 days (95% confidence interval [CI], 4.1 to 7.0), with the 95th percentile of the distribution at 12.5 days.

 Epidemic doubling time: In its early stages, every 7.4 days, with a mean serial interval of 7.5 days (95% CI, 5.3 to 19).

 Contagiousness or Basic reproductive number: 2.2 (95% CI, 1.4 to 3.9).  The reproduction number, referred to as R0 or “r naught” is the number of additional people that an infected person can infect. An outbreak with a reproductive number of below 1 will gradually disappear. The R0 for the common flu is 1.3 and for SARS it was 2.0.

 Comorbid conditions: 71%, deaths in comorbid cases.

 0-15 years age: Just like SARS, it mostly does not affect children 15 years of age or less

 Daily deaths:  73 deaths on 5^th (15% rise), 66 on 4^th, 64 on 3^rd Feb.

 Anticipation: One lac already infected.

 Secondary cases: Thailand, Taiwan, Germany, Vietnam, Japan, France and the United States

 Deaths outside China: Philippines on February 2 (44 M) and 2^nd in Hong Kong (39 M)  on February 4

 ICU need: 20% needed ICU care; 15% of them died

 Fever: In all (no fever no corona)

 Cough: 75% cases

 Weakness or muscle ache: 50%

 Shortness of breath: 50%

 TLC: low

 Liver transaminase levels: raised

 Case fatality: 2%

 Case fatality in admitted cases: 15%

 Time to death:  14 days

 Time to pneumonia:  9 days

 Origin: Bats

 Mode of spread: Large droplets and predominately from people having lower respiratory infections

Answer: Universal droplet precautions.

 Incubation period:  up to 2 weeks, according to WHO, with mean being 5.5 days

 Transmission: Predominantly a large droplet and contact and less frequently by means of aerosols and fomites

 Lab precautions: BSL-2 or -3

 Human-to-human contact period: Requires contact of ten minutes within six feet

 Virus life span: The virus can remain alive on any surface for 3-12 hours

 Travel preferable seat: Choosing a window seat and staying there lowers the risk

 Travel advisory:  Level 1 in all countries (Exercise normal safety precautions), Level 2 in all affected countries and states including Kerala (Exercise a high degree of caution), Level 3 in all countries with secondary cases (Reconsider your need to travel) and Level 4 in China (Do not travel). Hong Kong has imposed 14 days quarantine on people arriving from China. The Karnataka government has ordered that anybody arriving from the 23 coronavirus-affected countries must stay in isolation at home for 28 days. The home isolation requirement is regardless of the virus symptoms.

 High viral load: Detection of 2019-nCoV RNA in specimens from the upper respiratory tract with low Ct values on day 4 and day 7 of illness suggests high viral loads and potential for transmissibility. [NEJM]

 Risk to other Asian countries including India: Currently, people at risk are healthcare workers caring for 2019-nCoV patients and other close contacts of 2019-nCoV patients. For the general public unlikely to be exposed to this virus, the immediate health risk from 2019-nCoV is considered low at this time.

It is less likely to have serious illness in other countries. As patients with breathlessness are unlikely to board and patients will mild illness or asymptomatic illness are less likely to transmit infections.

Zoonotic but unlikely to spread through seafood: 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. 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. 

Infectiousness 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.

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 but the same has been challenged now.

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.

No sore throat: This new 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.

Asymptomatic transmission: 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. NEJM reported a transmission from asymptomatic case but the same has been challenged.

Mass Quarantine May Spark Irrational Fear, Anxiety, Stigma

Evacuation: US, Japan, India have evacuated their citizens trapped in China’s affected areas.  All 645 evacuees from Wuhan tested negative for the deadly infection in India.

Legal implications in India: Section 270 in The Indian Penal Code: 270. Malignant act likely to spread infection of disease danger­ous to life.—Whoever malignantly does any act which is, and which he knows or has reason to believe to be, likely to spread the infection of any disease dangerous to life, shall be punished with imprisonment of either description for a term which may extend to two years, or with fine, or with both.

Case fatality of coronavirus 2%

Case fatality of MERS 34% (2012, killed 858 people out of the 2,494 infected)

Case fatality of SARS 10% (Nov. 2002 - Jul. 2003, originated from Beijing, spread to 29 countries, with 8,096 people infected and 774 deaths)  

 Case fatality of Ebola 50%

 Case fatality of Smallpox 30-40%

 Case fatality of Measles 10-15% developing countries

 Case fatality of Polio 2-5% children and 15-30% adults

 Case fatality of Diphtheria 5-10%

 Case fatality of Whooping cough 4% infants < 1yr, 1% children < 4 years

 Case fatality of Swine flu < 0.1-4 %

 Case fatality of seasonal flu 0.01%.

 Case fatality of current virus in Wuhan 4.9%

 Case fatality of current virus in Hubei Province 3.1%

 Case fatality of current virus Nationwide 2.1%

 Case fatality of current virus in other provinces 0.16%

 Number of flu deaths every year: 290,000 to 650,000 (795 to 1,781 deaths per day)

 Treatment: No proven antiviral treatment.

 SARS Experience: A combination of lopinavir and ritonavir showed promise in lab

 MERS experience: Combination of lopinavir, ritonavir and recombinant interferon beta-1b has been tried

 Recreation of Virus: Scientists in Australia have reportedly developed a lab-grown version of coronavirus.

 Chloroquine: had 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.

 Thai experience: Oseltamivir along with lopinavir and ritonavir, both HIV drugs.

 Experimental drug: Rrom Gilead Sciences Inc., called remdesevir (started on 6^th Feb as a trial)

 Russia and China drug: Arbidol, an antiviral drug used in Russia and China for treating influenza, could be combined with Darunavir, the anti-HIV drug, for treating patients with the coronavirus. ( Coronavirus shares some similarity to HIV virus also)

 PVP-I mouthwashes and gargles are known to reduce viral load in the oral cavity and the oropharynx. PVP-I has high potency for viricidal activity against hepatitis A and influenza, MERS and SARS.

 DCGI Approval: The Drug Controller General of India has approved the "restricted use" of a combination of drugs used widely for controlling HIV infection in public health emergency for treating those affected by novel coronavirus.

 Universal respiratory droplets precautions

Self-quarantining: 2 weeks

Adherence: Strict

Soap and water: Wash your hands often and for at least 20 seconds.

Alcohol-based hand sanitizer: If soap and water is not available

Avoid touching:  your eyes, nose, and mouth with unwashed hands.

Avoid close contact:  (3-6 feet) with people who are sick with cough or breathlessness

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.

Surgical Masks: For patients

N 95 Masks: For health care providers and close contacts

Ten Common Myths Busted

1. People receiving packages from China are not at risk of contracting the new coronavirus as the virus does not survive long on objects, such as 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 petsto prevent transmission of common bacteria such as E. coli and Salmonella.

3. Pneumococcal vaccine and Haemophilus influenza type B (Hib) vaccine provide no protection against the new coronavirus.

4. Regularly rinsing the nose with saline does not protect people from infection with the new coronavirus or respiratory infections although it can hasten recovery from the common cold.

5. There is no evidence that using mouthwash protects you from infection with the new coronavirus although some brands of mouthwash can eliminate certain microbes for a few minutes in the saliva in your mouth.

6. Garlic may possess some antimicrobial properties; however, there is no evidence that eating garlic protects people from the new coronavirus.

7. Sesame oil does not kill the new coronavirus. Chemical disinfectants that can kill the 2019-nCoV on surfaces are 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 your skin.

8. People of all ages can be infected by the new coronavirus (2019-nCoV). Older people, and people with pre-existing medical conditions (such as asthma, diabetes, heart disease) have increased odds becoming severely ill with the virus.  People of all ages are advised to take steps to protect themselves from the virus, for example by following good hand hygiene and good respiratory hygiene.

9. Antibiotics do not work against viruses.  Hence, antibiotics should not be used to prevent or treat the new coronavirus unless you suspect bacterial co-infection.

10. To date, there is no specific medicine recommended to prevent or treat the new coronavirus (2019-nCoV).

Role of CMAAO and other Medical Associations

1. All countries should be prepared for containment, including active surveillance, early detection, isolation and case management, tracking contacts and prevention of spread of the virus and to share full data with WHO. 
2. It is a legal requirement that all countries share information with WHO under the IHR. 
3. 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.
4. All countries should emphasize on reducing human infection, prevention of secondary transmission and international spread.

PMO Suggestions sent

7^th Jan: CMAAO Alert: WHO to monitor Chinas mysterious pneumonia of unknown virus outbreak

8^th Jan: CMAAO warns Asian citizens travelling to China over mystery pneumonia outbreak

10^th Jan: I wrote an editorial: Coronavirus strain causing pneumonia in Wuhan, China, It’s a new strain of coronavirus in the China pneumonia

13^th Jan: China Virus Outbreak Linked to Seafood Market

15^th Jan: First Case of China Pneumonia Virus Found Outside China in Thailand

17^th Jan: WHO issues warning after mysterious Chinese coronavirus spreads to Japan

17^th Jan: India at threat of Coronavirus. CMAAO urges travel advisory on coronavirus: http://www.drugtodayonline.com/medical-news/nation/10379-cmaao-urges-travel-advisory-on-coronavirus.html

 (18^th Jan: Indian govt issues travel advisory as Chinas mysterious Coronavirus spreads in other countries)

18^th Jan: WHO issues warning after mysterious Chinese Coronavirus spreads to Japan [http://blogs.kkaggarwal.com/tag/who/]

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 issues 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 and people of  neighboring countries from China’s affected areas; Time to collaborate on Nosode therapy (Exports of masks banned on 31^st January by Indian Government)

Action:  Feb 1^st: Ibrahim Mohamed Solih thanked India for the evacuation of seven Maldivian nationals from the coronavirus-hit Chinese city of Wuhan. India evacuated 647 people

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  lead

30^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  

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

3^rd Feb: 100 crore budget for Coronavirus; 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;  Sea ports to have same precautions; price caps for masks, and gloves; National Droplet Control Program; clarification that import of goods is not risky; And suspend AI flights to China and Hong Kong

[Feb 4 - Air India suspended flight services to Hong Kong from Friday until March 28. Earlier, Air India had cancelled its flight to Shanghai from January 31 to February 14; and 5^th Feb - The Ministry of Defence is setting up 10 new laboratories across the country, primarily to conduct research on viruses]

4^th 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]

5^th Feb: PM should talk about Coronavirus in Man Ki Baat or a special address

6^th Feb: Time to have makeshift bed policy to tackle deaths in Kota, Muzaffarpur and Coronavirus cases

Confirmed Cases and Deaths by Country and Territory

(Affecting 28 countries and territories)

Search:

Total Deaths of Novel Coronavirus (2019-nCoV)

Daily Deaths of Novel Coronavirus (2019-nCoV)

Total Cases of Novel Coronavirus (2019-nCoV)

Daily Cases 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