Summary

7th Feb Friday to be observed as National Wear Red Day.

Continue asking patients with suspected flu or diarrhea if they, or someone they have been in contact with, recently returned from China’s affected area. Corona is a Public Health Emergency of International Concern as person-to-person transmission in UK, USA, Germany, Japan, Taiwan and Vietnam (mandatory to report to WHO human and animal cases) has been confirmed. A death in the Philippines on February 2 marks the first death occurring outside of China. 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 predominately 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 27 countries and territories worldwide, with 17387 confirmed cases and 362 deaths (median age 45, range 2-74, predominately males (71%), deaths more in comorbid cases, just like SARS, mostly does not affect children 15 years of age or less).  Countries and territories that have confirmed cases include 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 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 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.

 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.

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.

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 hours3.     Choose 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

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)

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: Anti-fever drugs at airports should be taken

28^th Jan: Do research on Nosodes29^th Jan: Closure of live markets30^th Jan: Paid flu leave, mask at public places31^st Jan: Respiratory hygiene advisory to schools, Pan-India task force  1^st Feb: Disaster Budget

Confirmed Cases and Deaths by Country and Territory

(Affecting 27 countries and territories)

 Total Deaths from 2019-nCoV

Daily Deaths from 2019-nCoV

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

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA