CMAAO Update 4^th February on Coronavirus 2019-nCoV

Over 2,239 people in the state are under observation, of which 2,155 are in their homes, while 84 are in hospitals. One hundred forty samples have so far been sent for testing, of which 46 are negative and the results of the rest are awaited. More are likely to be positive.

All three coronavirus cases have been reported in different parts of the state - Kasaragod district in north Kerala, Thrissur in central Kerala and Alappuzha in South Kerala.

 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 (mandatory to report to WHO human and animal cases) as person-to-person transmission has been confirmed in UK, USA, Germany, Japan, Taiwan and Vietnam, besides one death in the Philippines on Feb 2 (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 20626 confirmed cases and 426 deaths (median age45, range 2-74, predominately males 71%, deaths more in comorbid cases,  Just like SARS, it mostly do not affect children 15 years or less of age).  64 deaths on 3^rd feb. Anticipates one lac 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

to China.

It’s not new

Every decade a zoonotic coronavirus crosses species to infect human populations and in this decade, we have a virus, provisionally called 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

Virus has an RNA core and belongs to the corona virus family. ‘corona’ means crown or the halo surrounding the sun. The arteries supplying oxygen to the heart are also called coronary arteries, because the heart is considered the crown. In electron microscope, it is round in shape with spikes poking out from its periphery.

The three deadly human respiratory coronaviruses viruses 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 to 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 MERS 34%, SARS (out of 5327 cases) 10%, Ebola 50%, Small Pox 30-40%, Measles 10-15% developing countries, Polio 2-5% children and 15-30% adults, Diphtheria 5-10%, Whooping cough 4% infants < 1yr, 1% children < 4 years AND Swine flu < 0.1-4 %.

Once the province Hubei (where the epicenter Wuhan is situated) is removed from the calculation, the national (China) mortality rate drops to 0.3%. Within the Hubei province, the mortality rate is about 1% when excluding the city of Wuhan (where it is 5.5%).

The case fatality rate with seasonal flu is less than 0.01% (1 death per every 10,000 cases)^[8].

Role of CMAAO and other Medical Associations

All countries should be prepared for containment, including active surveillance, early detection, isolation and case management, contact tracing and prevention of onward spread of the virus and to share full data with WHO.  All countries are legally required to share information with WHO under the IHR. 

Any detection of 2019-nCoV in an animal (including information about the species, diagnostic tests, and relevant epidemiological information) should be reported to the World Organization for Animal Health (OIE) as an emerging disease.

All countries should emphasise on reducing human infection, prevention of secondary transmission and international spread.

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

Its Zoonotic but It is unlikely to spread through seafood in India

It is closely related to several bat coronaviruses. Bats are the primary reservoir for the virus. SARS-CoV was transmitted to humans from exotic animals in wet markets, whereas MERS-CoV is transmitted from camels to humans. In both cases, the ancestral hosts were probably bats.

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 in wild. Reports indicate that snakes were sold in the local seafood market in Wuhan, raising the possibility that the 2019-nCoV might have jumped from the host species - bats - to snakes and then to humans at the beginning of the outbreak. However, it remains a mystery as to how the virus could adapt to both the cold-blooded and warm-blooded hosts.

It is more infectious to humans

Notably, 2019-nCoV grows better in primary human airway epithelial cells than in standard tissue-culture cells, unlike SARS-CoV or MERS-CoV. It is likely that 2019-nCoV will behave more like SARS-CoV.

Human to Human infection

Both SARS-CoV and MERS-CoV infect intrapulmonary epithelial cells more than cells of the upper airways. Consequently, transmission 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 in which transmission appears to have occurred during the incubation period in the index patient.

It appears that 2019-nCoV uses the same cellular receptor as SARS-CoV (human angiotensin-converting enzyme 2 [hACE2]), so transmission is expected only after signs of lower respiratory tract disease develop.

The paramount reason for breathless is the fact that this new virus attacks the lungs and not just the throat. Patients so far have not presented with a sore throat, the reason being that the 2019-nCoV launches an attack at the intraepithelial cells of lung tissue.

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

 It’s predominantly a large droplet infection

Transmission of 2019-nCoV probably occurs by means of large droplets and contact and less so by means of aerosols and fomites, on the basis of experience with SARS-CoV and MERS-CoV. In lab we need minimum BSL 3 ( or BSL 4 facilities) to prevent transmission. 

The incubation period

Up to 2 weeks, according to WHO. Mean 5.5 days

Symptoms

One-third landed up in the intensive care unit; and as many as 15% of these succumbed to the infection. Almost all patients presented with fever, more than two-thirds had cough and almost 50% suffered from weakness or muscle ache. More than half complained of shortness of breath.

2019-nCoV not unlike other virus disease presents with low white cells 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

There is no proven antiviral treatment. A combination of lopinavir and ritonavir did show some promise in patients with SARS, but this was in the lab and not in humans. A randomised study is being done in Saudi Arabia in patients with MERS; a combination of lopinavir, ritonavir and recombinant interferon beta-1b versus placebo; the results are awaited.

Scientists in Australia have reportedly recreated a lab-grown version of coronavirus. The breakthrough would help researchers around the world as they race 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, there have been no studies of efficacy in humans.

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

PVP-I mouthwashes and gargles significantly reduce viral load in the oral cavity and the oropharynx. The importance of PVP-I has been emphasised by its inclusion in the World Health Organization’s list of essential medicines, and high potency for virucidal activity has been observed against viruses of significant global concern, including hepatitis A and influenza, as well as the Middle-East Respiratory Syndrome and Sudden Acute Respiratory Syndrome 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. Choosing a window seat and staying put clearly lowers your likelihood of encountering an infectious disease.

Contagiousness

The reproduction number—R0 or “r naught”—simply refers to the number of additional people that an infected person typically makes sick.

A more recent study is indicating a Ro as high as 4.08. This value substantially exceeds WHOs estimate (made on Jan. 23) of between 1.4 and 2.5^], and is also higher than recent estimates between 3.6 and 4.0 and between 2.24 to 3.58 . Preliminary studies had estimated Ro to be between 1.5 and 3.5.  Based on these numbers, on average every case of the Novel Coronavirus would create 3 to 4 new cases. An outbreak with a reproductive number of below 1 will gradually disappear. The Ro for the common flu is 1.3 and for SARS it was 2.0.

Evacuation

Tokyo, Japan, India have evacuated their citizens trapped in China afrected areas

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

Comparisons:

• Every year an estimated 290,000 to 650,000 people die in the world due to complications from seasonal influenza (flu) viruses. This figure corresponds to 795 to 1,781 deaths per day due to the seasonal flu.
• SARS (Nov. 2002 - Jul. 2003): was a coronavirus that originated from Beijing, China, spread to 29 countries, with 8,096 people infected and 774 deaths (with a fatality rate of 9.6%). Considering that SARS ended up infecting 5,237 people in mainland China, Wuhan Coronavirus surpassed SARS on January 29, 2020, when Chinese officials confirmed 5,974 cases of the novel coronavirus (2019-nCoV). One day later, on January 30, 2020 the novel coronavirus cases surpassed even the 8,096 cases worldwide representing the final SARS count in 2003.
• MERS (2012) killed 858 people out of the 2,494 infected (with a fatality rate of 34.4%).

PMO Suggestions

10th January: I wrote an editorial: Corona virus strain causing pneumonia in Wuhan, China

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

18-20 Jan: Three countries meet, also discussed Corona virus

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

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

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

26 Jan: Need of National droplet Infection Control program, Policy to ban export of face masks, policy to evacuate Indians from China affected areas, Time to collaborate on Nosode therapy (Masks banned on 31^st January)

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

28: Do research on Nosodes

29: Closure of live markets

30: Paid flu leave, surgical mask at public places, N 95 for health care providers

31: Respiratory hygiene advisory schools, Pan India task force to be made  

1^st Feb: Disaster Budget

3^rd Feb: 100 crore budget for Corona virus; Private labs to be recognised; one dedicated corona National help line, MTNL BSNL to have a line of advisory in their bills, isolation wards to be single rooms or two beds seperated with six feet distance, national insurance to cover cost of treatment,  

 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