Editorial

1st Coronavirus case confirmed in India in Kerala

Person-to-person transmission in three countries outside China - Germany, Japan and Vietnam

2019 n-CoV behaves like SARS, has its origin from bats, spreads through large droplets and predominantly from people having lower respiratory infections

India now has first confirmed case in Kerala in a student studying in China.

Public Health Concern: Yes

Public Concern: Not yet

Concern: Prevent person-to-person transmission in Kerala

Precautions: Universal flu prevention

Last week there had been around 600 cases in China and just 17 deaths. However, in the span of a week, Chinese officials report that the virus has infected more than 6,000 people with 132 deaths and thousands more suspected cases.

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.

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 -

Severe acute respiratory syndrome coronavirus [SARS-CoV] Middle East respiratory syndrome coronavirus [MERS-CoV]) 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 3% compared to 35% 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.

It’s not a global emergency yet but may be declared today

The World Health Organization (WHO) now has clarified that the risk was "very high in China, high at the regional level and high at the global level." According to the WHO, it had "incorrectly" stated previously that the global risk was "moderate". However, the correction of the global risk assessment does not mean that an international health emergency has been declared. This is an emergency in China but it has not yet become a global health emergency.

It’s Zoonotic

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.

It is unlikely to spread through seafood in India

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 is weak

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.

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 a large droplet infection

Transmission of 2019-nCoV occurs through large droplets and contact and less frequently by aerosols and fomites.

The incubation period

Up to 2 weeks, according to WHO.

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.

Universal droplets precautions the answer

Quarantining for two weeks of the LRTI patient Timely diagnosis Strict adherence to universal precautions

It’s all over - in 17 countries - including Australia, India, Macau, Hong Kong, France, Japan, Malaysia, Nepal, Singapore, Taiwan, South Korea, Thailand, United states, Vietnam with person-to-person transmission in three countries outside China - Germany, Japan and Vietnam

On 28th Jan, the German Health Ministry confirmed a 33-year-old German had contracted the virus from a Chinese colleague who had visited the company a week ago. The incubation period seems to be unusually long —up to two weeks. Therefore, it is possible that the Chinese colleague had no symptoms at the time. On her flight home on 23rd Jan, the woman began to fall ill. She sought medical treatment after reaching China and tested positive for coronavirus. The information was shared with the German company, and the 33-year-old also felt like he had flu and subsequently tested positive for the virus. Three more co-workers of the Chinese woman in Germany have tested positive for the virus.

A Japanese man, in his sixties, with no history of recent travel to China, contracted the virus apparently after driving tourists visiting from Wuhan. The man from Nara in western Japan drove two groups of tourists from Wuhan earlier in January and was hospitalised on 25th Jan with flu-like symptoms.

A 65-year-old Chinese man infected his son in Vietnam. On 22nd Jan, the Chinese man was admitted to a hospital in Ho Chi Minh City. He developed fever on 17th Jan, 4 days after he and his wife had flown to Hanoi from Wuhan. The couple’s healthy 27-year-old son had lived in Long An, 40 km southwest of Ho Chi Minh City, since October 2019 but had not visited Wuhan or had any known contact with any person returning from there except his parents.

On 17th Jan, he met his father in Nha Trang in central Vietnam and shared a bedroom with his parents for 3 days in a hotel. On 20th Jan, he developed dry cough and fever and reported having had vomiting and loose stools. When he came to the hospital with his father, he already had high fever (39°C). Both father and son tested positive for the Wuhan virus.

Evacuation

29th Jan:

9:15 am: Charter jet evacuating Japanese nationals from Wuhan lands in Tokyo.

No signs of illness among the 195 Americans flown out of Wuhan, China, on a chartered flight that landed Wednesday in Southern California. All passengers were screened for signs of the new virus, such as fever, cough and other respiratory symptoms, before boarding the plane in China. One person was not permitted on board because of a fever.

Coronavirus: Mass Quarantine - May spark irrational fear, anxiety, and stigma

PMO Suggestions

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

22nd 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 (23rd Jan: India advisory to airports)

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

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

26th 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

27th Jan: Anti-fever drugs at airports should be taken

28th Jan: Do research on Nosodes.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA