Friday, January 31, 2020

Corona update 31st January (Public Health Emergency of International Concern

Outbreak of 2019-nCoV constitutes a PHEIC (Public Health Emergency of International Concern)
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 like large droplets and predominately from people having lower respiratory infections and hence universal droplet precautions the answer

Dr KK Aggarwal
President CMAAO, HCFI and past National President IMA

There are now 7711 confirmed and 12167 suspected cases throughout the country. Of the confirmed cases, 1370 are severe and 170 people have died. 124 people have recovered and been discharged from hospital.  There are now 83 cases in 18 countries. Of these, only 7 had no history of travel in China. There has been human-to-human transmission in 3 countries outside China. One of these cases is severe and there have been no deaths.  India now has first confirmed case in Kerala in a student studying in 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.

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 3% compared to MERS 35%, 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 %.

Global emergency

The Director-General ICHR has declared that the outbreak of 2019-nCoV constitutes a PHEIC (Public Health Emergency of International Concern)

Role of CMAAO and other country medical associations

It is expected that further international exportation of cases may appear in any country.  All countries should be prepared for containment, including active surveillance, early detection, isolation and case management, contact tracing and prevention of onward spread of 2019-nCoVinfection, 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

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.

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 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 is weak

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. 

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.

 It’s 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.

The incubation period

Up to 2 weeks, according to WHO.


Lancet: 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.


There is no proven antiviral treatment for the coronavirus. 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.

Universal droplets precautions the answer

1.    Quarantining for two weeks of the LRTI patient
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!

Its all over  in 18 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

i.                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. Because the incubation period is believed to be unusually long — at up to two weeks — it is possible that the Chinese colleague had no symptoms at the time. On her flight home on 23 Jan, the woman began to fall ill on the plane. She sought medical treatment after landing in China and tested positive for coronavirus. When that information was relayed back to the German company, the 33-year-old also felt like he had flu and was subsequently tested positive for the virus too. Now, 3 more co-workers in Germany of the Chinese woman have been tested positive for the virus too.
ii.               A Japanese man with no recent travel to China has contracted the Wuhan virus apparently after driving tourists visiting from Wuhan. The man in his sixties from Nara in western Japan drove two groups of Wuhan tourists earlier in January and was hospitalised on 25 Jan with flu-like symptoms.
iii.             A 65-year-old Chinese man had infected his son in Vietnam. On 22 Jan, the 65-year-old was admitted to Cho Ray Hospital in Ho Chi Minh City. He had become ill with fever on 17 Jan, a total of 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, a province 40 km southwest of Ho Chi Minh City, since October 2019 but had not been to Wuhan or had any known contact with any person returning from there except his parents.

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


29th Jan: 9:15 am: Charter jet evacuating Japanese nationals from Wuhan lands in Tokyo.

There are no signs of illness among the 195 Americans who were flown out of Wuhan, China, on a chartered flight that landed Wednesday in Southern California, public health officials said. All were screened for signs of the new virus — 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, Stigma


PMO Suggestions

17th Jan: India at threat of Corona. Advisory should be issued (18th Indian govt issues travel advisory as China's mysterious 'Coronavirus' spread 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 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 ( 23rd India advisory to airports)
24th: Inter Ministerial Committee needs to be formed on Corona Virus ( PMO took a meeting on 24th evening)
25th 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
27: Anti fever drugs at airports should be taken
28: Do research on Nosodes
29: Closure of live markets
30: Paid leave for flu patients

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