Thursday, February 6, 2020

5% less cases on 5th 3723 cases as against 3927 on 4th similarly on 28th Jan cases dropped




CMAAO Update 6th February on Corona 2019 nCoV

5% less cases on 5th 3723 cases as against 3927 on 4th similarly on 28th Jan cases dropped

Beware of Common Myths: There is no evidence that eating garlic cannot prevent corona virus

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

Travel 4 advisory to china and Travel 2 to Kerala affected districts

DCGI approves combination of HIV drugs for corona infection

The government in Delhi on Saturday set up a round-the-clock National Centre for Disease Control Call Centre (+91-11-23978046) to attend to public queries.

Kerala government declares coronavirus as state emergency. Three primary cases in North, South and Central Kerala (Kasaragod district is 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 in the wake of positive coronavirus cases in Kerala.

It is les likely to have the 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.

Beware of Myths

1.     People receiving packages from China are not at risk of contracting the new coronavirus. Coronaviruses do not survive long on objects, such as letters or packages.

2.     There is no evidence that companion animals/pets such as dogs or cats can be infected with the new coronavirus. However, it is always a good idea to wash your hands with soap and water after contact with pets. This protects you against various common bacteria such as E. coli and Salmonella that can pass between pets and humans.

3.     Pneumococcal vaccine and Haemophilus influenza type B (Hib) vaccine, do not provide protection against the new coronavirus.

4.     Regularly rinsing the nose with saline does not protect people from infection with the new coronavirus. Rinsing nose with saline can help people recover more quickly from the common cold. However, regularly rinsing the nose has not been shown to prevent respiratory infections.

5.     There is no evidence that using mouthwash will protect you from infection with the new coronavirus. Some brands or mouthwash can eliminate certain microbes for a few minutes in the saliva in your mouth. However, this does not mean they protect you from 2019-nCoV infection.

6.     Garlic is a healthy food that may have some antimicrobial properties. However, there is no evidence from the current outbreak that eating garlic has protected people from the new coronavirus.

7.     Sesame oil does not kill the new coronavirus. There are some chemical disinfectants that can kill the 2019-nCoV on surfaces. These include bleach/chlorine-based disinfectants, either solvents, 75% ethanol, peracetic acid and chloroform. However, they have little or no impact on the virus if you put them on the skin or under your nose. It can even be 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) appear to be more vulnerable to becoming severely ill with the virus.  WHO advises people of all ages 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, only bacteria. The new coronavirus (2019-nCoV) is a virus and, therefore, antibiotics should not be used as a means of prevention or treatment. However, if you are hospitalized for the 2019-nCoV, you may receive antibiotics because bacterial co-infection is possible.

10.  To date, there is no specific medicine recommended to prevent or treat the new coronavirus (2019-nCoV). However, those infected with the virus should receive appropriate care to relieve and treat symptoms, and those with severe illness should receive optimized supportive care. Some specific treatments are under investigation and will be tested through clinical trials. WHO is helping to accelerate research and development efforts with a range or partners?
Summary

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

Corona is a Public Health Emergency of International Concern  (mandatory to report to WHO human and animal cases) as person-to-person transmission in UK, USA, Germany, Japan, Taiwan and Vietnam and two deaths, one in the Philippines on Feb 2 (44 M) and 2nd in Hong Kong ( 39 M)  on February outside of mainland China.

The virus 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 like large droplets and predominately from people having lower respiratory infections and hence universal droplet precautions the answer.


Status

The Novel Coronavirus (2019-nCoV) originating from Wuhan, China, has now spread to 28 countries and territories worldwide, with 28276 confirmed cases and 565 deaths.
NEJM: Among the first 425 patients with confirmed NCIP, the median age was 59 years (2-74 yrs)  and 56% were male. The majority of cases (55%) with onset before January 1, 2020, were linked to the Huanan Seafood Wholesale Market, as compared with 8.6% of the subsequent cases. The mean incubation period was 5.2 days (95% confidence interval [CI], 4.1 to 7.0), with the 95th percentile of the distribution at 12.5 days. In its early stages, the epidemic doubled in size every 7.4 days. With a mean serial interval of 7.5 days (95% CI, 5.3 to 19), the basic reproductive number was estimated to be 2.2 (95% CI, 1.4 to 3.9).
71%, deaths more in comorbid cases, Just like SARS, it mostly do not affect children 15 years or less of age).  73 deaths on 5th ( 15% rise), 66 on 4th,  64 on 3rd 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 with spikes poking out from its periphery.

The three deadly human respiratory coronaviruses viruses so far

Severe acute respiratory syndrome coronavirus [SARS-CoV]
Middle East respiratory syndrome coronavirus [MERS-CoV])
2019-nCoV: The virus is 75 to 80% identical to the SARS-CoV

The virus

2019-nCoV is sufficiently divergent from SARS-CoV to be considered a new human-infecting beta coronavirus. Structural analysis suggests that 2019-nCoV might be able to bind to the angiotensin-converting enzyme 2 receptor in humans. It is a single-strand, positive-sense RNA genome ranging from 26 to 32 kilobases in length.

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 epicentre 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.


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. Though 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 but the same has been challenged now.

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, based on experience with SARS-CoV and MERS-CoV. In lab we need minimum BSL 2 or 3 (not BSL 4 facilities) to prevent transmission. 

The incubation periods

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.

Clinical features

Epidemiologic risk
Fever* 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
Fever* and signs/symptoms of
lower respiratory illness (cough or shortness of breath)
PLUS
A history of travel from Hubei Province,
China within 14 days of symptom onset
Fever* and signs/symptoms of
lower respiratory illness (cough or shortness of breath) requiring hospitalization
PLUS
A history of travel from mainland China
within 14 days of symptom onset

nCoV: novel coronavirus; CDC: United States Centers for Disease Control and Prevention; NIOSH: National Institute for Occupational Safety and Health.

* Fever may be subjective or confirmed.

¶ CDC definition of close contact (any of following):
Being within approximately 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 can include caring for, living with, visiting, or sharing a health care waiting area or room with a 2019-nCoV case.
Having direct contact with infectious secretions of a 2019-nCoV case (e.g., being coughed on) while not wearing recommended personal protective equipment.
Δ Documentation of laboratory confirmation of 2019-nCoV may not be possible for travellers or persons caring for patients in other countries.

◊ This category also includes any member of a cluster of patients with severe acute lower respiratory illness (e.g., pneumonia, acute respiratory distress syndrome) of unknown aetiology in whom 2019-nCoV is being considered that requires hospitalization. Such persons should be evaluated in consultation with state and local health departments regardless of travel history.

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

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 viricidal 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.

The Drug Controller General of India (DGCI) today 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 (nCoV).
Universal droplets precaution the answer

Quarantining for two weeks
Timely diagnosis
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

Requires contact of ten minutes within six feet
The virus can remain alive on any surface for 3-12 hours
Choosing a window seat and staying put clearly lowers your likelihood of encountering an infectious disease.

Level 1 - Exercise normal safety precautions
Level 2 - Exercise a high degree of caution (Affected areas in Kerala)
Level 3 - Reconsider your need to travel (advisory for corona affected countries)
Level 4 - Do not travel (advisory for china)
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 irrespective of the virus symptoms.

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 WHO's 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.

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

Risk Assessment

The risk depends on characteristics of the virus, including whether and how well it spreads between people, the severity of resulting illness, and the medical or other measures available to control the impact of the virus (for example, vaccine or treatment medications).

The risk to individuals is dependent on exposure. At this time, some people will have an increased risk of infection, for example healthcare workers caring for 2019-nCoV patients and other close contacts of 2019-nCoV patients. For the general public, who are unlikely to be exposed to this virus, the immediate health risk from 2019-nCoV is considered low at this time.
Evacuation

Tokyo, Japan, India have evacuated their citizens trapped in China affected 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
7th January: CMAAO Alert: WHO to monitor China's mysterious pneumonia of unknown virus outbreak

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

10th January: I wrote an editorial: Corona virus strain causing pneumonia in Wuhan, China, It’s a new strain of corona virus in the china pneumonia

13th January:
China Virus Outbreak Linked to Seafood Market:

15th January:
First Case China Pneumonia Virus Found Outside China in Thailand

17th January: WHO issues warning after 'mysterious' Chinese corona virus spreads to Japan

 

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


 (18th Indian govt issues travel advisory as China's mysterious 'Coronavirus' spread in other countries)

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


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

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 (Exports of masks banned on 31st January by Indian Government)

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

28: Do research on Nosodes

29: Closure of live markets all over the world, India should take a lead

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  

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

3rd 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 separated with six feet distance, national insurance to cover cost of treatment,  suspend AI flights to China and Hong Kong [New Delhi, Feb 4 (IANS) National passenger carrier Air India on Tuesday said that it will suspend flight services to Hong Kong owing to the outbreak of deadly coronavirus. The suspension will come into force from Friday until March 28, the airline said in a statement. Earlier, Air India had cancelled its flight to Shanghai from January 31 to February 14.] Sea ports ton have same precautions, prize caps for masks and gloves, National droplet control program, clarification that import of goods is not risky]

4th 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]


Confirmed Cases and Deaths by Country and Territory
(Affecting 28 countries and territories)
Search:
Country
Cases
Deaths
Region
China
28,018
563
Asia
Japan
45
0
Asia
Singapore
28
0
Asia
Thailand
25
0
Asia
South Korea
23
0
Asia
Hong Kong
21
1
Asia
Australia
14
0
Australia/Oceania
Malaysia
12
0
Asia
United States
12
0
North America
Germany
12
0
Europe
Taiwan
11
0
Asia
Macao
10
0
Asia
Vietnam
10
0
Asia
France
6
0
Europe
Canada
5
0
North America
United Arab Emirates
5
0
Asia
Philippines
3
1
Asia
India
3
0
Asia
Russia
2
0
Europe
Italy
2
0
Europe
United Kingdom
2
0
Europe
Finland
1
0
Europe
Sweden
1
0
Europe
Sri Lanka
1
0
Asia
Cambodia
1
0
Asia
Nepal
1
0
Asia
Spain
1
0
Europe
Belgium
1
0
Europe

Total Deaths of Novel Coronavirus (2019-nCoV)

Date
Total
Deaths
Change
in Total
Change in
Total (%)
Feb. 5
565
73
15%
Feb. 4
492
66
15%
Feb. 3
426
64
18%
Feb. 2
362
58
19%
Feb. 1
304
45
17%
Jan. 31
259
46
22%
Jan. 30
213
43
25%
Jan. 29
170
38
29%
Jan. 28
132
26
25%
Jan. 27
106
26
33%
Jan. 26
80
24
43%
Jan. 25
56
15
37%
Jan. 24
41
16
64%
Jan. 23
25
8
47%

Daily Deaths of Novel Coronavirus (2019-nCoV)

Date
Daily
Deaths
Change
in Daily
Change in
Daily (%)
Feb. 5
73
7
11%
Feb. 4
66
2
3%
Feb. 3
64
6
10%
Feb. 2
58
13
29%
Feb. 1
45
-1
-2%
Jan. 31
46
3
7%
Jan. 30
43
5
13%
Jan. 29
38
12
46%
Jan. 28
26
0
0%
Jan. 27
26
2
8%
Jan. 26
24
9
60%
Jan. 25
15
-1
-6%
Jan. 24
16
8
100%
Jan. 23
8
0
0%

Total Cases of Novel Coronavirus (2019-nCoV)

Date
Total
Cases
Change
in Total
Change in
Total (%)
Feb. 5
28,276
3,723
15%
Feb. 4
24,553
3,927
19%
Feb. 3
20,626
3,239
19%
Feb. 2
17,387
2,836
19%
Feb. 1
14,551
2,603
22%
Jan. 31
11,948
2,127
22%
Jan. 30
9,821
2,005
26%
Jan. 29
7,816
1,755
29%
Jan. 28
6,061
1,482
32%
Jan. 27
4,579
1,778
63%
Jan. 26
2,801
786
39%
Jan. 25
2,015
703
54%
Jan. 24
1,312
468
55%
Jan. 23
844
265
46%

Daily Cases of Novel Coronavirus (2019-nCoV)

Date
Daily
Cases
Change
in Daily
Change in
Daily (%)
Feb. 5
3,723
-204
-5%
Feb. 4
3,927
688
21%
Feb. 3
3,239
403
14%
Feb. 2
2,836
233
9%
Feb. 1
2,603
476
22%
Jan. 31
2,127
122
6%
Jan. 30
2,005
250
14%
Jan. 29
1,755
273
18%
Jan. 28
1,482
-296
-17%
Jan. 27
1,778
992
126%
Jan. 26
786
83
12%
Jan. 25
703
235
50%
Jan. 24
468
203
77%
Jan. 23
265
132
99%
We


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