Saturday, February 1, 2020

Ask patients with suspected flu if they, or someone they have been in contact with, recently returned from China

Ask patients with suspected flu if they, or someone they have been in contact with, recently returned from China

Public Health Emergency of International Concern

Person-to-person transmission in UK, USA, Germany, Japan, Taiwan 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


As of Jan. 30, there were 8,236 confirmed cases of the coronavirus in China and 171 deaths, with another 112 cases identified outside of China in 21 other countries. 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 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 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 %.

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.

 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


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. 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.

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!
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.    The reproduction number—R0 or “r naught”—simply refers to the number of additional people that an infected person typically makes sick. Transmissibility rate for the new coronavirus ranging from 2.0 to 3.1 people. That’s higher than influenza—1.3 to 1.8—but like SARS, which has a basic reproduction number in the 2 to 4 range. So, coronaviruses are slightly more prone to spreading between people.
4.    Choosing a window seat and staying put clearly lowers your likelihood of encountering an infectious disease.

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

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 flu leave, mask at public places
31: Resp hygiene advisory schools, Pan India task force  

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