CMAAO Update 3rd February on Corina 2019 nCoV 58 deaths in last one day in China

CMAAO Update 3^rd February on Corina 2019 nCoV

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

Summary

7th Feb Friday observe as National Wear Red Day, continue asking patients with suspected flu or diarrhoea if they, or someone they have been in contact with, recently returned from China affected area. Corona is a Public Health Emergency of International Concern as person-to-person transmission in UK, USA, Germany, Japan, Taiwan and Vietnam an( mandatory to report to WHO human and animal cases), d a death in the Philippines on Feb2 marks the first death of 44 M  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 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 27 countries and territories worldwide, with 17387 confirmed cases and 362 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). 

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 been 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.

 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.

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 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.

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

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

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

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  

1^st feb: Disaster Budget

Confirmed Cases and Deaths by Country and Territory

(Affecting 27 countries and territories)

Country	Cases	Deaths	Region
China	17,206	361	Asia
Japan	20	0	Asia
Thailand	19	0	Asia
Singapore	18	0	Asia
South Korea	15	0	Asia
Hong Kong	14	0	Asia
Australia	12	0	Australia/Oceania
Germany	10	0	Europe
Taiwan	10	0	Asia
United States	9	0	North America
Malaysia	8	0	Asia
Macao	8	0	Asia
Vietnam	7	0	Asia
France	6	0	Europe
United Arab Emirates	5	0	Asia
Canada	4	0	North America
Philippines	2	1	Asia
Italy	2	0	Europe
India	2	0	Asia
United Kingdom	2	0	Europe
Russia	2	0	Europe
Nepal	1	0	Asia
Finland	1	0	Europe
Sweden	1	0	Europe
Sri Lanka	1	0	Asia
Cambodia	1	0	Asia
Spain	1	0	Europe

 Total Deaths of Novel Coronavirus (2019-nCoV)

Date	Total Deaths	Change in Total	Change in Total (%)
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. 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%