Corona Cases: 82% mild, 15% severe, 3% critical, 2% deaths

CMAAO Update 8^th February on Corona 2019 nCoV

37,553 confirmed cases, 813 deaths, Serious cases 6188

Cases: 82% mild, 15% severe, 3% critical, 2% deaths

6188 serious cases, Mortality in admitted cases 15%

Number of deaths likely to cross 1750

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

Summary

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.

The Director General of the World Health Organisation (WHO) has called on countries not to impose travel and trade restrictions over the coronavirus, warning that such measures could increase “fear and stigma” within the international community.

Some countries, including the UK, are advising their citizens to leave China altogether.

Around 3,700 people are being held on a ship in Japan after a passenger who had departed the vessel tested positive for the virus.

Case Definition

1.     Fever (subjective or confirmed)

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.

2.     [Contact means: 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 OR having direct contact with infectious secretions of a 2019-nCoV case (e.g., being coughed on) while not wearing recommended personal protective equipment.]

3.     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

4.     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.

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.]

Take Home Messages

Delhi Help line number: +91-11-23978046

Virus: Single-strand, positive-sense RNA genome ranging from 26 to 32 kilobases in length.

Type: Beta corona virus

Family: Corona virus family. ‘corona’ means crown or the halo surrounding the sun. Heart is considered crown and hence coronary arteries. In electron microscope, it is round with spikes poking out from its periphery.

Link to ACE: 2019-nCoV might be able to bind to the angiotensin-converting enzyme 2 receptor in humans.

Origin: Wuhan, China December 2019

1^st case informed to the world by Dr. Li Wenliang died Feb 6^th

Lockdown: 50 million people

Spread: 28 countries and territories

Confirmed cases: 37553 with 813 deaths 

New Cases: On Feb 8, 31 provincial-level regions on the Chinese mainland as well as the Xinjiang Production and Construction Corps reported 2656   (2147 in Hubei province)

Suspected cases on 8^th : 3916 new cases (2067 in Hubei province)

Serious new cases on 8^th : 87 new serious cases (52 in Hubei province)

Deaths on 8^th Feb:  89 (81 in Hubei province, 2 in Henan, I in Hebei, 1 in Heilongjiang province, 1 in Anhui province, 1 in Shandong province, 1 in Hunan province, and 1 in Guangxi Zhuang autonomous region]

Deaths on 6^th Feb: 73

Discharged on 6^th:  600 cured (324 in Hubei province)

Freed from medical observation on 5^th:  31124

 and in all 2,649 patients had been cured and discharged from hospital (reduced by 1 by Heilongjiang province after verification). There still remained 33,738 confirmed cases (including 6,188 in serious condition) and 28,942 suspected cases. So far, 371,905 people have been identified as having had close contact with infected patients. 188,183 are now under medical observation. 

Total cured: 2649

Suspected cases: 28942

Quarantine: 26,359 patients

Serious: 6188

Close contacts:  371905

Medical observation: 188183

Feb 8, 53 confirmed infections had been reported in the Hong Kong and Macao special administrative regions and Taiwan province: 26 in Hong Kong (1 death), 10 in Macao (1 had been cured and discharged from hospital) and 17 in Taiwan (1 had been cured and discharged from hospital).

Three deadly human respiratory coronaviruses viruses: Severe acute respiratory syndrome coronavirus [SARS-CoV], Middle East respiratory syndrome coronavirus [MERS-CoV]) and 2019-nCoV: The virus is 75 to 80% identical to the SARS-CoV

Emergency: It is a Public Health Emergency of International Concern  (mandatory to report to WHO human and animal cases)

Kerala: state public health 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.

Median age: 59 years (2-74 years)

Male to female ratio: 56% male

Link to Huanan Seafood Wholesale Market: 55% with onset before January 1, 2020 and 8.6% of the subsequent cases. The Chinese government has banned the wildlife trade until the epidemic passes. 

Mean incubation period: 5.2 days (95% confidence interval [CI], 4.1 to 7.0), with the 95th percentile of the distribution at 12.5 days.

Epidemic doubling time: In its early stages, every 7.4 days. With a mean serial interval of 7.5 days (95% CI, 5.3 to 19)

Contagiousness or Basic reproductive number: 2.2 (95% CI, 1.4 to 3.9).  The reproduction number R0 or “r naught” refers to the number of additional people that an infected person typically makes sick.  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.

Comorbid conditions: 71%, deaths in comorbid cases,

0-15 years age: Just like SARS, it mostly does not affect children 15 years or less of age

Daily deaths:  73 deaths on 5^th (15% rise), 66 on 4^th, 64 on 3^rd Feb.

Anticipates: one lac already infected.

Secondary cases: Thailand, Taiwan, Germany, Vietnam, Japan, France and the United States

Deaths outside China: Philippines on Feb 2 (44 M) and 2^nd in Hong Kong ( 39 M)  on February 4

ICU need: 20% needed ICU care with 15% of them died

Fever: In all (no fever no corona)

Cough: 75% cases

Weakness or muscle ache: 50%^

Shortness of breath: 50%

TLC: low

Liver transaminase levels: raised

Case fatality: 2%

Case fatality in admitted cases: 15%

Time to death:  14 days

Time to pneumonia:  9 days

Origin: Bats

Mode of spread: Large droplets and predominately from people having lower respiratory infections

Answer: Universal droplet precautions the answer.

Incubation period:  up to 2 weeks, according to WHO. Mean 5.5 days

Transmission: Predominantly a large droplet and contact and less so by means of aerosols and fomites

Lab precautions: BSL 2 or 3

Human to human contact period: Requires contact of ten minutes within six feet

Virus life span: The virus can remain alive on any surface for 3-12 hours

Travel preferable seat: Choosing a window seat and staying lowers the risk

Travel advisory:  Level 1 in all countries (Exercise normal safety precautions), Level 2 in all  affected countries and states including Kerala ( Exercise a high degree of caution), Level 3 in all countries with secondary cases (Reconsider your need to travel) and Level 4 in China ( Do not travel). 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.

To date, 72 countries are implementing travel restrictions.

High viral load: 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 to other Asian countries including India: Currently, people at risk are 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.

It is less 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.

Zoonotic but unlikely to spread through seafood: 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. 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.

Infectiousness to humans: 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.

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.

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.

No sore throat: 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.

Asymptomatic transmission: 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. NEJM reported a transmission from asymptomatic case but the same has been challenged.

Mass Quarantine May Spark Irrational Fear, Anxiety, Stigma

Evacuation: Tokyo, Japan, India have evacuated their citizens trapped in China affected areas.  All 645 evacuees from Wuhan test negative for the deadly infection in India.

Legal implications in India: Section 270 in The Indian Penal Code: 270. Malignant act likely to spread infection of disease danger­ous to life.—Whoever malignantly does any act which is, and which he knows or has reason to believe to be, likely to spread the infection of any disease dangerous to life, shall be punished with imprisonment of either description for a term which may extend to two years, or with fine, or with both.

Case fatality of coronavirus 2%

Case fatality of MERS 34% (2012, killed 858 people out of the 2,494 infected)

Case fatality of SARS 10% (Nov. 2002 - Jul. 200, originated from Beijing, spread to 29 countries, with 8,096 people infected and 774 deaths)  

Case fatality of Ebola 50%,

Case fatality of Smallpox 30-40%

Case fatality of Measles 10-15% developing countries

Case fatality of Polio 2-5% children and 15-30% adults

Case fatality of Diphtheria 5-10%

Case fatality of Whooping cough 4% infants < 1yr, 1% children < 4 years

Case fatality of Swine flu < 0.1-4 %

Case fatality of seasonal flu 0.01%.

Case fatality of current virus in Wuhan 4.9%.

Case fatality of current virus in Hubei Province 3.1%.

Case fatality of current virus in Nationwide 2.1%.

Case fatality of current virus in other provinces 0.16%.

Number of flu deaths every year: 290,000 to 650,000 (795 to 1,781 deaths per day)

Treatment: No proven antiviral treatment.

SARS Experience: A combination of lopinavir and ritonavir showed promise in lab

MERS experience: Combination of lopinavir, ritonavir and recombinant interferon beta-1b has been tried

Recreation of Virus: Scientists in Australia have reportedly recreated a lab-grown version of coronavirus.

Chloroquine: had 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.

Thai experience: Oseltamivir along with lopinavir and ritonavir, both HIV drugs.

Experimental drug: Rrom Gilead Sciences Inc., called remdesevir (started on 6^th Feb as a trial)

Russia and China drug: 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. PVP-I has high potency for viricidal activity against hepatitis A and influenza, MERS and SARS

DCGI Approval: The Drug Controller General of India has approved the "restricted use" of a combination of drugs (Lopinavir and ritonavir) used widely for controlling HIV infection in public health emergency for treating those affected by novel coronavirus.

Universal respiratory droplets precautions

Self-quarantining: 2 weeks

Adherence: Strict

Soap and water: Wash your hands often and  for at least 20 seconds.

Alcohol-based hand sanitizer: if soap and water is not available

Avoid touching:  your eyes, nose, and mouth with unwashed hands.

Avoid close contact:  (3-6 feet) with people who are sick with cough or breathlessness

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.

Surgical Masks: For patients

N 95 Masks: For health care providers and close contacts

The world is facing a chronic shortage of gowns, masks, gloves and other protective equipment in the fight.

Ten Common Myths

1.     People receiving packages from China are not at risk of contracting the new coronavirus as the virus does 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 good to wash your hands with soap and water after contact with pets. To prevent transmission of common bacteria such as E. coli and Salmonella.

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 or respiratory infections although it can help people recover more quickly from the common cold.

5.     There is no evidence that using mouthwash will protect you from infection with the new coronavirus although some brands or mouthwash can eliminate certain microbes for a few minutes in the saliva in your mouth.

6.     Garlic is a healthy food that may have some antimicrobial properties, however, there is no evidence that eating garlic protects people from the new coronavirus.

7.     Sesame oil does not kill the new coronavirus. Chemical disinfectants that can kill the 2019-nCoV on surfaces are 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.  Hence antibiotics should not be used as a means of prevention or treatment of new coronavirus unless you suspect bacterial co-infection.

10. To date, there is no specific medicine recommended to prevent or treat the new coronavirus (2019-nCoV).

Role of CMAAO and other Medical Associations

1.     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. 

2.      All countries are legally required to share information with WHO under the IHR. 

3.      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.

4.      All countries should emphasise on reducing human infection, prevention of secondary transmission and international spread.

PMO Suggestions sent

7^th January: CMAAO Alert: WHO to monitor China's mysterious pneumonia of unknown virus outbreak

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

10^th 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

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

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

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

 

17^th 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

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

18^th 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

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 and neighbouring countries from China affected areas, Time to collaborate on Nosode therapy (Exports of masks banned on 31^st January by Indian Government) Action:  [ Feb 1^st: Ibrahim Mohamed Solih thanked India for the evacuation of seven Maldivian nationals from the coronavirus-hit Chinese city of Wuhan. India evacuated 647 people]

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  

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

3^rd 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,  Sea ports to have same precautions, prize caps for masks, and gloves, National droplet control program, clarification that import of goods is not risky And suspend AI flights to China and Hong Kong

[Feb 4 Air India on Tuesday suspended flight services to Hong Kong from Friday until March 28. Earlier, Air India had cancelled its flight to Shanghai from January 31 to February 14 and on 5^th Feb the Ministry of Defence is setting up 10 new laboratories across the country, primarily to conduct research on viruses]

4^th 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]

5^th Feb: PM should talk about Corona in Man Ki Baat or a special address

6^th Feb: Time to have makeshift bed policy to tackle deaths in Kota, Muzaffarpur and Corona [Uttarakhand to set up two dedicated hospitals to tackle coronavirus : https://www.hindustantimes.com/india-news/uttarakhand-to-set-up-two-dedicated-hospitals-to-tackle-coronavirus/story-NYxBOw6XHTbugznTWa3CXK.html]

7^th Feb: IPC 269 should be applicable to corona virus

8^th Feb: teleconsultation should be allowed to flu and corona consultation

Confirmed Cases and Deaths by Country and Territory

(Affecting 28 countries and territories)

Country	Cases	Deaths	Region
China	37,198	811	Asia
Japan	89	0	Asia
Singapore	40	0	Asia
Thailand	32	0	Asia
Hong Kong	26	1	Asia
South Korea	25	0	Asia
Taiwan	17	0	Asia
Malaysia	16	0	Asia
Australia	15	0	Australia/Oceania
Germany	14	0	Europe
Vietnam	13	0	Asia
United States	12	0	North America
France	11	0	Europe
Macao	10	0	Asia
Canada	7	0	North America
United Arab Emirates	7	0	Asia
Philippines	3	1	Asia
Italy	3	0	Europe
India	3	0	Asia
United Kingdom	3	0	Europe
Russia	2	0	Europe
Sweden	1	0	Europe
Sri Lanka	1	0	Asia
Cambodia	1	0	Asia
Nepal	1	0	Asia
Finland	1	0	Europe
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. 8	813	89	12%
Feb. 7	724	86	13%
Feb. 6	638	73	13%
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. 8	89	3	3%
Feb. 7	86	13	18%
Feb. 6	73	0	0%
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. 8	37,552	2,676	8%
Feb. 7	34,876	3,437	11%
Feb. 6	31,439	3,163	11%
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. 8	2,676	-761	-22%
Feb. 7	3,437	274	9%
Feb. 6	3,163	-560	-15%
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%