COVID-19 : New Name and New Classification

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

CMAAO Update 13^th February on COVID-19 : New Name and New Classification  

Based on WHO guidelines set in 2015 that ensure the name does not refer to a geographical location, an animal, an individual or group of people, while still being pronounceable and related to the disease.

New Name and New Classification: Total number includes clinical diagnosis

Round table Experts from HCFI and MAMC Draft Document

Namaste: Let’s not shake hands

Sudden jump in deaths and new cases on 12^th due to inclusion of clinically diagnosed cases

Confirmed cases:  60,280, Countries 28, Deaths 1367

Active cases: 52950 (currently infected), 44707 (84%) mild cases; 8243 (16%) serious cases. 12 serious cases outside China

Closed cases: 7330 (with outcome), 5963 Recovered or discharged (81%)

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

Deaths yesterday: 252

Serious or critical mortality 15%

More than 136 cases have been confirmed on a ship quarantined in Japan

Secondary cases: Thailand, Taiwan, Germany, Vietnam, Japan, France, US

Deaths outside China: Philippines on Feb 2 (44 Chinese man M) and 2^nd in Hong Kong ( 39 M, local) on February 4, both had co-morbid conditions. Both acquired infection from Wuhan.

Likely deaths 1236+1367= 2603 with the present trend and available treatment

WHO warns epidemic could still 'go in any direction', Global expert says outbreak just 'beginning' outside China

Coronavirus vaccine could be ready in 18 months, WHO 

Summary

Possibly behaves like SARS with < 2 % case fatality (15% of admitted serious cases),  mean time to death 14 days,  mean time to pneumonia 9 days, mean time to symptoms 5 days, 3-4 reproductive number R0, incubation period 2-14 days- mean 5.5 days, has origin possibly from bats, spreads like large droplets and predominately from people having lower respiratory infections and hence standard droplet precautions the answer for the public and air born precautions for the healthcare workers. {So: RT Experts meet HCFI and MAMC]

New COVID-19 Cases Surge by Ten-fold or Nearly 15,000 in China's Hubei Province After Officials Change Classification System:  The province starting to include “clinically diagnosed” cases in its figures and that 13,332 of the new cases fall under that classification.

Case Definition

Suspect case

A. Patients with severe acute respiratory infection (fever, cough, and requiring admission to hospital), AND with no other etiology that fully explains the clinical presentation AND at least one of the following:

·       a history of travel to or residence in the city of Wuhan, Hubei Province, China in the 14 days prior to symptom onset, or

·       patient is a health care worker who has been working in an environment where severe acute respiratory infections of unknown etiology are being cared for.

B. Patients with any acute respiratory illness AND at least one of the following:

·       close contact with a confirmed or probable case of COVID 19 in the 14 days prior to illness onset, or

·       visiting or working in a live animal market in Wuhan, Hubei Province, China in the 14 days prior to

·       symptom onset, or

·       worked or attended a health care facility in the 14 days prior to onset of symptoms where patients with hospital-associated COVID 19 infections have been reported.

Probable case

A suspect case for whom testing for COVID 19 is inconclusive or for whom testing was positive on a pan-coronavirus assay.

Confirmed case

A person with laboratory confirmation of COVID 19 infection, irrespective of clinical signs and symptoms.

[WHO: https://www.who.int/publications-detail/global-surveillance-for-human-infection- with-novel-coronavirus-(COVID 19)

https://mohfw.gov.in/sites/default/files/Corona%20Discharge-Policy.pdf ]

Surveillance Definition

Severe acute respiratory infection (SARI) in a person, with history of fever and cough requiring admission to hospital, with no other etiology that fully explains the clinical presentation (clinicians should also be alert to the possibility of atypical presentations in patients who are immunocompromised)

AND any of the following:

a)  A history of travel to Wuhan, Hubei Province China in the 14 days prior to symptom onset; or

b)  the disease occurs in a health care worker who has been working in an environment where patients with severe acute respiratory infections are being cared for, without regard to place of residence or history of travel; or

c)  the person develops an unusual or unexpected clinical course, especially sudden deterioration despite appropriate treatment, without regard to place of residence or history of travel, even if another etiology has been identified that fully explains the clinical presentation

•        A person with acute respiratory illness of any degree of severity who, within 14 days before onset of illness, had any of the following exposures:

a)  close physical contact with a confirmed case of COVID 19 infection, while that patient was symptomatic; or

b)  a healthcare facility in a country where hospital-associated COVID 19 infections have been reported

SARI Definition

•        An ARI with history of fever or measured temperature ≥38 C° and cough; onset within the last ~10 days; and requiring hospitalization

•        Absence of fever does NOT exclude viral infection

Close Contact

•        Health care associated exposure, including providing direct care for COVID 19 patients, working with health care workers infected with COVID 19, visiting patients or staying in the same close environment of a COVID 19 patient

•        Working together in close proximity or sharing the same classroom environment with a with COVID 19 patient

•        Traveling together with COVID 19 patient in any kind of conveyance

•        Living in the same household as a COVID 19 patient

•        The epidemiological link may have occurred within a 14-day period before or after the onset of illness in the case under consideration

Public Health Emergency of International Concern 30^th Jan 2020

Mandatory to report to WHO each human and animal case.

Prior 5 PHEIC’s: 

26^th April 2009 Swine flu: 10 August 2010, WHO announced that the H1N1 influenza virus has moved into the post-pandemic period. However, localized outbreaks of various magnitudes are likely to continue.

 

May 2014 Polio: resurgence of wild polio. October 2019, continuing cases of wild polio in Pakistan and Afghanistan, in addition to new vaccine-derived cases in Africa and Asia, was reviewed and remains a PHEIC. It was extended on 11 December 2019.

 

August 2014 Ebola: It was the first PHEIC in a resource-poor setting.

 

Feb 1 2016 Zika: link with microcephaly and Guillain–Barré syndrome. This was the first time a PHEIC was declared for a mosquito‐borne disease. This declaration was lifted on 18 November 2016.

2018–20 Kivu Ebola: A review of the PHEIC had been planned at a fifth meeting of the EC on 10 October 2019^[44] and as of 18 October 2019, it continues to be a PHEIC.

Kerala: state public health emergency. Three primary cases in North, South and Central. 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.

Help line India:  +91-11-23978046, ncov2019@gmaildotcom, mohfw.gov.in/node/4904

Virus

Single-strand, positive-sense RNA genome ranging from 26 to 32 kilobases in length, Beta corona virus from Corona 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.

Origin: Wuhan, China December 2019. 1^st case informed to the world by Dr. Li Wenliang died Feb 6^th

Virus is likely killed by sunlight, temperature, humidity. The virus can remain intact at 4 degrees or 10 degrees for a longer period of time. But at 30 degrees then you get inactivation. SARS stopped around May and June in 2003 due to more sunlight and more humidity.  Alive on surface: possibly 3-12 hours

Link to ACE: COVID 19 might be able to bind to the angiotensin-converting enzyme 2 receptor in humans.

Three deadly human respiratory coronaviruses viruses: Severe acute respiratory syndrome coronavirus [SARS-CoV], Middle East respiratory syndrome coronavirus [MERS-CoV]) and COVID 19: The current virus is 75 to 80% identical to the SARS-CoV

Pathogenesis

High viral load: Detection of COVID 19 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]

COVID 19 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.

SARS is high [unintelligible] kind of inducer. This means that when it infects the lower part of the lung, the body develops a very severe reaction against it and leads to lots of inflammation and scarring. In SARS what we found is that after the first 10 to 15 days it wasn’t the virus killing the patients it was the body’s reaction. Is this virus in the MERS or SARS kind picture or is this the other type of virus which is a milder coronavirus like the NL63 or the 229. It may be the mild (unintelligible) kind inducer. [Dr John Nicholls University of Hong Kong]

Infectiousness to humans: COVID 19 grows better in primary human airway epithelial cells than in standard tissue-culture cells, unlike SARS-CoV or MERS-CoV. It is likely that COVID 19 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 COVID 19 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.

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 COVID 19 launches an attack at the intraepithelial cells of lung tissue.

Transmission

Types: Droplet (droplet, contact, fomites) Corona; aerosol,  nuclei or ait born e.g. TB

Kissing scenes banned in movies: China

Air crew exempted from breath analyser tests: Kerala

Burial:  China has banned death ceremonies, people gathering together,

Lockdown: 50 million people in China

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.

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. 

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 COVID 19 might have jumped from the host species - bats - to snakes and then to humans at the beginning of the outbreak. However, it is doubted as to how the virus could adapt to both the cold-blooded and warm-blooded hosts.

Risk to other Asian countries: 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.

NEJM reports a taxi driver infected with SARS-CoV-2 in Thailand, potentially from Chinese tourists; the infection appears not to have spread to others.

Legal Implications 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.

Clinical Features (Current trend)

•        Uncomplicated illness

Patients with uncomplicated upper respiratory tract viral infection, may have non- specific symptoms such as fever, cough, sore throat, nasal congestion, malaise, headache, muscle pain or malaise.

The elderly and immunosuppressed may present with atypical symptoms.

These patients do not have any signs of dehydration, sepsis or shortness of breath

Mild pneumonia

Patient with pneumonia and no signs of severe pneumonia

Child with non-severe pneumonia has cough or difficulty breathing + fast breathing:

fast breathing (in breaths/min): <2 months, ≥60; 2–11 months, ≥50; 1–5 years, ≥40 and no signs of severe pneumonia

•        Severe pneumonia

Adolescent or adult: fever or suspected respiratory infection, plus one of respiratory rate >30 breaths/min, severe respiratory distress, or SpO2 <90% on room air

Child with cough or difficulty in breathing, plus at least one of the following: central cyanosis or SpO2 <90%; severe respiratory distress (e.g. grunting, very severe chest indrawing); signs of pneumonia with a general danger sign: inability to breastfeed or drink, lethargy or unconsciousness, or convulsions. Other signs of pneumonia may be present: chest indrawing, fast breathing (in breaths/min): <2 months, ≥60; 2–11 months, ≥50; 1–5 years, ≥40.

The diagnosis is clinical; chest imaging can exclude complications.

•        Acute Respiratory Distress Syndrome

Onset: new or worsening respiratory symptoms within one week of known clinical insult.

Chest imaging (radiograph, CT scan, or lung ultrasound): bilateral opacities, not fully explained by effusions, lobar or lung collapse, or nodules.

Origin of oedema: respiratory failure not fully explained by cardiac failure or fluid overload. Need objective assessment (e.g. echocardiography) to exclude hydrostatic cause of oedema if no risk factor present.

Oxygenation (adults):

Mild ARDS: 200 mmHg < PaO2/FiO2 ≤ 300 mmHg (with PEEP or CPAP ≥5 cm H2O, or non-ventilated)

Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤200 mmHg with PEEP ≥5 cm H2O, or non-ventilated)

Severe ARDS: PaO2/FiO2 ≤ 100 mmHg with PEEP ≥5 cmH2O, or non- ventilated)

When PaO2 is not available, SpO2/FiO2 ≤315 suggests ARDS (including in non-ventilated patients)

Oxygenation (children; note OI = Oxygenation Index and OSI = Oxygenation Index using SpO2)

Bilevel NIV or CPAP ≥5 cmH2O via full face mask: PaO2/FiO2 ≤ 300 mmHg

or SpO2/FiO2 ≤264

Mild ARDS (invasively ventilated): 4 ≤ OI < 8 or 5 ≤ OSI < 7.5

Moderate ARDS (invasively ventilated): 8 ≤ OI < 16 or 7.5 ≤ OSI < 12.3

Sever Sepsis

Adults: life-threatening organ dysfunction caused by a dysregulated host response to suspected or proven infection, with organ dysfunction.

Signs of organ dysfunction include: altered mental status, difficult or fast breathing, low oxygen saturation, reduced urine output, fast heart rate, weak pulse, cold extremities or low blood pressure, skin mottling, or laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate or hyperbilirubinemia.

Children: suspected or proven infection and ≥2 SIRS criteria, of which one must be abnormal temperature or white blood cell count

Septic shock

Adults: persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP ≥65 mmHg and serum lactate level >2 mmol/L

Children: any hypotension (SBP <5th centile or >2 SD below normal for age) or 2-3 of the following: altered mental state; tachycardia or bradycardia (HR <90 bpm or >160 bpm in infants and HR <70 bpm or >150 bpm in children); prolonged capillary refill (>2 sec) or warm vasodilation with bounding pulses; tachypnea; mottled skin or petechial or purpuric rash; increased lactate; oliguria; hyperthermia or hypothermia

e ARDS (invasively ventilated): OI ≥ 16 or OSI ≥ 12.3

Median age: 59 years (2-74 years); Male to female ratio: 56% male

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, SARS affected people in their 30 or 50 years. And MERS affected people with co-morbidity. The China data indicate that it’s those with the co-morbidity are most at risk like seasonal influenza.

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

ICU need: 20% need ICU care with 15% mortality

Fever: In all (no fever no COVID 19)

Cough: 75% cases

Weakness or muscle ache: 50%^

Shortness of breath: 50%

TLC: low

Liver transaminase levels: raised

Case fatality: 2% [Dr John Nicholls, University of Hong Kong} China is only reporting those who come for test, stricter guidelines, actual mortality may be 0.8%-1% like outside China

Medscape: With the rapidly changing information, researchers are reporting two new case-series studies from China and a review of case-finding information in the United States. The largest case series published to date highlights the risk for hospital staff in the early part of the outbreak, with nearly one third of cases occurring in healthcare professionals.

Lab precautions: BSL 2 ( 3 for viral culture labs)

Human to human contact period: Requires prolonged contact ( possibly ten minutes or more) within three to six feet

Travel restrictions

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

Travel advisory:  Level 1 in all countries (Exercise normal standard hygiene 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) done by India and Level 4 ( Do not travel) done by US. Hong Kong has imposed 14 days quarantine on people arriving from china. The Karnataka government has ordered that anybody arriving from the 23 COVID 19 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.

Travel and trade restrictions: WHO says no to countries

Leave china all together: UK, condemned by many countries

Entry to India not allowed: foreigners who went to China on or after January 15

Visas Suspended: All visas issued to Chinese nationals before February 5 (not applicable to aircrew)

Flight suspended: IndiGo and Air India have suspended all of their flights between the two countries. SpiceJet continues to fly on Delhi-Hong Kong route.

Mass Quarantine May Spark Irrational Fear, Anxiety, Stigma

Evacuation

Many countries including Tokyo, Japan, India have evacuated their citizens.

Case fatality

COVID 19 2%

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

SARS 10% (Nov. 2002 - Jul. 2003, originated from Beijing, spread to 29 countries, with 8,096 people infected and 774 deaths) 

Ebola 50%,

Smallpox 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

Swine flu < 0.1-4 %

Seasonal flu 0.01%.

Current virus in Wuhan 4.9%.

Current virus in Hubei Province 3.1%.

Current virus in Nationwide 2.1%.

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)

Lab tests

There are two ways to detect a virus: through the genetic material DNA or RNA or to detect the protein of the virus. The rapid tests look at the protein. It takes 8-12 weeks to make commercial antibodies. So right now, for the diagnostics tests they are using PCR which give you a turnaround in 1-2 hours.

Blood culture

BOTH the upper respiratory tract (URT; nasopharyngeal and oropharyngeal) AND lower respiratory tract (LRT; expectorated sputum, endotracheal aspirate, or bronchoalveolar lavage)

Use PPE

Use viral swabs (sterile Dacron or rayon, not cotton) and viral transport media

In US January, all testing had to be done in CDC laboratories. However, on February 4, the US FDA issued an emergency-use authorization for the CDC's COVID 19 Real-Time RT-PCR Diagnostic Panel, which allows it to be used at any CDC-qualified laboratory in the United States.

Treatment

No proven antiviral treatment.

With SARS, in 6 months the virus was gone and it never came back.

Pharmaceutical companies may not spend millions and millions to develop a vaccine for something which may never come back.

Secondary infection, E Coli, are most likely the cause of deaths of the patients in the Philippines and HK.

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

Combination of lopinavir, ritonavir and recombinant interferon beta-1b was tried in MERS

Scientists in Australia have reportedly recreated a lab-grown version of COVID 19.

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.

Thailand: 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 COVID 19 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

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.

In SARS, people were put on long term steroids ending with immunosuppression and late complications and death. The current protocol is short term treatment.

Standard Respiratory droplets precautions

•        At triage

Surgical 3 layered mask to the patient

Isolation

Atleast 1m distance

Cough etiquette

Hand hygiene

•        Droplet precautions

Surgical mask

While caring- eye protection- face shields/goggles

Isolation/cohorting

Limit patient movement

Restrict attendants – w/ face mask

Hand hygiene

•        Contact precautions

When entering room - gown, mask, goggles, gloves – remove before leaving the room

Dedicated equipment/ disinfection after every use

Care for environment- door knobs, handles, articles, laundry

Avoid patient transport

Hand hygiene

•        Airborne precautions

performing aerosol-generating procedures

•        Adequately ventilated

•        Negative pressure rooms with minimum of 12 air changes per hour or at least 160 litres/second/patient in facilities with natural ventilation

•        Restricted movement of other people

gloves, long-sleeved gowns, eye protection, and fit-tested particulate respirators (N95 or equivalent, or higher level of protection)

Public

Self-quarantine if sick with flu like illness: 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:  Eyes, nose, and mouth with unwashed hands.

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

Cover your cough or sneeze with a tissue, then throw the tissue in the trash.

Clean and disinfect frequently touched objects and surfaces.

Surgical 3 layered Masks: For patients

N 95 Masks: For health care providers and close contacts

Common Myths

1.     People receiving packages from China are not at risk of contracting the COVID 19 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 COVID 19. 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 COVID 19.

4.     Regularly rinsing the nose with saline does not protect people from infection with COVID 19 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 COVID 19 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 COVID 19.

7.     Sesame oil does not kill the new coronavirus. Chemical disinfectants that can kill the COVID 19 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 COVID 19. 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 COVID 19 unless you suspect bacterial co-infection.

10.  To date, there is no specific medicine recommended to prevent or treat  COVID19.

Trolls and conspiracy theories: Not validated and are fake news

1.     COVID 19 is linked to Donald Trump, and US intelligence agencies or pharmaceutical companies are behind it.

2.     That eating snakes, wild animals or drinking bat soup cases corona

3.     Keep your throat moist, avoid spicy food and load up on vitamin C

4.     Avoiding cold or preserved food and drinks, such as ice cream and milkshakes, for "at least 90 days".

5.     Experts have been aware of the virus for years.

6.     The virus was part of China's "covert biological weapons programme" and may have leaked from the Wuhan Institute of Virology.

7.     Linked to the suspension of a researcher at Canada's National Microbiology Laboratory.

8.     China wants to kill 20,000 COVID 19 patients is totally false. The site is linked to a sex website.

Role of CMAAO and other Medical Associations

Get 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 should emphasise on reducing human infection, prevention of secondary transmission and international spread. Intensify IEC activities.

Search:

Country, Territory	Total Cases	Feb 12 Cases	Total Deaths	Feb 12 Deaths	Total Recovered	Total Severe
China	59,757	+15,104	1,365	+252	5,899	8,230
Japan	203	+1			4
Hong Kong	50	+1	1		1
Singapore	50	+3			15	8
Thailand	33				10	1
S. Korea	28				4
Malaysia	18				3
Taiwan	18				1
Germany	16
Australia	15				5
Vietnam	15				6
USA	13				3
France	11					1
Macao	10				2
U.K.	9	+1			1
U.A.E.	8				1	1
Canada	7				1
Philippines	3		1		2
India	3
Italy	3					2
Russia	2				2
Spain	2
Finland	1				1
Cambodia	1				1
Nepal	1
Sri Lanka	1				1
Sweden	1
Belgium	1

Total Deaths of Novel Coronavirus (COVID 19)

Date	Total Deaths	Change in Total	Change in Total (%)
Feb. 12*	1,367	252	23%
Feb. 11	1,115	97	10%
Feb. 10	1,018	108	12%
Feb. 9	910	97	12%
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%

* Provisional - 135 new deaths are due to the new diagnosis classification adopted by Hubei starting on Feb. 12

Daily Deaths of Novel Coronavirus (COVID 19)

Date	Daily Deaths	Change in Daily	Change in Daily (%)
Feb. 12*	252	155	160%
Feb. 11	97	-11	-10%
Feb. 10	108	11	11%
Feb. 9	97	8	9%
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%

* Provisional - 135 new deaths are due to the new diagnosis classification adopted by Hubei starting on Feb. 12

Total Cases of Novel Coronavirus (COVID 19)

Date	Total Cases	Change in Total	Change in Total (%)
Feb. 12*	60,280	15,110	33%
Feb. 11	45,170	2,071	5%
Feb. 10	43,099	2,546	6%
Feb. 9	40,553	3,001	8%
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	3,925	19%
Feb. 3	20,628	3,239	19%
Feb. 2	17,389	2,837	19%
Feb. 1	14,552	2,604	22%
Jan. 31	11,948	2,127	22%
Jan. 30	9,821	2,008	26%
Jan. 29	7,813	1,755	29%
Jan. 28	6,058	1,477	32%
Jan. 27	4,581	1,781	64%
Jan. 26	2,800	785	39%
Jan. 25	2,015	698	53%
Jan. 24	1,317	472	56%
Jan. 23	845	266	46%

* Provisional - 13,332 new cases are due to the new diagnosis classification adopted by Hubei starting on Feb. 12

Daily Cases of Novel Coronavirus (COVID 19)

Date	Daily Cases	Change in Daily	Change in Daily (%)
Feb. 12*	15,110	13,039	630%
Feb. 11	2,071	-475	-19%
Feb. 10	2,546	-455	-15%
Feb. 9	3,001	325	12%
Feb. 8	2,676	-761	-22%
Feb. 7	3,437	274	9%
Feb. 6	3,163	-560	-15%
Feb. 5	3,723	-202	-5%
Feb. 4	3,925	686	21%
Feb. 3	3,239	402	14%
Feb. 2	2,837	233	9%
Feb. 1	2,604	477	22%
Jan. 31	2,127	119	6%
Jan. 30	2,008	253	14%
Jan. 29	1,755	278	19%
Jan. 28	1,477	-304	-17%
Jan. 27	1,781	996	127%
Jan. 26	785	87	12%
Jan. 25	698	226	48%
Jan. 24	472	206	77%
Jan. 23	266	133	100%

* Provisional - 13,332 new cases are due to the new diagnosis classification adopted by Hubei starting on Feb. 12

CMAAO Suggestions so far

1.     7^th January: CMAAO Alert: WHO to monitor China's mysterious pneumonia of unknown virus outbreak

2.      8^th Jan: CMAAO warns Asian citizens travelling China over mystery pneumonia outbreak

3.      10^th January: Editorial: COVID 19 strain causing pneumonia in Wuhan, China, It’s a new strain of corona virus in the china pneumonia

4.      13^th Jan: China Virus Outbreak Linked to Seafood Market

5.      15^th Jan: First Case China Pneumonia Virus Found Outside China in Thailand

6.      17^th Jan: WHO issues warning after 'mysterious' Chinese COVID 19 spreads to Japan

7.      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)

8.      18^th Jan: WHO issues warning after mysterious Chinese Coronavirus spreads to Japan [http://blogs.kkaggarwal.com/tag/who/]

9.      18-20 Jan: Three countries CMAAO meet, also discussed COVID 19

10.   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)

11.   24^th: Inter Ministerial Committee needs to be formed on COVID 19 (PMO took a meeting on 24^th evening)

12.   25^th Jan: Indian government should pay for Indians affected with the virus in China

13.   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] [ on 30^th India banned gloves, PEP and masks but on 8^th lifted the ban on surgical masks/disposable masks and all gloves except NBR gloves. All other personal protection equipment, including N-95 and equipment accompanying masks and gloves shall remined banned.] 

14.   27^th Jan: History of anti-fever drugs at airports should be taken

15.   28^th Jan: Do research on Nosodes

16.   29^th Jan: Closure of live markets all over the world, India should take a lead

17.   30^th Jan: Paid flu leave, surgical mask at public places, N 95 for health care providers

18.   31^st Jan: Respiratory hygiene advisory schools, Pan India task force to be made 

19.   1^st Feb: Disaster Budget is the need of the hour

20.   3^rd Feb: 100 crore budget for COVID 19; Private labs to be recognised; one dedicated COVID 19National 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]

21.   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]

22.   5^th Feb: PM should talk about COVID 19in Man Ki Baat or a special address

23.   6^th Feb: Time to have makeshift bed policy to tackle deaths in Kota, Muzaffarpur and COVID 19[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]

24.   7^th Feb: IPC 269 should be applicable to COVID 19

25.   8^th Feb: teleconsultation should be allowed to flu and COVID 19consultation