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Coronavirus, It’s all over now, practically pandemic: 76 countries; all continents except Antarctica, community spread; no immunity in public; deaths in 10 countries; > 10,000 cases outside China, epidemics in China, S Korea, Iran and Italy(81% cases), cases outside China are 9 times higher than inside over last 24 hours

 by .
Dr Kailash Chand

Total number of cases in 76 countries, 90,443 cases, 3125 deaths, 48128 recovered,  39196  Currently Infected Patients, 32012 (82%) in Mild Condition, 7094 (18%) Serious or Critical, likely deaths ( 3125  + 7094  x 15 =1064) = 4189 with the present trend and available treatment, 10,000 cases outside China

UK, over 10,000 tested,37 positive, one death.

Coronavirus- Possibly behaves like SARS; near pandemic in 30 days. causes mild illness in 82%, severe illness in 15%, critical illness in 3% and death in 2.3 % cases  ( 15% of admitted serious cases, 71% with comorbidity, 10% in Iran); affects all ages but predominately males ( 56%, 87% aged 30-79, 10% aged < 20, 3% aged > 80); with variable incubation period days ( 2-14;  mean 3 based on 1,324 cases, 5.2 days based on 425 cases,  6.4 days in travellers from Wuhan);  mean time to symptoms 5 days,  mean time to pneumonia 9 days, mean time to death 14 days,  mean time to CT changes 4 days,  3-4 reproductive number R0  ( flu 1.2, SARS 2), epidemic doubling time 7.5 days ( Korea 1 day probably due to super spreader), Tripling time in Korea 3 days,  Positivity rate ( UK 0.2%, Italy 5.0%, France 2.2%, Austria 0.6% and USA 3.1% ;  has origin possibly from bats (mammal), spreads like large droplets and predominately from people having lower respiratory infections and hence standard droplet precautions the answer for the public and close contacts and air born precautions for the healthcare workers dealing with the secretions.

  • Clinically all patients have fever, 75% have cough; 50% weakness; 50% breathlessness with low total white count and deranged liver enzymes. 20% need ICU care and 15% of them are fatal. Treatment is symptomatic though chloroquine, anti-viral and anti-HIV drugs have shown some efficacy.
  • Only 20% will have symptoms and will go for testing, rest may self-quarantine, 15% of serious will die.  In Iran 16 died of 95 tested means they are only testing serious patients.
Surgeons conduct first lung transplant for coronavirus victim, Tweeple reacts by .
Surgeons conduct first lung transplant for coronavirus victim, Tweeple reacts

Is it in a pandemic state? 

  • As per WHO and CDC pandemic declaration is likely.  WHO says outbreak is “getting bigger”, can spread worldwide and is “literally knocking at the doors?”
  • Who said, “… we are concerned about the number of cases with no clear epidemiological link, such as travel history to China or contact with a confirmed case”.
  • Community spread: Cases are detected in Singapore, South Korea, Taiwan, Vietnam, Hong Kong and Japan in community where it’s not known what the source of the infection was.

WHO raises Global Risk from Coronavirus to the highest level of alert We have now increased our assessment of the risk of spread and the risk of impact of COVID-19 to very high at global level,”

  • WHO: “If we don’t act… that may be a future that we have to experience,” a lot of the future of this epidemic is in the hands of ourselves?”.

What is a pandemic? 

  • WHO: “the worldwide spread of a new disease” and ability to spread from person to person.
  • UK’s Health and Safety Executive: Virus markedly different from recently circulating strains and humans have little or no immunity to it.

 by . What is coranxiety?

Anxiety about falling ill and dying; avoiding or not approaching Healthcare facilities due to fear of becoming infected during care; fear of losing livelihood; fear of not being able to work during isolation; fear of  being dismissed from work if found positive; fear of being socially excluded; fear of getting put into Quarantine; fear of being separated from loved ones and caregivers due to quarantine; refusal to take care of unaccompanied or separated minors; refusal to take care of people with disabilities or elderly because of their high- risk nature; feeling of helplessness; feeling of boredom; feeling of depression due to being isolated; stigmatization of being positive infection; possible anger and aggression against government; unnecessary approaching the courts, possible mistrust on information provided by government. relapses of mental illness in already mental patients; overstress on people to cover work of infected colleagues, quarantined for 14 days and insufficient or incomplete information leading to myths and fake news.

The population is totally susceptible and in a country like UK where the NHS is at breaking point.  deaths in numbers will be very high.

How medics are affected?

1,716 medical workers have contracted the virus and six died in China. 1,502 were in Hubei Province, with 1,102 of them in Wuhan.  The number represent 3.8% of China’s overall confirmed infections as of Feb. 11 with 0.3% deaths. (18th Feb: Director of Wuhan Hospital died).  Over 3000 workers involved so far. 2 workers who were sent to Wuhan in January end to help build new hospital got infected.

Coronavirus causes mild illness in 82%, severe illness in 15%, critical illness in 3% and death in 2.3 % cases. About 6% patients admitted in ICU require mechanical ventilation, or died [NEJM]

 How much time it takes to recover?

People with mild cases recover in about two weeks, while those who are sicker can take anywhere from three to six weeks.

In which cases it is riskier?

 by . It caused death in 15% of admitted serious cases.  71% deaths are in patients with comorbidity. [ 72,314 Chinese cases, largest patient-based study, JAMA)

What is the case fatality of other viruses?

  • MERS 34% (2012, killed 858 people out of the 2,494 infected)
  • SARS 10% (Nov. 2002 – Jul. 2003, originated from Beijing, spread to 41 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%
  • Number of flu deaths every year: 290,000 to 650,000 (795 to 1,781 deaths per day)

Why elderly people are at risk?

The elderly and the sick – may have an immune response that is dangerous. It’s called a “cytokine storm,” when immune cells are overproduced and flood into the lungs, causing pneumonia, inflammation and shortness of breath. 

What is the incubation period?

  • Variable, 2-14 days (mean 3 based on 1,324 cases, 5.2 days based on 425 cases, 6.4 days in travellers from Wuhan)
  • 24 days has been observed. WHO said it could reflect a second exposure rather than a long incubation period. Hubei Province local government on Feb. 22 has reported a case with an incubation period of 27 days.
Scary!: Passengers cover themselves in plastic to avoid coronavirus. by .
Scary!: Passengers cover themselves in plastic to avoid coronavirus.

What is the positivity rate in contacts who are tested?

UK 0.2%, Italy 5.0%, France 2.2%, Austria 0.6% and USA 3.1%

Which countries one should not travel?

Travel advisory

  • Level 1 in all countries (Exercise normal standard hygiene precautions)
  • Level 2 in all affected countries (Exercise a high degree of caution)
  • Level 3 in all countries with secondary cases (Reconsider your need to travel)
  • Level 4 in affected parts of China and S Korea, Iran, Italy (Do not travel)

Is it a Zoonotic disease?

Zoonotic and linked to Huanan Seafood Wholesale Market as 55% with onset before January 1, 2020 were originated there but only 8.6% of the subsequent cases. The Chinese government has banned the wildlife trade until the epidemic passes.

Is it linked to bats?

It is closely related to several bat coronaviruses. Bats are the primary reservoir for the virus. SARS-CoV was transmitted to humans from exotic civet animals in wet markets, whereas MERS-CoV is transmitted from camels to humans. In both cases, the ancestral hosts were probably bats. Snakes and pangolins have been thought to be the intermediate host. One thing is clear the origin is from a mammal.

 by . What is the clinical presentation?

  • Clinically all patients have fever (subjective or evident). No fever no corona.
  • 75% have cough
  • 50% weakness
  • 50% breathlessness
  • Low total white count
  • Deranged liver enzymes.
  • It starts with fever, followed by a dry cough. After a week, it can lead to shortness of breath, with about 20% of patients requiring hospital treatment.Notably, the COVID-19 infection rarely seems to cause a runny nose, sneezing, or sore throat (these symptoms have been observed in only about 5% of patients). Sore throat, sneezing, and stuffy nose are most often signs of a cold.

How many need admission and ICU care?

20% need ICU care and 15% of them are fatal.  Those cases categorised as critical has the highest fatality rate—at 49.0 per cent.

What is the treatment?

Symptomatic though chloroquine, anti-viral & anti-HIV drugs have shown some efficacy.

What do you mean by Public Health Emergency of International Concern?

COVID 19 was declared as PHEIC on 30th Jan 2020 which means it is mandatory to report to WHO each human and animal case.

 by . What are the possible modes of spread? Myths and facts

  • Person-to-person: Yes, the virus can spread from one person to another, most likely through droplets of saliva or mucus carried in the air for up to six feet or so when an infected person coughs or sneezes, or through viral particles transferred when shaking hands or sharing a drink with someone who has the virus.
  • Casual exposure: No, Human to human contact requires prolonged contact (possibly ten minutes or more) within three to six feet. But with contact transmission this may not be applicable.
  • Currency notes: The central banking authorities of China are disinfecting, stashing and reportedly even destroying cash to stop the spread of the coronavirus. People’s Bank of China says that the cash collected by commercial banks must be disinfected before being released back to customers.
  • Fabric, carpet, and other soft surfaces: Currently, there’s no evidence.
  • Hard surfaces: Virus could be on frequently-touched surfaces, such as a doorknob, although early information suggests viral particles would be likely to survive for just a few hours (WHO).
  • Kissing: Kissing scenes have been banned in movies in China.  France have advised to cut back on “la bise,” the custom in France and elsewhere in Europe of giving greetings with kisses, or air kisses, on the cheeks.
  • Public gatherings: Affected countries have banned death ceremonies, people gathering.
  • Uncovered eyes: The transmission is through mucus membra contamination. One case got infected while using gown, but eyes not covered.
  • Eating meat, fish or Chicken: Its not a food borne illness but a respiratory illness. It cannot occur by eating any food or meat. However, it is always advised not to touch raw meat, eat raw meat or eat partially cooked meat to prevent meat related food borne illnesses. Eating fish and chicken is safe.
  • Handling wild animals or their meat: Yes, if their secretions are handled by the animal handlers.
  • Semen: We do not know, in patients infected with Ebola, the virus may persist for months in the testes or eyes even after recovery — and can infect others and keep the epidemic going.
  • Sex like EBOLA and ZIKA: We have no evidence yet.
  •  Goods for affected areas: People receiving packages from China or other affected areas are not at risk of contracting the COVID 19 as the virus does not survive long on objects, such as letters or packages.
  • Pipes: Ventilation system connects one room to the next. There has been previous concern that the coronavirus can spread through pipes
  • Stress: Stress and anxiety are known to suppress the immune system, making people more susceptible to contracting the virus.
  • Patients without symptoms: 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 of mild cases appears to have occurred during the incubation period in the index patient but the same has been challenged now.

 by . Should we fear?

It’s time for facts, not fear; for rationality, not rumours and for solidarity, not stigma.

What is a spreader and a super spreader?

Spreader: An infected person with normal infectivity.

Super spreader

  • An infected person with high infectivity, can infect hundreds of cases in no time. What cause a person to become super spreader is not known, HIV person becomes a super spreader if he or she is coinfected with STI.
  • The examples are the first case in Wuhan, a female in the S Korea Daegu fringe Christian group Shincheonji Church where she (61 years) infected more than 51 were infected.
  • In the church people shout out ‘amen’ after every sentence the pastor utters, pretty much every few seconds. And they do that at the top of their lungs, sending respiratory droplets flying everywhere.

What can be the cause of a cluster of cases or a hot spot without a super spreader?

People catching the virus from infected surfaces. We don’t know how long the germs stay on surfaces, but similar viruses can live for a week.

Chinese President Xi Jinping, also general secretary of the Communist Party of China (CPC) Central Committee and chairman of the Central Military Commission, inspects the novel coronavirus pneumonia prevention and control work in Beijing, capital of China

What are the various clusters of corona viruses? 

  • The largest cluster was the Wuhan itself where over five crore people were locked down ending up with over 2000 deaths.
  • The second largest lockdown was in Japanese diamond princess ship where over 3000 patients were locked up and 23% of them developed COVID 19 virus infection.
  • The third example the cult church in South Korea where one lady infected with the virus spread it to over 30 people attending the church and she also infected multiple people in a hospital where she was treated and one person later died.
  • Shandong province in China reported that 207 cases of the new coronavirus were reported in Rencheng prison as of Feb. 20, citing information from the provincial government. A jail in the Zhejiang province has also reported a total of 34 infections. All of them are inmates, according to Chinese media.  A jail will behave like a ship and end up with 21% getting infected.

Can the court take cognigence in corona epidemic?

  • Despite CDC protest, 14 Americans infected with coronavirus on the Diamond. Princess cruise ship shared a plane back to the U.S. with healthy passengers, separated by plastic sheeting. (New York Post)
  • A court temporarily blocked the U.S. government from sending up to 50 people infected with a new virus from China to a Southern California city for quarantine after local officials argued that the plan lacked details about how the community would be protected from the outbreak.
  • Hong Kong police this week nabbed a part-time security guard at a shopping mall for allegedly writing on social media that multiple staff members had caught a fever and gone on sick leave. The messages “caused panic” and helped “breed paranoia”.
  • The government separately blamed “evil” rumour-mongers for fuelling a run on goods at supermarkets such as toilet paper and rice.
  • Singapore has announced severe penalties for non-compliance of the quarantine order, including fines or jail time.
  • Prosecutors may investigate the founder and top leaders of Shincheonji Church of Jesus, whose members account for > 60% of confirmed cases on murder and other charges for failing to provide an accurate list of church members and by interfering with the government’s efforts to fight the outbreak.
  •  IPC: 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.
WUHAN, Feb. 14, 2020 (Xinhua) -- Mobile photo taken on Feb. 14, 2020 shows Gao Yongzhe (L) and Huang Wenli posing for a photo gesturing a heart-shaped sign at "Wuhan Livingroom" in Wuhan, central China's Hubei Province. Doctor Gao Yongzhe and nurse Huang Wenli are a couple working at the frontline against the novel coronavirus. Although they both spend all day at "Wuhan Livingroom", a temporary hospital, the busy couple barely had time to meet each other. On Feb. 14, under the arrangement of the hospital, the couple met and had a lunch together. As Huang put it, it was their special and meaningful 23rd Valentine's Day even though there was no flower and gift. (Photo by Gao Xiang/Xinhua/IANS) by .
Mobile photo shows Gao Yongzhe (L) and Huang Wenli posing for a photo gesturing a heart-shaped sign at \”Wuhan Livingroom\” in Wuhan, central China\’s Hubei Province. Doctor Gao Yongzhe and nurse Huang Wenli are a couple working at the frontline against the novel coronavirus. Although they both spend all day at \”Wuhan Livingroom\”, a temporary hospital, the busy couple barely had time to meet each other. On Feb. 14, under the arrangement of the hospital, the couple met and had a lunch together. As Huang put it, it was their special and meaningful 23rd Valentine\’s Day even though there was no flower and gift. (Photo by Gao Xiang/Xinhua/IANS)

What do you mean by the word corona?

‘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.

What is the composition of this virus?

It is a single-strand, positive-sense RNA genome ranging from 26 to 32 kilobases in length, Beta corona virus from Corona family.

What are other dreaded corona viruses?

  • COVID 19 is one of the three deadly human respiratory coronaviruses. Others are Severe acute respiratory syndrome coronavirus [SARS-CoV] and Middle East respiratory syndrome coronavirus [MERS-CoV]).
  • COVID 19 virus is 75 to 80% identical to the SARS-CoV

Where did it originate?

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

Will this virus survive heat?

Virus is likely to be killed by sunlight, temperature, humidity. SARS stopped around May and June in 2003 due to more sunlight and more humidity.

 by .
Medical team members get ready to set off at Nanjing Lukou International Airport in Nanjing, east China’s Jiangsu Province. (Xinhua/Ji Chunpeng/IANS)

What are different precautions?

  • Droplet precautions: Three-layer surgical mask by patients, their contacts and health care workers, in an adequately ventilated isolation room, health care workers while caring with the secretions should use eye protection, face shields/goggles. One should limit patient movement, restrict attendants and observe 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 and Hand hygiene
  •  Airborne precautions when handling virus in the lab and while performing aerosol-generating procedures: Room should be with negative pressure with minimum of 12 air changes per hour or at least 160 litres/second/patient in facilities with natural ventilation. There should be restricted movement of other people and all should use gloves, long-sleeved gowns, eye protection, and fit-tested particulate respirators (N95 or equivalent, or higher level of protection)

What are the precautions for general public?

  • Strict self-quarantine if sick with flu like illness: 2 weeks
  • Wash your hands often and for at least 20 seconds with soap and water or use an alcohol-based hand sanitizer.
  • 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.
Tweeple poured love and wished for the speedy recovery of a six-month-old baby diagnosed with the deadly coronavirus and quarantined alone at a Wuhan hospital. Heartwarming photos of the six-month-old baby went viral as the baby now has "nurse moms" taking care of him 24/7. by .
Tweeple poured love and wished for the speedy recovery of a six-month-old baby diagnosed with the deadly coronavirus and quarantined alone at a Wuhan hospital..

What are the 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.

Who is more vulnerable?

People with pre-existing medical conditions (such as asthma, diabetes, heart disease) appear to be more vulnerable to becoming severely ill with the virus.

What is the role of 14 days quarantine?

Quarantines and travel restrictions now in place in many counties, including the US, are also intended to help break the chain of transmission. Public health authorities like the CDC may recommend other approaches for people who may have been exposed to the virus, including isolation at home and symptom monitoring for a period of time (usually 14 days), depending on level of risk for exposure.                                                           

BEIJING, Jan. 29, 2020 (Xinhua) -- A staff member disinfects plants at a community in Haidian District in Beijing, capital of China, Jan. 29, 2020. Haidian District of Beijing has carried out disinfection work with the help of professional staff at residential communities to curb the spread of the novel coronavirus. (Xinhua/Ren Chao/IANS) by .
A staff member disinfects plants at a community in Haidian District in Beijing, capital of China,(Xinhua/Ren Chao/IANS)

Should I wear a face mask to protect against coronavirus?

Currently, face masks are not recommended for the general public. Some health facilities require people to wear a mask under certain circumstances, such as if they have travelled from the city of Wuhan, China or surrounding Hubei Province, or other affected countries or have been in contact with people who did or with people who have confirmed coronavirus.

If you have respiratory symptoms like coughing or sneezing, experts recommend wearing a mask to protect others. This may help contain droplets containing any type of virus, including the flu, and protect close contacts (anyone within three to six feet of the infected person).

What will be the preparedness needed then in UK?

Several thousand corona beds (15% of patients); self-quarantine of patients; no admission for patients without breathlessness; teleconsultation of mild cases; ICU beds with ventilatory care 3% Listing of hospitals with ECHMO machines; PPE 5 per patient); Surgical masks usage: ; Hand sanitisers: many a million per day; Health care providers dedicated with corona handling training:; 250 persons trained in handling dead bodies of infected cases; dedicated mental health councillors to tackled corona anxiety; corona spokesmen to speak the same language; Prize cap of masks, other related diagnostics and PEPs; censoring of myths and fake news on social media and earmarked and segregated areas for Corona triage: suspect but not serious; suspect and serious; confirmed but not serious and confirmed and serious?

ZHENGZHOU, Jan. 26, 2020 (Xinhua) -- Members of a medical team prepare to board a train at Zhengzhou East railway station in Zhengzhou, central China's Henan Province, on Jan. 26, 2020. A team comprised of 137 members from five medical institutions in Henan left Zhengzhou for Wuhan on Sunday to aid the coronavirus control efforts there. (Xinhua/Li Jianan/IANS) by .
Members of a medical team prepare to board a train at Zhengzhou East railway station in Zhengzhou, central China’s Henan Province. (Xinhua/Li Jianan/IANS)
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