Understanding Coronavirus and its management- Dr Shrikant Sharma

1. What is coronavirus?

• Coronaviruses are named for the crown-like spikes on their surface. These spikes are a defining feature of the virion and give them the appearance of a solar corona, prompting the name, coronaviruses. It is an enveloped, non-segmented positive-sense RNA viruses. It belongs. to the Nidovirales order, which includes the Coronaviridae family. The three deadly human respiratory coronaviruses 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

2. What is the mortality rate of corona as compared to other deadly flu viruses?

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): originated from Beijing, China. It spread to 29 countries and it infected 8,096 people 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. On Feb 10, 2020, Deaths in China reach 908, surpassing the death toll from SARS.(774)

MERS (2012) it originated in UAE and 2,494 people were infected. It killed 858 (with a fatality rate of 34.4%).

As of Feb 10, 2020, 40,171 cases of 2019-nCoV infection have been confirmed, with 908 deaths in China and 1 in Philippines most of which involved people living in or visiting Wuhan, and human-to-human transmission has been confirmed.

3. What is the status of coronavirus in India?

• Over 2,239 people in the Kerala state are under observation, of which 2,155 are in their homes, while 84 are in hospitals. 1202 samples have so far been sent for testing, of which 645 are negative and the results of the rest are awaited. 3 out of 645 are tested positive for nCoV

• All three coronavirus cases have been reported in different parts of the state –

• Kasaragod district in north Kerala

• Thrissur in central Kerala

• Alappuzha in South Kerala

4. Who are mainly affected by the deadly virus?

It mainly affects male (71%) with a median age of 45 years. Deaths are more common in people having comorbid conditions. Just like SARS, it mostly do not affect children 15 years or less of age.

5. What is the mode of transmission?

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.

6. How is the virus being transmitted in humans?

It is more infectious to humans. It infects intrapulmonary epithelial cells in humans. Transmission occurs primarily from patients with recognized illness and not from patients with mild, nonspecific signs. 2019-nCoV uses the same cellular receptor as SARS-CoV (human angiotensin-converting enzyme 2 [hACE2]). 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. It requires contact of ten minutes within a distance of six feet.

7. If someone comes in contact with a patient, within how much time will symptoms appear?

The symptoms can appear in 2-14 days, usually within 5 days (Incubation period- 2-14 days).

8. What are the symptoms of coronavirus infection?

Fever is the most common symptom which is present in 100% of cases.75% of people have cough and shortness of breath in >50% people. Diarrhea is also seen in 1-2% of cases.15-20% of people affected have severe illness and require ICU. The patient will have low white cells and reduction in lymphocyte count and raised liver transaminase levels. Patients so far have not presented with a sore throat.

9. In whom to suspect corona-virus infection?

Surveillance Case Definitions by WHO

1. A person with Severe Acute Respiratory Infection (SARI), with history of fever and cough requiring admission to hospital, with no other etiology that fully explains the clinical presentation

AND any of the following

● A history of travel to Wuhan, Hubei Province China in the 14 days prior to symptom onset

● 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 the place of residence or history of travel.

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

2. Individuals with acute respiratory illness (ARI) of any degree of severity who, within 14 days before the onset of illness, had any of the following exposures:

• Close physical contact with a confirmed case of nCoV infection, while that patient was symptomatic.

• A healthcare facility in a country where hospital-associated nCoV infections have been reported.

• Direct contact with animals (if the animal source is identified) in countries where the nCoV is known to be circulating in animal populations or where human infections have occurred as a result of presumed zoonotic transmission.

10. What investigations to be done in cases suspected of coronavirus infection?

The sample should be collected from both the Upper respiratory tract(Nasopharyngeal swab AND oropharyngeal swab (NP/OP swab) and Lower respiratory tract(expectorated sputum, endotracheal aspirate, or bronchoalveolar lavage).

11. How is the diagnosis being made and where to send the samples?

The diagnosis is made by the RT-PCR method. Serology for diagnostic purposes is recommended only when RT-PCR is not available. National Institute of Virology – Pune is the Apex center for sample testing. Also, tests are being done at the National center for disease control- New Delhi.

12. How to manage a patient of corona-virus?

By giving Early Supportive Therapy And Monitoring. Give supplemental oxygen therapy, Conservative fluid management, and empiric antimicrobials therapy. There is no proven antiviral treatment. However, a combination of lopinavir and ritonavir did show some promise in patients with SARS, but this was in the lab and not in humans. Chloroquine, which has potent antiviral activity against the SARS-CoV, has been shown to have similar activity. However, there have been no studies of efficacy in humans. Some doctors have used oseltamivir along with lopinavir and ritonavir, both HIV drugs.

An experimental drug from Gilead Sciences Inc., called Remdesevir, has encouraging results . PVP-I mouthwashes and gargles significantly reduce viral load in the oral cavity and the oropharynx.

13. What can a person do at a personal Level to prevent the transmission of the disease?

• Vanakkam (namaste) instead of shaking hands

Strict adherence to standard 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.

14. What are the precautions for Healthcare Workers that need to be kept in mind?

1. EARLY RECOGNITION AND SOURCE CONTROL:

• Encourage HCWs to have a high level of clinical suspicion

• Institute screening questionnaire.

• Awareness in public areas reminding symptomatic patients to alert HCWs.

• The promotion of respiratory hygiene is an important preventive measure.

• Suspected cases should be placed in an area separate from other patients.

2.APPLICATION OF STANDARD PRECAUTIONS FOR ALL PATIENTS:

• This includes hand and respiratory hygiene measures:

• medical mask to the suspected patients

• cover nose and mouth during coughing with tissue/flexed elbow

• perform hand hygiene after contact with respiratory secretions

• Use of personal protective equipment (PPE).

• Prevention of needle-stick or sharps injury.

• Safe waste management.

15. What are the steps To Wear The Medical Mask (N95 mask)?

1. Wash hands before putting the mask

2. The select mask that fits you well

3. Hold the mask in your hand and place it firmly over your nose, mouth, and chin

4. First stretch and position bottom band under your ears, then top band at the back of the head

5. Press the metal wire to adjust

6. Perform a fit check

16. What can a hospital do to limit the transmission of the virus?

● Use medical mask in suspected patients and HCWs, eye/facial protection, clean non-sterile long-sleeved fluid resistant gown, gloves.

• Use either single-use disposable equipment or dedicated equipment (stethoscopes, BP cuffs). If need to be shared among patients clean and disinfect them.

• Avoid the movement of patients out of the room.

• Limit the number of HCWs, family members in contact with the suspect.

• Maintain a record of all persons entering the room including the staff.

17. How to dispose of the waste related to NCoV?

All the related waste and the personal protective equipments like masks, gloves, gowns etc should be thrown in a RED bag and the following should be autoclaved or incinerated.

18. What are the antiseptics that are effective against it?

As it is an enveloped virus, various disinfectants like alcohol, aldehydes, iodine compounds, sodium hypochlorite are effective against it. QAC(Quarterary ammonium compounds), that are Roccal, diquat, D256, are not effective.

Environmental cleaning and sterilization of patient-care equipment and linen should be done by a thorough cleaning with water and detergent. Applying hospital-level disinfectants like 1% sodium hypochlorite is an effective and sufficient procedure.

19. Is there a Vaccine available to safeguard ourselves from rapidly evolving viruses?

No vaccine is available yet. However, 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. Hence a future vaccine will be available.

20. What is India doing to limit the number of cases in the country?

N 95 and Oseltamivir are included in the list of essential drugs and is price capped. Patient not declaring there flu-like symptoms is considered a punishable offence and would be punishable under Section IPC 270 wherein they can be punished with 2 years of jail or fine or both.(for patients malignly not declaring there symptoms etc.). IPC 270 is a malignant act likely to spread infection of disease dangerous to lives.

• The Indian government will pay for Indians affected with the virus in China.

• On 26 Jan 2020, a meeting was held where the need for the National droplet Infection Control program was discussed. The policy was made to ban the export of face masks and policy to evacuate Indians from China affected areas.

• Closure of live markets done on 29/1/2020.

• Paid flu leave to be given to the disease affected- needed people. Surgical mask to be provided at public places and N 95 masks for health care providers.

• On 3rd Feb: 100 crore budget was decided for Coronavirus to be recognized. One dedicated corona National helpline, MTNL, and BSNL, to have a line of advisory. Isolation wards to be single rooms or two beds separated with six feet distance. National insurance to cover the cost of treatment.

21. In India whom to contact in case of a suspected case of coronavirus?

A specific 24-hour helpline has been made. Nodal officers in every state have been assigned. Helpline number in Delhi - 011- 22307145.

22. What are the latest updates on travel to/from china by govt of India?

In view of the spurt of cases being reported from China and travel-related cases appearing in many countries, the travelers to China are advised the following:

• Indian travelers are hereby advised to REFRAIN FROM TRAVELING TO CHINA.

Those planning a visit to India from China:

• Existing visas (including eVisa already issued) are no longer valid for any foreign national traveling from China. People traveling to China henceforth will be quarantined on return. Intending visitors may contact Embassy in Beijing (visa.beijing@mea.gov.in) or the Consulates in Shanghai (ccons.shanghai@mea.gov.in) and Guangzhou (visa.guangzhou@mea.gov.in) to apply afresh for an Indian visa.

23. What is happening at Indian airports/seaports to screen for NCoV?

Airports are already under surveillance which includes the airport of Chennai, Trichy, Coimbatore, Madurai, Mumbai, Delhi, Kolkata, Bengaluru, Hyderabad, Cochin, Ahmedabad, Amritsar, Guwahati, Gaya, Bagdogra, Jaipur, Lucknow, Trivandrum, Varanasi, Visakhapatnam, Bhubaneshwar, Goa.

• Sea Port Screening is done at Chennai, Ennore, Tuticorin, Cuddalore, Nagappattinam, Kattuppalli.

• All passengers from all flights from China, Hongkong, Thailand, and Singapore are screened universally through thermal screening or infrared thermometers and medical examination. All the passengers are followed up daily for two incubation periods of 28 days. In case of development of symptoms, to be admitted immediately in the isolation room and managed.

24. What is happening at International Level to combat the deadly virus?

• The World Health Organization declared the coronavirus outbreak a public health emergency of international concern on 30th Jan 2020 as the first person-to-person transmission of the virus was reported in the U.S.

• The CDC said that people who had recently traveled should be vigilant for symptoms and signs of the virus, which include fever, cough, and shortness of breath.

• Evacuations of there citizens from china is being done by many countries.

• Quarantining the people for 2 weeks.

25. What is the take-home message?

W – wash hands properly with soap and water for 20 seconds.

U- use medical mask for patients at high risk.

H- have vegetarian food as of now.

A- avoid large crowd areas (min distance 6 feet)

N- never touch face without washing hands.

Article compiled and created by  Dr Srikant Sharma ,Senior Consultant Physician , And Dr Aayushi Gupta , Moolchand Medcity , New Delhi .