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com

Abstract

There is a new puhlic health crises threatening the

world with the emergence and spread of 2019
novel coronavirus (2019-nCoV) or the severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2).
The virus originated in bats and was transmitted to
humans through yet unknown intermediary animals
in Wuhan, Hubei province, China in December
2019.

There have heen around 96,000 reported cases of

coronavirus disease 2019 (COVID-2019) and 3300
reported deaths to date (05/03/2020). The disease
is transmitted by inhalation or contact with infected
droplets and the incubation period ranges from 2
to 14d. The symptoms are usually fever, cough,
sore throat, breathlessness, fatigue, malaise
among others. The disease is mild in most people;
in some (usually the elderly and those with help tis
to control the spread of this tirtis. However, this is
both challenging as well as time-consuming due to
the present extent of infection (226). The current
scenario demands effective implementation of
vigorous prevention and control strategies owing
to the prospect of COVID-19 for nosocomial

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infections (68). Follow-ups of infected patients by

telephone on day 7 and day 14 are advised to
avoid any further unintentional spread or
nosocomial transmission (312). The availability of
public data sets provided by independent
analytical teams will act as robust evidence that
would guide us in designing interventions against
the COVID-19 outbreak. Newspaper reports and
social media can be used to analyze and
reconstruct the progression of an outbreak. They
can help us to obtain detailed patient- level data in
the early stages of an outbreak (227). Immediate
travel restrictions imposed by several counties
might have contributed significantly to preventing
the spread of SARS-CoV-2 globally (89, 228).
Following the outbreak, a temporary ban was
imposed on the wildlife trade, keeping in mind the
possible role played by wild animal species in the
origin of SARS-CoV-2/COVID-19 (147). Making a
permanent and bold decision on the Yade of wild
animal species is necessary to prevent the
possibility to evaluate the risk of future epidemics.
Presently, licensed antiviral drugs or vaccines
against SARS-CoV, MERS-CoV, and SARS-CoV-2
are lacking. However, advances in designing
antiviral drugs and vaccines against several other

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emerging diseases will help develop suitable

therapeutic agents against COVID-19 in a short
time. Until then, we must rely exclusively on
various control and prevention measures to
prevent this new disease from becoming a
pandemic. respiratory syncytial virus, rhinovirus,
human metapneumovirus and SARS coronavirus. It
is advisable to distinguish COVID-19 from other
pneumonias such as mycoplasma pneumonia,
chlamydia pneumonia and bacterial pneumonia.
Several published pieces of literature based on the
novel coronavirus reported in China declared that
stool and blood samples can also collected from
the suspected persons in order to detect the virus.
However, respiratory samples show better viability
in identifying the virus, in comparison with the
other specimens.

Nucieic acid ampiification tests (NAAT) for

COViD-19 virus

The gold standard method of confirming the

suspected cases of COVID-19 is carried out by
detecting the unique sequences of virus RNA
through reverse transcription polymerase chain
reaction (RT-PCR) along with nucleic acid

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sequencing if needed. The various genes of virus

identified so far include N, E, S (N: nucleocapsid
protein, E: envelope protein gene, S: spike

protein gene) and RdRP genes (RNA-dependent

RNA polymerase gene).

exponentially in other countries including South

Korea, Italy and Iran. Of those infected, 20% are in
critical condition, 25% have recovered, and 3310
(3013 in China and 297 in other countries) have
died [2]. India, which had reported only 3 cases till
2/3/2020, has also seen a sudden spurt in cases.
By 5/3/2020, 29 cases had been reported; mostly
in Delhi, Jaipur and Agra in Italian tourists and their
contacts. One case was reported in an Indian who
traveled back from Vienna and exposed a large
number of school children in a hirthday party at a
city hotel. Many of the contacts of these cases
have been quarantined.

These numbers are possibly an underestimate of

the infected and dead due to limitations of
surveillance and testing. Though the SARS-CoV-2
originated from bats, the intermediary minimum
signs and symptoms (82). Another study,

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conducted in South Korea, related to SARS-CoV-2

viral load, opined that SARS-CoV-2 kinetics were
significantly different from those of earlier reported
CoV infections, including SARS-CoV (253). SARS-
CoV-2 transmission can occur early in the viral
infection phase; thus, diagnosing cases and
isolation attempts for this virus warrant different
strategies than those needed to counter SARS-
CoV. Smdies are required to establish any
correlation between SARS-CoV-2 viral load and
cultivable virus. Recognizing patients with fewer or
no symptoms, along with having modest
detectable viral RNA in the oropharynx for 5 days,
indicates the requirement of data for assessing
SARS-CoV-2 transmission dynamics and updating
the screening procedures in the clinics (82).

4,170,424 cases and 287,399 deaths across the

globe. There is an urgent need for a rational
international campaign against the unhealthy food
practices of China to encourage the sellers to
increase hygienic food practices or close the crude
live-dead animal wet markets. There is a need to
modify food policies at national and international
levels to avoid further life threats and economic
consequences from any emerging or reemerging

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pandemic due to close animal-human interaction

(2d5).

Even though individuals of all ages and sexes are

susceptible to COVID-19, older people with an
underlying chronic disease are more likely to
become severely infected (80). Recently,
individuals with asymptomatic infection were also
found to act as a source of infection to susceptible
individuals (81). Both the asymptomatic and
symptomatic patients secrete similar véal loads,
which indicates that the transmission capacity of
asymptomatic or minimally symptomatic patients
is very high. Thus3 SARS-CoV-2 transmission can
happen early in the course of infection (82).
Atypical clinical manifestations have also been
reported in COVID-19 in which the only reporting
symptom was fatigue. Such patients may lack
respiratory signs3 such as fever, cough, and
sputum (83). Hence, the clinicians SARAS-CoV-2
stiaiixs available iii the National Center for
Biotechnology Information and GISAID databases
were subjected to multiple-sequence alignment
and phylogenetic analyses for studying variations
in the viral genome (260). All the viral stains
revealed high homology og 99.99% (99.91% 10

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100%) at the nucleotide level and 99.99% (99.97%

10 100%) at the (99.79% to 100%) at the amino
acid level. Overall variation was found to be low in
ORF regions, with 13 variation sites recognized in
la, lb, S, 3a, M, 8, and N regions. Mutation rates of
30.53% (29/95) and 29.47% (28/95) were observed
at nt 28144 (ORF8) and nt 8782 (ORFla) positions,
respectively. Owing to such selective mutations, a
few specific regions of SARS-CoV-2 should not be
considered for designing primers and probes. The
SARS-CoV-2 reference sequence could pave the
way to study molecular biology and pathobiology,
along with developing diagnostics and appropriate
prevention and control strategies for countering
SARS-CoV-2 (260).
Nucleic acids of SARS-CoV-2 can be detected
Aom samples (64) such as bronchoalveolar lavage
fluid, sputum, nasal swabs, fiber bronchoscope
brush biopsy specimen, pharyngeal swabs, feces,
blood, and urine, with different levels of diagnostic
twice in a volume of 200 to ?i0 ml on the day o1
collection (310). At present, treatment for sepsis
and ARDS mainly involves antimicrobial therapy,
source conCol, and supportive care. Hence, the
use of therapeutic plasma exchange can be
considered an option in managing such severe

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conditions. Further randomized trials can be

designed to investigate its efficacy (311).

Potential Therapeutic Agents

Potent therapeutics to combat SARS-CoV-2
infection include virus binding molecules,
molecules or inhibitors targeting particular
enzymes implicated in replication and transcription
process of the virus, helicase inhibitors, vital viral
proteases and proteins, protease inhibitors of host
cells, endocytosis inhibitors, short interfering RNA
(siRNA), neuCalizing antibodies, MAbs against the
host receptor, MAbs interfering with the SI RBD,
antiviral peptide aimed at S2, and naNral drugs/
medicines (7, 166, 186). The S protein acts as the
critical target for developing CoV antivirals, like
inhibitors of S protein and S cleavage, neutralizing
antibodies, RBD-ACE2 blockers, siRNAs, blockers
of the fusion core, and proteases (168).
All of these therapeutic approaches have revealed
Hciicc, bascd on the viial load, we can quickly
evaluate the progression of infection (291). In
addition to all of the above findings, sequencing
and phylogenetics are critical in the correct

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identification and confirmation of the causative

viral agent and useful to establish relationships
with previous isolates and sequences, as well as to
know, especially during an epidemic, the
nucleotide and amino acid mutations and the
molecular divergence. The rapid development and
implementation of diagnostic tests against
emerging novel diseases like COVID-19 pose
significant challenges due to the lack of resources
and logistical limitations associated with an
outbreak (155).
SARS-CoV-2 infection can also be confirmed by
isolation and culturing. The human airway epithelial
cell culture was found to be useful in isolating
SARS-CoV-2 (3). The efficient control of an
outbreak depends on the rapid diagnosis of the
disease. Recently, in response to the COVID-19
outbreak, 1-step quantitative real-time reverse
transcription-PCR assays were developed that
detect the ORF lb and N regions of the SARS-
CoV-2 genome (156). That assay was found to
achieve the rapid detection of SARS-CoV-2.
Nucleic acid-based assays offer high accuracy in
the diagnosis of SARS- Tliei‘e is no ctin cntly
licensed speci1\c antiviral Yeatment for MERS-
and SARS-CoV infections, and the main focus in

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clinical settings remains on lessening clinical signs

and providing supportive care (183-186). Effective
drugs to manage COVID-
19 patients include remdesivir, lopinavir/ritonavir
alone or in a blend with interferon beta,
convalescent plasma, and monoclonal antibodies
(MAbs); however, efficacy and safety issues of
these dngs require additional clinical Cials (187,
281). A controlled trial of ritonavir-boosted
lopinavir and interferon alpha 2b treatment was
performed on COVID-19 hospitalized patients
(ChiCTR2000029308) (188). In addition, the use of
hydroxychloroquine and tocilizumab for their
potential role in modulating inflammatory
responses in the lungs and antiviral effect has
been proposed and discussed in many research
articles. Still, no fool-proof clinical trials have been
published (194, 196, 197, 261-272). Recently, a
clinical trial conducted on adult patients suffering
from severe COVID-19 revealed no benefit of
lopinavir-ritonavir Yeatment over standard care
(273).
The efforts to control SARS-CoV-2 infection utilize
defined strategies as followed against MERS and
SARS, along with adopting and strengthening
aranging from the common cold to severe and

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ultimately fatal illnesses, such as SARS, MERS,

and, presently, COVID-19. SARS-CoV-2 is
considered one of thePotential Therapeutic Agents
Potent therapeutics to combat SARS-CoV-2
infection include virus binding molecules,
molecules or inhibitors targeting particular
enzymes implicated in replication and transcription
process of the virus, helicase inhibitors, vital viral
proteases and proteins, protease inhibitors of host
cells, endocytosis inhibitors, short interfering RNA
(siRNA), neuCalizing antibodies, MAbs against the
host receptor, MAbs interfering with the SI RBD,
antiviral peptide aimed at S2, and naNral drugs/
medicines (7, 166, 186). The S protein acts as the
critical target for developing CoV antivirals, like
inhibitors of S protein and S cleavage, neutralizing
antibodies, RBD-ACE2 blockers, siRNAs, blockers
of the fusion core, and proteases (168).
All of these therapeutic approaches have revealed
Hciicc, bascd on the viial load, we can quickly
evaluate the progression of infection (291). In
addition to all of the above findings, sequencing
and phylogenetics are critical in the correct
identification and confirmation of the causative
viral agent and useful to establish relationships
with previous isolates and sequences, as well as to

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know, especially during an epidemic, the

nucleotide and amino acid mutations and the
molecular divergence. The rapid development and
implementation of diagnostic tests against
emerging novel diseases like COVID-19 pose
significant challenges due to the lack of resources
and logistical limitations associated with an
outbreak (155).
SARS-CoV-2 infection can also be confirmed by
isolation and culturing. The human airway epithelial
cell culture was found to be useful in isolating
SARS-CoV-2 (3). The efficient control of an
outbreak depends on the rapid diagnosis of the
disease. Recently, in response to the COVID-19
outbreak, 1-step quantitative real-time reverse
transcription-PCR assays were developed that
detect the ORF lb and N regions of the SARS-
CoV-2 genome (156). That assay was found to
achieve the rapid detection of SARS-CoV-2.
Nucleic acid-based assays offer high accuracy in
the diagnosis of SARS- Tliei‘e is no ctin cntly
licensed speci1\c antiviral Yeatment for MERS-
and SARS-CoV infections, and the main focus in
clinical settings remains on lessening clinical signs
and providing supportive care (183-186). Effective
drugs to manage COVID-

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19 patients include remdesivir, lopinavir/ritonavir

alone or in a blend with interferon beta,
convalescent plasma, and monoclonal antibodies
(MAbs); however, efficacy and safety issues of
these dngs require additional clinical Cials (187,
281). A controlled trial of ritonavir-boosted
lopinavir and interferon alpha 2b treatment was
performed on COVID-19 hospitalized patients
(ChiCTR2000029308) (188). In addition, the use of
hydroxychloroquine and tocilizumab for their
potential role in modulating inflammatory
responses in the lungs and antiviral effect has
been proposed and discussed in many research
articles. Still, no fool-proof clinical trials have been
published (194, 196, 197, 261-272). Recently, a
clinical trial conducted on adult patients suffering
from severe COVID-19 revealed no benefit of
lopinavir-ritonavir Yeatment over standard care
(273).
The efforts to control SARS-CoV-2 infection utilize
defined strategies as followed against MERS and
SARS, along with adopting and strengthening
aranging from the common cold to severe and
ultimately fatal illnesses, such as SARS, MERS,
and, presently, COVID-19. SARS-CoV-2 is
considered one of the seven members of the CoV

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family that infect humans (3), and it belongs to the

same lineage of CoVs that causes SARS; however,
this novel virus is genetically distinct. Until 2020,
six CoVs were known to infect humans, including
human CoV 229E (HCoV-229E), HCoV-NL63,
HCoV-OC43, HCoV-HKUl, SARS- CoV, and
MERS-CoV. Although SARS-CoV and MERS-CoV
have resulted in outbreaks with high mortality,
others remain associated with mild upper-
respiratoiy-tract illnesses (4).
Newly evolved CoVs pose a high threat to global
public health. The current emergence of COVID-19
is the third CoV outbreak in humans over the past
2 decades (5). It is no coincidence that Fan et al.
predicted potential SARS- or MERS-like CoV
outbreaks in China following pathogen
transmission from bats (6). COVID-19 emerged in
China and spread rapidly throughout the country
and, subsequently, to other countries. Due to the
severity of this outbreak and the potential of
spreading on an international scale, the WHO
declared a global siigiiificaitt outbicak occur's drio-
to a viiris—liko- SARS-CoV-2.
There is a steady increase in the reports of
COVID-19 in companion and wild animals around
the world. Further studies are required to evaluate

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the potential of animals (especially companion

animals) to serve as an efficient reservoir host that
can further alter the dynamics of human-to-human
Yansmission (330). To date, two pet dogs (Hong
Kong) and four pet cats (one each from Belgium
and Hong Kong, two from the United States) have
tested positive for SARS-CoV-2 (335). The World
Organization for Animal Health (OIE) has confirmed
the diagnosis of COVID-19 in both dogs and cats
due to human-to-animal transmission (331). The
similarity observed in the gene sequence of SARS-
CoV-2 from an infected pet owner and his dog
further confirms the occurrence of human to
animal Gansmission (333). Even though
asymptomatic, feline species should be
considered a potential Yansmission route from
animals to humans (326). However, currently, there
are no reports of SARS- CoV-2 transmission from
felines to human beings. Based on the current
evidence, we can conclude that cats are
susceptible to SARS-CoV-2 and can get infected
by human beings. However, evidence of cat-

Inhibition ofvirus entry. SARS-CoV-2 uses ACE2 as

the receptor and human proteases as entry

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activators; sub- sequently it fuses the viral

membrane with the cell mem- brane and achieves
invasion. Thus, drugs that interfere with entry may
be a potential treatment for COVID-19. Umifenovir
(Arbidol) is a drug approved in Russia and China
for the treatment of influenza and otlicr respira-
tory viral infections. It can target the interaction
between the S protein and ACE2 and inhibit
membrane fusion (FIG '- ). In vitro experiments
showed that it has activity against SARS-CoV-2,
and current clinical data revealed it may be more
effective than lopinavir and ritonavir in treating
COVID-19 (REFS -- '-'). However, other clinical
studies showed umifenovir might not improve the
prog- nosis of or accelerate SARS-CoV-2
clearance in patients with mild to moderate
COVID-19 (REFS"’
--’).Yetsomeongoingclinicaltrialsareevaluatingitseffi
cacyforCOVID-19treatment.Camostat mesylate is
approved in Japan for the treatment of pancreatitis
and postoper- ative reflux oesophagitis. Previous
studies showed that it can prevent SARS-CoV
from entering cells by blocking TMPRSS2 activity
and protect mice from lethal infection with SARS-
CoV in a pathogenic mouse model (wild- type mice
infected with a mouse-adapted SARS-CoV strain) "

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^’. Recently, a study revealed that camostat

mesylate blocks the entry of SARS-CoV-2 into
human lung cells . Thus, it can be a potential
antiviral drug against SARS-CoV-2 infection,
although so far there are not sufficient clinical data
to support its efficacy.

liiitctions fcinain caRcelcd in tltc a1”lécted cities,

and persons are asked to work from home (232).
Hence, it is a relief that the current outbreak of
COVID-19 infection can be brought under control
with the adoption of strategic preventive and
control measures along with the early isolation of
subsequent cases in the coming days. Studies
also report that since air traffic between China and
African countries increased many times over in the
decade after the SARS outbreak, African counties
need to be vigilant to prevent the spread of novel
coronavirus in Africa (225). Due to fear of virus
spread, Wuhan City was completely shut down
(233). The immediate control of the ongoing
COVID-19 outbreaks appears a mammoth task,
especially for developing countries, due to their
inability to allocate quarantine stations that could
screen infected individuals' movements (234).
Such underdeveloped countries should divert their

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resources and
energytoenforcingtheprimarylevelofpreventivemeas
ures,likecontrollingtheentryofindividuals from China
or counties where the disease has flared up,
isolating the infected individuals, and quarantining
individuals with suspected infection. Most of the
sub-Saharan African countries have a fragile health
system that can be few precautionary itteasui‘cs
owing to tlte unkitowit nature of this novel virus
(36, 189). Presently, the main course of treatment
for severely affected SARS-CoV-2 patients
admitted to hospitals includes mechanical
ventilation, intensive care unit (ICU) admittance,
and symptomatic and supportive therapies.
Additionally, RNA synthesis inhibitors (lamivudine
and tenofovir disoproxil fumarate), remdesivir,
neuraminidase inhibitors, peptide (EKI), anti-
inflammatory drugs, abidol, and Chinese traditional
medicine (Lianhuaqingwen and ShuFengJieDu
capsules) could aid in COVID-19 treatment.
However, further clinical trials are being carried out
concerning their safety and efficacy (7). It might
require months to a year(s) to design and develop
effective drugs, therapeutics, and vaccines against
COVID-19, with adequate evaluation and approval
from regulatory bodies and moving to the bulk

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production of many millions of doses at

commercial levels to meet the timely demand of
mass populations across the globe (9). Continuous
efforts are also warranted to identify and assess
viable drugs and immunotherapeutic regimens that
revealed proven potency in combating other viral
agents similar to SARS- CoV-2.
COVID-19 patients showing severe signs are
Analysis of the initial cluster of infections suggests
that the infected individuals had a common
exposure point, a seafood market in Wuhan, Hubei
Province, China (Fig. 6). The restaurants of this
market are well-known for providing different types
of wild aniivtals for huivtait consumption (71). The
Huanan South China Seafood Market also sells live
animals, such as poultry, bats, snakes, and
marmots (72). This might be the point where
zoonotic (animal-to- human) transmission occurred
(71). Although SARS-CoV-2 is alleged to have
originated from an animal host (zoonotic origin)
with further human-to- human transmission (Fig.
6), the likelihood of foodborne transmission should
be ruled out with further investigations, since it is a
latent possibility
(1). Additionally, other potential and expected
routes would be associated with Cansmission, as

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in other respiratory viruses, by direct contact, such

as shaking contaminated hands, or by direct
contact with contaminated surfaces (Fig. 6). Still,
whether blood transfusion and organ
transplantation (276), as well as transplacental and
perinatal routes, are possible routes for SARS-
CoV-2 transmission needs to be determined (Fig.
6). patients with COVID-19 can be found on the
WHO and CDC websites.67

CONCULSION
The corona virus (COVID-19) spreads at an
alarming rate all over the world. The outbreak of
the virus has confronted the world's economic,
medical and public health infrastructure. Elderly
and immunocompromised patients also are
susceptible to the virus's mortal
c

impacts.
Currently, there is no documented cure for the
virus and no vaccine has been created, although
some treatment protocols have been promising.

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Therefore, the virus can be controlled with the

appropriate prevention strategies. Also, attempts
have to be made to formulate systematic
strategies to prevent such future zoonotic
outbreaks.clinical trials will not be available. The
newly developed drugs cannot be marketed due to
the lack of end users.
Vaccines
The S protein plays a significant role in the
induction of protective immunity against SARS-
CoV by mediating T-cell responses and
neutralizing antibody production (168). In the past
few decades, we have seen several anempts to
develop a vaccine against human coronaviruses by
using S protein as the target (168, 169). However,
the developed vaccines have minimal application,
even among closely related strains of the virus,
due to a lack of cross-protection. That is mainly
because of the extensive diversity existing among
the different antigenic variants of the virus (104).
The contributions of the structural proteins, like
spike (S), maCix (M), small envelope (E), and
nucleocapsid (N) proteins, of SARS-CoV to induce
protective immunity has been evaluated by
expressing them in a recombinant parainfluenza
virus type 3 vector (BHPIV3). Of note, the result

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was conclusive that the expression of M, E, or

variant group. The receptor-binding gene region
appears to be very similar to that of the SARS-
CoV and it i believed that the same receptor would
be used for cell entry,17

4.1 Virion structure and its genome

Coronaviruses are structurally enveloped,
belonging to the positive-strand RNA viruses
category that has the largest known genomes of
RNA. The structures of the coronavirus are more
spherical in shape, but their structure has the
potential to modify their morphology in response to
environmental conditions, being pleomorphic. The
capsular membrane which represents the outer
envelope usually has glycoprotein projection and
covers the nucleus, comprising a matrix protein
containing a positive-strand RNA. Since the
structure possesses 5'-capped and 3’-
polyadenyIated ends, it remains identical to the
cellularmRNAs.'The structure is comprised of
hemagglutinin esterase (HE) (present only in some
beta-coronaviruses), spike (S), small membrane
(E), membrane (M) and nucleocapsid (N), as shown
(Figure ¿). The envelope containing glycoprotein is

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responsible for attachment to the host cell, which

possesses the primary anti-genic epitopes mainly
those Coionaviirlses in Huivians SAKS, I\ILKS, and
COVID-19 Coronavirus infection in humans is
commonly associated with mild to severe
respiratory diseases, with high fever, severe
inflammation, cough, and internal organ
dysfunction that can even lead to death (92). Most
of the identified coronaviruses cause the common
cold in humans. However, this changed when
SARS-CoV was identified, paving the way for
severe forms of the disease in humans (22). Our
previous experience with the outbreaks of other
coronaviruses, like SARS and MERS, suggests that
the mode of transmission in COVID- 19 as mainly
human-to-human transmission via direct contact,
droplets, and fomites (25). Recent studies have
demonstrated that the virus could remain viable for
hours in aerosols and up to days on surfaces; thus,
aerosol and fomite contamination could play
potent roles in the transmission of SARS-CoV-2
(257).
The immune response against coronavirus is vital
to control and get rid of the infection. However,
maladjusted immune responses may contribute to
the immunopathology of the disease, resulting in

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impairment of pulmonary gas exchange.

Understanding the interaction between CoVs and
host innate immune systems could enlighten our &
ncbi.mm.nih.gov/pmc/arti glass opacities and suh
segmental consolldation. It is also abnormal in
asymptomatic patients/ patients with no clinical
evidence of lower respiratory tract involvement. In
fact, ahnormal CT scans have been used to
diagnose COVID-19 in suspect cases with negative
molecular diagnosis; many of these patients had
positive molecular tests on

repeat testing [22].

Differential Diagnosis [21]
The differential diagnosis includes all types of
respiratory viral infections [influenza, parainfluenza,
respiratory syncytial virus (RSV), adenovirus,
human metapneumovirus, non COVID- 19
coronavirus], atypical organisms (mycoplasma,
chlamydia) and bacterial infections. It is not
possible to differentiate COVID-19 from these
infections clinically or through routine had >95%
homology with the bat coronavirus and > 70%

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similarity with the SARS- CoV. Environmental

samples from the Huanan sea food market also
tested positive, signifying that the virus originated
from there [7]. The number of cases started
increasing exponentially, some of which did not
have exposure to the live animal market,
suggestive of the fact that human-to-human
transmission was occurring [8]. The first fatal case
was reported on 11th Jan 2020. The massive
migration of Chinese during the Chinese New Year
fuelled the epidemic. Cases in other provinces of
China, other countries (Thailand, Japan and South
Korea in quick succession) were reported in people
who were returning from Wuhan. Transmission to
healthcare workers caring for patients was
descrihed on 20th Jan, 2020. By 23rd January, the
11 million population of Wuhan was placed under
lock down sanitation practices needs to be given
due emphasis (249-252). Future explorative
research needs to be conducted with regard to the
fecal-oral transmission of SARS-CoV-2, along with
focusing on environmental investigations to find
out if this virus could stay viable in situations and
atmospheres facilitating such potent routes of
transmission. The correlation of fecal
concentrations of viral RNA with disease severity

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needs to be determined, along with assessing the

gastrointestinal symptoms and the possibility of
fecal SARS-CoV-2 RNA detection during the
COVID-19 incubation period or convalescence
phases of the disease (249-252).
The lower respiratoiy tract sampling techniques,
like bronchoalveolar lavage fluid aspirate, are
considered the ideal clinical materials, rather than
the throat swab, due to their higher positive rate on
the nucleic acid test (148). The diagnosis of
COVID-19 can be made by using upper-
respiratory-tract specimens collected using
nasopharyngeal and oropharyngeal swabs.
However, these techniques are associated with
unnecessary risks to health care workers due to
close contact with patients (152). Similarly, a single
patient
withahighviralloadwasreportedtocontaminateanenti
reendoscopyroombyshedding the virus, which may
remain viable for at 6.2

Serological testing

Serological surveys are also considered to be one

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of the most effective ones in facilitating outbreak

investigation and it also helps us to derive a
retrospective assessment of the disease by
estimating the attack rate.^* According to the
recent literature, paired serum samples can also
help clinicians to diagnose COVID-19 in case of
false negative results in NAAT essays." The
literature also declared that the commercial and
non-commercial serological tests are under
consideration in order to suppol thepractising
clinicians by assisting them in diagnosis. Similarly,
there are studies published on COVID-19 which
are comprised of the serological data on clinical
samples.

Viral sequencing

Apart from confirming the presence of virus in the

specimens, viral sequencing is also quite useful in
monitoring the viral genomic mutations, which
plays a very significant role in influencing the
performance of the medical countermeasures
inclusive of the diagnostic test. Genomic
sequencing of the virus can also help further in

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developing several studies related tomolecular

epidemiology.^2

assessed intrauterine vertical transmission of

COVID-19 infection in nine infants born to infected
mothers, found that none of the infants tested
positive for the virus.^ Likewise, there was no
evidence of intrauterine infection caused by
vertical transmission in the SARS and MERS
epidemics.
The CDC asserts that infants born to mothers with
confirmed COVID-19 are considered persons
under investigation (PUI) and should be temporarily
separated from the mother and isolated.4

7.1 Breastfeeding and infant care

The data available to date is limited and cannot

confirm whether or not COVID-19 can be
transmitted through breast milk. Assessing the
presence of COVID-19 in breast milk samples from
six patients showednegative
result.’TheCDCpointsoutthatincaseofaconfirmedor
suspectedCOVID-19 infection, the decision of
whether or how to start or continue breastfeeding

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should be made by the mother in collaboration

with the family and healthcare practitioners.
Careful precautions need to be taken by the
mother to prevent transmitting the disease to her
infant through respiratory droplets during
breastfeeding. This include

Wearing a facemask and practising hand

ariicie gives a nirn s eye view anoui this new virus.

Since knowledge ahout this virus ls rapidly
evolving, readers are urged to update themselves
regularly.

ÑÏSÏOFÿ

Coronaviruses are enveloped posltive sense RNA

viruses ranging from 60 nm to 140 nm in diameter
with spike like projections on its surface giving it a
crown like appearance under the electron
microscope; hence the name coronavirus [3]. Four
corona viruses namely HKU1, NL63, 229E and
OC43 have been in circulatlon ln humans, and
generaûy cause mild respiratory disease.

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There have heen two events in the past two

decades wherein crossover of animal betacorona
viruses to humans
hasresultedinseveredisease.Thefirst
suchinstancewasin2002—2003whena (SADS-CoV)
was 1\rst ideiitilicd iii suckling piglets having severe
enteritis and belongs to the genus
Alphacnrnnavirus (10b). The outbreak was
associated with considerable scale mortality of
piglets (24,693 deaths) across four fams in China
(134). The virus isolated from the piglets was
almost identical to and had 95% genomic similarity
with horseshoe bat (Rhinolophus species)
coronavirus HKU2, suggesting a bat origin of the
pig virus (106, 134, 135). It is also imperative to
note that the SADS-CoV outbreak started in
Guangdong province, near the location of the
SARS pandemic origin
(134). Before this outbreak, pigs were not known to
be infected with bat-origin coronaviruses. This
indicates that the bat-origin coronavirus jumped to
pig by breaking the species barrier. The next step
of this jump might not end well, since pigs are
considered the mixing vessel for influenza A
viruses due to their ability to be infected by both
human and avian influenza A viruses (136).

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Similarly, they may act as the mixing vessel for

coronaviruses, since they are in frequent contact
with both humans and multiple wildlife species.
Additionally, pigs are also found to be susceptible
to infection with human SARS-CoV and MERS-
CoV, making this scenario a nightmare (109, 137).
It is epidemics (13). The iaiost common symptoms
associated with COVID-19 are fever, cough,
dyspnea, expectoration, headache, and myalgia or
fatigue.
In contrast, less coivlmon signs at the tiiiie of
hospital admission include diarrhea, hemoptysis,
and shortness of breath (14). Recently, individuals
with asymptomatic infections were also suspected
of transmitting infections, which further adds to the
complexity of disease transmission dynamics in
COVID- 19 infections (1). Such efficient responses
require in-depth knowledge regarding the virus,
which currently is a novel agent; consequently,
further studies are required.
Comparing the genome of SARS-CoV-2 with that
of the closely related SARS/SARS-like CoV
revealed that the sequence coding for the spike
protein, with a total length of 1,273 amino acids,
showed 27 amino acid substitutions. Six of these
substitutions are in the region of the receptor-

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binding domain (RBD), and another six

substitutions are in the underpinning subdomain
(SD) (16). Phylogenetic analyses have revealed that
SARS-CoV-2 is closely related (88% similarity) to
two SARS-like CoVs derived from bat SARS-like
CoVs (bat-SL-
prevailing chronic medical conditions such as lung
disease, heart failure, cancer, cerebrovascular
disease, renal disease, diabetes, liver disease and
immunocompromising conditions and pregnancy
are risk factors for developing severe illness.
Management includes implementation of
prevention and control measures and supportive
therapy to manage the complications, together
with advanced organ support."
Corticosteroids must be avoided unless specified
for chronic obstructive pulmonary disease
exacerbation or septic shock, as it is likely to
prolong viral replication as detected in MERS-CoV
patients.^

12 EARLY SUPPORTIVE THIRAPY AND

MONITORING

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Management of patients with suspected or

documented COVID-19 consists of ensuring
appropriate infection control and supportive care.
WHO and the CDC posted clinical guidance for
COVID-19,59
Immediate therapy of add-on oxygen must be
started for patients with severe acute respiratory
infection (SARI) and respiratory relaxation drugs to
prevent veiitilatOi”-i”Gldltid lunp injury associated
with human-machine incoordination (122). The
result obtained from a clinical study of four
patients infected with COVID-19 claimed that
combination therapy using lopinavir/ritonavir,
arbidol, and Shufeng Jiedu capsules (traditional
Chinese medicine) was found to be effective in
managing COVID-19 pneumonia (193). It is difficult
to evaluate the therapeutic potential of a drug or a
combination of drugs for managing a disease
based on such a limited sample size. Before
choosing the ideal therapeutic agent for the
management of COVO-19, randomized clinical
control studies should be performed with a
sufficient study population.

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Antiviral Drugs
Several classes of routinely used antiviral drugs,
like oseltamivir (neuraminidase inhibitor), acyclovir,
ganciclovir, and ribavirin, do not have any effect on
COVID-19 and, hence, are not recommended
(187). Oseltamivir, a neuraminidase inhibitor, has
been explored in Chinese hospitals for treating
suspected COVID-19 cases, although proven
efficacy against SARS-CoV-2 is still lacking for this
drug (7). The in vitro antiviral potential of FAD-
approved drugs, viz.,

rcpeat 2 (HR2) can interact and form a six-helix

bundle that brings the viral and cellular membranes
in close proximity, facilitating its fusion. The
sequence alignment study conducted between
COVID-19 and SARS-CoV identified that the S2
subunits are highly conserved in these CoVs. The
HR1 and HR2 domains showed 92.6% and 100%
overall identity, respectively (210). From these
findings, we can confirm the significance of
COVID-19 HRl and HR2 and their vital role in host
cell entry. Hence, fusion inhibitors target the HR1
domain of S protein, thereby preventing viral fusion
and entry into the host cell. This is another

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potential therapeutic strategy that can be used in

the management of COVID-19. Other than the
specific therapy directed against COVID-19,
general 8eatments play a vital role in the
enhancement of host immune responses against
the viral agent. Inadequate nuCition is linked to the
weakening of the host immune response, making
the individual more susceptible. The role played by
nutrition in disease susceptibility should be
measured by evaluating the nutritional status of
patients with COVID-19 (205).

anilnal meats without arty fear or COVlD-19. The

Chinese government is encouraging people to feel
they can return to nomalcy. However, this could be
a risk, as it has been mentioned in advisories that
people should avoid contact with live-dead
animals as much as possible, as SARS-CoV-2 has
shown zoonotic spillover. Additionally, we cannot
rule out the possibility of new mutations in the
same virus being closely related to contact with
both animals and humans at the market (284). In
January 2020, China imposed a temporary ban on
the sale of live- dead animals in wet markets.
However, now hundreds of such wet markets have
been reopened without optimizing standard food

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safety and sanitation practices (286).

With China being the most populated country in
the world and due to its domestic and international
food exportation policies, the whole world is now
facing the menace of COVID-19, including China
itself. Wet markets of live-dead animals do not
maintain strict food hygienic practices. Fresh blood
splashes are present everywhere, on the floor and
tabletops, and such food customs could
encourage many pathogens to adapt, mutate, and
jump the species barrier. As a result, the whole
world is suffering from novel SARS- CoV-2, with
more than

To assess the genetic variation of different SARS-

CoV 2 strains, the 2019 Novel Coronavirus
Resource of China National Center for
Bioinformation aligned 77,801 genome sequences
of SARS-CoV-2 detected glob- ally and identified a
total of 15,018 mutations, including 14,524 single-
nucleotide polymorphisms (BICID)-’ . In the S
protein, four amino acid alterations, V483A, L455I,
F456V and G476S, are located near the binding
interface in the RBD, but their effects on binding to
the host receptor are unknown. The alteration D6l
4G in the SI subunit was found far more frequently

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than other S variant sites, and it is the marker of a

major subclade of SARS CoV-2 (clade G). Since
March 2020, SARS-CoV-2 variants with G6l4 in the
S protein have replaced the original D6l4 variants
and become the dominant form circulating
globally. Compared with the D6l4 variant, higher
viral loads were found in patients infected with the
G6l4 variant, but clinical data suggested no signif-
icant link between the D6l 4G alteration and
disease severity". Pseudotyped viruses carrying
the S protein with G6l4 generated higher infectious
titres than viruses carrying the S protein with D6l4,
suggesting the altera- tion may have increased the
infectivity of SARS-CoV-2 (REF "). However, the
results of in vitro experñnents based on
pseudovirus models may not exactly reflect natural
infection. This preliminary finding should be
validated by more studies using wild-type SARS-
CoV-2 variants to infect different target cells and
animal models. Whether this amino acid change
enhanced virus transmissibil- ity is also to be
determined. Another marker mutation for SARS-
CoV-2 evolution is the single nucleotide been used
based on the experience with SARS and MERS. In
a historical control study ln patients wlth SARS,
patients treated with lopinavir- ritonavir with

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ribavirin had hetter outcomes as compared to

those given rihavirin alone [15].
In the case series of 99 hospitalized patients with
COVID-19 infection from Wuhan, oxygen was
given to 76%, non- invasive ventUation in 13%,
mechanical ventilation in 4%, extracorporeal
membrane oxygenatlon (ECMO) in 3%, continuous
renal replacement therapy (CRRT) in 9%,
antibiotics in 71%, antifungals in 15%,
glucocorticoids in 19% and intravenous
immunoglobulin therapy in 27% [15]. Antiviral
therapy consisting of oseltamivir, ganciclovir and
lopinavir- ritonavir was given to 75% of the
patients. The duration of non-invasive ventilation
was 4—22 d [median 9 d]

Interestingly, disease in patients outside Hubei

province has been reported to he milder than
those from Wuhan [17]. SllTlUarly, the severlty and
case fatality rate in patients outslde China has
been reported to be mUder [6]. This may either be
due to selection bias wherein the cases reporting
from Wuhan included only the severe cases or due
to predisposition of the Asian population to the
virus due to higher expression of ACE2receptors
on the respiratory mucosa [11].

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Diseaseinneonates,infantsand
childrenhasbeenalsoreportedtobe
significantlymilderthantheiradult
counterparts.Inaserlesof34childrenadmittedtoahos
pitalinShenzhen, ChinabetweenJanuary19th and
February 7th, there were 14 males and 20 females.
The median age was 8 y 11 mo and in 28 children
the infection was linked to a family member and 26

( «o J. Vlicld lc-agctl ›int3 cltlcl ly |naticn ts w illa |

n›”iinai’y chronic diseases, especially high blood
pressure and diabetes, were found to be more
susceptible to respiratory failure and, therefore,
had poorer prognoses. Providing respiratory
support at early stages improved the disease
prognosis and facilitated recovery (18). The ARDS
in COVID-19 is due to the occurrence of cytokine
storms that results in exaggerated immune
response, immune regulatory network imbalance,
and, finally, multiple-organ failure (122). In addition
to the exaggerated inflammatory response seen in
patients with COVID-19 pneumonia, the bile duct
epithelial cell- derived hepatocytes upregulate
ACE2 expression in liver tissue by compensatory
proliferation that might result in hepatic tissue
injury (123).

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CORONAVIRUSES IN ANIMALS AND

ZOONOTIC LINI€S—A BRIEF VIEWPOINT

Coronavirus can cause disease in several species

of domestic and wild animals, as well as humans
(23). The different animal species that are infected
with CoV include horses, camels, cattle, swine,
dogs, cats, rodents, birds, ferrets, ivtinks, bats,
rabbits, snakes, and various other wild animals (20,
30, 79,
treated syniptoinatically aloit with oxygen therapy.
In such cases where the patients progress toward
respiratory failure and become refractory to
oxygen therapy, ivtechanical ventilation is
necessitated. The COVID-19-induced septic shock
can be managed by providing adequate
hemodynamic support (299). Several classes of
drugs are currently being evaluated for their
potential therapeutic action against SARS- CoV-2.
Therapeutic agents that have anti-SARS-CoV-2
activity can be broadly classified into three
categories: drugs that block virus entry into the
host cell, drugs that block viral replication as well

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as its survival within the host cell, and drugs that

attenuate the exaggerated host immune response
(300). An inflammatory cytokine stom is commonly
seen in critically ill COVID-19 patients. Hence, they
may benefit from the use of timely anti-
inflammation Ceatment. Anti-inflammatory therapy
using drugs like glucocorticoids, cytokine
inhibitors, JAK inhibitors, and chloroquine/
hydroxychloroquine should be done only añer
analyzing the risk/benefit ratio in COVID-19
patients (301). There have not been any studies
concerning the application of nonsteroidal anti-
inflammatory drugs (NSAID) to COVID-19-infected
patients.However,reasonablepieces of evidence
are available that link NSAID

5.2 Specimen collection and storage

A Nasopharyngeal and oropharyngeal swab should

be collected using Dacron or polyester flocked
swabs. It should be transported to the laboratory
at a temperature of 4°C and stored in the
laboratory between 4 and —70°C on the basis of

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the number of days and, in order to increase the

viral load, both nasopharyngeal and oropharyngeal
swabs should be placed in the same tube.
Bronchoalveolar lavage and nasopharyngeal
aspirate should be collected in a sterile container
and transported similarly to the laboratory by
maintain a temperature of 4°C.
Sputum samples, especially from the lower
respiratory tract, should be collected with the help
of a sterile container and stored, whereas tissue
from a biopsy or autopsy should be collected
using a sterile container along with saline.
However, both should be stored in the laboratory
at a temperature that ranges between 4 and -70°C.
Whole blood for detecting the antigen, particularly
in the first week of illness, should be collected in a
collecting tube and stored in the laboratory
between 4 and —70°C. Urine samples must also
be collected using a sterile container and stored

other clinical trials in different phases are still

ongoing elsewhere.
I Jmffnomodulatory agents. SARS-CoV 2 triggers a
strong immune response which may cause
cytokine storm syndrome""“. Thus,

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immunomodulatory agents that inhibit the

excessive inflammatory response may be a
potential adjunctive therapy for COVID - 19.
Dexamethasone is a corticosteroid often used in a
wide range of conditions to relieve inflammation
through its anti-inflammatory and
immunosuppressant effects. Recently, the
RECOVERY trial found dexamethasone reduced
mortality by about one third in hospitalized patients
with COVID-19 who received invasive mechan- ical
ventilation and by one fifth in patients receiving
oxygen. By contrast, no benefit was found in
patients without respiratory support" .
Tocilizumab and sarilumab, two types
ofinterleukin-6 (IL-6) receptor-specific antibodies
previously used to treat various types of arthritis,
including rheumatoid arthritis, and cytokine release
syndrome, showed effec-tivenessinthetreatment
ofsevereCOVID-19byattenuatingthecytokinestormi
nasmalluncontrolled trial’ ' . Bevacizumab is an
anti-vascular endothelial growth factor (VEGF)
medication that could potentially reduce
pulmonary oedema in patients with severe
COVID-19. Eculizumab is a specific monoclonal
antibody that inhibits the proinflammatory
complement protein CS. Preliminary results

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showed that it induced a drop of inflammatory

markers and C-reactive protein levels, suggesting
its
potentialtobeanoptionforthetreatmentofsevereCOVI
D-19(REF ‘").

All of these therapeutic approaches have revealed

both in vitro and in vivo anti-CoV potential.
Although in vitro research carried out with these
therapeutics showed efficacy, most need
appropriate support from randomized animal or
human trials. Therefore, they might be of limited
applicability and require trials against SARS-CoV-2
to gain practical usefulness. The binding of SARS-
CoV-2 with ACE2 leads to the exacerbation of
pneumonia as a consequence of the Imbalance in
the reninangiotensin system (RAS). The virus-
induced pulmonary inflammatory responses may
be reduced by the administration of ACE inhibitors
(ACED and angiotensin type-I receptor (ATI R)
(207).

Several Investigations have suggested the use of

small-molecule inhibitors for the potential control
of SARS-CoV infections. Drugs of the FDA-

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approved compound library were screened to

identify four small-molecule inhibitors of MERS-
C0V (chlorpromazine, chloroquine, loperamide,
and lopinavir) that inhibited Viral replication. These
compounds also hinder SARS-CoV and human
CoVs (208). Therapeutic strategies involving the
use of specific antibodies or compounds that
neutralize cytokines and their receptors will help to
restrain the host inflammatory responses. Such
drugs acting specifically in the respiratory tract will
help to

Prevention [21, 30]

Since at this time there are no approved

treatments for this infection, prevention is crucial.
Several properties of this virus make prevention
difficult namely, nonspecific features of the
disease, the infectivity even before onset of
symptoms in the incubation period, transmission
from asymptomatic people, long incubation period,
tropism for mucosal surfaces such as the
conjunctiva, prolonged duration of the illness and
transmission even after clinical recovery.

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Isolation of confirmed or suspected cases with

mild illness at home is recommended. The
ventilation at home should be good with sunlight to
allow for destruction of virus. Patients should be
asked to wear a simple surgical mask and practice
cough hygiene.
wearing a facemask and practising hand hygiene
before feeding the baby. In addition, it is advisable
that breast pumps are cleaned properly after each
use and, if possible, a healthy individual is
available to feed the expressed breast milk to the
infant.42
7.2 Children and elderly population
On the basis of the available reports, COVID-19
among children accounted for 1-5% of the
confirmed cases, and this population does not
seem to be at higher risk for the disease than
adults. There is no difference in the COVID-19
symptoms between adults and children.
However, the available evidence indicated that
children diagnosed with COVID-19 have milder
symptoms than the adults, with a low mortality
rate.48, 49 On the contrary, older people who are
above the age of 65 years are at higher risk for a
severe course of disease. In the United Stated,
approximately 31 -59% of those with confirmed

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COVID-19 between the ages of 65 and 84 years

old required hospitalisation, 1 1-31% of them
required admission to the intensive care unit, and
4- 1 1% died.50
of persistent local transmission or contact with
patients with similar travel history or those with
confirmed COVID-19 infection. However cases
may be asymptomatic or even without fever. A
confirmed case is a suspect case with a positive
molecular test.

Specific diagnosis is by specific molecular tests on

respiratory samples (throat swab/ nasopharyngeal
swab/ sputum/ endotracheal aspirates and
bronchoalveolar lavage). Virus may also be
detected in the stool and in severe cases, the
blood. It must be remembered that the multiplex
PCR panels currently available do not include the
COVID-19. Commercial tests are also not available
at present. In a suspect case in India, the
appropriate sample has to be sent to designated
reference labs in India or the National Institute of
Virology in Pune. As the epidemic progresses,
commercial tests

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specifically in the respiratory tract will help to

reduce virus-triggered immune pathologies in
COVID-19 (209). The later stages of
coronavirusinduced inflammatory cascades are
characterized by the release of proinflammatory
interleukin-1 (IL-I) family members, such as IL-I
and IL-33. Hence, there exists a possibility that the
Inflammation associated with coronavirus can be
inhibited by utilizing anti-inflammatory cytokines
that belong to the IL-I family (92). It has also been
suggested that the actin protein is the host factor
that is involved in cell entry and pathogenesis of
SARS-CoV-2. Hence, those drugs that modulate
the biological activity of this protein, like ibuprofen,
might have some therapeutic application in
managing the disease (174). The plasma
angiotensin 2 level was found to be markedly
elevated in COVID-19 infection and was correlated
with viral load and lung injury. Hence, drugs that
block angiotensm receptors may have potential for
treating COVID-19 infection (121). A scientist from
Germany, named Rolf Hilgenfeld, has been
working on the identification of drugs for the
treatment of coronaviral infection smce the time of
the first SARS outbreak (19).
The SARS-CoV S2 subunit has a significant

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function in mediating virus fusion that provides

entry into the host cell. Heptad repeat 1 (HR 1) and
heptad
(96.7 0 0), and S genes (90.4%). The RBI) of S
protein in COV isolated from pangolin was almost
identical (one amino acid difference) to that of
SARS-CoV-2. A comparison of the genomes
suggests recombination between pangolin-CoV-
like viruses with the bat-CoV-RaTG13-like virus. All
this suggests the potential of pangolins to act as
the intermediate host of SARS-CoV-2 (145).
Human-wildlife interactions, which are increasing
in the context of climate change (142), are further
considered high risk and responsible for the
emergence of SARS-C0V. COVID-19 is also
suspected of having a similar mode of origin.
Hence, to prevent the occurrence of another
zoonotic spillover (1), exhaustive coordinated
efforts are needed to identify the high-risk
pathogens harbored by wild animal populations,
conducting surveillance among the people who are
susceptible to zoonotic spillover events (12), and
to improve the biosecurity measures associated
with the wildlife trade (146). The serological
surveillance studies conducted in people living in
proximity to bat caves had earlier identified the

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serological confirmation of SARSrelated CoVs in

humans. People living at the wildlife-human
Interface, mainly in rural China, are regularly
exposed to SARS-related CoVs (147) These
findings will not have any significance until a
inelicase activity.

Among the evaluated compounds, 4-(cyclopentI-

en-3-ylamino)-5-(4iodophenyl)hydrazinyl] -41-1-1
,2,4-triazole-3 -thiol and 4-(cyclopent-1-en-3-
ylamino)-5-[2-(4chlorophenyl)hydrazinyl] - 4H-1 ,2
,4-triazole-3 -thiol were found to be the most
potent. These compounds were used for in silico
studies, and molecular docking was accomplished
into the active binding site of MERS- CoV helicase
nsp13 (21). Further studies are required for
evaluating the therapeutic potential of these newly
identified compounds in the management of
COVID- 19 infection.
Passive Immunization/Antibody Therapy/MAb
Monoclonal antibodies (MAbs) may be helpful in
the intervention of disease in CoV-exposed
individuals. Patients recovering from SARS
showed robust neutralizing antibodies against this

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COV infection (164). A set of MAbs aimed at the

MERS COV S protein-specific domains,
comprising six specific epitope groups Interacting
with receptorbinding, membrane fusion, and sialic
acid-binding sites, make up crucial entry tasks of S
protein (198, 199). Passive immunization
employing weaker and strongly neutralizing
antibodies provided considerable protection in
mice against a MERS-
The exploration of fully human antibodies (human
single-chain antibodies; HuscFvs) or humamzed
nanobodies (single-domain antibodies; sdAb, VH/
VHH) could aid in blocking virus replication, as
these agents can traverse the virusinfected cell
membranes (transbodies) and can interfere with
the biological characteristics of the replicating
virus proteins. Such examples include transbodies
to the influenza virus, hepatitis C virus, Ebola virus,
and dengue virus (206). Producing similar
transbodies against intracellular proteins of
coronaviruses, such as papain-like proteases
(PLpro) cysteine-like protease (3CLpro), or other
nsps, which are essential for replication and
transcription of the virus, might formulate a
practical move forward for a safer and potent
passive immunization approach for virus-exposed

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persons and rendering therapy to infected

patients.
In a case study on five grimly sick patients having
symptoms of severe pneumonia due to COVID-19,
convalescent plasma administration was found to
be helpful in patients recovering successfully. The
convalescent plasma containing a SARS-CoV-2-
specific ELISA (serum) antibody titer higher than 1:
1,000 and neutralizing antibody titer more
significant than 40 was collected from the
recovered patients and used for plasma
transfusion considerable protection 111 mice
against a MERSCOV lethal challenge. Such
antibodies may play a crucial role in enhancing
protective humoral responses agamst the
emergmg CoVs by aiming appropriate epitopes
and functions of the S protein. The cross-
neutralization ability of SARS-CoV RBI)specific
neutralizing MAbs considerably relies on the
resemblance between their RBDs; therefore,
SARS-CoV RBD- specific antibodies could
crossneutralized SL covs, i.e., bat-SL-C0V strain
WIVI (RBD with eight amino acid differences from
SARSCOV) but not bat-SL-CoV strain SHC014 (24
amino acid differences) (200).
Appropriate RBD-specific MAbs can be recognized

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by a relative analysis of RBD of SARSCoV-2 to that

of SARS-CoV, and cross-neutralizing SARS-CoV
RBD-specific MAbs could be explored for their
effectiveness against COVID-19 and further need
to be assessed clinically. The U.S. biotechnology
company Regeneron is attempting to recognize
potent and specific MAbs to combat COVID-19.
An ideal therapeutic option suggested for SARS-
C0V-2 (COVID-19) is the combination therapy
comprised of MAbs and the drug remdesivir
(COVID-19) (201). The SARS- C0V-specific human
MAb CR3022 is found to bind with SARS-C0V-2
RBD, indicating its potential as a therapeutic agent
respectively140. However, this study did not
include a control arm, and most of the trials of
favilavir were based on a small sample size. For
more reliable assessment of the effectiveness of
favilavir for treating COVID-19, large-scale
randomized controlled trials should be conducted.
Lopinavir and ritonavir were reported to have in
vitro inhibitory activity against SARS-CoV and
MERS-CoV 141 ' 142. Alone, the combination of
lopinavir
system (30).
Bovine coronaviruses (BoCoVs) are known to
infect several domestic and wild ruminants (126).

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BoCoV inflicts neonatal calf diarrhea in adult cattle,

leading to bloody diarrhea (winter dysentery) and
respiratory disease complex (shipping fever) in
cattle of all age groups (126). BoCoV-like viruses
have been noted in humans, suggesting its
zoonotic potential as well (127). Feline enteric and
feline infectious peritonitis (FIP) viruses are the two
major feline CoVs (128), where feline CoVs can
affect the gastrointestinal tract, abdominal cavity
(peritonitis), respiratory tract, and central nervous
system (128). Canines are also affected by CoVs
that fall under different genera, namely, canine
enteric coronavlrus in Alphacoronavirus and canine
respiratory coronavlrus In Betacoronavirus,
affecting the enteric and respiratory tract,
respectively (129, 130). 1BV, under
Gammacoronavirus, causes diseases of
respiratory, urinary, and reproductive systems,
with

substantial economic losses in chickens (131,

132). In small laboratory animals, mouse hepatitis
virus, rat sialodacryoadenitis coronavirus, and
guinea pig and rabbit coronaviruses are the major
CoVs associated with disease manifestations like
enteritis, hepatitis, and respiratory infections (10,

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133).
Swine acute diarrhea syndrome coronavirus with
SARS and MERS (117).
SARS-CoV-2 invades the lung parenchyma,
resulting m severe interstitial inflammation of the
lungs. This is evident on computed tomography
(CT) images as ground-glass opacity in the lungs.
This lesion Initially involves a single lobe but later
expands to multiple lung lobes (I l 8). The
histological assessment of lung biopsy samples
obtained from COVID-19-infected patients
revealed diffuse alveolar damage, cellular
fibromyxoid exudates, hyaline membrane
formation, and desquamation of pneumocytes,
indicative of acute respiratory distress syndrome
(119). It was also found that the SARS-CoV-2-
infected patients often have lymphocytopenia with
or without leukocyte abnormalities. The degree of
lymphocytopenia gives an idea about disease
prognosis, as it is found to be positively correlated
with disease severity (118). Pregnant women are
considered to have a higher risk of getting infected
by COVID-19. The coronaviruses can cause
adverse outcomes for the fetus, such as
intrauterine growth restriction, spontaneous
abortion, preterm

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delivery, and perinatal death.

Nevertheless, the possibility of intrauterine
maternal-fetal transmission (vertical
transmission) of CoVs is low and was not seen
during either the SARS- or MERS-C0V outbreak
(120). However,
countries have a fragile health system that can be
crippled in the event of an outbreak. Effective
management of COVID-19 would be difficult for
low-income countries due to then- inability to
respond rapidly due to the lack of an efficient
health care system (65). Controlling the imported
cases is critical in preventing the spread of
COVID-19 to other countries that have not
reported the disease until now. The possibility of
an imported case of COVID-19 leading to
sustained human- to-human transmission was
estimated to be 0.41. This can be reduced to a
value of 0.012 by decreasing the mean time from
the onset of symptoms to hospitalization and can
only be made possible by using intense disease
surveillance systems (235). The silent importations
of infected individuals (before the manifestation of
clinical signs) also contributed significantly to the
spread of disease across the major cities of the
world. Even though the travel ban was

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implemented in Wuhan (89), infected persons who

traveled out of the city just before the imposition of
the ban might have remained undetected and
resulted in local outbreaks (236). Emerging novel
diseases like COVID-19 are difficult to contain
within the country of origin, smce globalization has
led to a world without borders. Hence, international
collaboration plays a vital role
pandemic flu where patients were asked to resume
work/school once afebrile for 24 h or by day 7 of
illness. Negative molecular tests were not a
prerequisite for discharge.
At the community level, people should be asked to
avoid crowded areas and postpone non-essential
travel to places with ongoing transmission. They
should be asked to practice cough hygiene by
coughing in sleeve/ tissue rather than hands and
practice hand hygiene frequently every 15—20
min. Patients with respiratory symptoms should be
asked to use surgical masks. The use of mask by
healthy people in public places has not shown to
protect against respiratory viral infections and is
currently not recommended by
WHO. However, in China, the public has been
asked to wear masks in public and especially in
crowded places and large scale gatherings are

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prohibited
(entertainment parks etc).
China is alsohealth emergency on 31 January
2020; subsequently, on 11 March 2020, they
declared it a pandemic situation. At present, we
are not in a position to effectively treat COVID-19,
since neither approved vaccines nor specific
antiviral drugs for treating human COV infections
are available (7—9). Most nations are currently
making efforts to prevent the further spreading of
this potentially deadly virus by implementing
preventive and control strategies.

In domestic animals, infections with CoVs are

associated with a broad spectrum of pathological
conditions. Apart from infectious bronchitis virus,
canine respiratory COV, and mouse hepatitis virus,
CoVs are predominantly associated with
gastrointestinal diseases (10). The emergence of
novel CoVs may have become possible because of
multiple CoVs being maintained in their natural
host, which could have favored the probability of
genetic recombination (10). High genetic diversity
and the ability to infect multiple host species are a
result of high-frequency mutations in CoVs, which
occur due to the instability of RNA-dependent RNA

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polymerases along with higher rates of

homologous RNA recombination (10, 11).
Identifying the origin of SARS- CoV-2 and the
pathogen's evolution will be helpful for disease
surveillance (12), development of major problem
associated With this diagnostic kit IS that it works
only when the test subject has an active infection,
limiting its use to the earlier stages of infection.
Several laboratories around the world are currently
developing antibody-based diagnostic tests
against SARS-C0V-2 (157).
Chest CT is an ideal diagnostic tool for identifying
viral pneumonia. The sensitivity of chest CT is far
superior to that of X-ray screening. The chest CT
findings associated with COVID- 19infected
patients include characteristic patchy Infiltration
that later progresses to ground-glass opacities
(158). Early manifestations of COVID-19
pneumonia might not be evident in X-ray chest
radiography. In such situations, a chest CT
examination can be performed, as it IS considered
highly specific for COVID-19 pneumonia (118).
Those patients having COVID-19 pneumonia will
exhibit the typical ground-glass opacity in their
chest CT images (154). The patients infected with
COVID- 19 had elevated plasma angiotensin 2

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levels. The level of angiotensin 2 was found to be

linearly associated with viral load and lung injury,
indicating its potential as a diagnostic biomarker
(121). The chest CT imaging abnormalities
associated with COVID-19 pneumonia have also
been observed even in asymptomatic patients.
These abnormalities other emergmg viral diseases.
Several therapeutic and preventive strategies,
including vaccmes, immunotherapeutics, and
antiviral drugs, have been exploited against the
previous COV outbreaks (SARS-C0V and MERS-
C0V) (8, 104, 164—167). These valuable options
have already been evaluated for their potency,
efficacy, and safety, along with several other types
of current research that will fuel our search for
ideal therapeutic agents against COVID-19 (7, 9,
19, 21, 36). The primary cause of the unavailability
of approved and commercial vaccines, drugs, and
therapeutics to counter the earlier SARS-C0V and
MERS-C0V seems to owe to the lesser attention of
the biomedicine and pharmaceutical companies,
as these two CoVs did not cause much havoc,
global threat, and panic like those posed by the
SARS- CoV-2 pandemic (19). Moreover, for such
outbreak situations, the requirement for vaccmes
and therapeutics/drugs exists only for a limited

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period, until the outbreak is controlled. The

proportion of the human population infected with
SARS-C0V and MERS-C0V was also much lower
across the globe, failing to attract drug and
vaccine manufacturers and producers. Therefore,
by the time an effective drug or vaccine is
designed against such disease outbreaks, the virus
would have been controlled by adopting
appropriate and strict
Coronaviruses are a diverse group of viruses
infecting many different animals, and they can
cause mild to severe respiratory infections in
humans. In 2002 and 2012, respectively, two
highly pathogenic coronaviruses with zoonotic
origin, severe acute respiratory syndrome
coronavirus (SARS-CoV) and Middle East
respiratory syndrome coronavirus (MERS-CoV),
emerged in humans and caused fatal respiratory
illness, making emerging coronaviruses a new
public health concern in the twenty-first century. At
the end of 2019, a novel coronavirus designated as
SARS- CoV-2 emerged in the city ofWuhan, China,
and caused an outbreak of unusual viral
pneumonia. Being highly transmissible, this novel
coronavirus disease, also known as coronavirus
disease 2019

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(COVID-19), has spread fast all over the world It

has overwhelmingly surpassed SARS and MERS in
terms of both the number of infected people and
the spatial range ofepidemic areas. The ongoing
outbreak of COVID-19 has posed an extraordinary
threat to global public health4'5. In this Review, we
summarize the current understanding of the nature
of SARS-CoV-2 and COVID-19. On the basis of
recently published findings, this comprehensive
Review covers the basic biology of SARS-CoV-2,
including the genetic characteristics, the potential
zoonotic origin and its receptor binding.
Furthermore, we will discuss the clinical and
epidemiological features, diagnosis of and
countermeasures against COVID- 19.

Emergence and spread

In late December 2019, several health facilities in
Wuhan, in Hubei province in China, reported
clusters of patients with pneumonia of unknown
cause6. Similarly to patients with SARS and
MERS, these patients showed symptoms of viral
pneumonia, including fever, cough absence of this
protein is related to the altered virulence of
coronaviruses due to changes in morphology and
tropism (54). The E protein consists of three

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domains, namely, a short hydrophilic amino

terminal, a large hydrophobic transmembrane
domain, and an efficient C-terminal domain (51).
The SARS- CoV-2 E protein reveals a similar amino
acid constitution without any substitution (16).
N Protein
The N protein of coronavirus is multipurpose.
Among several functions, it plays a role m complex
formation with the viral genome, facilitates M
protein interaction needed during virion assembly,
and enhances the transcription efficiency of the
virus (55, 56). It contains three highly conserved
and distinct domains, namely, an NTD, an RNA-
binding domain or a linker region (LKR), and a CTD
(57). The NTD binds with the 3' end of the viral
genome, perhaps via electrostatic interactions, and
is highly diverged both in length and sequence
(58). The charged LKR is serine and arginine rich
and is also known as the SR (serine and arginine)
domain (59). The LKR is capable of direct
interaction with in vitro
RNA interaction and is responsible for cell
signaling (60, 61). It also modulates the antiviral
response of the host by working as an antagonist
for interferon
Practice Points from an Indian Perspective

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At the time of writing this article, the risk of

coronavirus in India is extremely low. But that may
change in the next few weeks. Hence the following
is recommended:
• Healthcare providers should take travel history of
all patients with respiratory symptoms, and any
international travel in the past 2 wks as well as
contact with sick people who have travelled
internationally.
• They should set up a system of triage of patients
with respiratory illness in the outpatient
department and give them a simple surgical mask
to wear. They should use surgical masks
themselves while examining such
wrougiil havoc anu caused a panucnnc situation in
the worldwide population, leading to disease
outbreaks that have not been controlled to date,
although extensive efforts are being put in place to
counter this virus (25). This virus has been
proposed to be designated/named severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2)
by the International Committee on Taxonomy of
Viruses (ICTV), which determined the virus belongs
to the Severe acute respiratory syndrome- related
coronavirus category and found this virus is related
to SARS-C0Vs (26). SARS-C0V-2 is a member of

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the order Nidovirales, family Coronaviridae,

subfamily Orthocoronavirinae, which is subdivided
into four genera, viz., Alphacoronavirus,
Betacoronavirus, Gammacoronavirus, and
Deltacoronavirus (3, 27). The genera
Alphacoronavirus and Betacoronavirus originate
from bats, while Gammacoronavirus and
Deltacoronavirus have evolved from bird and swine
gene pools (24, 28, 29, 275).
Coronaviruses possess an unsegmented,
singlestranded, positive-sense RNA genome of
around 30 14b, enclosed by a 5'-cap and 3'-
poly(A) tail (30). The genome of SARS-CoV-2 is
29,891 bp long, with a G+C content of 38% (31).
These viruses are encircled with an envelope
containing viral k0VV ducks, and pigs are not at all
susceptible to SARScov-2 (329).
Similarly, the National Veterinary Services
Laboratories of the USDA have reported COVID-19
in tigers and lions that exhibited respiratory signs
like dry cough and wheezing. The zoo animals are
suspected to have been Infected by an
asymptomatic zookeeper (335). The total number
of COVID-19positive cases in human beings is
Increasing at a high rate, thereby creating ideal

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conditions for viral spillover to other species, such

as pigs. The evidence obtained from SARS-CoV
suggests that pigs can get infected with SARS-
CoV-2 (336). However, experimental inoculation
with SARS-CoV-2 failed to infect pigs (329).
Further studies are required to identify the possible
animal reservoirs of SARS-CoV-2 and the seasonal
variation in the circulation of these viruses in the
animal population. Research collaboration
between human and animal health sectors is
becoming a necessity to evaluate and identify the
possible risk factors of transmission between
animals and humans. Such cooperation will help to
devise efficient strategies for the management of
emerging zoonotic diseases (12).
• All clinicians should keep themselves updated
about recent developments including global
spread of the disease.
• Non-essential international travel should be
avoided at this time.
• People should stop spreading myths and false
information about the disease and try to allay panic
and anxiety of the public.
Conclusions
This new virus outbreak has challenged the
economic, medical and public health infrastructure

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of China and to some extent, of other countries

especially, its neighbours. Time alone will tell how
the virus will impact our lives here in India. More
so, future outbreaks of viruses and pathogens of
zoonotic origin are likely to continue. Therefore,
apart from curbing this outbreak- efforts should
be made to route warrants the introduction of
negative fecal viral nucleic acid test results as one
of the additional discharge criteria In laboratory-
confirmed cases of COVID-19 (326).
The COVID-19 pandemic does not have any novel
factors, other than the genetically unique pathogen
and a further possible reservoir. The cause and the
likely future outcome are just repetitions of our
previous interactions with fatal coronauruses. The
only difference is the time of occurrence and the
genetic distinctness of the pathogen involved.
Mutations on the RBI) of CoVs facilitated their
capability of infecting newer hosts, thereby
expanding their reach to all corners of the world
(85). This is a potential threat to the health of both
animals and humans. Advanced studies using
Bayesian phylogeographic reconstruction
identified the most probable origin of SARS-CoV- 2
as the bat SARS-1ike coronavn-us, circulating in
the Rhinolophus bat family (86).

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Phylogenetic analysis of 10 whole-genome

sequences of SARS-CoV-2 showed that they are
related to two CoVs of bat origin, namely, bat-
SLCOVZC45 and bat-SL-C0VZXC21, which were
reported during 2018 in China (17). It was reported
that SARS-CoV-2 had been confirmed to use
ACE2 as an entry receptor while exhibiting an RBD
similar
severe illness, to minimise the risk of exposure to
COVID-1 9 during outbreaks.53
9 VACCINES
The strange coronavirus outbreak in the Chinese
city of Wuhan, now termed COVID-1 9, and its
rapid transmission, threatens people around the
world. Because of its pandemic nature, the
National Institutes of Health (NIH) and
pharmaceutical companies are involved in the
development of COVID-1 9 vaccines. Xu Nanping,
China's vice-minister of science and technology,
announced that the first vaccine is expected to be
ready for clinical trials in China at the end of April
2020. 54 There is no approved vaccine and
treatment for COVID-1 9 infections.

Vaccine development is sponsored and supported

by the Biomedical Advanced Research and

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Development Authority (BARDA), a component of

the Office of the Assistant Secretary for
Preparedness and Response
(ASPR). Sanofi will use its egg-free, recombinant
DNA technology to produce an exact genetic
match to proteins of the virus.55
involved in the COVID-19 outbreak is of great
importance, because the stram on their mental
wellbeing will affect their attention, concentration,
and decision-making capacity. Hence, for control
of the COVID-19 outbreak, rapid steps should be
taken to protect the mental health of medical
workers (229).
Since the living mammals sold in the wet market
are suspected to be the intermediate host of
SARSCoV-2, there is a need for strengthening the
regulatory mechanism for wild animal trade (13).
The total number of COVID-19 confirmed cases is
on a continuous rise and the cure rate is relatively
low, making disease control very difficult to
achieve. The Chinese government is making
continuous efforts to contain the disease by taking
emergency control and prevention measures. They
have already built a hospital for patients affected
by this virus and are currently building several
more for accommodating the continuously

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increasing infected population (230). The effective

control of SARSCoV-2/COVID-19 requires high-
level interventions like intensive contact tracing, as
well as the quarantine of people with suspected
infection and the isolation of infected individuals.
The implementation of rigorous control and
preventive measures together might control the Ro
number and reduce the transmission risk (228).
Considering the zoonotic 07:28 0 • category A
agents (cholera, plague). Patients should be placed
in separate rooms or cohorted together. Negative
pressure rooms are not generally needed. The
rooms and surfaces and equipment should
undergo regular decontamination preferably with
sodium hypochlorite. Healthcare workers should
be provided with fit tested N95 respirators and
protective suits and goggles. Airborne
transmission precautions should be taken during
aerosol generating procedures such as intubation,
suction and tracheostomies. All contacts including
healthcare workers should be monitored for
development of symptoms of COVID-19. Patients
can be discharged from isolation once they are
afebrile for atleast 3 d and have two consecutive
negative molecular tests at 1 d sampling interval.
This recommendation is different from pandemic

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flu where patients were

Animal Models and Cell Cultures
For evaluating the potential of vaccines and
therapeutics against CoVs, including SARS- CoV,
MERS-CoVs, and the presently emerging
SARSCoV-2, suitable animal models that can
mimic the clinical disease are needed (211, 212).
Various ammal models were assessed for SARS-
and MERSCoVs, such as mice, guinea pigs,
golden Syrian hamsters, ferrets, rabbits,
nonhuman primates like rhesus macaques and
marmosets, and cats (185, 213—218). The
specificity of the virus to hACE2 (receptor of
SARS-CoV) was found to be a significant barrier in
developing animal models. Consequently, a SARS-
CoV transgenic mouse model has been developed
by inserting the hACE2 gene into the mouse
genome (219). The inability of MERS-CoV to
replicate in the respiratory tracts of animals (mice,
hamsters, and ferrets) is another limiting factor.
However, with genetic engineering, a 288-330+|+
MERS-CoV genetically modified mouse model was
developed and now is in use for the assessment of
novel drugs and vaccmes against MERS-CoV
(220). In the past, small animals (mice or hamsters)
have been targeted for being closer to a

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humanized structure, such as mouse DPP4 altered

with human DPP4 (hDPP4), hDPP4-transduced
mice and hDPP4-Tg mice transgenic for
exDressing
perfonnance (iable 2) (80, 245, 246). The viral loads
of SARS-CoV-2 were measured using N-
genespecific quantitative RT-PCR in throat swab
and sputum samples collected from COVID-19-
infected individuals. The results indicated that the
viral load peaked at around 5 to 6 days following
the onset of symptoms, and it ranged from 104 to
107 copies/ml during this time (151). In another
study, the viral load was found to be higher in the
nasal swabs than the throat swabs obtained from
COVID-19 symptomatic patients (82). Although
initially it was thought that viral load would be
associated with poor outcomes, some case
reports have shown asymptomatic individuals with
high Viral loads (247). Recently, the viral load in
nasal and throat swabs of 17 symptomatic patients
was

determined, and higher viral loads were recorded

soon after the onset of symptoms, particularly in
the nose compared to the throat. The pattern of
viral nucleic acid shedding of SARS-CoV-2-

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mfected patients was similar to that of Influenza

patients but seemed to be different from that of
SARS-CoV patients. The viral load detected in
asymptomatic patients resembled that of
symptomatic patients as studied in China, which
reflects the transmission perspective of
asymptomatic or symptomatic patients having
minimum signs and symptoms (82). Another study,
6.1 Laboratory testing for coronavirus disease
2019 (COVID19) in suspected human cases
The assessment of the patients with COVID-1 9
should be based on the clinical features and also
epidemiological factors. The screening protocols
must be prepared and followed per the native
context. 31 Collecting and testing of specimen
samples from the suspected individual is
considered to be one of the main principles for
controlling and managing the outbreak of the
disease in a country. The suspected cases must
be screened thoroughly in order to detect the virus
with the help of nucleic acid amplification tests
such as reverse transcription polymerase chain
reaction (RTPCR). If a country or a particular region
does not have the facility to test the specimens,
the specimens of the suspected individual should
be sent to the nearest reference laboratories per

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the list provided by WHO.32

It is also recommended that the suspected
patients be tested for the other respiratory
pathogens by performing the routine laboratory
investigation per the local guidelines, mainly to
differentiate from other viruses that include
influenza virus, parainfluenza virus, adenovirus,
respiratory syncytial virus, rhinovirus, human
another study, the average reproductive number of
COVID-19 was found to be 3.28, which is
significantly higher than the initial WHO estimate of
1.4 to 2.5 (77). It is too early to obtain the exact Ro
value, since there is a possibility of bias due to
insufficient data. The higher Ro value is indicative
of the more significant potential of SARS-CoV-2
transmission in a susceptible population. This is
not the first time where the culinary practices of
China have been blamed for the origin of novel
coronavirus infection In humans. Previously, the
animals present in the live-animal market were
identified to be the intermediate hosts of the SARS
outbreak in China (78). Several wildlife species
were found to harbor potentially evolving
coronavirus strains that can overcome the species
barrier (79). One of the main principles of Chinese
food culture is that liveslaughtered animals are

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considered more nutritious (5).

After 4 months of struggle that lasted from
December 2019 to March 2020, the COVID-19
situation now seems under control in China. The
wet animal markets have reopened, and people
have started buying bats, dogs, cats, birds,
scorpions, badgers, rabbits, pangolins (scaly
anteaters), minks, soup from palm civet, ostriches,
hamsters, snapping turtles, ducks, fish, Siamese
crocodiles, and other A suspected case of
COVID-19 infection is said to be confirmed if the
respiratory tract aspirate or blood samples test
positive for SARS-CoV-2 nucleic acid using RT-
PCR or by the identification of SARSCoV-2 genetic
sequence in respiratory tract aspirate or blood
samples (80). The patient will be confirmed as
cured when two subsequent oral swab results are
negative (153). Recently, the live virus was
detected in the self-collected saliva of patients
infected with COVID- 19. These findings were
confirmative of using saliva as a noninvasive
specimen for the diagnosis of COVID-19 infection
in suspected individuals (152). It has also been
observed that the initial screening of COVID-19
patients infected with RT-PCR may give negative
results even if they have chest CT findings that are

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suggestive of infection. Hence, for the accurate

diagnosis of COVID-19, a combination of repeated
swab tests using RT-PCR and CT scanning is
required to prevent the possibility of false-negative
results during disease screening (154). RT-PCR is
the most widely used test for diagnosing
COVID-19. However, it has some significant
limitations from the clinical perspective, since it will
not give any clarity regarding disease progression.
Droplet digital PCR (ddPCR) can be used for the
quantification of viral load in the samples obtained
from lower respiratory tracts.
Infected by human bemgs. However, evidence of
catto-human transmission is lacking and requires
further studies (332). Rather than waiting for firmer
evidence on animal-to-human transmission,

necessary preventive measures are advised, as

well as following social distancing practices among
companion animals of different households (331).
One of the leading veterinary diagnostic
companies, IDEXX, has conducted large-scale
testing for COVID-19 in specimens collected from
dogs and cats. However, none of the tests turned
out to be positive (334).
In a study conducted to investigate the potential of

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different animal species to act as the intermediate

host of SARS-CoV-2, it was found that both ferrets
and cats can be infected via experimental
Inoculation of the virus. In addition, infected cats
efficiently transmitted the disease to naive cats
(329). SARSCoV-2 infection and subsequent
transmission in ferrets were found to recapitulate
the clinical aspects of COVID-19 in humans. The
infected ferrets also shed virus via multiple routes,
such as saliva, nasal washes, feces, and urine,
postinfection, making them an ideal animal model
for studying disease transmission (337).
Experimental inoculation was also done in other
animal species and found that the dogs have low
susceptibility, while the chickens,
Splits Tree phylogeny analysis.
In the unrooted phylogenetic tree of different
betacoronaviruses based on the S protein, virus
sequences from different subgenera grouped into
separate clusters. SARS-CoV-2 sequences from
Wuhan and other countries exhibited a close
relationship and appeared in a single cluster (Fig. l)
The CoVs from the subgenus Sarbecovirus
appeared jointly in SplitsTree and divided into
three subclusters, namely, SARS-CoV-2, bat-
SARS-likeCOV (bat-SL-C0V), and SARS-C0V (Fig.

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1). In the case of other subgenera, like

Merbecovirus, all of the sequences grouped in a
single cluster, whereas in Embecovirus, different
species, comprised of camne respiratory CoVs,
bovine CoVs, equine CoVs, and human COV strain
(OC43), grouped in a common cluster. Isolates in
the subgenera Nobecovorus and Hibecovirus were
found to be placed separately away from other
reported SARS-CoVs but shared a bat origin.
CURRENT WORLDWIDE SCENARIO OF
SARS-C0V-2
This novel virus, SARS-CoV-2, comes under the
subgenus Sarbecovirus of the
Orthocoronavirinae subfamily and is entirely
different from the viruses
as an entry receptor wilile exliióilmg an sillillar to
that of SARS-C0V (17, 87, 254, 255). Several
countries have provided recommendations to their
people traveling to China (88, 89). Compared to
the previous coronavirus outbreaks caused by
SARSCOV and MERS-C0V, the efficiency of
SARS- C0V2 human-to-human transmission was
thought to be less. This assumption was based on
the finding that health workers were affected less
than they were in previous outbreaks of fatal
coronaviruses (2). Superspreading events are

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considered the main culprit for the extensive

transmission of SARS and MERS (90, 91). Almost
half of the MERS-C0V cases reported in Saudi
Arabia are of secondary origin that occurred
through contact with infected asymptomatic or
symptomatic individuals through human-to-human
transmission (92). The occurrence of
superspreading events in the COVID-19 outbreak
cannot be ruled out until its possibility is evaluated.
Like SARS and MERS, COVID-19 can also infect
the lower respiratory tract, with milder symptoms
(27). The basic reproduction number of COVID-19
has been found to be in the range of 2.8 to 3.3
based on real-time reports and 3.2 to 3.9 based on
predicted infected cases (84). virological,
radiological, and pathological observations
indicated that the monkeys with reexposure had
no recurrence of COVID- 19, like the SARS-CoV-2-
infected monkeys without rechallenge. These
findings suggest that primary infection with SARS-
CoV-2 could protect from later exposures to the
virus, which could help in defining disease
prognosis and crucial Inferences for desigmng and
developing potent vaccines against COVID-19
(274).
PREVENTION, CONTROL, AND MANAGEMENT

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In contrast to their response to the 2002 SARS

outbreak, China has shown immense political
openness in reporting the COVID-19 outbreak
promptly. They have also performed rapid
sequencing of COVID-19 at multiple levels and
shared the findings globally within days of
identifying the novel virus (225). The move made
by China opened a new chapter in global health
security and diplomacy. Even though complete
lockdown was declared following the COVID-19
outbreak in Wuhan, the large-scale movement of
people has resulted in a radiating spread of
infections in the surrounding provinces as well as
to several other countries. Large-scale screening
programs might
ul UPIELò ILL UCPUò1L on surfaces. The virus can
remain viable on surfaces for days in favourable
atmospheric conditions but are destroyed in less
than a minute by common disinfectants like
sodium hypochlorite, hydrogen peroxide etc. [13].
Infection is acquired either by inhalation of these
droplets or touching surfaces contaminated by
them and then touching the nose, mouth and eyes.
The virus is also present in the stool and
contamination of the water supply and subsequent

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transmission via aerosolization/feco oral route is

also hypothesized [6]. As per current information,
transplacental transmission from pregnant women
to their fetus has not been described [14].
However, neonatal disease due to post natal
transmission is described [14].
The incubation period varies from 2 to 14 d
[median 5 d]. Studies have
identified angiotensin receptor 2 cat and camels,
respectively, act as amplifier hosts (40, 41).
Coronavirus genomes and subgenomes encode
six ORFs (31). The majority of the 5' end is
occupied by ORFla/b, which produces 16 nsps.
The two polyproteins, ppla and pplab, are initially
produced from ORFla/b by a —l frameshift
between ORFla and ORFlb (32). The virus-encoded
proteases cleave polyproteins into individual nsps
(main protease [Mpro], chymotrypsin-like protease
[3CLpro], and papain-like proteases [PLPs]) (42).
SARS-C0V-2 also encodes these nsps, and their
functions have been elucidated recently (31).
Remarkably, a difference between SARS- CoV-2
and other CoVs is the identification of a novel short
putative protein within the ORF3 band, a secreted
protein with an alpha helix and beta-sheet with SIX
strands encoded by ORF8 (31).

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Coronaviruses encode four major structural

proteins, namely, spike (S), membrane (M),
envelope (E), and nucleocapsid (N), which are
described in detail below.
S Glycoprotein
Coronavirus S protein is a large, multifunctional
class I viral transmembrane protein. The
size of this
Based on molecular characterization, SARSCoV-2
is considered a new Betacoronavirus
belonging to the subgenus Sarbecovirus (3). A few
other critical zoonotic viruses (MERS-related COV
and SARS-related COV) belong to the same genus.
However, SARS-CoV-2 was identified as a distinct
virus based on the percent identity with other
Betacoronavirus; conserved open reading frame la/
b (ORF1a/b) is below 90% identity (3). An overall
80% nucleotide identity was observed between
SARS-C0V-2 and the original SARS-C0V, along
with identity with ZC45 and ZXC21 SARSrelated
CoVs of bats (2, 31, 36). In addition, 82% identity
has been observed between SARS- CoV-2 and
human SARS-C0V Tor2 and human SARS-C0V
BJOI 2003 (31). A sequence identity of only 51.8%
was observed between MERS-related COV and
the recently emerged SARS-CoV-2 (37).

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Phylogenetic analysis of the structural genes also

revealed that SARS-C0V-2 is closer to bat SARS-
re1ated COV. Therefore, SARS-CoV-2 might have
originated from bats, while other amplifier hosts
might have played a role in disease transmission to
humans (31). Of note, the other two zoonotic CoVs
(MERS-related COV and SARS-related COV) also
originated from bats (38, 39). Nevertheless, for
SARS and MERS, civet
this emerging virus will establish a niche in humans
and coexist with us for a long time166. Before
clinically approved vaccines are widely available,
there is no better way to protect us from SARS-
CoV-2 than personal preventive behaviours such
as social distancing and wearing masks, and
public health measures, including active testing,
case tracing and restrictions on social gatherings.
Despite

a flood of SARS-CoV-2 research published every

week, current knowledge of this novel coronavirus
is just the tip of the iceberg. The animal origin and
cross-species infection route of SARS-CoV-2 are
yet to be uncovered. The molecular mechanisms of
SARS-CoV-2 infection pathogenesis and virus-
host

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by the University of Oxford. In a randomized

controlled phase 1/11 trial, it induced neutralizing
antibodies against SARS-CoV-2 in all 1,077
participants after a second vaccine dose, while its
safety profile was acceptable as well 63. The NIAID
and Moderna co-manufactured mRNA- 1273, a
lipid nanoparticle-formulated mRNA vaccine
candidate that encodes the stabilized prefusion
SARS-CoV-2 S protein. Its immunogenicity has
been confirmed by a phase I trial in which robust
neutralizing antibody responses were induced in a
dose-dependent manner and increased after a
second dose 64. Regarding inactivated vaccines, a
successful phase 1/11 trial involving 320
participants has been reported in China. The
whole-virus COVID-19 vaccine had a low rate
ofadverse reactions and effectively induced
neutralizing antibody production 65. The verified
safety and immunogenicity support advancement
of these vaccine candidates to phase Ill clinical
trials, which will evaluate their efficacy in
protecting healthy populations from SARS-CoV-2
infection.

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Future perspectives
COVID-19 is the third highly pathogenic human
coronavirus disease to date. Although less deadly
than SARS and MERS, the rapid spreading of this
highly contagious disease has posed the severest
threat to global health in this century. The SARS-
CoV-2 outbreak has lasted for more than half a
year now, and it is likely that
asymptomatic patients. These abnormalities
progress from the initial focal unilateral to diffuse
bilateral ground-glass opacities and will further
progress to or coexist with lung consolidation
changes within I to 3 weeks (159). The role played
by radiologists in the current scenario is very
important. Radiologists can help in the early
diagnosis of lung abnormalities associated with
COVID-19 pneumonia. They can also help in the
evaluation of disease severity, identifying its
progression to acute respiratory distress syndrome
and the presence of secondary bacterial infections
(160). Even though chest CT is considered an
essential diagnostic tool for COVID-19, the
extensive use of CT for screening purposes In the
suspected individuals might be associated with a
disproportionate risk-benefit ratio due to Increased
radiation exposure as well as increased risk of

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crossinfection. Hence, the use of CT for early

diagnosis of SARS-CoV-2 Infection In high- risk
groups should be done with great caution (292).
More recently, other advanced diagnostics have
been designed and developed for the detection of
SARS-C0V-2 (345, 347, 350-352). A reverse
transcriptional loop-mediated isothermal
amplification (RT-LAMP), namely, iLACO, has been
developed for rapid and colorimetric detection of
this Some therapeutic options for treating
COVID-19 showed efficacy In in vitro studies;
however, to date, these treatments have not
undergone any randomized animal or human
clinical trials, which limit their practical applicability
in the current pandemic (7, 9, 19-21).
The present comprehensive review describes the
various features of SARS-CoV-2/COVID- 19
causing the current disease outbreaks and
advances in diagnosis and developing vaccines
and therapeutics. It also provides a brief
comparison with the earlier SARS and MERS
CoVs, the veterinary perspective of CoVs and this
emerging novel pathogen, and an evaluation of the
zoonotic potential of similar CoVs to provide
feasible One Health strategies for the management
of this fatal virus (22—367).

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THE VIRUS (SARS-C0V-2)

Coronaviruses are positive-sense RNA viruses
having an extensive and promiscuous range
of natural hosts and affect multiple systems (23,
24). Coronauruses can cause clinical diseases m
humans that may extend from the common cold to
more severe respiratory diseases like SARS and
MERS (17, 279). The recently emerging SARS-
C0V-2 has wrought havoc in China and caused a
pandemic qitnntinn in the worldwide nonillntinn
lendino to

Epidemiology and Pathogenesis [10, 11]

All ages are susceptible. Infection is transmitted
through large droplets generated during coughing
and sneezing by symptomatic patients but can
also occur from asymptomatic people and before
onset of symptoms [9]. Studies have shown higher
viral loads in the nasal cavity as compared to the
throat with no difference in viral burden between
symptomatic and asymptomatic people [12].
Patients can be infectious for as long as the
symptoms last and even on clinical recovery.
Some people may act as super spreaders; a UK
citizen who attended a conference in Singapore
infected 11 other people while staying in a resort in

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the French Alps and upon return to the UK [6].

These infected droplets can spread 1—2 m and
deposit SÂåQb- or IVIEIQS-CoV outbreak (ILO).
flowcvcr, there has been concern regarding the
impact of SARS-C0V-2/COVID-19 on pregnancy.
Researchers have mentioned the probability of in
utero transmission of novel SARS-CoV-2 from
COVID19-infected mothers to their neonates in
China based upon the rise in IgM and IgG antibody
levels and cytokine values in the blood obtained
from newborn infants immediately postbirth;
however, RT-PCR failed to confirm the presence of
SARS-CoV-2 genetic material in the infants (283).
Recent studies show that at least in some cases,
preterm delivery and its consequences are
associated with the virus. Nonetheless, some
cases have raised doubts for the likelihood of
vertical transmission (240—243)
COVID-19 infection was associated with
pneumonia, and some developed acute respiratory
distress syndrome (ARDS). The blood biochemistry
indexes, such as albumm, lactate dehydrogenase,
Creactive protein, lymphocytes (percent), and
neutrophils (percent) give an idea about the
disease severity in COVID-19 infection (121).
During COVID-19, patients may present

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leukocytosis, leukopenia with lymphopenia (244),

hypoalbuminemia, and an increase of lactate
dehydrogenase, aspartate transaminase, alanine
aminotransferase, bilirubin, and, especially, D-
dimer
protems without the presence of S protem would
not confer any noticeable protection, with the
absence of detectable serum SARS-CoV-
neutralizing antibodies (170). Antigenic determinant
sites present over S and N structural proteins of
SARS-CoV-2 can be explored as suitable vaccine
candidates (294). In the Asian population, S, E, M,
and N proteins of SARSCoV-2 are being targeted
for developing subunit vaccines against COVID-19
(295)
The identification of the immunodominant region
among the subunits and domains of S protein is
critical for developing an effective vaccine against
the coronavirus. The C-terminal domain of the Sl
subunit IS considered the immunodominant region
of the porcine deltacoronavirus S protein (171).
Similarly, further investigations are needed to
determine the immunodominant regions of
SARSCoV-2 for facilitating vaccine development.
However, our previous attempts to develop a
universal vaccine that is effective for both

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SARSCOV and MERS-C0V based on T-cell

epitope similarity pointed out the possibility of
crossreactivity among coronaviruses (172). That
can be made possible by selected potential
vaccine targets that are common to both viruses.
SARS-CoV-2 has been reported to be closely
related to SARS-CoV (173, 174). Hence,
knowledge and understanding of
visible Signs oi miecuon, making It challengmg to
identify animals actively excreting MERS-CoV that
has the potential to infect humans. However, they
may shed MERS-CoV through milk, urine, feces,
and nasal and eye discharge and can also be
found in the raw organs (108). In a study
conducted to evaluate the susceptibility of animal
species to MERS-CoV infection, llamas and pigs
were found to be susceptible, indicating the
possibility of MERSCOV circulation in animal
species other than dromedary camels (109).
Following the outbreak of SARS in China, SARS-
CoV-like viruses were isolated from Himalayan
palm civets (Paguma larvata) and raccoon dogs
(Nyctereutes procyonoides) found in a live-animal
market in Guangdong, China. The animal isolates
obtained from the live-animal market

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retained a 29-nucleotide sequence that was not

present in most of the human isolates (78). These
findings were critical in identifying the possibility of
Interspecies transmission in SARS-CoV. The
higher diversity and prevalence of bat
coronaviruses in this region compared to those in
previous reports indicate a host/pathogen
coevolution. SARS-1ike coronauruses also have
been found circulating in the Chinese horseshoe
bat (Rhinolophus sinicus) populations. The in vitro
and in vivo studies carried
13 CONVALESCENT PLASMA THERAPY
Guo Yanhong, an official with the National Health
Commission (NHC), stated that convalescent
plasma therapy is a significant method for treating
severe COVID-19 patients. Among the COVID- 19
patients currently receiving convalescent plasma
therapy in the virus-hit Wuhan, one has been
discharged from hospital, as reported by Chinese
science authorities on Monday, 17th February
2020 in Beijing. The first dose of convalescent
plasma from a COVID-19 patient was collected on
1st and 9th February 2020 from a severely ill
patient who was given treatment at a hospital in
Jiangxia District in Wuhan. The presence of the
virus in patients is minimised by the antibodies in

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the convalescent plasma. Guiqiang stated that

donating plasma may cause minimal harm to the
donor and that there is nothing to be worried
about. Plasma donors must be cured patients and
discharged from hospital. Only plasma is used,
whereas red blood cells (RBC), white blood cells
(WBC) and blood platelets are transfused back into
the donor's body. Wang alleged that donor's
plasma will totally improve to its initial state after
one or 2 weeks from the day of plasma donation of
around 200 to 300 millilitres.61
We assessed the nucleotide percent similarity
using the MegAlign software program, where the
similarity between the novel SARS-CoV-2 isolates
was in the range of 99.4% to 100%. Among the
other Serbecovirus COV sequences, the novel
SARS-CoV2 sequences revealed the highest
similarity to batSL-CoV, with nucleotide percent
identity ranges between 88.12 and 89.65%.
Meanwhile, earlier reported SARS-C0Vs showed
70.6 to 74.9% similarity to SARS-CoV-2 at the
nucleotide level. Further, the nucleotide percent
similarity was 55.4%,
45.5% to 47.9%, 46.2% to 46.6%, and 45.0% to
46.3% to the other four subgenera, namely,
Hibecovirus, Nobecovirus, Merbecovirus, and

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Embecovirus, respectively. The percent similarity

index of current outbreak isolates indicates a close
relationship between SARS-CoV-2 isolates and
batSL-CoV, indicating a common origin. However,
particular pieces of evidence based on further
complete genomic analysis of current isolates are
necessary to draw any conclusions, although it
was ascertained that the current novel SARS-
CoV-2 isolates belong to the subgenus
Sarbecovirus in the diverse range of
betacoronaviruses. Their possible ancestor was
hypothesized to be from bat COV strains, wherein
bats might have played a crucial role in harboring
this class of viruses.
having proven uses against other viral pathogens
can be employed for SARS-CoV-2-infected
patients. These possess benefits of easy
accessibility and recognized pharmacokinetic and
pharmacodynamic activities, stability, doses, and
side effects (9). Repurposed drugs have been
studied for treating COV infections, like lopinavir/
ritonaur, and interferon-IP revealed in vitro anti-
MERS-CoV action. The in vivo experiment carried
out in the nonhuman primate model of common
marmosets treated with lopinavir/ritonavlr and
interferon beta showed superior protective results

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In treated animals than in the untreated ones (190).

A combination of these drugs is being evaluated to
treat MERS in humans (MIRACLE trial) (191). These
two protease inhibitors (lopinavir and ritonavir), in
combination with ribavirin, gave encouraging
clinical outcomes in SARS patients, suggesting
their therapeutic values (165). However, in the
current scenario, due to the lack of specific
therapeutic agents against SARSCoV-2,
hospitalized patients confirmed for the disease are
given supportive care, like oxygen and fluid
therapy, along with antibiotic therapy for managing
secondary bacterial infections (192). Patients with
novel coronavirus or COVID-19 pneumonia who
are mechanically ventilated often require
sedatives- analgesics. and even muscle comprised
a small population and, hence, Ille possibility of
misinterpretation could arise. However, In another
case study, the authors raised concerns over the
efficacy of hydroxychloroquineazithromycin in the
treatment of COVID-19 patients, since no
observable effect was seen when they were used.
In some

cases, the treatment was discontinued due to the

prolongation of the QT interval (307). Hence,

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further randomized clinical trials are required

before concluding this matter.
Recently, another FDA-approved drug, ivermectin,
was reported to inhibit the in vitro replication of
SARS-CoV-2. The findings from this study indicate
that a single treatment of this drug was able to
induce an —5,000-fold reduction in the viral RNA
at 48 h in cell culture. (308). One of the main
disadvantages that limit the clinical utility of
ivermectin is its potential to cause cytotoxicity.
However, altering the vehicles used in the
formulations, the pharmacokinetic properties can
be modified, thereby having significant control over
the systemic concentration of ivermectin (338).
Based on the pharmacokinetic simulation, it was
also found that ivermectin may have limited
therapeutic utility m managing COVID-19, since
the inhibitory concentration that has to be
achieved for effective anti-SARS-CoV-2 activity is
far higher than the results of the clinical trial
showed that the patients who were given
chloroquine had a significant reduction in their
body temperature. The clinical trial also showed
better recovery among the patients who were
given chloroquine and hydroxy chloroquine.63-65
Hydroxychloroquine treatment is significantly

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associated with viral load reduction as well as

disappearance in COVID-1 9 patients. Further, the
outcome is reinforced by azithromycin. The role of
lopinavir and ritonavir in the treatment of
COVID-19 is uncertain. A potential benefit was
suggested by preclinical data, but additional data
has failed to confirm it. Tocilizumab is an
immunomodulating agent used as adjunct therapy
in some protocols based on a theoretical
mechanism and limited preliminary data.66

15 HOME CARE
Home management may be appropriate for
patients with mild infection who can be adequately
isolated in the outpatient setting. Management of
such patients should focus on prevention of
transmission to others, and monitoring for clinical
deterioration, which should prompt hospitalisation.
Interim recommendations on home management
of patients with COVID-19 can be found on
The pathogenesis of SARS-CoV-2 infection in
humans manifests itself as mild symptoms to
severe respiratory failure. On binding to epithelial
cells in the respiratory tract, SARS-CoV-2 starts
replicating and migrating down to the airways and
enters alveolar epithelial cells in the lungs. The

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rapid replication of SARS-CoV-2 in the lungs may

trigger a strong immune response. Cytokine storm
syndrome causes acute respiratory distress
syndrome and respiratory failure, which is
considered the main cause of death in patients
with COVID-19 (REFS60'61). Patients of older age
(>60 years) and with serious pre-existing diseases
have a greater risk of developing acute respiratory
distress syndrome and death62-64 (FIG. 4).
Multiple organ failure has also been reported in
some COVID-19 cases
Histopathological changes in patients with COVID-
19 occur mainly in the lungs. Histopathology
analyses showed bilateral diffused alveolar
damage, hyaline membrane formation,
desquamation of pneumocytes and fibrin deposits
in lungs of patients with severe COVID-19.
Exudative inflammation was also shown in some
cases. Immunohistochemistry assays detected
SARS-CoV-2 antigen in the upper airway,
bronchiolar epithelium and submucosal gland
epithelium, as well as in type I and type Il
pneumocytes, alveolar macrophages and hyaline
membranes in the lungs
Animal models used for studying SARS-CoV-2
infection pathogenesis include non-human

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primates (rhesus macaques, cynomolgus

monkeys, marmosets and African green monkeys),
mice (wild-type mice (with mouse-adapted virus)
and human ACE2-transgenic or human ACE2-
knock- in mice), ferrets and golden hamsters . In
non-human primate animal models, most species
display clinical features similar to those of patients
with COVID- 19, including virus shedding, virus
replication and host responses to SARS-CoV-2
infection For example, in the rhesus macaque
model, high viral loads were detected in the upper
and
Initially, the epicenter of the SARS-CoV-2
pandemic was China, which reported a significant
number of deaths associated with COVID-19, with
84,458 laboratory-confirmed cases and 4,644
deaths as of 13 May 2020 (Fig. 4). As of 13 May
2020, SARS-CoV-2 confirmed cases

have been reported in more than 210 countries

apart from China (Fig. 3 and 4) (WHO Situation
Report 114) (25, 64). COVID-19 has been reported
on all continents except Antarctica. For many
weeks, Italy was the focus of concerns regarding
the large number of cases, with 221,216 cases and
30,911 deaths, but now, the United States is the

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country with the largest number of cases,

1,322,054, and 79,634 deaths. Now, the United
Kingdom has even more cases (226,4671) and
deaths (32,692) than Italy. A John Hopkins
University web platform has provided daily
updates on the basic epidemiology of the
COVID-19 outbreak
vitro antiviral potential of FAD-approved drugs,
viz., ribavirin, penciclovir, nitazoxanide,
nafamostat, and chloroquine, tested in comparison
to remdesivir and favipiravir (broad-spectrum
antiviral drugs) revealed remdesivir and
chloroquine to be highly effective against SARS-
CoV-2 Infection in vitro (194). Ribavirin, penciclovir,
and favipiravir might not possess noteworthy in
vivo antiviral actions for SARS-CoV-2, since higher
concentrations of these nucleoside analogs are
needed in vitro to lessen the Viral infection. Both
remdesivir and chloroquine are being used in
humans to treat other diseases, and such safer
drugs can be explored for assessing their
effectiveness in COVID-19 patients.
Several therapeutic agents, such as lopmavir/
ritonaur, chloroquine, and hydroxychloroquine,
have been proposed for the clinical management
of COVID-19 (299). A molecular docking study,

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conducted in the RNAdependent RNA polymerase

(RdRp) of SARS-CoV-2 using different
commercially available antipolymerase drugs,
identified that drugs such as ribavirin, remdesivir,
galidesivir, tenofovir, and sofosbuvir bind RdRp
tightly, indicating their vast potential to be used
against COVID-19 (305). A broad-spectrum
antiviral drug that was developed in the United
States, tilorone dihydrochloride (tilorone),
and chest discomfort, and in severe cases
dyspnea and bilateral lung infiltration6' . Among
the first 27 documented hospitalized patients,
most cases were epidemiologically linked to
Huanan Seafood Wholesale Market a wet market
located in downtown Wuhan, which sells not only
seafood but also live animals, including poultry and
wildlife4J. According to a retrospective study, th€
onset of the first known case dates back to 8
December 2019 (REF.). On 31 December, Wuhan
Municipal Health Commission notified the public of
a pneumonia outbreak of unidentified cause and
informed
the World Health Organization (WHO) 9 (FIG, l).
By metagenomic RNA sequencing and virus
isolation from bronchoalveolar lavage fluid
samples from patients with severe pneumonia,

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independent teams ofChinese scientists identified

that the causative agent oi this emerging disease is
a betacoronavirus that had never been seen
before6'10'11 On 9 January 2020, the result oj this
etiological identification was publicly announced
(FIG. l). The first genome sequence of the novel
coronavirus was published on the Virological
website on 10 January, and more nearly complete
genome sequences determined by different
researchinstituteswerethenreleasedviatheGISAIDd
atabaseon12January7 Later,morepatients with no
history of exposure tc
Huanan Seafood Wholesale Market were identified
Several familial clusters of infection were reported
and nosocomial infection also occurred in health-
car€ facilities. All these cases provided clear
evidence for human-to-human transmission of the
new virus4, 12-14 As the outbreak coincided with
the approach of lunar New Year, travel between
cities before the festival facilitated virus
transmission in China. This novel coronavirus
pneumonia soon spread to other cities in Hubei
Drovince and to other Darts of China. Within 1
month,
vaccine, and Ii-Key peptide COVID-19 vaccine are
under preclinical trials (297). Similarly, the WHO,

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on its official website, has mentioned a detailed list

of COVID-19 vaccine agents that are under
consideration. Different phases of trials are
ongoing for live attenuated virus vaccines,
formaldehyde alum inactivated vaccine,
adenovirus type 5 vector vaccine, LNP-
encapsulated mRNA vaccine, DNA plasmid
vaccine, and S protein, S-trimer, and Ii-Key
peptide as a subunit protein vaccme, among
others (298). The process of vaccine development
usually takes approximately ten years, in the case
of Inactivated or live attenuated vaccines, since it
involves the generation of long-term efficacy data.
However, this was brought down to 5 years during
the Ebola emergency for viral vector vaccines. In
the urgency associated with the COVID-19
outbreaks, we expect a vaccine by the end of this
year (343). The development of an effective
vaccine against COVID-19 with high speed and
precision is the combined result of advancements
in computational

biology, gene synthesis, protein engineering, and

the Invention of advanced manufacturing platforms
(342).
The recurring nature of the coronavirus outbreaks

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calls for the development of a pan- coronavirus

vaccine that can produce cross-reactive
antibodies.
N Protein
The N protein of coronavirus is multipurpose.
Among several functions, it plays a role In complex
formation with the viral genome, facilitates M
protein interaction needed during virion assembly,
and enhances the transcription efficiency of the
virus (55, 56). It contains three highly conserved
and distinct domains, namely, an NTD, an RNA-
binding domain or a linker region (LKR), and a CTD
(57). The NTD binds with the 3' end of the viral
genome, perhaps via electrostatic interactions, and
is highly diverged both in length and sequence
(58). The charged LKR is serine and arginine rich
and is also known as the SR (serine and arginine)
domain (59). The LKR is capable of direct
interaction with in vitro
RNA interaction and is responsible for cell
signaling (60, 61). It also modulates the antiviral
response of the host by working as an antagonist
for interferon (IFN) and RNA interference (62).
Compared to that of SARS-C0V, the N protein of
SARS-C0V-2 possess five amino acid mutations,
where two are in the intrmsically dispersed region

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(IDR; positions 25 and 26), one each in the NTD

(position 103), LKR (position 217), and CTD
(position 334) (16).
nsps and Accessory Proteins
ammal species is necessary to prevent the
possibility of virus spread and initiation of an
outbreak due to zoonotic spillover (1).
Personal protective equipment (PPE), like face
masks, will help to prevent the spread of
respiratory infections like COVID-19. Face masks
not only protect from infectious aerosols but also
prevent the transmission of disease to other
susceptible individuals while traveling through
public transport systems (313). Another critical
practice that can reduce the transmission of
respiratory diseases is the maintenance of hand
hygiene. However, the efficacy of this practice in
reducing the transmission of respiratory viruses
like SARS-CoV-2 is much dependent upon the size
of droplets produced. Hand hygiene will reduce
disease transmission only if the virus is transmitted
through the formation of large droplets (314).
Hence, it is better not to overemphasize that hand
hygiene will prevent the transmission of SARS-
CoV-2, since it may produce a false sense of
safety among the general public that further

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contributes to the spread of COVID- 19. Even

though airborne spread has not been reported in
SARS-CoV-2 infection, transmission can occur
through droplets and fomites, especially when
there is close, unprotected contact between
infected and susceptible individuals. Hence, hand
hygiene is
differs from that in SARS-CoV in the five residues
critical for ACE2 binding, namely Y455L, L486F,
N493Q, D494S and T501N52 (FIG 5b c). Owing to
these residue changes, interaction of SARS-CoV-2
with its receptor stabilizes the two virus-binding
hotspots on the surface ofhACE2 (REF.;0) (FIG.
3d). Moreover, a four-residue motif in the RBM of
SARS-CoV-2 (amino acids 482— 485: G-V-E-G)
results in a more compact conformation of its
hACE2-binding ridge than in SARS- CoV and
enables better contact with the N-terminal helix of
hACE2 (REF. 50). Biochemical data confirmed that
the structural features of the SARS-CoV-2 RBD
has strengthened its hACE2 binding affinity
compared with that of SARS-CoV
Similarly to other coronaviruses, SARS-CoV-2
needs proteolytic processing of the S protein to
activate the endocytic route. It has been shown
that host proteases participate in the cleavage of

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the S protein and activate the entry of SARS-

CoV-2, including transmembrane protease serine
protease 2 (TMPRSS2), cathepsin L and furin
Single-cell RNA sequencing data showed that
TMPRSS2 is highly expressed in several tissues
and body sites and is co-expressed with ACE2 in
nasal epithelial cells, lungs and bronchial
branches, which explains some of the tissue
tropism of SARS-CoV-2 (REFS56,57). SARS-
CoV-2 pseudovirus entry assays revealed that
TMPRSS2 and cathepsin L have cumulative effects
with furin on activating virus entry55 Analysis of
the cryo- electron microscopy structure of SARS-
CoV-2 S protein revealed that its RBD is mostly in
the lying-down state, whereas the SARS-CoV S
protein assumes equally standing-up and lying-
down

conformational states A lying-down conformation

of the SARS-CoV-2 S protein may not be in favour
of receptor binding but is helpful for immune
evasion55
epidemic progresses, commercial tests will
become available.
Other laboratory investigations are usually non
specific. The white cell count is usually normal or

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low. There may be lymphopenia; a lymphocyte

count <1000 has been associated with severe
disease. The platelet count is usually normal or
mildly low. The CRP and ESR are generally
elevated but procalcitonin levels are usually
normal. A high procalcitonin level may indicate a
bacterial co- infection. The ALT/AST, prothrombin
time, creatinine, D-dimer, CPK and LDH may be
elevated and high levels are associated with severe
disease.
The chest X-ray (CXR) usually shows bilateral
infiltrates but may be normal in early disease. The
CT is more sensitive and specific. CT imaging
generally shows infiltrates, ground glass opacities
and sub segmental
RBI), Indicating Its potential as a therapeutic agent
in the management of COVID-19. It can be used
alone or in combination with other effective
neutralizing antibodies for the treatment and
prevention of COVID-19 (202). Furthermore,
SARSCoV-specific neutralizing antibodies, like
m396 and CR3014, failed to bind the S protein of
SARS-CoV2, indicating that a particular level of
similarity is mandatory between the RBDs of
SARS-CoV and SARS-CoV-2 for the cross-
reactivity to occur.

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Further assessment is necessary before confirming

the effectiveness of such combination therapy. In
addition, to prevent further community and
nosocomial spread of COVID-19, the
postprocedure risk management program should
not be neglected (309). Development of broad-
spectrum inhibitors against the human coronaviral
pathogens will help to facilitate clinical trials on the
effectiveness of such inhibitors against endemic
and emerging coronaviruses (203). A promising
animal study revealed the protective effect of
passive immunotherapy with immune serum from
MERSimmune camels on mice infected with
MERS-CoV (204). Passive immunotherapy using
convalescent plasma is another strategy that can
be used for treating COVID-19-infected, critically ill
patients (205).
Ihal remdesivir has to be further evaluated for its
efficacy in the treatment of COVID-19 infection in
humans. The broad-spectrum activity exhibited by
remdesivir will help control the spread of disease in
the event of a new coronavirus outbreak.
Chloroquine is an antimalarial drug known to
possess antiviral activity due to its ability to block
virus-cell fusion by raising the endosomal pH
necessary for fusion. It also interferes with

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virusreceptor binding by interfering with the

terminal glycosylation of SARS-CoV cellular
receptors, such as ACE2 (196). In a recent
multicenter clinical trial that was conducted in
China, chloroquine phosphate was found to exhibit
both efficacy and safety in the therapeutic
management of SARS-CoV-2-associated
pneumonia (197). This drug is already included in
the treatment guidelines issued by the National
Health Commission of the People's Republic of
China. The preliminary clinical trials using
hydroxychloroquine, another aminoquinoline drug,
gave promising results. The COVID-19 patients
received 600 mg of hydroxychloroquine daily along
with azithromycin as a single-arm protocol. This
protocol was found to be associated with a
noteworthy reduction in viral load. Finally, it
resulted in a complete cure (271); however, the
study comprised a small population and, hence,
the
Cases continued to increase exponentially and
modelling studies reported an epidemic doubling
time of
1.8 d [10]. In fact on the 12th of
February, China changed its definition of
confirmed cases to include patients with negative/

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pending molecular tests but with clinical, radiologic

and epidemiologic features of COVID-19 leading to
an increase in cases by 15,000 in a single day [6].
As of 05/03/2020 96,000 cases worldwide (80,000
in China) and 87 other countries and 1 international
conveyance (696, in the

cruise ship Diamond Princess parked off the coast

of Japan) have been reported [2]. It is important to
note that while the number of new cases has
reduced in China lately, they have increased
exponentially in other countries including South
Korea, Italy and Iran.
Of those infected, 20% are in critical
ÎaUgue. Individuals With asymptomatic and
atypical clinical manifestations were also identified
recently, further adding to the complexity of
disease transmission dynamics. Atypical clinical
manifestations may only express symptoms such
as fatigue instead of respiratory signs such as
fever, cough, and sputum. In such cases, the
clinician must be vigilant for the possible
occurrence of asymptomatic and atypical clinical
manifestations to avoid the possibility of missed
diagnoses.
The present outbreak caused by SARS-CoV-2

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was, Indeed, expected. Similar to previous

outbreaks, the current pandemic also will be
contained shortly. However, the real question is,
how are we planning to counter the next zoonotic
COV epidemic that is likely to occur within the next
5 to 10 years or perhaps sooner? Our knowledge
of most of the bat CoVs is scarce, as these viruses
have not been isolated and studied, and extensive
studies on such viruses are typically only
conducted when they are associated with specific
disease outbreaks. The next step following the
control of the COVID-19 outbreak In China should
be focused on screening, identification, isolation,
and characterization of CoVs present in wildlife
species of China, particularly in bats. Both in vitro
and in vivo studies (using suitable animal models)
should be conducted 07:23 0 • and Middle East
respiratory syndrome coronavirus (MERS-CoV),
but has lower fatality. The global impact of this
new epidemic is yet uncertain.
Keywords: 2019-nCOV, SARS-C0V-2, COVID-19,
Pneumonia, Review
Introduction
The 2019 novel coronavirus (2019nCoV) or the
severe acute respiratory syndrome corona virus 2
(SARS-CoV-2) as it is now called, is rapidly

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spreading from its origin in Wuhan City of Hubei

Province of China to the rest of the world [1]. Till
05/03/2020 around 96,000 cases of coronavirus
disease 2019
(COVID-19) and 3300 deaths have been reported
[2]. India has reported 29 cases till date.
Fortunately so far, children have been infrequently
affected with no deaths. But the future course of
this virus is unknown. This article gives a bird's
eye view about
primary anti-genic epitopes mainly those
recognised by neutralising antibodies. The spike S-
protein being in a spike form is subjected to a
structural rearrangement process so that fusing
the outer membrane of the virus with the hostcell
membrane becomes easier.19, 20 Recent SARS-
CoV work has also shown that the membrane
exopeptidase ACE enzyme
(angiotensin-converting enzyme) functions as a
COVID-19 receptor to enter the human cell.21

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FIGURE 1

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Coronavirus S protein is a large, multifunctional class I viral
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transmembrane protein. The size of this abundant S protein
varies from 1,160 ammo acids (1BV, infectious bronchitis
virus, in poultry) to 1,400 amino acids (FCoV, feline
coronavirus) (43). It lies in a trimer on the vinon surface,
giving the vinon a corona or crown-like appearance.
Functionally it is required for the entry of the infectious
virion particles into the cell through interaction with various
host cellular receptors (44).
Furthermore, it acts as a critical factor for tissue tropism and
the determination of host range (45). Notably, S protein is
one of the vital immunodominant proteins of CoVs capable
of inducing host immune responses (45). The ectodomains
in all CoVs S proteins have similar domain organizations,
divided into two subunits, Sl and S2 (43). The first one, Sl,
helps in host receptor binding, while the second one, S2,
accounts for fusion. The former (Sl) is further divided into
two subdomains, namely, the N-terminal domain (NTD) and C
-terminal domain (CTD). Both of these subdomams act as
receptor-binding domains, interacting efficiently with various
host receptors (45). The Sl CTD contains the receptor-
binding motif (RBM). In each coronavirus spike protein, the
trimeric Sl locates itself on top of the trimeric S2
lower respiratory tracts. Acute viral interstitial pneumonia
and humoral and cellular immune responses were
observed48'ë. Moreover, prolonged virus shedding peaked
early in the course of infection in asymptomatic macaques69
, and old monkeys showed severer interstitial pneumonia
than young monkeys76, which is similar to what is seen in
patients with COVID- 19, In human

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ACE2-transgenic mice infected with SARS-CoV-2, typical
interstitial pneumonia was present, and viral antigens were
observed mainly in the bronchial epithelial cells,
macrophages and alveolar epithelia.SomehumanACE2-
transgenicmiceevendiedafterinfection70,71 Inwide-typemice
,a SARS-CoV-2 mouse-adapted strain with the N501Y
alteration in the RBD of the S protein was generated at
passage 6. Interstitial pneumonia and inflammatory
responses were found in both young and aged mice after
infection with the mouse-adapted strain . Golden hamsters
also showed

typical symptoms after being infected with SARS-CoV-2 (

REF. 77). In other animal models, including cats and ferrets,
SARS-CoV-2 could efficiently replicate in the upper
respiratory tract but did not induce severe clinical
symptoms43' 8. As transmission by direct contact and air
was observed in infected ferrets and hamsters, these
animals could be used to model different transmission
modes of COVID-19 (REFS77 79). Animal models offer
important information for understanding the pathogenesis
of SARS-CoV-2 infection and the transmission dynamics of
SARSCoV-2, and are important to evaluate the efficacy of
antiviral therapeutics and vaccines.
Clinical and epidemiological features
It appears that all ages ofthe population are susceptible to
SARS-CoV-2 infection, and the median age of infection is
around 50 years However, clinical manifestations differ with
age. In general, older men (>60 years old) with co-
morbidities are more likely to develop severe respiratory
disease

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Flexcil - The Smart Study Toolkit & PDF, Annotate, Note