Novel corona virus 2019 (2019 - nCov)

The spike glycoproteins create corona, bind and fuse with host cell membranes

 Human coronaviruses were first identified in the mid-1960s, are so
named because of the crown-like appearance of their virus particles
when seen under an electron microscope (corona, meaning crown).
 Coronaviruses are a diverse group of viruses that infect and cause
disease in humans and other animals.

 Coronaviruses are large, enveloped, positive-strand RNA viruses that
be divided into 4 genera: alpha, beta, delta, and gamma, of which alpha
and beta CoVs are known to infect humans.
 Four HCoVs (HCoV 229E, NL63, OC43, and HKU1) are endemic globally
and account for 10% to 30% of upper respiratory tract infections in
adults.

Coronavirus Infections—More Than Just the Common Cold
 Human coronaviruses (HCoVs) have long been considered inconsequential
pathogens, causing the “common cold” in otherwise healthy people.
 Until recently, HCoVs received relatively little attention due to their mild
phenotypes in humans.

 However, in the 21st century, 2 highly pathogenic HCoVs—severe acute
respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory
syndrome coronavirus (MERS-CoV) — emerged from animal reservoirs to
cause global epidemics with alarming morbidity and mortality.
 In December 2019, yet another pathogenic HCoV, 2019 novel coronavirus
(2019-nCoV), was recognized in Wuhan, China, and has caused serious
illness and death.

 Coronaviruses are ecologically diverse with the greatest variety seen in
bats, suggesting that they are the reservoirs for many of these viruses.
 Peridomestic mammals may serve as intermediate hosts, facilitating
recombination and mutation events with expansion of genetic diversity.

 Coronaviruses are a family of viruses causing infection in humans and a
variety of animals including birds and mammals such as camels, cats
and bats.
 When animal coronaviruses evolve, infect people and then spread
between humans, it can lead to outbreaks such as what happened with
MERS-CoV and SARS.

 Several known coronaviruses are circulating in animals that have not
yet infected humans.
 To date, seven coronaviruses have been shown to also infect and cause
illness in humans.

 People around the world commonly get infected with human
coronaviruses 229E, NL63, OC43, and HKU1.
 Sometimes coronaviruses that infect animals can evolve and make
people sick and become a new human coronavirus.
 Three recent examples of this are 2019-nCoV, SARS-CoV, and MERS-CoV.

In the case of SARS, the virus jumped from bats to civet cats before
gaining the ability to infect humans. In the case of MERS, camels
served as the intermediate host.

Background
 The current outbreak of the 2019-nCoV virus started in Wuhan City,
Hubei Province, China.
 While the first cases were reported as early as December 8, 2019, the
outbreak gained global attention on December 31, 2019, when the
World Health Organization (WHO) was alerted to “several cases of
pneumonia” by an unknown virus.

 The new virus was soon identified as a novel corona virus and named
2019-nCOV.
 The 2019-nCoV identified in China is a new strain of coronavirus that
has not been previously identified in humans.
 It belongs to the family of viruses that include the common cold and
viruses such as SARS and MERS.

Cluster of pneumonia cases linked to seafood market in Wuhan

 In the case of 2019-nCoV outbreak, reports state that most of the first group
of patients hospitalized were workers or customers at a local seafood
wholesale market which also sold processed meats and live consumable
animals .
 The study of the genetic code of 2019-nCoV reveals that the new virus is most
closely related to two bat SARS-like coronavirus samples from China

 "Bats being the native host of the Wuhan CoV (coronavirus) would be the
logical and convenient reasoning, though it remains likely there was
intermediate host(s) in the transmission cascade from bats to humans,“
 When the researchers performed a more detailed bioinformatics analysis
of the sequence of 2019-nCoV, it suggests that this coronavirus might
come from snakes (snake is the most probable wildlife animal reservoir).

From bats to snakes
 Snakes often hunt for bats in wild. Reports indicate that snakes were
sold in the local seafood market in Wuhan, raising the possibility that
the 2019-nCoV might have jumped from the host species — bats — to
snakes and then to humans at the beginning of this coronavirus
outbreak

 The novel corona virus, is likely originated in a wet market in the city of
Wuhan.
 The markets put shoppers, vendors, and live and dead animals in close
proximity, which raises the risk of a disease outbreak, since corona
viruses are zoonotic diseases (meaning they can jump from animals to
people).

Craze for exotic meat
 The food market where the deadly virus surfaced offered a range of
exotic wildlife for sale, including live foxes, crocodiles, wolf puppies,
giant salamanders, snakes, rats, peacocks, porcupines, camel meat
other game.
 Authorities believe the virus likely came from "wild animals at the
seafood market" .

 Many exotic species are still widely consumed in China or other Asian
countries where they are considered a delicacy - like the civet or some
rats or bats - or for purported health benefits unproven by science.
 Severe Acute Respiratory Syndrome, or SARS, was linked to Chinese
consumption of civet meat.
 The 2019-nCoV outbreak is another reminder that people should limit
the consumption of wild animals to prevent zoonotic infections.

 First SARS, now the Wuhan coronavirus. Here’s why China should ban its
wildlife trade forever.
 Both coronaviruses are linked to live animal markets, where sick,
injured and dying animals are sold as exotic foods but end up
transmitting disease.
 For too long, wildlife traders have been allowed to hide behind empty
claims of medicine or conservation. It’s time to ban the unsavoury trade
permanently.

The Huanan Seafood Wholesale Market in Wuhan, closed on January 1, is thought to be ground
zero in the spread of the deadly coronavirus named 2019-nCoV.

It's being passed between humans
 The WHO said that it believed an animal source was the "primary source"
of the outbreak, and Wuhan authorities identified a seafood market as
the centre of the epidemic.
 There was evidence the virus is now passing from person to person, without
any contact with the now-closed market.

The Arkansas Democrat-Gazette
Chinese lock down 8 cities to curb deadly virus's spread

 TheWHO defines a global emergency — formally, a Public Health Emergency
of International Concern — as “an extraordinary event which is determined
to constitute a public health risk to other States through the international
spread of disease and to potentially require a coordinated international
response.”
 Despite the emergency declaration, the WHO is not recommending any
restrictions on travel or trade at this time.
 Countries should implement evidence-based public health policies, combat
misinformation, share data, and work together to stop the spread of the virus

US State Department issues highest level alert: ‘Do Not Travel to Ch

 Human to human transmission has been confirmed. Researchers
and public health officials determine how contagious a virus is by
calculating a reproduction number, or R0.
 The R0 is the average number of other people that one infected
person will infect, in a completely non-immune population.
 The World Health Organization said that the preliminary R0
(reproduction number) estimate is 1.4 to 2.5, meaning that every
person infected could infect between 1.4 and 2.5 people.

 Person-to-person spread of 2019-nCoV is occurring. Chinese officials
report that sustained person-to-person spread in the community is
occurring in China.
 Person-to-person spread in the United States has not yet been
detected, but it’s likely to occur to some extent.

 "An initial first impression is that this is significantly milder than
SARS," "That's reassuring. On the other hand, it may be more
transmissible than SARS, at least in the community setting.“
 For now, 2019-nCoV appears to have a lower fatality rate than the
SARS virus, but it is certainly appears to be spreading quicker.

How does it compare with SARS or MERS?
 MERS was first identified in Saudi Arabia in 2012, and around 34% of people
reported as infected with the virus have died (858 of 2494 cases). Its R0 is less
than one.
 The SARS outbreak of 2002-03led to 8098 identified cases and 774 deaths
(9.6%). It has an R0 of 2-5.7
 The good news is that the data to date suggest that this virus may have a lower
mortality than SARS

Incubation Period of 2019-nCoV
 1-14 days after exposure (Most cases remain asymptomatic during this
period)
 The virus has been noted to have a long incubation period of 1-14 days,
with patients remaining asymptomatic until the occurrence of the
disease.
 China has confirmed human-to-human transmission, and said the virus is
infectious during its 1-14 day incubation period -- in other words, before
the first symptoms appear.

Risk Factors of 2019-nCoV
From the data collected by the CDC, the persons at risk are:`
1. Elderly persons above the age of 50 persons with underlying diseases
like diabetes, Parkinson’s disease, cardiovascular diseases.
2. Demographically, it can also be stated that the persons living in China
around Wahun town are most at risk, especially those working&
shopping from Animal markets within the localities; and persons
traveling into and out of Wahun.
3. Hospital-acquired infection- Health care workers caring for patients with
the 2019-nCoV

The epidemiological and clinical criteria that should prompt laboratory
testing of suspected cases of 2019-nCoV. The criteria include:
Epidemiological criteria Clinical criteria
Any person with travel-history to Wuhan City,
China in the 14 days before the onset of illness
Any person with clinical symptoms compatible
with severe acute respiratory infection seeking
healthcare or admitted to hospital with clinical
or radiological evidence of pneumonia
(or) Any person being in close contact with a
laboratory-confirmed case of 2019-nCoV in the
14 days before the onset of illness
(or) Any person with fever or recent history of
fever (>=38°C) and acute respiratory infection
(sudden onset of respiratory infection with one
or more of the following symptoms: shortness of
breath, cough or sore throat)

Criteria to initiate testing for 2019-nCoV
 Any person fulfilling the criteria for a suspect case should be tested for
2019-nCoV. The laboratory test should be initiated immediately.
 it is likely that respiratory specimens collected early after symptoms’
onset would yield higher virus concentrations.
 Rapid collection and testing of appropriate specimens from suspected
cases is a priority.

Samples to be collected
1. Respiratory samples (nasopharyngeal and oropharyngeal swab in
ambulatory patients and sputum (if produced) and/or
endotracheal aspirate or bronchoalveolar lavage in patients with more severe
respiratory disease).
2. Serum for serological testing, acute sample and convalescent sample (this
is additional to respiratory materials and can support the identification of the
true agent, once serologic assay is available).

 Recommendations for specimen collection Lower respiratory specimens likely
have a higher diagnostic value than upper respiratory tract specimens for
detecting 2019-nCoV infection.
 If patients do not have signs or symptoms of lower respiratory tract disease
or if specimen collection for lower respiratory tract disease is clinically
indicated but the collection is not possible, upper respiratory tract
specimens such as a nasopharyngeal aspirate or combined nasopharyngeal and
and oropharyngeal swabs should be collected.

 Patients that meet the case definition for suspected 2019- nCoV
should be screened for the virus with RT-PCR.
 If case management requires, screen also for other common causes of
respiratory illness according to local guidelines.
 As coinfections can occur, all patients that meet the case definition
should be tested for 2019-nCoV regardless of whether a conventional
respiratory pathogen is found.

 If initial testing is negative in a patient who is strongly suspected to have
2019-nCoV infection, the patient should be resampled and specimens
collected from multiple respiratory tract sites (sputum, endotracheal
aspirate).
 A single negative test result, particularly if this is from an upper respiratory
tract specimen, does not exclude infection.
 Repeat sampling and testing, lower respiratory specimen is strongly
recommended in severe or progressive disease.

Remarks:
 Use appropriate PPE for specimen collection (droplet and contact
precautions for URT specimens; airborne precautions for LRT specimens).
 When collecting URT samples, use viral swabs (sterile Dacron or rayon,
not cotton) and viral transport media. Do not sample the nostrils or
tonsils.
 In a patient with suspected novel coronavirus, especially with pneumonia
or severe illness, a single URT sample does not exclude the diagnosis, and
additional URT and LRT samples are recommended.

Remarks:
 LRT (vs. URT) samples are more likely to be positive and for a longer
period.
 Clinicians may elect to collect only LRT samples when these are readily
available (for example, in mechanically ventilated patients).
 Sputum induction should be avoided due to increased risk of
increasing aerosol transmission.

Remarks:
 Dual infections with other respiratory viral infections have been found in
SARS and MERS cases.
 Both URT and LRT specimens can tested for other respiratory viruses,
such as influenza A and B (including zoonotic influenza A), respiratory
syncytial virus, parainfluenza viruses, ect.
 LRT specimens can also be tested for bacterial pathogens, including
Legionella pneumophila.

 In hospitalized patients with confirmed nCoV infection, repeat URT and
LRT samples should be collected to demonstrate viral clearance.
 The frequency of specimen collection will depend on local circumstances
but should be at least every 2 to 4 days until there are two consecutive
negative results (both URT and LRT samples if both are collected) in a
clinically recovered patient at least 24 hours apart.

Clinical management of severe acute respiratory infection when
novel coronavirus (2019-nCoV) infection is suspected
1. Triage: recognize and sort all patients with SARI associated with 2019-
nCoV infection at first point of contact with health care system (such as
the emergency department).
 Consider 2019-nCOV as a possible etiology of SARI under certain
conditions
 Triage patients and start emergency treatments based based on disease
severity.

Remarks
 2019-nCoV infection may present with mild, moderate, or severe illness; the
latter includes severe pneumonia, ARDS,sepsis and septic shock.
 Early recognition of suspected patients allows for timely initiation of IPC
 Early identification of those with severe manifestations allows for immediate
optimized supportive care treatments and safe, rapid admission (or referral)
to intensive care unit according to institutional or national protocols.

2. Immediate implementation of appropriate IPC measures
 IPC is a critical and integral part of clinical management of patients and
should be initiated at the point of entry of the patient to hospital (typically
the Emergency Department).
 Standard precautions should always be routinely applied in all areas of
health care facilities.
 Standard precautions include hand hygiene; use of PPE to avoid direct
contact with patients’ blood, body fluids,secretions (including respiratory
secretions) and non-intact skin.
 Standard precautions also include prevention of needle-stick or sharps
safe waste management; cleaning and disinfection of equipment; and
cleaning of the environment.

3. Early supportive therapy and monitoring
Give supplemental oxygen therapy immediately to patients with SARI and
respiratory distress, hypoxaemia, or shock.
Remarks: Initiate oxygen therapy at 5 L/min and titrate flow rates to reach target
SpO2 ≥90% in non-pregnant adults and SpO2 ≥92-95 % in pregnant patients.
 Children with emergency signs (obstructed or absent breathing, severe
respiratory distress, central cyanosis, shock, coma or convulsions) should receive
oxygen therapy during resuscitation to target SpO2 ≥94%; otherwise, the target
SpO2 is ≥90%.
 All areas where patients with SARI are cared for should be equipped with pulse
oximeters, functioning oxygen systems and disposable, single-use, oxygen-
delivering interfaces (nasal cannula, simple face mask, and mask with reservoir

4. Give empiric antimicrobials to treat all likely pathogens
causing SARI.
 Give antimicrobials within one hour of initial patient assessment for patients
with sepsis
 Empiric antibiotic treatment should be based on the clinical diagnosis
(community-acquired pneumonia, health care-associated pneumonia [if
infection was acquired in healthcare setting], or sepsis), local epidemiology
susceptibility data, and treatment guidelines.

 Empiric therapy includes a neuraminidase inhibitor for treatment of
influenza when there is local circulation or other risk factors, including
travel history or exposure to animal influenza viruses.
 Empiric therapy should be de-escalated on the basis of microbiology results
and clinical judgment.

Remarks
 Patients with SARI should be treated cautiously with intravenous fluids,
because aggressive fluid resuscitation may worsen oxygenation, especially
in settings where there is limited availability of mechanical ventilation.
 Do not routinely give systemic corticosteroids for treatment of viral
pneumonia or ARDS outside of clinical trials unless they are indicated for
another reason.

 Closely monitor patients with SARI for signs of clinical deterioration, such
as rapidly progressive respiratory failure and sepsis,and apply supportive
care interventions immediately.
 Remarks: Application of timely, effective, and safe supportive therapies is
the cornerstone of therapy for patients that develop severe
manifestations of 2019-nCoV.

 Understand the patient’s co-morbid condition(s) to tailor the management
of critical illness;
 Remarks: During intensive care management of SARI, determine which
chronic therapies should be continued and which therapies should be
stopped temporarily.

 There is no current evidence from RCTs to recommend any
specific anti-nCoV treatment for patients with suspected or
confirmed 2019-nCoV infection.

Special considerations for pregnant patients
 Pregnant women with suspected or confirmed 2019-nCoV infection
should be treated with supportive therapies as described above, taking
into account the physiologic adaptations of pregnancy
 Emergency delivery and pregnancy termination decisions are challenging
and based on many factors: gestational age, maternal condition, and
fetal stability. Consultations with obstetric, neonatal, and intensive care
specialists (depending on the condition of the mother) are essential.

A militia member uses a digital thermometer to take a driver's temperature at
a checkpoint at a highway toll gate in Wuhan, China, January 23, 2020.

A worker monitors display screens for infrared thermometers as
part of traveler screenings at Hankou Railway Station in Wuhan,
China, January 21, 2020.

Panic is our enemy
Knowledge is our friend
Preparation is our best line of
defence

“The only thing more difficult than planning for an
emergency is having to explain why you didn’t.”
Be Proactive NOT Reactive!!!!
Final Messages!

Novel corona virus 2019 (2019 - nCov)

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