With novel Coronavirus 2019 (nCov – 2019)spreading like a wildfire, affecting country after country, fear and panic, spreadingat a much faster rate than the virus itself, are gripping and crippling people.It can lead to social stigma towards affected or quarantined people, and can hurtby creating more fear or anger instead of the disease. Providing socialsupport, learning and sharing facts will help fight the stigma. Universities,colleges, schools, malls, recreation and coaching centres shut for a month tocontain the spread. Footfall very less in government hospitals unlike privatenursing homes and clinics; may be advisory issued for former not for thelatter. As a student of epidemiology, I wonder why movement/travel restrictionsweren’t imposed early in the course of outbreak to prevent entry of infectionfrom the affected countries. Rather students and other people working inaffected countries were on-priority brought/rushed of their own to the valleywhich could well be a reason for its spread here. Better was to prevent theirentry to valley and/or house them there only with provision of adequate healthcare facilities. After reading research articles by various authors on 2019Novel Coronavirus in Journal of American Medical Association, March issue andCDC website, I considered it my professional responsibility to jot down thispiece for reader information and knowledge gain in general andstudent/professional community in particular.
In early December, 2019 a patient wasdiagnosed with an unusual pneumonia in city of Wuhan, China. By December 31,WHO regional office in Beijing had received notification of a cluster ofpatients with pneumonia of unknown cause from the same city. Over the next fewdays, researchers at the Wuhan Institute of Virology performed metagenomicsanalysis using next-generation sequencing from a sample collected from abroncho-alveolar lavage and identified a novel Coronovirus as the potentialaetiology. They called it novel Coronavirus 2019 (nCov – 2019). The US centrefor Disease Control and Prevention (CDC) referred to it as 2019 novelCoronovirus (2019 – nCov). On February 11, 2020 the WHO announced Coronavirusdisease 2019, abbreviated as COVID-19, as an official name for the disease. [TheWHO cautioned years ago that a mysterious “Disease X” could spark aninternational contagion. The nCov illness, with its ability to quickly morphfrom mild to deadly, is emerging as a contender. Let’s hope and pray thatCOVID-19 isn’t disease X and is contained as soon as possible]. Basisreproductive rate (R0 – number of cases one infected individual generates) ofthis outbreak was calculated to be 2.69 (95 % CI, 2.47 – 2.86) and that theepidemic is doubling every 6.4 days. As testing becomes more frequent, truenumber of cases and full disease spectrum will become more clear. However fornow, it appears that compared with two other zoonotic Cov outbreaks thatoccurred in last two decades (SARS in 2002 and MERS in 2012), 2019 – nCov seemsto have greater infectivity and a lower case-fatality rate (Mortality rate:2019-nCov 2 %, SARS > 40 % in patients aged > 60 years, MERS 30%). From genetic sequencing data, it appears thatthere was a single introduction into humans followed by human – human spread.This novel virus shares 79.5 % of genetic sequence with SARS – Cov and has 96.2% homology to a bat Coronavirus. Also, 2019-nCov shares same cell entryreceptor, ACE2 with SARS-Cov. What is yet unclear is which animal is theintermediate species between bats and humans. For SARS it was Civet cats, forMERS it is camels. While the source of 2019-nCov is yet unknown, early on theHuanan seafood wholesale market (selling wild animals) was linkedepidemiologically. Although there have not been reports of pets or otheranimals becoming sick with COVID-19, it is still recommended that people sickwith COVID-19 limit contact with animals until more information is known aboutthe virus.
Incubation period of this virus as reportedis 5.2 days (95 % CI, 4.1 – 7.0), although it is suggested to be as long as 14days. It is unclear when transmission begins and, although cases have beenreported that suggest transmission during asymptomatic phase, it is likely thatmajority of secondary cases come from symptomatic individuals. Clinicalsyndrome is non-specific, characterized by fever and dry cough in majority ofpatients, with about a third experiencing shortness of breath. Some patientsexhibited symptoms like myalgias, headache, sore-throat, and diarrhoea. Medianage of patients reported is between 49 and 56 years, cases in children havebeen rare. This has been related to limited travel by younger and olderpatients rather than decreased susceptibility of these populations. Althoughmost cases appeared to be mild, all hospital-admitted patients had pneumoniawith infiltrates on chest X-ray and ground glass opacities on chest computedtomography. About a third of patients subsequently developed acute respiratorydistress syndrome and required intensive care. This was particularly true withdiabetic or hypertensive patients. Yes, it is equally important to obtaintissue pathology findings of the lung and other organs and to study cofactorssuch as bacterial co-infection or even pollution particles to determine causeof death. Person under investigation (PUI) is a patient with fever andrespiratory symptoms particularly dry cough who has a history of travel toaffected areas in the last 14 days. Close contact is defined as being withinapproximately 6 feet (2 meters) of a COVID-19 case for a prolonged period oftime; close contact can occur while caring for, living with, visiting, orsharing a health care waiting area or room with a COVID-19 case or havingdirect contact with infectious secretions of a COVID-19 case (e.g., beingcoughed on). If such contact occurs while not wearing recommended personalprotective equipment (gowns, gloves, N95 respirator, eye protection), criteriafor PUI consideration are met. Since this is an influenza season cliniciansshould also test for other respiratory pathogens as well.
In response to the outbreak, on January 232020, Chinese authorities suspended travel in and out of Wuhan. Similar travelbans followed in other cities in Hubei province, and in total close to 50million people have been quarantined, an unprecedented effort to control anyinfectious disease. Similarly other countries responded by suspending travel toand from China and established screening at airports that have flights fromChina. The WHO on January 30 declared the outbreak a public health emergency ofinternational concern. The effectiveness of these quarantines in curtailing theoutbreak is doubtful because these measures haven’t worked in prior outbreaks,such as 2009 H1N1 Influenza or the 2014 Ebola pandemics, and quarantines arecontrary to previously proven public health measures and the internationalhealth regulations. What interventions will ultimately control this outbreak isunclear because of absence of vaccine, and the effectiveness of antivirals isunproven. However, basic public health measures such as staying home when ill,hand washing with soap and water for at least 20 seconds or using analcohol-based hand sanitizer that contains at least 60% alcohol, andrespiratory etiquette including covering the mouth and nose during sneezing andcoughing will be effective in controlling 2019-nCov outbreak as were effectivein controlling SARS. There is little value to wearing a regular face maskabsent a high probability of being exposed to Cov, but when there is a highdegree of suspicion that a patient might have 2019-nCov, they should have aface mask placed immediately and health care practitioners should wear N95respirators.
Given its occurrence and spread in thevalley we don’t need to show overwhelming panic as it will die down as seen withpast outbreaks of similar aetiology and as is true to all outbreaks. Let’s hopeit has attained its peak. But the need of the time is frontline clinicians,public health authorities and epidemiologists work together to educate thepublic by providing accurate and up-to-date information and by taking care ofpatients with respiratory illness in a timely and effective way.
Aijaz Ahmad Dar, PhD (Veterinary Medicine),is Subject Matter Specialist, KVK Kupwara, SKUAST Kashmir