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| GUEST EDITORIAL |
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| Year : 2020 | Volume
: 2
| Issue : 1 | Page : 4-7 |
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Pandemic of coronavirus infection
Gajanan S Gaude
Department of Respiratory Medicine, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| Date of Submission | 15-Mar-2020 |
| Date of Decision | 19-Mar-2020 |
| Date of Acceptance | 24-Apr-2020 |
| Date of Web Publication | 03-Jul-2020 |
Correspondence Address:
Dr. Gajanan S Gaude
Department of Respiratory Medicine, KAHERfs J. N. Medical College, Belgaum - 590 010, Karnataka
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijptr.ijptr_7_20
How to cite this article:
Gaude GS. Pandemic of coronavirus infection. Indian J Phys Ther Res 2020;2:4-7 |
Beginning from December 08, 2019, several cases of pneumonia of unknown origin were reported from Wuhan, the capital of the Chinese Province of Hubei. The initial cluster of cases was traced to the Wuhan live animal and seafood market. The causative pathogen has hence been identified as an enveloped RNA beta coronavirus with genealogical similarity to the severe acute respiratory syndrome (SARS) coronavirus and named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Initial reports from Wuhan pointed toward an atypical pneumonia and were termed “Coronavirus disease 2019” (COVID-2019). The World Health Organization (WHO) reported about this mysterious atypical pneumonia on December 31, 2019, and as the number of affected persons in the Wuhan District was too many, they declared this coronavirus infection as the global health emergency[1] on January 30, 2020. In January 2020, due to the resemblance to the old coronavirus, the infirmity by SARS-CoV-2 was termed COVID-19 by the WHO, which means “Coronavirus disease 2019.” This name was chosen to prevent the similarities of the sources of the virus in terms of populations, geography, or animal associations.[2] However, coronavirus name was kept as the genetic behavior of the virus that was similar to the corona family group of viruses. On February 11, 2020, the coronavirus study group of the international committee on virus taxonomy named the novel virus as coronavirus 2 (SARS-CoV-2), an extreme acute respiratory syndrome. As of March 23, 2020, COVID-19 has affected nearly all the countries in the world with confirmed cases to more than 316,000 (majority in China) and has resulted in more than 13,600 deaths, and about 96,000 patients have recovered fully. Even far off countries such as Greenland have reported COVID-19 cases.[3] In India, as of now, 341 cases have been confirmed cases from different states, and all these cases had a travel history from COVID-19-affected countries or the close contacts of the infected case. The full-genomic structure of SARS-CoV-2 was first posted by Chinese health authorities soon after the initial detection, and this facilitated the viral characterization and made easy for the diagnosis.[4] After analyzing the genome structure of the first US patients on January 24, 2020, the Centers for the Disease Control and Prevention (CDC) concluded that the sequence was nearly identical to the sequences reported by China. SARS-CoV-2 is a Group 2b beta coronavirus ad with a genetic sequence similarity of at least 70% to SARS-CoV identified in 2003. SARS-CoV-2 had also originated in bats, similar to Middle East Respiratory Syndrome-Related Coronavirus and SARS-CoV and was then transmitted to humans.
According to the CDC, the individuals at the high risk of contracting the COVID-19 infection include individuals living in areas with continuing local transmission, health-care workers taking care of patients with COVID-19 infection, close connections with infected persons, and travelers returning from the locations where there has been a strong local spread.[4] SARS-CoV-2 spread has been reported quite rarely person-to-person, as in the United States. Individuals who believe that they might have been exposed to an infected person with SARS-CoV-2 should contact their health-care provider immediately.
| Route of Transmission | |  |
Similar to the spread of other respiratory diseases, including influenza and rhinovirus infections, COVID-19 infection is thought to be transmitted by coughing and sneezing. According to the WHO, the spread of SARS-CoV-2 infection in China has been largely restricted to family members, health-care providers, and other close contacts and is likely transmitted through the respiratory droplets. WHO officials predicted that the infection can be curtailed if the chain of transmission can be broken down. Several cases developed the COVID-19 infection in China in adults older than 40 years old with significant comorbidities. Very few young children have been infected with this viral disease, and those infected seem to have mild illness.[5] It has been stated recently that even asymptomatic patients are still capable of transmitting infection by droplet infection. Hence, there are the concerns for the effectiveness of isolation.[6] In a study, Zou et al.[7] found that the viral expression of nasal and throat swabs infection in a small group of patients had elevated viral loads at the time the patients were symptomatic. Transmission can also occur by touching the face with contaminated hands. Respiratory droplets do not remain suspended in the air for long; hence, a distance of six feet away from an infected person may be considered safe. Coronaviruses may contaminate metal, glass, or plastic surfaces that may remain infective for several days. Contact with such contaminated surfaces (fomites) and subsequent transfer to the face by touch may also be an important mode of transmission.[8] COVID-19 virus may remain on the surfaces, including chairs, table, glass, door handle for almost up to 9 h. In moist conditions, the viruses may remain active for almost several days. For this reason, frequent cleaning of the surfaces, especially in hospitals, is required to eliminate all the viruses. Air-borne transmission, distinct from droplet infection, is characterized by the viruses that drift through the air. It is unclear if airborne transmission occurs with COVID-19 infection. The possibility of airborne transmission requires the use of additional protective measures, including N95 masks.
| Screening For Patients | | |
Patients who present with fever and respiratory symptoms with an epidemiological link to COVID-19 should carry a high index of suspicion for the disease.[9] The epidemiological link may involve (a) travel to an area that experienced an outbreak, (b) close contact with an individual with confirmed or high risk of infection, or (c) close contact with an individual with respiratory symptoms who had been in a geographic location that witnessed an outbreak within a 14-day period before the onset of symptoms. Fever may not be a presenting symptom in all cases. Fever may present late during the course of the disease. Patients who present with bilateral pneumonia with the above-mentioned risk factors carry a high index of suspicion even in the absence of fever. As the geographic area of involvement is expanding, clinicians need to keep themselves updated on the list of affected countries and territories. Following several generations of spread with a country, local transmission of disease occurs, and patients may present with no history of travel to a location with a known outbreak. Other symptoms that may present include malaise, cough, and breathing difficulties. Some patients may also develop vomiting, headache, and severe respiratory distress leading to respiratory failure.
In such instances, a detailed enquiry should be carried out to ensure appropriate screening and infection control precautions should be followed. A large number of patients develop pneumonic infiltrates. The disease appears to mainly affect the adults between the age group of 30 and 79 years, with a male preponderance.[10] The large majority of patients appear to develop mild disease, and the overall mortality appears to be low (2%–3%). However, a high mortality of up to 49% has been observed among critically ill patients who develop multi-organ failure.
The COVID-19 diagnostic test is a real-time reverse transcription–polymerase chain reaction (rRT-PCR) test that was developed by CDC and obtained special food and drug administration emergency authorization for its use.[11] The test is a rRT-PCR test which can be used to diagnose the virus from the clinical specimens in the respiratory and serum samples. Serum antibody titers to IgG can also be demonstrated in COVID-19 patients in a large number of patients, and this can be useful test for the early diagnosis of COVID-19 case.
| Treatment of Covid-19 | | |
No specific antiviral therapy for the management of COVID-19 infection is available so far. About 80% of the patients present with mild symptoms involving the upper respiratory tract. These patients require symptomatic care along with home isolation, and they do not require hospitalization. Infected patients should receive medical treatment to help in symptom relief. Moderate-to-severe patients along with pneumonia presentation should be hospitalized and to be managed according to the standard protocols. In extreme cases, vital organ function should be supported. Various drugs are being tried in these cases, so that the mortality can be reduced. Some of the dugs include ramdesivir, chloroquin, hydroxychloroquin, lopinavir/ritonavir combination, and tumor necrosis factor blocker. A total of 23 different treatment combinations are being tried in patients with COVID-19 infection. One study done in China has observed that chloroquine phosphate 500 mg given twice daily in tablet form for 10 days may be considered in patients with COVID-19 pneumonia.[12] Wang et al.[13] reported that chloroquine effectively inhibits SARS-CoV-2 in vitro. Currently, no vaccine is available for SARS-CoV-2, but the first dose of the proposed vaccine was given to a US person just 7 days ago, and we should have the vaccine available in the near future in 12–18 months' period. Moderna is now conducting a Phase 1 clinical trial on an experimental vaccine against SARS-CoV-2, mRNA-1273. Currently, the main form of deterrence is avoidance.
| Infection Control Measures | | |
As the predominant mode of transmission of COVID-19 disease appears to be through droplet and contact with respiratory secretions, air-borne transmission may occur, and appropriate precautions are recommended in high-risk situations, especially when treating patients who are critically ill. The use of high-flow nasal oxygen, nebulizers, noninvasive ventilation, bag-mask ventilation, the performance of laryngoscopy, and endotracheal intubation are likely to generate aerosols that may predispose to the transmission of the virus. Considering the uncertainty regarding airborne transmission, isolation rooms with negative pressure and frequent air exchanges are advisable for suspected cases.[14] If sufficient airborne isolation areas are unavailable, patients should be accommodated in single rooms behind the closed doors. Anterooms to enable caregivers to put on and remove personal-protective equipment (PPE) should also be available.
Health-care workers who care for critically ill patients with suspected or confirmed COVID-19 disease must use PPE. Operating room scrubs or full coveralls should form the first layer of protection beneath PPE. The PPE must include fluid-resistant gowns and gloves, goggles with side protection, hair covers or hoods, and fit-tested N95 respirator masks. Caregivers should also wear disposable shoe covers or water-resistant shoes that can be decontaminated. Doffing of PPE should be carried out carefully, with diligent hand hygiene after the removal.[15] A powered air-purifying respirator is often recommended and may offer greater protection compared to N95 masks. It consists of a respirator worn as a hood; it draws in and filters potentially contaminated ambient air, and delivers clean, decontaminated air to the user through the hood.
For the prevention of COVID-19 infection, the general measures to be followed for the prevention of viral respiratory infections include[16] individuals should avoid close contact with sick people; hand washing with soap and water for at least 20 s; use of an alcohol-based hand sanitizer when soap and water is unavailable; people should avoid rubbing their eyes, nose, and mouth with unwashed hands; people with more than 60 years should stay indoors; sick people should stay at home; respiratory etiquette should be followed for cough and sneezing; and objects and surfaces often affected should be routinely washed and disinfected.
| References | | |
| 1. | Ramzy A, McNeil DG. W.H.O. Declares Global Emergency as Wuhan Coronavirus Spreads. The New York Times; 2020. Available from: https://nyti.ms/2RER70M. [Last accessed on 2020 Jan 30].  |
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| 5. | Wei M, Yuan J, Liu Y, Fu T, Yu X, Zhang ZJ. Novel coronavirus infection in hospitalized infants under 1 year of age in China. JAMA 2020;323:1313-4. |
| 6. | Bai Y, Yao L, Wei T, Tian F, Jin DY, Chen L, et al. Presumed asymptomatic carrier transmission of COVID-19. JAMA 2020;323:1406-7. |
| 7. | Zou L, Ruan F, Huang M, Liang L, Huang H, Hong Z, et al. SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med 2020;382:1177-9. |
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| 12. | Multicenter Collaboration Group of Department of Science and Technology of Guangdong Province and Health Commission of Guangdong Province for Chloroquine in the Treatment of Novel Coronavirus Pneumonia. Expert consensus on chloroquine phosphate for the treatment of novel coronavirus pneumonia. Zhonghua Jie He He Hu Xi Za Zhi 2020;43:E019. |
| 13. | Wang M, Cao R, Zhang L, Yang X, Liu J, Xu M, et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Res 2020;30:269-71. |
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| 15. | CDC Health Alert Network. Update and Interim Guidance on Outbreak of 2019 Novel Coronavirus (2019-nCoV) in Wuhan, China. CDC; 2020. Available from: https://emergency.cdc.g ov/han/han00426.asp. [Last accessed on 2020 Jan 27]. |
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