Dr Basab Ghosh

March 23, 2020, 05:35:49   

[Dr Basab Ghosh, Diabetologist, Dr Basab's Diabetes Care, Opposite Ramnagar 3, Krishnanagar, Agartala, Tripura. email: ]

Corona has become a household name now a day! That tiny life threatened virus notoriously gradually going to shut down the global life including market, if we are not aware about the ways to how to come out of it! Coronvirus is a simple zoonotic virus family; they are actually respiratory disease causing virus to animals but some genetic transformation inside the natural host animal and sometimes further transformation inside the human host, once they are transmitted to human, make them human respiratory virus; once they are human virus they spread respiratory diseases from one human to another.

On 11 February 2020 World Health Organization (WHO) announced Corona Virus Disease-2019 as "COVID-19". First infection was expected in somewhere in mid November 2019 in Wuhan city, Hubei province of China in a 55 year old man. It was thought that he got the infection from the Huanan Seafood Wholesale Market, which also sold live animals. Might be the zoonotic virus was contaminated from live animals to eatable seafood products in the market which was consumed uncooked or the viruses were inhaled (as it is a respiratory virus) to him; cooked animal product will not carry coronavirus infection to the humans from animal (it is a myth!). In the first week of December he was suspected to have a different disease by his symptoms and the virus was discovered in China in the last week of December 2019. The WHO considers bats the most likely natural reservoir of SARS-CoV-2, but some differences between the bat coronavirus SARS of 2002 and SARS-CoV-2 of 2019 suggest that an intermediate reservoir such as a Pangolin corona virus might be involved in its introduction to humans. However it is believed that the virus possibly originated in horseshoe bats (genus Rhinolophus).

How does it spread?

1.     How easily virus spreads from person-to-person can vary. Some viruses are highly contagious i.e. spread easily, while other viruses do not spread as easily.

2.     This SARS-CoV-2 virus, responsible for COVID-19 disease, is highly contagious. There are proteins look like crowns scattered (so named Corona) in the outer lipid layer of the virus structure and with those spike like crown proteins they land up in the cells of our windpipe (respiratory tract) wall through a protein called ACE-2 and this bonding between spikes of CVID-19 and ACE-2 is helped by another protein Furin. Those two proteins ACE-2 and Furin are so abundant in our windpipe and further down there in the lung cells that even few viruses when entered lodged into the windpipe very easily and thereafter multiply to increase their numbers. From that point itself spreading to other humans start though cough and sneezing, though it may take 2 to 14 days for the virus to get deep into the lung and cause symptoms. Hence now we are practicing "social distancing" to avoid spreading easily!

3.     Another factor is whether the spread is sustained, spreading continually without stopping. SARS-CoV-2 virus of COVID-19 seems to be spreading easily and sustainably as "community spread" in some affected geographic areas.

4.     Community spread means people are infected with the virus in an area, where some are not sure how or where they got the infection. Best way to see community spread is the instance of Hubei province of China where first time SARS-CoV-2 is isolated in December 2019; till 14 March 2020, just 67,790 cases and 3,075 deaths have been reported only in Hubei province! Whereas since 11th March 2020, out of 114 countries 1,18,000 have been reported infected by the virus and 4,300 people have died so far. Community spread is so dangerous!

Asymptomatic cases are equally important

An article published in NEJM medical journal on 19th March 2020, showed that SARS-CoV-2 virus transmission occurs mainly after days of illness, with viral loads peaking approximately 10 days after symptom onset. However the viral load in asymptomatic patient was similar to that of symptomatic patient, which suggests high transmission potential of even asymptomatic candidates. They even mentioned in that article Viral nucleic acid shedding pattern of COVID-19 patients resemble that of influenza, which gives ray of hope that like influenza here also immunity is expected fast, but how fast!!

Person-to-person spread

1.    This respiratory virus is thought to spread mainly from person-to-person though coughing or sneezing droplets. When we cough the droplets come out at the speed of 120-150 km per hour and can travel six foot very easily. Each droplet is loaded with 6000-7000 viruses in an infected person.

2.     Between people who are in close contact with one another within about 6 foot distance through respiratory droplets the infection can spread very easily. So the new term "social-distance" is advocated to prevent the easy transmission!

Spread from contact with contaminated surfaces or objects

1.     Indirect spread via contaminated surfaces is another possible cause of getting infection, though the main spread is by respiratory droplets produced by their coughs or sneezes.

2.     A recent published paper in NEJM medical journal indicates the virus may remain alive on plastic and steel for up to three days, but does not survive in cardboard for more than a day or on copper for more than four hours.

3.     So, it may be possible that a person can get COVID-19 by touching a surface or object that has live virus on it and then touching their own mouth, nose, or possibly their eyes. But the good news is that it is inactivated by soap!

Who are to be tested at Viral Research and Diagnostic Laboratories (VRDL) for COVID-19 as per Indian Council of Medical Research (ICMR) directions?

1.     All persons having symptoms of fever, cough and breathing difficulty within 14 days of international travel,

2.     All symptomatic contacts of confirmed cases,

3.     All symptomatic healthcare workers,

4.   All hospitalised patients with Severe Acute Respiratory Illness (fever and cough and / or shortness of breath),

5.     Asymptomatic direct and high-risk contacts of a confirmed case should be tested once between day 5 and day 14 of coming in his / her contact. Direct and high-risk contact include:

a)     Those who live in the same household with a confirmed case,

b)   Healthcare workers who examined a confirmed case without sufficient protection as per WHO recommendations.

How to tackle the situation at individual level?

1.     Avoid non essential travel.

2.    Stay home for people with high-risk susceptibility, like children below 10 year, old age person above 65 year, immunity suppressed people due to some medical conditions or under some immunosuppressive drugs.

3.     Avoid public activities to cut short person to person contacts.

4.    Use soap and water for hand washing for at least 20 seconds. If you don't have soap and water, you can also use hand sanitizer with at least 60 percent alcohol. Wash as frequently as virus contamination is possible may be every 10 minute.

5.     Practice good respiratory hygiene by covering mouth and nose with handkerchief, tissue paper or at least a piece of cloth while coughing. One can try best alternate coughing practise by using any of the elbows.

6.     Avoid touching the eyes, nose, or mouth with unwashed hands.

7.     Social distancing strategies aim to reduce contact of infected persons with large groups by closing schools and workplaces, restricting travel and cancelling mass gatherings.

8.     According to the WHO, the use of masks is only recommended if a person is coughing or sneezing or when one is taking care of someone with a suspected infection.

9.     Stay home and call your doctor if you start having respiratory issues like cough with high fever and breathing difficulty and think your symptoms are consistent with those of COVID-19.

10.      Presently, isolation or quarantine recommended for suspected cases for 14 days, as incubation period for this coronavirus is somewhere between 2 to 14 days after exposure. On average, it takes about 5 days to develop symptoms, but this may change as we learn more about the virus. According to some recent reports, more than 97 percent of people who contract SARS-CoV-2 show symptoms within 11.5 days of exposure.

How COVIT-19 situation in 2019-2020 is obligated for outbreak to pandemic?

There are many positive thoughts we could make out in this crisis of COVID-19 during 2019-2020 pandemic:

1.     The time interval of within three weeks from the first case description in a Chinese patient on first week of December 2019 to the isolation of the virus SARS-CoV-2 on last week of December 2019 was very fast in case of COVID-19.

2.     Diagnostic tests were available globally within 2 weeks of reports of cases from China.

3.     In such a short period of approximately ten weeks from isolation of the virus a clinical trial of vaccine is undergoing which is unprecedented!

4.     Within this short period of less than ten weeks from the time of virus isolation now we gathered much information about the virus. This shows the power of international co-operative science. It took us a decade to know about HIV back in 1980-90, and about two years to know about coronavirus SARS in 2003.

5.    Now all countries have higher medical standards, better educated health-care workforce, and more technical and scientific expertise in 2020.

6.    Organisations such as the Global Outbreak Alert and Response Network, the Coalition for Epidemic Preparedness Innovations (EPI), and the Global Research Collaboration for Infectious Disease Preparedness, supported by the WHO Research Blueprint and its Global Coordinating Mechanism, were able to accelerate the outbreak response and rapidly initiate technical platforms for the development of vaccines and therapeutics.

In spite of all above positive points and many more, COVID-19 has become a pandemic in early 2020!

1.     Epicentre plays an important role here! Wuhan is the largest city in central China, a major transport hub, a centre for industry and commerce, home to the largest train station, biggest airport, and largest deep-water port in central China; all together huge population size was the biggest confront and those multiple elements made infection control challenging!

2.     The absolute population size is the single biggest challenge. Hospitals were initially plagued by the number of patients, and many patients were not hospitalised because of a shortage of hospital beds, thereby contributing to seeding in the community. A new hospital was built within 10 days thereafter.

3.     Worse happened when just before Wuhan was put under lockdown, more than 50 lakh people, of them many of whom might have been incubating the virus, had travelled out of Wuhan because of the upcoming Spring Festival, thus spreading COVID-19 to other provinces in China. Then virus spread from China to other parts of the globe, ultimately pandemic declared by WHO on 11th March 2020.

4.     The speed of spread of COVID-19 from the first documented case in early December 2019, to 1,18,000 cases of 114 countries by the 11th March 2020, despite massive control efforts is certainly much faster than expected. 

5.     The clinical spectrum is different in COVID-19. Initial case definition was focused on pneumonia, but as the epidemic unfolds, it has become apparent that mild cases are common in COVID-19. Patients with mild disease manifestations will be missed even if a more sensitive surveillance system and these patients might spread the disease silently, similar to influenza.

6.     Widespread community transmission is already evident for COVID-19. Consequently, there will be more unknown contacts than known contacts in the community, which means that many contacts who will subsequently develop an infection are not quarantined and under proper medical observation.

Scenario in India

India is so far following the right tract of public health interventions by sealing the borders with travel ban and cancelling almost all visas, closing schools and colleges in some states, following respectfully individual quarantine recommendations. WHO appreciated India for its overall performance till date!

Now it's our time to do like China to control the situation, because our infected COVID-19 numbers are increasing drastically! Otherwise scenario will be like Italy; they initially misinterpreted the situation and very fast became another epicentre for COVID-19 after Wuhan of China. In India from 30th January 2020 to 22nd March 2020, the confirmed cases crossed 350 marks and out of that more than 90% are hospitalised, 2% is the death rate!  China has essentially issued the largest social quarantine in history to prevent its spread to the rest of the world and succeeded. We need to enforce the same model of most drastic of all classic public health measures:

1.     Community control with social distancing,

2.     Community use of facemasks,

3.     A lockdown of public transportation, including buses, trains, ferries, and airport.

4.     Tracking of all close contacts of infected persons and put them under medical care.

The "Janta-Curfew" from 7 am to 9 pm on Sunday 22nd March 2020 as announced by Prime Minister, is to create awareness for SOCIAL-DISTANCE. It is the first step ultimately to break the chain of transmission from human to human. Now, India is in level 2 of infection, means the infection is well tracked. Community spread is the level 3 of infection, where the infectious disease is transmitted to individuals in a particular geographic area who have no known contact with other infected individuals or who have not recently even travelled to an area where the disease has any documented case.

Government must have further plans according to China model as discussed above to break the chain of transmission at the earliest before it turns to level 3 of community spread in India! It may be lockdown from tomorrow! This is a medical emergency and let us fights together by joining hand with the government machineries to come out from this extreme situation!


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