The World Health Organization (WHO) has declared the coronavirus outbreak a global emergency, as the outbreak continues to spread outside China.

What is coronavirus?

Coronavirus is a large family of viruses that are often the source of respiratory infections, including the common cold.

A small number of common infecting virus: Most of the viruses are common among animals and only a small number of them infect humans.

Mutation of animal base virus: Sometimes, an animal-based coronavirus mutates and successfully finds a human host.

Dangers of rapid urbanisation: Rapid urbanisation that forces animals and humans into closer proximity (as in the “wet market” in Wuhan) creates a perfect petri dish from where such zoonotic outbreaks can originate.

Origin of the outbreak and deadly it could turn out?

  • Outbreak of unknown virus: In December 2019, an outbreak of viral pneumonia of unknown aetiology emerged in Wuhan, a city in the central Chinese province of Hubei.
  • Discovery of novel coronavirus:  A few weeks later, the World Health Organization (WHO) and Chinese health authorities announced the discovery of a novel coronavirus, known now as 2019-nCoV, as being responsible for the pneumonia.
  • Important questions: The two most important questions asked in a fast-evolving pandemic of this nature are:
    • 1) How deadly is the disease, and;
    • 2) Can it be contained?
    • The latest available figures suggest that the death toll in China is 304 and 14,411 have been infected. The current fatality rate estimate of 2% is unstable and is likely to fall as more cases are detected.

Containment attempts by China and spread to the other countries

  • Unprecedented attempt by China: The attempt at containment started late, but has never been attempted in the fashion that China has gone about it.
    • Wuhan lockdown: Belatedly, on 23 January, China locked down Wuhan and 12 other cities, quarantining 52 million people in one sweeping action.
    • This is the first known case in modern history of any country locking down an entire large city.

Concern for India

  • Reported case in Nepal and cause of concern for India: For India, the most critical is cases being reported in Nepal since India and Nepal share an open border though so far.
  • All tests undertaken in India have been negative.
    Reports of confirmed cases from other countries: Confirmed cases have since been reported from Hong Kong, Macau, Taiwan, Thailand, South Korea, Japan, Singapore, Australia and the US.

    • India reported its first case from Kerala of a medical student from Wuhan University, followed by two more.
    • Singapore and the US have now banned foreign nationals who have recently been in China from entering the country.
    • Russia, Canada, the UK and India have begun evacuating citizens from Hubei province.

Understanding the new virus

  • The possible mode of transmission: According to the World Health Organization, during previous outbreaks due to other coronavirus, human-to-human transmission occurred through droplets, contact and fomites (objects or materials which are likely to carry infection, such as clothes, utensils, and furniture).
  • This suggests that the transmission mode of the 2019-nCoV can be identical.
  • The transmission even in incubation period: More significant is the new understanding that the virus is contagious even during incubation, that is even before a patient exhibits any symptoms.

Experience from the past outbreaks

  • Comparison with SARS: Comparisons are being drawn the Severe Acute Respiratory Syndrome) outbreak in 2002-03.
  • Zoonotic case: SARS is also a zoonotic case, part of the coronavirus family with clues pointing to horseshoe bats in China as the likely source.

Late reporting by China in SARS:

The first incidents were reported in Guangdong province in November 2002 but WHO was officially informed only after three months.

Different response this time: Comparison with SARS: Comparisons are being drawn the Severe Acute Respiratory Syndrome) outbreak in 2002-03.

Zoonotic case: SARS is also a zoonotic case, part of the coronavirus family with clues pointing to horseshoe bats in China as the likely source.

Late reporting by China in SARS: The first incidents were reported in Guangdong province in November 2002 but WHO was officially informed only after three months.

Different response this time: This time around, the Chinese government has been more open but the question being asked is whether it has been open enough?

The difference in time to develop vaccine: For SARS, it took 20 months from the genome sequencing to the first human vaccine trials; for the 2019-nCoV, authorities in the U.S. are working on a deadline of 90 days.

Lessons from Kerala in Nipah outbreak

Managing an outbreak with few casualties: Kerala managed to curtail the Nipah outbreak with few casualties.

Nipah is also zoonotic and made the jump from fruit bats to humans.

Though there were 17 deaths in India, effective quarantine measures by local authorities prevented the spread.

Infectious disease on the rise: Infectious diseases including those of the zoonotic variety are on the rise in India.

In addition, regions in India suffer from seasonal outbreaks of dengue, malaria and influenza strains.

The nation-wide disease surveillance programme needs to be strengthened.

Research on coronavirus so far

  • Coronaviruses (CoVs) are characterized by club-like spikes that project from their surface, an unusually large RNA genome and a unique replication strategy.
    • CoVs cause a variety of diseases in mammals and birds, ranging from enteritis in hoofed animals to potentially lethal human respiratory infections.
    • Genome sequence: The 2019-nCov genome was sequenced in China in early January and reported in The Lancet last week.
    • It suggests that the original host of this coronavirus was a bat reservoir, though it is unclear whether there was an intermediate host.
  • A recent entry to the human host: The uniformity of the sequenced genome suggests that the virus has entered human hosts very recently.
  • Recent emergence from the animal reservoir: Several other countries, including the US and France, have sequenced the RNA of the 2019-nCoV as well. These sequences and their similarity to the initial samples from China suggest a single, recent emergence from an animal reservoir.

Tests and vaccine development

  • How is the virus tested? Testing for 2019-nCoV requires a reverse transcription polymerase chain reaction test (RT-PCR) which converts RNA into DNA, making study and comparison easier.
  • No vaccine yet: There are no vaccines yet for this virus, but promising paths have been identified, borrowed from the SARS related vaccines.
    • Development of an effective vaccine may only come after the 2019-nCoV is contained, but it may still be useful if there were to be a subsequent outbreak.
    • The frequency of future outbreaks is only likely to increase because of climate change, global travel and fast mutating viruses.

What lessons can India learn?

  • Develop framework and capacity: For India, this global health emergency should serve as an eye-opener.
    • If lockdown turns out to be a useful tool to prevent the spread of a deadly virus, India will need to develop the framework and capacity to implement such a drastic measure.
    • Under-equipped municipalities: Our municipalities are hopelessly under-equipped to implement strict isolation and containment strategies.
    • We will need to develop the capacity to build large facilities for housing patients in isolation wards.
    • Use of pre-cast: This will require India to accelerate the use of construction methods like pre-cast technology.
  • Protocol and instructions: The National Centre for Disease Control (NCDC) has been proactive in updating its protocol related to the 2019-nCov and has clear instructions for reporting and assay preparation.
  • Develop capacity in geographically diverse regions: Samples in India need to be sent to the National Institute of Virology in Pune.
    • While the public health and epidemic escalation framework appears capable of handling a small number of cases well, it is not clear how it will stand up to a large number of cases in a specific geographic region.

Conclusion

“Nothing happens quite by chance. It is a question of accretion of information and experience,” said Jonas Salk, the virologist who developed the polio vaccine, in some ways, China is setting the standard for a public health response that may become a necessary way of life in the 21st century. India must use this as a guidepost to greater preparedness.

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