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https://doi.org/10.1007/s12098-020-03263-6
REVIEW ARTICLE
Received: 23 February 2020 / Accepted: 25 February 2020 / Published online: 13 March 2020
# Dr. K C Chaudhuri Foundation 2020
Abstract
There is a new public health crises threatening the world with the emergence and spread of 2019 novel coronavirus (2019-nCoV)
or the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The virus originated in bats and was transmitted to
humans through yet unknown intermediary animals in Wuhan, Hubei province, China in December 2019. There have been
around 96,000 reported cases of coronavirus disease 2019 (COVID-2019) and 3300 reported deaths to date (05/03/2020). The
disease is transmitted by inhalation or contact with infected droplets and the incubation period ranges from 2 to 14 d. The
symptoms are usually fever, cough, sore throat, breathlessness, fatigue, malaise among others. The disease is mild in most people;
in some (usually the elderly and those with comorbidities), it may progress to pneumonia, acute respiratory distress syndrome
(ARDS) and multi organ dysfunction. Many people are asymptomatic. The case fatality rate is estimated to range from 2 to 3%.
Diagnosis is by demonstration of the virus in respiratory secretions by special molecular tests. Common laboratory findings
include normal/ low white cell counts with elevated C-reactive protein (CRP). The computerized tomographic chest scan is
usually abnormal even in those with no symptoms or mild disease. Treatment is essentially supportive; role of antiviral agents is
yet to be established. Prevention entails home isolation of suspected cases and those with mild illnesses and strict infection
control measures at hospitals that include contact and droplet precautions. The virus spreads faster than its two ancestors the
SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV), but has lower fatality. The global impact of this
new epidemic is yet uncertain.
virus, designated as severe acute respiratory syndrome coro- Cases continued to increase exponentially and modelling
navirus affected 8422 people mostly in China and Hong Kong studies reported an epidemic doubling time of 1.8 d [10]. In
and caused 916 deaths (mortality rate 11%) before being fact on the 12th of February, China changed its definition of
contained [4]. Almost a decade later in 2012, the Middle confirmed cases to include patients with negative/ pending
East respiratory syndrome coronavirus (MERS-CoV), also molecular tests but with clinical, radiologic and epidemiologic
of bat origin, emerged in Saudi Arabia with dromedary camels features of COVID-19 leading to an increase in cases by
as the intermediate host and affected 2494 people and caused 15,000 in a single day [6]. As of 05/03/2020 96,000 cases
858 deaths (fatality rate 34%) [5]. worldwide (80,000 in China) and 87 other countries and 1
international conveyance (696, in the cruise ship Diamond
Princess parked off the coast of Japan) have been reported
Origin and Spread of COVID-19 [1, 2, 6] [2]. It is important to note that while the number of new cases
has reduced in China lately, they have increased exponentially
In December 2019, adults in Wuhan, capital city of Hubei in other countries including South Korea, Italy and Iran. Of
province and a major transportation hub of China started pre- those infected, 20% are in critical condition, 25% have recov-
senting to local hospitals with severe pneumonia of unknown ered, and 3310 (3013 in China and 297 in other countries)
cause. Many of the initial cases had a common exposure to the have died [2]. India, which had reported only 3 cases till 2/3/
Huanan wholesale seafood market that also traded live ani- 2020, has also seen a sudden spurt in cases. By 5/3/2020, 29
mals. The surveillance system (put into place after the SARS cases had been reported; mostly in Delhi, Jaipur and Agra in
outbreak) was activated and respiratory samples of patients Italian tourists and their contacts. One case was reported in an
were sent to reference labs for etiologic investigations. On Indian who traveled back from Vienna and exposed a large
December 31st 2019, China notified the outbreak to the number of school children in a birthday party at a city hotel.
World Health Organization and on 1st January the Huanan Many of the contacts of these cases have been quarantined.
sea food market was closed. On 7th January the virus was These numbers are possibly an underestimate of the infect-
identified as a coronavirus that had >95% homology with ed and dead due to limitations of surveillance and testing.
the bat coronavirus and > 70% similarity with the SARS- Though the SARS-CoV-2 originated from bats, the interme-
CoV. Environmental samples from the Huanan sea food diary animal through which it crossed over to humans is un-
market also tested positive, signifying that the virus originated certain. Pangolins and snakes are the current suspects.
from there [7]. The number of cases started increasing expo-
nentially, some of which did not have exposure to the live
animal market, suggestive of the fact that human-to-human Epidemiology and Pathogenesis [10, 11]
transmission was occurring [8]. The first fatal case was report-
ed on 11th Jan 2020. The massive migration of Chinese during All ages are susceptible. Infection is transmitted through large
the Chinese New Year fuelled the epidemic. Cases in other droplets generated during coughing and sneezing by symp-
provinces of China, other countries (Thailand, Japan and tomatic patients but can also occur from asymptomatic people
South Korea in quick succession) were reported in people and before onset of symptoms [9]. Studies have shown higher
who were returning from Wuhan. Transmission to healthcare viral loads in the nasal cavity as compared to the throat with no
workers caring for patients was described on 20th Jan, 2020. difference in viral burden between symptomatic and asymp-
By 23rd January, the 11 million population of Wuhan was tomatic people [12]. Patients can be infectious for as long as
placed under lock down with restrictions of entry and exit the symptoms last and even on clinical recovery. Some people
from the region. Soon this lock down was extended to other may act as super spreaders; a UK citizen who attended a con-
cities of Hubei province. Cases of COVID-19 in countries ference in Singapore infected 11 other people while staying in
outside China were reported in those with no history of travel a resort in the French Alps and upon return to the UK [6].
to China suggesting that local human-to-human transmission These infected droplets can spread 1–2 m and deposit on sur-
was occurring in these countries [9]. Airports in different faces. The virus can remain viable on surfaces for days in
countries including India put in screening mechanisms to de- favourable atmospheric conditions but are destroyed in less
tect symptomatic people returning from China and placed than a minute by common disinfectants like sodium hypochlo-
them in isolation and testing them for COVID-19. Soon it rite, hydrogen peroxide etc. [13]. Infection is acquired either
was apparent that the infection could be transmitted from by inhalation of these droplets or touching surfaces contami-
asymptomatic people and also before onset of symptoms. nated by them and then touching the nose, mouth and eyes.
Therefore, countries including India who evacuated their cit- The virus is also present in the stool and contamination of the
izens from Wuhan through special flights or had travellers water supply and subsequent transmission via aerosolization/
returning from China, placed all people symptomatic or oth- feco oral route is also hypothesized [6]. As per current infor-
erwise in isolation for 14 d and tested them for the virus. mation, transplacental transmission from pregnant women to
Indian J Pediatr (April 2020) 87(4):281–286 283
their fetus has not been described [14]. However, neonatal were seen. The most common symptoms were fever (50%)
disease due to post natal transmission is described [14]. The and cough (38%). All patients recovered with symptomatic
incubation period varies from 2 to 14 d [median 5 d]. Studies therapy and there were no deaths. One case of severe pneu-
have identified angiotensin receptor 2 (ACE2) as the receptor monia and multiorgan dysfunction in a child has also been
through which the virus enters the respiratory mucosa [11]. reported [19]. Similarly the neonatal cases that have been re-
The basic case reproduction rate (BCR) is estimated to ported have been mild [20].
range from 2 to 6.47 in various modelling studies [11]. In
comparison, the BCR of SARS was 2 and 1.3 for pandemic
flu H1N1 2009 [2]. Diagnosis [21]
COVID-19 coronavirus], atypical organisms (mycoplasma, management of COVID-19 [27]. More evidence is needed
chlamydia) and bacterial infections. It is not possible to before these drugs are recommended. Other drugs proposed
differentiate COVID-19 from these infections clinically or for therapy are arbidol (an antiviral drug available in Russia
through routine lab tests. Therefore travel history becomes and China), intravenous immunoglobulin, interferons, chloro-
important. However, as the epidemic spreads, the travel quine and plasma of patients recovered from COVID-19 [21,
history will become irrelevant. 28, 29]. Additionally, recommendations about using tradition-
al Chinese herbs find place in the Chinese guidelines [21].
24 h or by day 7 of illness. Negative molecular tests were not a pathogen is identified, refer the samples for testing
prerequisite for discharge. for SARS-CoV-2.
At the community level, people should be asked to avoid & All clinicians should keep themselves updated about re-
crowded areas and postpone non-essential travel to places cent developments including global spread of the disease.
with ongoing transmission. They should be asked to practice & Non-essential international travel should be avoided at
cough hygiene by coughing in sleeve/ tissue rather than hands this time.
and practice hand hygiene frequently every 15–20 min. & People should stop spreading myths and false informa-
Patients with respiratory symptoms should be asked to use tion about the disease and try to allay panic and anxiety
surgical masks. The use of mask by healthy people in public of the public.
places has not shown to protect against respiratory viral infec-
tions and is currently not recommended by WHO. However,
in China, the public has been asked to wear masks in public
and especially in crowded places and large scale gatherings Conclusions
are prohibited (entertainment parks etc). China is also consid-
ering introducing legislation to prohibit selling and trading of This new virus outbreak has challenged the economic, medi-
wild animals [32]. cal and public health infrastructure of China and to some ex-
The international response has been dramatic. tent, of other countries especially, its neighbours. Time alone
Initially, there were massive travel restrictions to China will tell how the virus will impact our lives here in India. More
and people returning from China/ evacuated from China so, future outbreaks of viruses and pathogens of zoonotic or-
are being evaluated for clinical symptoms, isolated and igin are likely to continue. Therefore, apart from curbing this
tested for COVID-19 for 2 wks even if asymptomatic. outbreak, efforts should be made to devise comprehensive
However, now with rapid world wide spread of the measures to prevent future outbreaks of zoonotic origin.
virus these travel restrictions have extended to other
countries. Whether these efforts will lead to slowing of Compliance with Ethical Standards
viral spread is not known.
A candidate vaccine is under development. Conflict of Interest None.
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