Image 1

These findings will not have any significance until a significant outbreak occurs due to a virus-like SARS-
CoV-2.

There is a steady increase in the reports of COVID-19 in companion and wild animals around the world.
Further studies are required to evaluate the potential of animals (especially companion animals) to serve as
an efficient reservoir host that can further alter the dynamics of human-to-human transmission (330). To
date, two pet dogs (Hong Kong) and four pet cats (one each from Belgium and Hong Kong, two from the
United States) have tested positive for SARS-CoV-2 (335). The World Organization for Animal Health
(OIE) has confirmed the diagnosis of COVID-19 in both dogs and cats due to human-to-animal transmission
(331). The similarity observed in the gene sequence of SARS- CoV-2 from an infected pet owner and his
dog further confirms the occurrence of human-to-animal transmission (333). Even though asymptomatic,
feline species should be considered a potential transmission route from animals to humans (326). However,
currently, there are no reports of SARS- CoV-2 transmission from felines to human beings. Based on the
current evidence, we can conclude that cats are susceptible to SARS-CoV-2 and can get infected by human
beings. However, evidence of cat-

Image 2

CLINICAL PATHOLOGY OF SARS-CoV-2 (COVID-19)

The disease caused by SARS-CoV-2 is also named severe specific contagious pneumonia SSCP), Wuhan
pneumonia, and, recently, COVID-19 (110). Compared to SARS-CoV, SARS-CoV-2 has less severe
pathogenesis but has superior transmission capability, as evidenced by the rapidly increasing number of
COVID-19 cases (111). The incubation period of SARS-CoV-2 in familial clusters was found to be 3 to 6
days (112). The mean incubation period of COVID-19 was found to be 6.4 days, ranging from 2.1 to 11.1
days (113). Among an early affected group of 425 patients, 59 years was the median age, of which more
males were affected (114). Similar to SARS and MERS, the severity of this nCoV is high in age groups
above 50 years (2,115). Symptoms of COVID-19 include fever, cough, myalgia or fatigue, and, less
commonly, headache, hemoptysis, and diarrhea (116, 282). Compared to the SARS-CoV-2-infected patients
in Wuhan during

Image 3
Patients with SARS can be given conservative fluid therapy only when there is no evidence of shock.
Empiric antimicrobial therapy must be started to manage SARI. For patients with sepsis, antimicrobials must
be administered within 1 hour of initial assessments. The WHO and CDC recommend that glucocorticoids
not be used in patients with COVID-19 pneumonia except where there are other indications (exacerbation
of chronic obstructive pulmonary disease).

Patients’ clinical deterioration is closely observed with SARI; however, rapidly progressive respiratory
failure and sepsis require immediate supportive care interventions comprising quick use of neuromuscular
blockade and sedatives, hemodynamic management, nutritional support, maintenance of blood glucose
levels, prompt assessment and treatment of nosocomial pneumonia, and prophylaxis against deep venous
thrombosis (DVT) and gastrointestinal (Gl) bleeding.®® Generally, such patients give way to their primary
illness to secondary complications like sepsis or multiorgan system failure.*®
Image 4

progress from the initial focal unilateral to diffuse bilateral ground-glass opacities and will further
progress to or coexist with lung consolidation changes within 1 to 3 weeks (159). The role played by
radiologists in the current scenario is very important. Radiologists can help in the early diagnosis of lung
abnormalities associated with COVID-19 pneumonia. They can also help in the evaluation of disease
severity, identifying its
progression to acute respiratory distress syndrome and the presence of secondary bacterial infections
(160). Even though chest CT is considered an essential diagnostic tool for COVID-19, the extensive use of
CT for screening purposes in the suspected individuals might be associated with a disproportionate risk-
benefit ratio due to increased radiation exposure as well as increased risk of cross- infection. Hence, the use
of CT for early diagnosis of SARS-CoV-2 infection in high-risk groups should be done with great caution
(292).

More recently, other advanced diagnostics have been designed and developed for the detection of
SARS-CoV-2 (345, 347, 350-352). A reverse transcriptional loop-mediated isothermal amplification (RT-
LAMP), namely, iLACO, has been developed for rapid and colorimetric detection of this

Image 5

was linked to a family member and 26 children had history of travel/residence to Hubei province in China.
All the patients were either asymptomatic (9%) or had mild disease. No severe or critical cases were seen.
The most common symptoms were fever (50%) and cough (38%). All patients recovered with symptomatic
therapy and there were no deaths. One case of severe pneumonia and multiorgan dysfunction in a child has
also been
reported [19]. Similarly, the neonatal cases that have been reported have been mild [20].

A suspect case is defined as one with fever, sore throat and cough who has history of travel to China or other
areas of persistent local transmission or contact with patients with similar travel historv or those with
confirmed
Image 6

help us to control the spread of this virus. However, this is both challenging as well as time-consuming due
to the present extent of infection (226). The current scenario demands effective implementation of vigorous
prevention and control strategies owing to the prospect of COVID-19 for nosocomial infections (68).
Follow-ups of infected patients by telephone on day 7 and day 14 are advised to avoid any further
unintentional spread or nosocomial transmission (312). The availability of public data sets provided by
independent analytical teams will act as robust evidence that would guide us in designing interventions
against the COVID-19 outbreak. Newspaper reports and social media can be used to analyze and reconstruct
the progression of an outbreak. They can help us to obtain detailed patient- level data in the early stages of
an outbreak (227). Immediate travel restrictions imposed by several countries might have contributed
significantly to preventing the spread of SARS-CoV-2 globally (89, 228). Following the outbreak, a
temporary ban was imposed on the wildlife trade, keeping in mind the possible role played by wild animal
species in the origin of SARS-CoV-2/COVID-19 (147). Making a permanent and bold decision on the trade
of wild animal species is necessary to prevent the possibility

Image 7

between the genome sequence of the new coronavirus (SARS-CoV-2) and SARS-like CoVs, the
comparative analysis recognized a furin-like cleavage site in the SARS-CoV-2 S protein that is missing from
other SARS-like CoVs (99). The furin- like cleavage site is expected to play a role in the life cycle of the
virus and disease pathogenicity and might even act as a therapeutic target for furin inhibitors. The highly
contagious nature of SARS- CoV-2 compared to that of its predecessors might be the result of a stabilizing
mutation that occurred in the endosome-associated-protein-like domain ofnsp2 protein.

Similarly, the destabilizing mutation near the phosphatase domain of nsp3 proteins in SARS-CoV-2 could
indicate a potential mechanism that differentiates it from other CoVs (100). Even though the CFR reported
for COVID-19 is meager compared to those of the previous SARS and MERS outbreaks, it has caused more
deaths than SARS and MERS combined (101). Possibly related to the viral pathogenesis is the recent finding
of an 832- nucleotide (nt) deletion in ORFS8, which appears to reduce the replicative fitness of the virus and
leads to
attenuated phenotypes of SARS-CoV-2 (256). Coronavirus is the most prominent example of a

Image 8

treated symptomatically along with oxygen therapy. In such cases where the patients progress toward
respiratory failure and become refractory to oxygen therapy, mechanical ventilation is necessitated. The
COVID-19-induced septic shock can be managed by providing adequate hemodynamic support (299).
Several classes of drugs are currently being evaluated for their potential therapeutic action against SARS-
CoV-2. Therapeutic agents that have anti-SARS-CoV-2 activity can be broadly classified into three
categories: drugs that block virus entry into the host cell, drugs that block viral replication as well as its
survival within the host cell, and drugs that attenuate the exaggerated host immune response (300). An
inflammatory cytokine storm is commonly seen in critically ill COVID-19 patients. Hence, they may benefit
from the use of timely anti-inflammation treatment. Anti-inflammatory therapy using drugs like
glucocorticoids, cytokine inhibitors, JAK inhibitors, and chloroquine/hydroxychloroquine should be done
only after analyzing the risk/benefit ratio in COVID-19 patients (301). There have not been any studies
concerning the application of nonsteroidal anti-inflammatory drugs (NSAID) to COVID-19-infected
patients. However, reasonable
pieces of evidence are available that link NSAID

Image 9
In the unrooted phylogenetic tree of different betacoronaviruses based on the S protein, virus sequences from
different subgenera grouped into separate clusters. SARS-CoV-2 sequences from Wuhan and other countries
exhibited a close relationship and appeared in a single cluster (Fig. 1). The CoVs from the subgenus
Sarbecovirus appeared jointly in SplitsTree and divided into three subclusters, namely, SARS-CoV-2, bat-
SARS-like- CoV (bat-SL-CoV), and SARS-CoV (Fig. 1). In the case of other subgenera, like Merbecovirus,
all of the sequences grouped in a single cluster, whereas in Embecovirus, different species, comprised of
canine respiratory CoVs, bovine CoVs, equine CoVs, and human CoV strain (OC43), grouped in a common
cluster. Isolates in the subgenera Nobecovorus and Hibecovirus were found to be placed separately
away from other reported SARS-CoVs but shared a bat origin.

CURRENT WORLDWIDE SCENARIO OF

SARS-CoV-2

This novel virus, SARS-CoV-2, comes under the

subgenus Sarbecovirus of the Orthocoronavirinae subfamily and is entirely different from the viruses

Image 10
stalk (45). Recently, structural analyses of the S proteins of COVID-19 have revealed 27 amino acid
substitutions within a 1,273-amino-acid stretch (16). Six substitutions are located in the RBD (amino acids
357 to 528), while four substitutions are in the RBM at the CTD of the S1 domain (16). Of note, no amino
acid change is seen in the RBM, which binds directly to the angiotensin-converting enzyme-2 (ACE2)
receptor in SARS-CoV (16, 46). At present, the main emphasis is knowing how many differences would be
required to change the host tropism. Sequence comparison revealed 17 nonsynonymous changes between the
early sequence of SARS-CoV-2 and the later isolates of SARS-CoV. The changes were found scattered over
the genome of the virus, with nine substitutions in ORFlab, ORF8 (4 substitutions), the spike gene (3
substitutions), and ORF7a (single substitution) (4). Notably, the same nonsynonymous changes were found
in a familial cluster, indicating that the viral evolution happened during person-to-person transmission (4,
47). Such adaptive evolution events are frequent and constitute a constantly ongoing process once the virus
spreads among new hosts (47). Even though no functional changes occur in the virus associated with this
adaptive evolution, close monitoring of the viral

Image 11

wearing a facemask and practicing hand hygiene before feeding the baby. In addition, it is advisable that
breast pumps are cleaned properly after each use and, if possible, a healthy individual is available to feed the
expressed breast milk to the infant.

7.2 Children and elderly population

On the basis of the available reports, COVID-19 among children accounted for 1-5% of the confirmed cases,
and this population does not seem to be at higher risk for the disease than adults. There is no difference in
the COVID-19 symptoms between adults and children. However, the available evidence indicated that
children diagnosed with COVID-19 have milder symptoms than the adults, with a low mortality rate.*® 49
On the contrary, older people who are above the age of 65 years are at higher risk for a severe course of
disease. In the United Stated, approximately 31-59% of those with confirmed COVID-19 between the ages
of 65 and 84 years old required hospitalization, 11-31% of them required admission to the intensive care
unit, and 4-11% died.”

Image 12

residues for receptor binding™ (FIG. 3b). In comparison with the Guangdong strains, pangolin
coronaviruses reported from Guangxi are less similar to SARS-CoV-2, with 85.5% genome sequence
identity”. The repeated occurrence of SARS-CoV-2-related coronavirus infections in pangolins from
different smuggling events suggests that these animals are possible hosts of the viruses. However, unlike
bats, which carry coronaviruses healthily, the infected pangolins showed clinical signs and histopathological
changes, including interstitial pneumonia and inflammatory cell infiltration in diverse organs”. These
abnormalities suggest that pangolins are unlikely to be the reservoir of these coronaviruses but more likely
acquired the viruses after spillover from the natural hosts.

An intermediate host usually plays an important role in the outbreak of bat-derived emerging coronaviruses;
for example, palm civets for SARS-CoV and dromedary camels for MERS-CoV. The virus strains carried by
these two intermediate hosts were almost genetically identical to the corresponding viruses in humans (more
than 99% genome sequence identity). Despise an RBD that is virtually identical to that of SARS-CoV-2, the
pangolin coronaviruses known to date have no more than 92% genome identity with SARS-CoV-2 (REF.*).
The avail- able data are insufficient to interpret pangolins as the intermediate host of SARS-CoV-2. So far,
no evidence has shown that pangolins were directly involved in the emergence of SARS-CoV-2.

Image 13
Interestingly, disease in patients outside Hubei province has been reported to be milder than those from
Wuhan (17). Similarly, the severity and case fatality rate in patients outside China has been reported to be
milder (6). This may either be due to selection bias wherein the cases reporting from Wuhan included only
the severe cases or due to predisposition of the Asian population to the virus due to higher expression of
ACE2 receptors on the respiratory mucosa (11).

Disease in neonates, infants and children has also been reported to be significantly milder than their adult
counterparts. Ina series of 34 children admitted to a hospital in Shenzen, China between January 19 th and
February 7th, there were 14 males and 20 females. The median age was 8 y 11 mo and in 28 children the
infection was linked to a family member and 26

Image 14

The global impact of this new epidemic is yet uncertain.

Keywords: 2019-Ncov, SARS-CoV-2, COVID-19, Pneumonia, Review

Introduction

The 2019 novel coronavirus(2019-nCoV) or the severe acute respiratory syndrome corona virus 2 (SARS-
CoV-2) as it is now called, is rapidly spreading from its origin in Wuhan City of Hubei Province of China to
the rest of the world (1). Till 05/03/2020 around 96,000 cases of coronavirus disease 2019 (COVID-19) and
3300 deaths have been reported (2). India has reported 29 cases till date. Fortunately, so far, children have
been infrequently affected with no deaths. But the future course of this virus is unknown. This article gives a
bird's eye view about

Image 15

(entertainment parks etc). China is also considering introducing legislation to prohibit selling and trading of
wild animals (32).

The international response has been dramatic. Initially, there were massive travel restrictions to China and
people returning from China/evacuated from China are being evaluated for clinical symptoms, isolated and
tested for COVID-A9 for 2 weeks even if asymptomatic. However, now with rapid world wide spread of the
virus these travel restrictions have extended to other countries. Whether these efforts will lead to slowing of
viral spread is not known.

A candidate vaccine is under development.

Practice Points from an Indian Perspective

Image 16

dogs have low susceptibility, while the chickens, ducks, and pigs are not all susceptible to SARS-CoV-2
(329).

Similarly, the National Veterinary Services Laboratories of the USDA have reported COVID-19 in tigers
and lions that exhibited respiratory signs like dry cough and wheezing. The zoo animals are suspected to
have been infected by an asymptomatic zookeeper (335). The total number of COVID-19 positive cases in
human beings is increasing at a high ate, thereby creating ideal conditions for viral spillover to other species,
such as pigs. The evidence obtained from SARS-CoV suggests that pigs can get infected with SARAS-CoV-
2 (336). However, experimental inoculation with SARS-CoV-2 failed to infect pigs. (329).

Further studies are required to identify the possible animal reservoirs of SARS-CoV-2 and the seasonal
variation in the circulation of these viruses in the animal population. Research collaboration between human
and animal health sectors is becoming a necessity to evaluate and identify the possible risk factors of
transmission between animals and humans. Such cooperation will help to devise efficient strategies for the
management of emerging zoonotic diseases. (12).

Image 17

prongs, face mask, high flow nasal cannula (HFNC) or non-invasive ventilation is indicated. Mechanical
ventilation and even extra corporeal membrane oxygen support may be needed. Renal replacement therapy
may be needed in some. Antibiotics and antifungals are required if coinfections are suspected or proven. The
role of corticosteroids is unproven; while current international consensus and WHO advocate against their
use,
Chinese guidelines do recommend short term therapy with low-to moderate dose corticosteroids in COVID-
19 ARDS [24, 25]. Detailed guidelines for critical care management for COVID-19 have been published by
the WHO [26]. There is, as of now, no approved treatment for COVID-19. Antiviral drugs such as ribavirin,
lopinavir-ritonavir have been used based on the experience with SARS and MERS. In a historical

Image 18

new targeted drugs, and prevention of further epidemics (13). The most common symptoms associated with
COVID-19 are fever, cough, dyspnea, expectoration, headache, and myalgia or fatigue.
CoVZC45 and bat-SI-CoVZXC21) In contrast, less common signs at the time of hospital admission include
diarrhea, hemoptysis, and shortness of breath (14). Recently, individuals with asymptomatic infections were
also suspected of transmitting infections, which further adds to the complexity of disease transmission
dynamics in COVID-19 infections (1). Such efficient responses require in-depth knowledge regarding the
virus, which currently is a novel agent; consequently, further studies are required.
Comparing the genome of SARS-CoV-2 with that of the closely related SARS/SARS-like COV revealed
that the sequence coding for the spike protein, with a total length of 1,273 amino acids, showed 27 amino
acid substitutions. Six of these substitutions are in the region of the receptor-binding domain (RBD), and
another six substitutions are in the underpinning subdomain (SD) (16). Phylogenetic analyses have revealed
that SARS-CoV-2 is closely related (88% similarity) to two SARS-like COVs derived from bat SARS-like
CoVs (bat-SL-

Image 19

differs from that in SARS-CoV in the five residues critical for ACE2 binding, namely Y455L, L486F,
N493Q, D494S and T501N52 (FIG. 5b,c). Owing to these residue changes, interaction of SARS-CoV-2 with
its receptor
stabilizes the two virus-binding hotspots on the surface ofhACE2 (REF. 50) (FIG. 3d). Moreover, a four-
residue motif in the RBM of SARS-CoV-2 (amino acids 482—485: G-V-E-G) results in a more compact
conformation of its hACE2-binding ridge than in SARS-CoV and enables better contact with the N-terminal
helix of hACE2 (REF. 50). Biochemical data confirmed that the structural features of the SARS-CoV-2
RBD has strengthened its hACE2 binding affinity compared with that of SARS-C0V. Similar to other
coronaviruses, SARS-CoV-2 needs proteolytic processing of the S protein to activate the endocytic route. It
has been shown that host proteases participate in the cleavage of the S protein and activate the entry of
SARS-CoV-2, including transmembrane protease serine protease 2 (TMPRSS2), cathepsin L and furin
Single-cell RNA sequencing data showed that TMPRSS2 is highly expressed in several tissues and body
sites and is co-expressed with ACE2 in nasal epithelial cells, lungs and bronchial branches, which explains
some of the tissue tropism of SARS-CoV-2 (REFS56,57). SARS-CoV-2 pseudovirus entry assays revealed
that TMPRSS2 and cathepsin L have cumulative effects with furin on activating virus entry55. Analysis of
the cryo-electron microscopy structure of SARS-CoV-2 S protein revealed that its RBD is mostly in the
lying-down state, whereas the SARS-CoV S protein assumes equally standing-up and lying-down
conformational states. A lying-down conformation of the SARS-CoV-2 S protein may not be in favour of
receptor binding but is helpful for immune evasion 55.

Image 20

and ritonavir had little therapeutic benefit in patients with COVID- 19, but appeared more effective when
used in combination with other drugs, including ribavirin and interferon beta-lb (143,144). The Randomized
Evaluation of COVID-19 Therapy (RECOVERY) trial, a national clinical trial program in the UK, has
stopped treatment with lopinavir and ritonavir as no significant beneficial effect was observed in a
randomized trial established in March 2020 with a total of 1,596 patients (145). Nevertheless,
Image 21
wrought havoc in China and caused a pandemic situation in the worldwide population, leading to disease
outbreaks that have not been controlled to although extensive efforts are being put in place to counter
this virus (25). This virus has been proposed to be designated/named severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) by the International Committee on Taxonomy of Viruses (ICTV), which
determined the virus belongs to the Severe acute respiratory syndrome-related coronavirus category and
found this virus is related to SARS-C0Vs (26). SARS-C0V-2 is a member of the order Nidovirales, family
Coronaviridae, subfamily Orthocoronavirinae, which is subdivided into four genera, viz.,
Alphacoronavirus, Betacoronavirus, Gammacoronavirus, and Deltacoronavirus (3,27). The genera
Alphacoronavirus and Betacoronavirus originate from bats, while Gammacoronavirus and Deltacoronavirus
have evolved from bird and swine gene pools (24, 28, 29, 275). Coronaviruses possess an unsegmented,
single stranded, positive-sense RNA genome of around 30 kb, enclosed by a 5'-cap and 3'-poly(Å) tail (30).
The 4. genome of SARS-CoV-2 is 29,891 bp long, with a G+C content of 38% (31). These viruses are
encircled with an envelope containing viral

Image 22

Princess, Celebrity Apex, and Ruby Princess. The number of confirmed COVID-19 cases around the world
is on the rise. The success of preventive measures put forward by every country is mainly dependent upon
their ability to anticipate the approaching waves of patients. This will help to properly prepare the health
care workers and increase the intensive care unit (ICU) capacity (321). Instead of entirely relying on
lockdown protocols, countries should focus mainly on alternative intervention strategies, such as large-scale
testing, contract tracing, and localized quarantine of suspected cases for limiting the. spread of this
pandemic virus. Such intervention strategies will be useful either at the beginning of the pandemic or after
lockdown relaxation (322). Lockdown should be imposed only to slow down disease progression among the
population so that the health care system is not overloaded. The reproduction number (RD of COVID-19
infection was earlier estimated to be in the range of 1.4 to 2.5 (70); recently, it was estimated to be 2.24 to
3.58 (76). Compared to its coronavirus predecessors, COVID-19 has a Ro value that is greater than that of
MERS (Ro < 1) (108) but less than that of SARS (Ro value of 2 to 5) (93). Still, to prevent further spread of
disease at mass gatherings,
Image 23

disease transmission are not yet identified (70). Analysis of the initial cluster of infections suggests that the
infected individuals had a common exposure point, a seafood market in Wuhan, Hubei Province, China (Fig.
6). The restaurants of this market are well-known for providing different types of wild animals for human
consumption (71). The Huanan South China Seafood Market also sells live animals, such as poultry, bats,
snakes, and marmots (72). This might be the point where zoonotic (animal-to- human) transmission occurred
(71). Although SARS-CoV-2 is alleged to have originated from an animal host (zoonotic origin) with
further human-to human transmission (Fig. 6), the likelihood of foodborne transmission should be ruled out
with further investigations, since it is a latent possibility (1). Additionally, other potential and expected
routes would be associated with transmission, as in other respiratory viruses, by direct contact, such as
shaking contaminated hands, or by direct contact with contaminated surfaces (Fig. 6). Still, whether blood
transfusion and organ transplantation (276), as well as transplacental and perinatal routes are possible routes
for SARS-CoV-2 transmission needs to be determined (Fig. 6).

Image 24

results of the clinical trial showed that the patients who were given chloroquine had a significant reduction
in their body temperature. The clinical trial also showed better recovery among the patients who were given
chloroquine and hydroxy chloroquine (63-65) Hydroxychloroquine treatment is significantly associated with
viral load reduction as well as disappearance in COVID-19 patients. Further, the outcome is reinforced by
azithromycin. The role of lopinavir and ritonavir in the treatment of COVID-19 is uncertain. A potential
benefit was suggested by preclinical data, but additional data has failed to confirm it. Tocilizumab is an
immunomodulating agent used as adjunct therapy in some protocols based on a theoretical mechanism and
limited preliminary data. (66)

HOME CARE

Home management may be appropriate for patients with mild infection who can be adequately isolated in
the outpatient setting. Management of such patients should focus on prevention of transmission to others,
and monitoring for clinical deterioration, which should prompt hospitalization. Interim recommendations on
home management of patients with COVID-19 can be found on

Image 25

lever, cough, and sputum (83). Hence, tile clinicians must be on the look-out for the possible occurrence of
atypical clinical manifestations@ to avoid the possibility of missed diagnosis. The early transmission ability
of SARS-CoV-2 was found to be similar to or slightly higher than that of SARS-CoV, reflecting that it could
be controlled despite moderate to high transmissibility (84).
Increasing reports of SARS-CoV-2 in sewage and wastewater warrants the need for further investigation due
to the possibility of fecal-oral transmission. SARS-CoV-2 present in environmental compartments such as
soil and water will finally end up in the wastewater and sewage sludge of treatment plants (328). Therefore,
we have to reevaluate the current wastewater and sewage sludge treatment procedures and introduce
advanced techniques that are specific and effective against SARS-CoV-2. Since there is active shedding of
SARS-CoV-2 in the stool, the prevalence of infections in a large population can be studied using
wastewater-based epidemiology. Recently, reverse transcription quantitative PCR (RT-qPCR) was used to
enumerate the copies of SARS-CoV-2 RNA concentrated from wastewater collected from a wastewater
treatment plant (327). The calculated viral RNA copy numbers determine the number of infected individuals.
The

Image 26
respectively (140). However, this study did not include a control arm, and most of the trials of favilavir were
based on a small sample size. For more reliable assessment of the effectiveness of favilavir for treating
COVID-19, large-scale randomized controlled trials should be conducted.
Lopinavir and ritonavir were reported to have in vitro inhibitory activity against SARS-CoV and
MERS-CoV(141'142). Alone, the combination of lopinavir

Image 27

such instance was in 2002—2003 when a new coronavirus of the genera and with origin in bats crossed over
to humans via the intermediary host of palm civet cats in the Guangdong province of China. This virus,
designated as severe acute respiratory syndrome coronavirus affected 8422 people mostly in China and
Hong Kong and caused 916 deaths (mortality rate 11%) before being contained [4]. Almost a decade
later in 2012, the Middle East respiratory syndrome coronavirus (MERS-CoV), also of bat origin, emerged
in Saudi Arabia with dromedary camels as the intermediate host and affected 2494 people and caused 858
deaths (fatality rate 34%) (5)

Origin and Spread of COVID-19

[1, 2, 6)
In December 2019, adults in Wuhan, capital city of Hubei Province and a

Image 28
Therapeutics and Drugs

There is no currently licensed specific antiviral treatment for MERS- and SARS-CoV infections, and the
"main focus in clinical settings remains on lessening clinical signs and providing supportive care (183—
186). Effective drugs to manage COVID19 patients include remdesivir, lopinavir/ritonavir alone or in a
blend with interferon beta, convalescent plasma, and monoclonal antibodies (MAbs); however, efficacy and
safety issues of these drugs require additional clinical trials (187, 281). A controlled trial of ritonavir-
boosted lopinavir and interferon alpha 2b treatment was performed on COVID-19 hospitalized patients
(ChiCTR2000029308) (188). In addition, the use of hydroxychloroquine and tocilizumab for their potential
role in modulating inflammatory responses in the lungs and antiviral effect has been proposed and discussed
in many research articles. Still, no fool-proof clinical trials have been published (194, 196, 197, 261—272).
Recently, a clinical trial conducted on adult patients suffering from severe COVID-19 revealed no benefit
of lopinavir-ritonavir treatment over standard care (273).
The efforts to control SARS-CoV-2 infection utilize defined strategies as followed against MERS and
SARS, along with adopting and strengthening a

Image 29

infections clinically or through routine lab tests. Therefore, travel history becomes important. However, as
the epidemic spreads, the travel history will become irrelevant.
Treatment [21, 23]
Treatment is essentially supportive and symptomatic.
The first step is to ensure adequate isolation (discussed later) to prevent transmission to other
contacts, patients and healthcare workers. Mild illness should be managed at home with counseling about
danger signs. The usual principles are maintaining hydration and nutrition and controlling fever and cough.
Routine use of antibiotics and antivirals such as oseltamivir should be avoided in confirmed cases. In
hypoxic patients, provision of oxygen through nasal prongs, face mask, high flow nasal

Image 30
Coronavirus is the most prominent example of a virus that has crossed the species barrier twice from wild
animals to humans during SARS and MERS outbreaks (79, 102). The possibility of crossing the species
barrier for the third time has also been suspected in the case of SARS-C0V-2 (COVID-19). Bats are
recognized as a possible natural reservoir host of both SARS-C0V and MERS-C0V infection. In contrast,
the possible intermediary host is the palm civet for SARS-CoV and the dromedary camel for MERS-CoV
infection (102). Bats are considered the ancestral hosts for both SARS and MERS (103). Bats are also
considered the reservoir host of human coronaviruses like HC0V-229E and HC0V-NL63 (104). In the case
of COVID-19, there are two possibilities for primary transmission: it can be transmitted either through
intermediate hosts, similar to that of SARS and MERS, or directly from bats (103). The emergence paradigm
put forward in the SARS outbreak suggests that SARS-CoV originated from bats (reservoir host) and later
jumped to civets (intermediate host) and incorporated changes within the receptor-binding domain (RBD) to
improve binding to civet ACE2. This civet-adapted virus, during their subsequent exposure to humans at live
markets, promoted further adaptations that resulted in the epidemic strain (104). Transmission can also

Image 31

Some therapeutic options for treating COVID-19 showed efficacy in in vitro studies; however, to date,
these treatments have not undergone any randomized animal or human clinical trials, which limit their
practical applicability in the current pandemic (7, 9, 19-21).
The present comprehensive review describes the various features of SARS-CoV-2/COVID-19 causing the
current disease outbreaks and advances in diagnosis and developing vaccines and therapeutics. It also
provides a brief comparison with the earlier SARS and MERS CoVs, the veterinary perspective of CoVs and
this emerging novel pathogen, and an evaluation of the zoonotic potential of similar CoVs to provide
feasible One Health strategies for the management of this fatal virus (22—367).

THE VIRUS (SARS-C0V-2)

Coronaviruses are positive-sense RNA viruses having an extensive and promiscuous range of natural hosts
and affect multiple systems (23, 24). Coronaviruses can cause clinical diseases in humans that may extend
from the common cold to more severe respiratory diseases like SARS 411d MERS (17, 279). The recently
emerging SARS-C0V-2 has wrought havoc in China and caused a pandemic

Image 32

mice, and hDPP4-Tg mice (transgenic for expressing hDPP4) for MERS-C0V infection (221). The CRISPR-
Cas9 gene-editing tool has been used for Inserting genomic alterations in mice, making them susceptible to
MERS-CoV infection (222). Efforts are under way to recognize suitable animal models for
SARS-C0V2/COVID-19, identify the receptor affinity of this virus, study pathology in experimental animal
models, and explore virus-specific immune responses and protection studies, which together would increase
the pace of efforts being made for developing potent vaccines and drugs to counter this emerging virus. Cell
lines, such as monkey epithelial cell lines (LLC-MK2 and Vero-B4), goat lung cells, alpaca kidney cells,
dromedary umbilical cord cells, and advanced ex vivo three-dimensional tracheobronchial tissue, have been
explored to study human covs (MERS-C0V) (223, 224). Vero and Huh-7 cells (human liver cancer cells)
have been used for isolating SARS-CoV-2 (194).
Recently, an experimental study with rhesus monkeys as animal models revealed the absence of any viral
loads in nasopharyngeal and anal swabs, and no viral replication was recorded in the primary tissues at a
time interval of 5 days post-reinfection in reexposed monkeys (274). The subsequent virological,
radiological, and pathological

Image 33
respiratory syncytial virus, rhinovirus, human metapneumovirus and SARS coronavirus. It is advisable to
distinguish COVID-19 from other pneumonias such as mycoplasma pneumonia, chlamydia pneumonia and
bacterial pneumonia.33 Several published pieces of literature based on the novel coronavirus reported in
China declared that stool and blood samples can also collected from the suspected persons in order to detect
the virus. However, respiratory samples show better viability in identifying the virus, in comparison with the
other specimens (34-36)

6.2 Nucleic acid amplification tests (NAAT) for COVID-19 virus

The gold standard method of confirming the suspected cases of COVID-19 is carried out by detecting the
unique sequences of virus RNA through reverse transcription polymerase chain reaction (RT-PCR) along
with nucleic acid sequencing if needed. The various genes of virus identified so far include N, E, S (N:
nucleocapsid protein, E: envelope protein gene, S: spike protein gene) and RdRP genes (RNA dependent
RNA polymerase gene).32

Image 34

We also predict the possibility of another outbreak, as predicted by Fan et al. (6). Indeed, the present
outbreak caused by SARS-CoV-2 (COVID19) was expected. Similar to previous outbreaks, the
current outbreak also will be contained shortly. However, the real issue is how we are planning to counter
the next zoonotic COV epidemic that is likely to occur within the next 5 to 10 years or even sooner (Fig. 7).

Image 35

other clinical trials in different phases are still ongoing elsewhere.

Immunomodulatory agents. SARS-CoV-2 triggers a strong immune response which may cause cytokine
storm syndrome60'6. Thus, immunomodulatory agents that inhibit the excessive inflammatory response may
be a potential adjunctive therapy for COVID-19. Dexamethasone is a corticosteroid often used in a wide
range of conditions to relieve inflammation through its anti-inflammatory and immunosuppressant effects.
Recently, the RECOVERY trial found dexamethasone reduced mortality by about one third in hospitalized
patients with COVID- 19 who received invasive mechanical ventilation and by one fifth in patients receiving
oxygen. By contrast, no benefit was found in patients without respiratory support146
Tocilizumab and sarilumab, two types ofinterleukin-6 (IL-6) receptor-specific antibodies previously used to
treat various types of arthritis, including rheumatoid arthritis, and cytokine release syndrome, showed
effectiveness in the treatment of severe COVID- 19 by attenuating the cytokine storm in a small
uncontrolled trial147 Bevacizumab is an anti-vascular endothelial growth factor (VEGF) medication that
could potentially reduce pulmonary oedema in patients with severe COVID-19. Eculizumab is a specific
monoclonal antibody that inhibits the proinflammatory complement protein C5. Preliminary results showed
that it induced a drop of inflammatory markers and C-reactive protein levels, suggesting its potential to be an
option for the treatment of severe COVID-19 148

Image 36
as an entry receptor while exhibiting an RBD similar to that of SARS-C0V (17, 87, 254, 255). Several
countries have provided recommendations to their people traveling to China (88, 89). Compared to the
previous coronavirus outbreaks caused by SARSCOV and MERS-C0V, the efficiency of SARS-C0V2
human-to-human transmission was thought to be less. This assumption was based on the finding that health
workers were affected less than they were in previous outbreaks of fatal coronaviruses (2). Superspreading
events are considered the main culprit for the extensive transmission of SARS and MERS (90, 91). Almost
half of the MERS-C0V cases reported in Saudi Arabia are of secondary origin that occurred through contact
with infected asymptomatic or symptomatic individuals through human-to-human transmission (92). The
occurrence of superspreading events in the COVID-19 outbreak cannot be ruled out until its possibility is
evaluated. Like SARS and MERS, COVID-19 can also infect the lower respiratory tract, with milder
symptoms (27). The basic reproduction number of COVID-19 has been found to be in the range of 2.8 to 3.3
based on real-time reports and 3.2 to 3.9 based on predicted infected cases

Image 37

the SARS- CoV. Environmental samples from the Huanan sea food market also tested positive, signifying
that the yirus originated from there [7]. The number of cases started increasing exponentially, some of which
did not have exposure to the live animal market, suggestive of the fact that human-to-human transmission
was occurring [8]. The first fatal case was reported on 11th Jan 2020. The massive migration of Chinese
during the Chinese New Year fueled the epidemic. Cases in other provinces of China, other countries
(Thailand, Japan and South Korea in quick succession) were reported in people who were returning from
Wuhan. Transmission to healthcare workers caring for patients was described on 20th Jan, 2020. By 23rd
January, the 11 million population of Wuhan was placed under lock down with restrictions of entry and exit
from the region. Soon this lock down was

Image 38

of persistent local transmission or contact with patients with similar o travel history or those with confirmed
COVID-19 infection. However, cases may be asymptomatic or even without fever. A confirmed case is a
suspect case with a positive molecular test.
Specific diagnosis is by specific molecular tests on respiratory samples (throat swab/ nasopharyngeal swab/
4. sputum/ endotracheal aspirates and bronchoalveolar lavage). Virus may also be detected in the stool and
in severe cases, the blood. It must be remembered that the multiplex PCR panels currently available do not
include the COVID-19. Commercial tests are also not available at present. In a suspect case in India, the
appropriate sample has to be sent to designated reference labs in India or the National Institute of Virology
in Pune. As the epidemic progresses, commercial tests

Image 39

polymorphism at nucleotide position 28,144, which results in amino acid substitution of Ser for Lys at
residue 84 of the ORF8 protein. Those variants with this mutation make up a single subclade labelled as
'clade S'33,34 Currently, however, the available sequence data are not sufficient to interpret the early global
transmission history of the virus, and travel patterns, founder effects and public health measures also
strongly influence the spread of particular lineages, irrespective of potential biological differences between
different virus variants.

Animal host and spillover

Bats are important natural hosts; of alphacoronaviruses and betacoronaviruses. The Closest relative to
SARS-CoV-2 known to date is a bat coronavirus detected in Rhinolophus affinis from Yunnan province,
China, named 'RaTG13', whose full-length genome sequence is 96.2% identical to that of SARS-CoV-2
(REF. 11). This bat virus shares more than 90% sequence identity with SARS-CoV-2 in all ORFs throughout
the genome, including the highly variable S and ORF8 (REF. 11). Phylogenetic analysis confirms that SARS-
CoV-2 closely clusters with RaTG13 (FIG. 2). The high genetic similarity between SARS-CoV-2 and
RaTG13 supports the hypothesis that SARS-CoV-2 likely originated from bats 35. Another related
coronavirus has been reported more recently in a Rhinolophu malayanus bat sampled in Yunnan. This novel
bat virus denoted

Image 40

into the host cell. Heptad repeat I (HR l) and heptad repeat 2 (HR2) can interact and form a six-helix bundle
that brings the viral and cellular membranes in close proximity, facilitating its fusion. The sequence
alignment study conducted between COVID-19 and SARS-C0V identified that the S2 subunits are highly
conserved in these CoVs. The HRI and HR2 domains showed 92.6% and 100% overall identity, respectively
(210). From these findings, we can confirm the significance of COVID-19 HRI and HR2 and their vital role
in host cell entry. Hence, fusion inhibitors target the HRI domain of S protein, thereby preventing viral
fusion and entry into the host cell. This is another potential therapeutic strategy that can be used in the
management of COVID-19. Other than the specific therapy directed against COVID-19, general treatments
play a vital role in the enhancement of host immune responses against the viral agent. Inadequate nutrition is
linked to the weakening of the host Immune response, making the individual more susceptible. The role
played by nutrition in disease susceptibility should be measured by evaluating the nutritional status of
patients with COVID-19 (205).

Image 41

Coronavirus S protein is a large, multifunctional class I viral transmembrane protein, The size of this
abundant S protein varies from 1,160 amino acids (1BV, infectious bronchitis virus, in poultry) to 1,400
amino acids (FCoV, feline coronavirus) (43). It lies in a trimer on the virion surface, giving the vinon a
corona or crown-like appearance. Functionally it is required for the entry of the infectious vinon particles
into the cell through interaction with various host cellular receptors (44) Furthermore, it acts as a critical
factor for tissue tropism and the determination of host range (45). Notably, S protein is one of the vital
immunodominant proteins of CoVs capable of inducing host immune responses (45). The ectodomains in all
CoVs S proteins have similar domain organizations, divided into two subunits, Sl and S2 (43). The first one,
S 1, helps in host receptor binding, while the second one, S2, accounts for fusion. The
former (S 1) is further divided into two subdomains, namely, the N-terminal domain (NTD) and C-terminal
domain (CTD). Both of these subdomains act as receptor-binding domains, Interacting efficiently with
various host receptors (45). The Sl CTD contains the receptor-binding motif (RBM). In each coronavirus
spike protein, the trimeric Sl locates itself on top of the trimeric S2

Image 42

responsible for MERS-C0V and SARS-C0V (3). The newly emerged SARS-CoV-2 is a group 2B
coronavirus (2). The genome sequences of SARSCoV-2 obtained from patients share 79.5% sequence
similarity to the sequence of SARS-CoV (63). As of 13 May 2020, a total of confirmed cases of COVID-19
(with 287,399 deaths) have been reported in more than 210 affected countries worldwide (WHO Situation
Report 114

Image 43
Coronaviruses are a diverse group of viruses infecting many different animals, and they can cause mild to
severe respiratory infections in humans. In 2002 and 2012, respectively, two highly pathogenic
Coronaviruses with zoonotic origin, severe acute respiratory syndrome coronavirus (SARS-CoV) and
Middle East respiratory syndrome coronavirus (MERS-CoV), emerged in humans and caused fatal
respiratory illness, making emerging coronaviruses a new public health concern in the twenty-first century.
At the end of 2019, a novel coronavirus designated as SARS-CoV-2 emerged in the city of Wuhan, China,
and caused an outbreak of unusual viral pneumonia. Being highly transmissible, this novel coronavirus
disease, also known as coronavirus disease 2019 (COVID-19), has spread fast all over the world It has
overwhelmingly surpassed SARS and MERS in terms of both the number of infected people and the spatial
range of epidemic areas. The ongoing outbreak of COVID-19 has posed an extraordinary threat to global
public health4'5. In this Review, we summarize the current understanding of the nature of SARS-CoV-2 and
COVID-19. On the basis of recently published findings, this comprehensive Review covers the basic
biology of SARS-CoV-2, including the genetic characteristics, the potential zoonotic origin and its receptor
binding. Furthermore, we will discuss the clinical and epidemiological features, diagnosis of and
countermeasures against COVID- 19.

Emergence and spread

In late December 2019, several health facilities in Wuhan, in Hubei province in China, reported clusters of
patients with pneumonia of unknown cause 6. Similarly, to patients with SARS and MERS, these patients
showed symptoms of viral pneumonia, including fever, cough

Image 44

The host spectrum of coronavirus increased when a novel coronavirus, namely, SWI, was recognized in the
liver tissue of a captive beluga whale (Delphinapterus leucas) (138). In recent decades, several novel
coronaviruses were identified from different animal species. Bats can harbor these viruses without
manifesting any clinical disease but are persistently infected (30). They are the only mammals with the
capacity for self-powered flight, which enables them to migrate long distances, unlike land mammals. Bats
are distributed worldwide and also account for about a fifth of all mammalian species (6). This makes them
the ideal reservoir host for many viral agents and also the source of novel coronaviruses that have yet to be
identified. It has become a necessity to study the diversity of coronavirus in the bat population to prevent
future outbreaks that could jeopardize livestock and public health. The repeated outbreaks caused by bat-
origin coronaviruses call for the development of efficient molecular surveillance strategies for studying
Betacoronavirus among animals (12), especially in the Rhinolophus bat family (86). Chinese bats have high
commercial value, since they are used in

Image 45

6.3 Serological testing

Serological surveys are also considered to be one of the most effective ones in facilitating outbreak
investigation and it also helps us to derive a retrospective assessment of the disease by estimating the attack
rate.32 According to the recent literature, paired serum samples can also help clinicians to diagnose COVID-
19 in case of false negative results in NAAT essays. 37 The literature also declared that the commercial and
non-commercial serological tests are under consideration in order to support the practising clinicians by
assisting them in diagnosis. Similarly, there are studies published on COVID-1 9 which are comprised of the
serological data on clinical samples.38, 39

6.4 Viral sequencing

Apart from confirming the presence of virus in the specimens, viral sequencing is also quite useful in
monitoring the viral genomic mutations, which plays a very significant role in influencing the performance
of the medical countermeasures inclusive of the diagnostic test. Genomic sequencing of the virus can also
help further in developing several studies related to molecular epidemiology.32

Image 46
animal species IS necessary to prevent the possibility of virus spread and initiation of an outbreak due to
zoonotic spillover (l).
Personal protective equipment (PPE), like face masks, will help to prevent the spread of respiratory
infections like COVID-19. Face masks not only protect from infectious aerosols but also prevent the
transmission of disease to other susceptible individuals while traveling through public transport systems
(313). Another critical practice that can reduce the transmission of respiratory diseases is the maintenance of
hand hygiene. However, the efficacy of this practice in reducing the transmission of respiratory viruses like
SARS-CoV-2 is much dependent upon the size of droplets produced. Hand hygiene will reduce disease
transmission only if the virus is transmitted through the formation of large droplets (314). Hence, it is better
not to overemphasize that hand hygiene will prevent the transmission of SARS-CoV-2, since it may produce
a false sense of safety among the general public that further contributes to the spread of COVID-19. Even
though airborne spread has not been reported in SARS-CoV-2 infection, transmission can occur through
droplets and fomites, especially when there is close, unprotected contact between infected and susceptible
individuals. Hence, hand hygiene is

Image 47

Hence, hand hygiene is equally as important as the use of appropriate PPE, like face masks, to break the
transmission cycle of the yirus; both hand hygiene and face masks help to lessen the risk of COVID-19
transmission (315).
Medical staff are in the group of individuals most at risk of getting COVID-19 infection. This is because
they are exposed directly to infected patients. Hence, proper training must be given to all hospital staff on
methods of prevention and protection so that they become competent enough to protect themselves and
others from this deadly disease (316). As a preventive measure, health care workers caring for infected
patients should take extreme precautions against both contact and airborne transmission. They should use
PPE such as face masks (N95 or FFP3), eye protection (goggles), gowns, and gloves to nullify the risk of
infection (299).
The human-to-human transmission reported in SARS-CoV-2 infection occurs mainly through droplet or
direct contact. Due to this finding, frontline health care workers should follow stringent infection control
and preventive measures, such as the use of PPE, to prevent infection (110). The mental health of the
medical/health workers who are involved in the COVID-19 outbreak is of great

Image 48

Practice Points from an Indian Perspective

At the time of writing this article, the risk of coronavirus in India is extremely low. But that may change in
the next few weeks. Hence the following is recommended:

• Healthcare providers should take

respiratory symptoms, and any international travel in the past 2 wks as well as contact with sick people who
have travelled internationally.
• They should set up a system of triage of patients with respiratory illness in the outpatient department and
give them a simple surgical mask to wear. They should use surgical masks themselves while examining
such
Image 49

10 RECOMBINANT SUBUNIT VACCINE

Clover Biopharmaceuticals is producing a recombinant subunit vaccine based on the trimeric S-protein of
COVID-1 9. 55 The oral recombinant vaccine is being expanded by Vaxart in tablet formulation, using its
proprietary oral vaccine platform.
1 1 CLINICAL MANAGEMENT
AND TREATMENT
In severe COVID-19 cases, treatmen!should be given to support vital organ functions. People who think
they may have been exposed to COVID-19 should contact their healthcare provider immediately. Healthcare
personnel should care for patients in an Airborne Infection Isolation Room (AIIR). Precautions must be
taken by the healthcare professional, such as contact precautions and airborne precautions with eye
protection.56
Individuals with a mild clinical presentation may not require primary hospitalisation. Close monitoring is
needed for the persons infected with COVID-19. Elderly patients and those with prevailing chronic medical
conditions such as

Image 50

Coronaviruses in Humans SARS, MERS, and COVID-19

Coronavirus infection in human is is commonly associated with mild to severe respiratory diseases, with
high fever, severe inflammation, cough, and internal organ dysfunction that can even lead to death (92).
Most of the identified coronaviruses cause the common cold in humans. However, this changed when
SARS-CoV was identified, paving the way for severe forms of the disease in humans (22). Our previous
experience with the outbreaks of other coronaviruses, like SARS and MERS, suggests that the mode of
transmission in COVID-19 as mainly human-to-human transmission via direct contact, droplets, and fomites
(25). Recent studies have demonstrated that the virus could remain viable for hours in aerosols and up to
days on surfaces; thus, aerosol and fomite contamination could play potent roles in the transmission of
SARS-CoV-2 (257).
The immune response against coronavirus is vital to control and get rid of the infection. However,
maladjusted immune responses may contribute to the immunopathology of the disease, resulting in
impairment of pulmonary gas exchange. Understanding the interaction between CoVs and host innate
immune systems could enlighten our

Image 51

Initially, the epicenter of the SARS-CoV-2 pandemic was China, which reported a significant number of
deaths associated with COVID-19, with 84,458 laboratory-confirmed cases and 4,644 deaths as of 13 May
2020 (Fig. 4). As of 13 May 2020, SARS-CoV-2 confirmed cases have been reported in more than 210
countries apart from China (Fig. 3 and 4) (WHO Situation Report 114) (25, 64). COVID-19 has been
reported on all continents except Antarctica. For many weeks, Italy was the focus of concerns regarding the
large number of cases, with 221,216 cases and 30,911 deaths, but now, the United States is the country with
the largest number of cases, 1,322,054, and 79,634 deaths. Now, the United Kingdom has even more cases
(226,4671) and deaths (32,692) than Italy. A John HopkinS University web platform has provided daily
updates on the basic epidemiology of the COVID-19 outbreak

Image 52
it had spread massively to all 34 provinces of China. The number of confirmed cases suddenly increased,
with thousands of new cases diagnosed daily during late o January 5. On 30 January, the WHO declared the
novel coronavirus outbreak a public health emergency of international concern 16. On 11 February, the
International Committee on Taxonomy of Viruses named the novel coronavirus 'SARS-CoV-2', and the
WHO named the disease 'COVID-19' 17).
The outbreak of COVID-19 in China reached an epidemic peak in February. According to the National
Health Commission of China, the total number of cases continued to rise sharply in early February at an
average rate of more than 3,000 newly confirmed cases per day. To control COVID-19, China implemented
unprecedentedly strict public health measures. The city of Wuhan was shut down on 23 January, and all
travel and transportation connecting the city was blocked. n the following couple of weeks, all outdoor
activities and gatherings were restricted, and public facilities were closed in most cities as well as in
countryside18. Owing to these measures, the daily number of new cases in China started to decrease
steadily19
However, despite the declining trend in China, the international spread of COVID- 19 accelerated from late
February. Large clusters of infection have been reported from an increasing number of countries 18. The high
transmission efficiency of SARS-CoV-2 and the abundance of international travel enabled rapid worldwide
spread of COVID-19. On 11 March 2020, the WHO officially characterized the global COVID-19 outbreak
as a pandemic 0. Since March, while COVID-19 in China has become effectively controlled, the case
numbers in Europe, the USA and other regions have jumped sharply. According to the COVID-19
dashboard of the Center for System Science and Engineering at Johns Hopkins University, as of 11 August
2020,

Image 53

Bovine coronaviruses (BoCoVs) are known to Infect several domestic and wild ruminants (126). BoeoV
inflicts neonatal calf diarrhea in adult cattle, leading to bloody diarrhea (winter dysentery) and respiratory
disease complex (shipping fever) in cattle of all age groups (126). BoCoV-like viruses have been noted in
humans, suggesting its zoonotic potential as well (127). Feline enteric and feline infectious peritonitis (FIP)
viruses are the two major feline CoVs (128), where feline CoVs can affect the gastrointestinal tract,
abdominal cavity (peritonitis), respiratory tract, and central nervous system (128). Canines are also affected
by CoVs that fall under different genera, namely, canine enteric coronavirus in Alphacoronavirus and canme
respiratory coronavirus in Betacoronavirus, affecting the enteric and respiratory tract, respectively (129,
130). 1BV, under Gammacoronavirus, causes diseases of respiratory, urinary, and reproductive systems,
with substantial economic losses in chickens (131, 132). In small laboratory animals, mouse hepatitis virus,
rat sialodacryoadenitis coronavirus, and guinea pig and rabbit coronaviruses are the rmajor CoVs
associated with disease manifestations like enteritis, hepatitis, and respiratory infections (10, 133).

Image 54
risk regions. It is derived from a live attenuated strain of Mycobacterium bovis. At present, three new
clinical trials have been registered to evaluate the protective role of BCG vaccination against SARSCoV-2
(363). Recently, a cohort study was conducted to evaluate the impact of childhood BCG vaccination in
COVID-19 PCR positivity rates. However, childhood BCG vaccination was found to be associated with a
rate of COVID-19-positive test results similar to that of the nonvaccinated group (364). Further studies are
required to analyze whether BCG vaccination in childhood can induce protective effects against COVID-19
in adulthood. Population genetic studies conducted on 103 genomes identified that the SARS-CoV-2 virus
has evolved into two major types, L and S. Among the two types, L type is expected to be the most prevalent
(-70%), followed by the S type (-30%) (366). This finding has a significant impact on our race to develop an
ideal vaccine, since the vaccine candidate has to target both strains to be considered effective. At present,
the genetic differences between the L and S types are very small and may not affect the immune response.
However, we can expect further genetic variations in the coming days that could lead to the emergence of
new strains (367).

Image 55

Inhibition of virus entry. SARS-CoV-2 uses ACE2 as the receptor and human proteases as entry activators;
subsequently it fuses the viral membrane with the cell membrane and achieves invasion. Thus, drugs that
interfere with entry may be a potential treatment for COVID-19. Umifenovir (Arbidol) is a drug approved in
Russia and China for the treatment of influenza and other respiratory viral infections. It can target the
interaction between the S protein and ACE2 and inhibit membrane fusion (FIG. 5). In vitro experiments
showed that it has activity against SARS-CoV-2, and current clinical data revealed it may be more effective
than lopinavir and ritonavir in treating COVID-19 (REFS122,123). However, other clinical Studies showed
umifenovir might not improve the prog- •S nosi$ of or accelerate SARS-CoV-2 clearance in patients with
mild to moderate COVID-19 (REFS 124'125). Yet some ongoing clinical trials are evaluating its efficacy for
COVID-19 treatment. Camostat mesylate is approved in Japan for the treatment of pancreatitis and
postoperative reflux oesophagitis. Previous studies showed that it can prevent SARS-CoV from entering
cells by blocking TMPRSS2 activity and protect mice from lethal infection with SARS-CoV in a pathogenic
mouse model (wildtype mice infected with a mouse-adapted SARS-CoV strain) 126,127. Recently, a study
revealed that camostat mesylate blocks the entry of SARS-CoV-2 into human lung cells 4 . Thus, it can be a
potential antiviral drug against SARS-CoV-2 infection, although so far there are not sufficient clinical data
to support its efficacy.

Image 56

8 PREVENTION
The WHO and other agencies such as the CDC have published protective measures to mitigate the spread of
COVID-19. This involves frequent hand washing with handwash containing 60% of alcohol and soap for at
least 20 seconds. Another important measure is avoiding close contact with sick people and keeping a social
distance of 1 metre always to everyone who is coughing and sneezing. Not touching the nose, eyes and
mouth was also suggested. While coughing or sneezing, covering the mouth and nose with a cloth/tissue or
the bent elbow is advised. Staying at home is recommended for those who are sick, and wearing a facial
mask is advised when going out among people. Furthermore, it is recommended to clean and sterilise
frequently touched surfaces such as phones and doorknobs on a daily basis.51 , 52 Staying at home as much
as possible is advisable for those who are at higher risk for severe illness, to minimise the risk of exposure to
COVID-19 during outbreaks.53

Image 57

It is also evident that remdesivir was effective in treating the patients who were infected with Ebola virus.
Per this evidence, China has already started testing the efficacy of remdeslvir in treating the patients with
COVID-1 9, especially in Wuhan, where the outbreak occurred. Chloroquine, which is an existing drug
which is currently used in treating malaria cases, was given to more than 100 patients who were affected
with novel coronavirus to test its efficacy.62
A multicentric study was conducted in China to test the effectiveness of remdesivir in treating the patients
with COVID-19. Thus, the results of the clinical trial proved that remdesivir has a considerably acceptable
level of efficacy for treating the patients with COVID-1 9. Therefore, the National Health Commission of
the People's Republic of China decided to include remdesivir in the Guidelines for the Prevention, Diagnosis
and Treatment of Pneumonia Caused by COVID-
1 9.62
Chloroquine and hydroxychloroquine are existing anti-malaria drugs also given to more than 30 patients
infected with COVID-19 in Guangdong province and Hunan province to test their effectiveness and
efficacy. Thus, the results of the clinical trial showed that the

Image 58

Epidemiology and Pathogenesis L [10, 11]

All ages are susceptible. Infection is transmitted through large droplets generated during coughing and
sneezing by symptomatic patients but can also occur from asymptomatic people and before onset of
symptoms
[9]. Studies have shown higher viral

loads in the nasal cavity as compared

to the throat with no difference m viral burden between symptomatic and asymptomatic people [12]. Patients
can be infectious for as long as the symptoms last and even on clinical recovery. Some people may act as
super spreaders; a UK citizen who attended a conference in Singapore infected 11 other people while
staying in a resort in the French Alps and upon return to the UK [6]. These infectious droplets can spread 1-
2 m and deposit

Image 59
vaccine that can produce cross-reactive antibodies. However, the success of such a vaccine relies greatly on
its ability to provide protection no! only against present versions of the virus but also the ones that are likely
to emerge in the future. This can be achieved by identifying antibodies that can recognize relatively
conserved epitopes that are maintained as such even after the occurrence of considerable variations (362).
Even though several vaccine clinical trials are being conducted around the world, pregnant women have
been completely excluded from these studies. Pregnant women are highly vulnerable to emerging diseases
such as COVID-19 due to alterations in the immune system and other physiological systems that are
associated with pregnancy. Therefore, in the event of successful vaccine development, pregnant women will
not get access to the vaccines (361). Hence, it is recommended that pregnant women be included in the
ongoing vaccine trials, since successful vaccination in pregnancy will protect the mother, fetus, and
newborn.
The heterologous immune effects induced by Bacillus Calmette Guérin (BCG) vaccination is a promising
strategy for controlling the COVID-19 pandemic and requires further investigations. BCG is a widely used
vaccine against tuberculosis in high

Image 60

[Link]/pmc/arti( O exponentially in other countrieé including South Korea, Italy and Iran. Of
those infected, 20% are in critical condition, 25% have recovered, and 3310 (3013 in China and 297 in other
countries) have died [2]. India, which had reported only 3 cases till 2/3/2020, has also seen a sudden spurt in
cases. By 5/3/2020, 29 cases had been
reported; mostly in Delhi, Jaipur and
Agra in Italian tourists and their contacts. One case was reported in an Indian who traveled back from
Vienna and exposed a large number of school children in a birthday party at a city hotel. Many of the
contacts of these cases have been quarantined.
These numbers are possibly an underestimate of the infected and dead due to limitations of surveillance
and testing. Though the SARS-CoV-2 originated from bats, the intermediary

Image 61

14 ANTIVIRAL THERAPY
COVID-19 is an infectious disease caused by SARS-CoV-2, which is also termed the novel coronavirus and
is diligently associated with the SARS virus. The Ministry of Science and Technology from the People's
Republic of China declared three potential antiviral medicines suitable for treating COVID-1 9. Those three
medicines are, namely, Favilavir, chloroquine phosphate and remdesivir. A clinical trial was conducted to
test the efficacy of those three drugs, and the results proved that out of the three medicines above only
Favilavir is effective in treating the patients with novel coronavirus. The remaining two drugs were effective
in treating malaria.62
Likewise, a study carried out in the United States by the National Institute of Health proved that remdesivir
is effective in treating the Middle East respiratory syndrome coronavirus (MERSCOV), which is also a type
of coronavirus that was transmitted from monkeys. The drug remdesivir was also used in the United States
for treating the patients with COVID-19. There has been a proposal to use the combination of protease
inhibitors lopinavir-ritonavir for treating the patients affected by COVID-19. 62

Image 62

the initial stages of the outbreak, only mild symptoms were noticed in those patients that are Infected by
human-to-human transmission (14).
The initial trends suggested that the mortality associated with COVID-19 was less than that of previous
outbreaks of SARS (101). The updates obtained from countries like China, Japan, Thailand, and South
Korea indicated that the COVID-19 patients had relatively mild manifestations compared to those with
SARS and MERS (4). Regardless of the coronavirus type, immune cells, like mast cells, that are present in
the submucosa of the respiratory tract and nasal cavity are considered the primary barrier against this virus
(92). Advanced in-depth analysis of the genome has identified 380 amino acid substitutions between the
ammo acid sequences of SARS-C0V-2 and the SARS/SARS-1ike coronaviruses. These differences in the
amino acid sequences might have contributed to the difference in the pathogenic divergence of SARS-CoV-
2 (16). Further research is required to evaluate the possible differences in tropism, pathogenesis, and
transmission of this novel agent associated with this change in the ammo acid sequence. With the current
outbreak of COVID-19, there is an expectancy of a significant increase in the number of published studies
about this emerging coronavirus, as occurred

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urological, radiological, and pathological observations indicated that the monkeys with reexposure had no
recurrence of COVID-19, like the SARS-CoV-2-infected monkeys without rechallenge. These findings
suggest that primary infection with SARS-CoV-2 could protect from later exposures to the virus, which
could help in defining disease prognosis and crucial inferences for designing and developing potent vaccines
against COVID-19 (274).
PREVENTION, CONTROL, AND
MANAGEMENT
In contrast to their response to the 2002 SARS outbreak, China has shown immense political openness in
reporting the COVID-19 outbreak promptly. They have also performed rapid sequencing of COVID-19 at
multiple levels and shared the findings globally within days of identifying the novel virus (225). The move
made by China opened a new chapter in global health security and diplomacy. Even though complete
lockdown was declared following the COVID-19 outbreak in Wuhan, the large-scale movement of people
has resulted in a radiating spread of infections in the surrounding provinces as well as to several other
countries. Large-scale screening programs might

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length to the corresponding proteins in SARS-CoV. Of the four structural genes, SARS-CoV-2 shares more
than 90% amino acid identity with SARS-CoV except for the S gene, which diverges11'24. The replicase
gene covers two thirds of the 5' genome, and encodes a large polyprotein (pplab), which is proteolytically
cleaved into 16 non-structural proteins that are involved in transcription and virus replication. Most of these
SARS-CoV-2 non-structural proteins have greater than 85% amino acid sequence identity with SARS-
CoV25.
The phylogenetic analysis for the whole genome shows that SARS-CoV-2 is clustered with SARS-CoV and
SARS-related coronaviruses (SARSr-CoVs) found in bats, placing it in the subgenus Sarbecovirus of the
genus Betacoronavirus. Within this clade, SARS-CoV-2 is grouped in a distinct lineage together with four
horseshoe bat coronavirus isolates (RaTG13, RmYN02, ZC45 and ZXC21) as well as novel coronaviruses
recently identified in pangolins, which group parallel to SARS-CoV

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(96.7 0 0), and S genes (90.4 0 0). The RBI) of S protein in COV isolated from pangolin was almost identical
one amino acid difference) to that of FARS-CoV-2. A comparison of the genomes suggests recombination
between pangolin-CoV-like viruses with the bat-CoV-RaTG13-like virus. All this suggests the potential of
pangolins to act as the intermediate host of SARS-CoV-2 (145).
Human-wildlife Interactions, which are increasing in the context of climate change (142), are
further considered high risk and responsible for the emergence of SARS-C0V. COVID-19 is also suspected
of having a similar mode of origin. Hence, to 4 prevent the occurrence of another zoonotic spillover (l),
exhaustive coordinated efforts are needed to identify the high-risk pathogens harbored by wild animal
populations, conducting surveillance among the people who are susceptible to zoonotic spillover events (12),
and to improve the biosecurity measures associated with the wildlife trade (146). The serological
surveillance studies conducted in people living in proximity to bat caves had earlier identified the serological
confirmation of SARSrelated CoVs in humans. People living at the wildlife-human interface, mainly in rural
China, are regularly exposed to SARS-related CoVs (147). These findings will not have any significance
until a

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Furthermore, SARS-CoV-2 is genetically distinct from SARS-C0V (79% similarity) and MERS-C0V
(nearly 50%) (17). COVID-19 is associated with afflictions of the lungs in all cases and generated
characteristic chest computer tomography findings, such as the presence of multiple lesions in lung lobes
that appear as dense, ground-glass opaque structures that occasionally coexist with consolidation shadows
(18).

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been used based on the experience with SARS and MERS. In a historical control study in patients with
SARS patients treated with lopinavirritonavir with ribavirin had better outcomes as compared to those given
ribavirin alone [15].
In the case series of 99 hospitalized patients with COVID-19 infection fromWuhan, oxygen was given to
76%, non-invasive ventilation in 13%, mechanical ventilation in 4%, extracorporeal membrane oxygenation
(ECMO) in 3%, continuous renal replacement therapy (CRRT) in 9%, antibiotics in 71%, antifungals in
15%, glucocorticoids in 19% and intravenous immunoglobulin therapy in 27% [15]. Antiviral therapy
consisting of oseltamivir, ganciclovir and lopinavir ritonavir was given to 75% of the patients. The
duration of non-invasive ventilation was 4—22 d [median 9 d]

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6.1 Laboratory testing for coronavirus disease 201 9 (COVID19) in suspected human cases
The assessment of the patients with COVID-1 9 should be based on the clinical features and also
epidemiological factors. The screening protocols must be prepared and followed per the native context. 31
Collecting and testing of specimen samples from the suspected individual is considered to be one of the
main principles for controlling and managing the outbreak of the disease in a country. The suspected cases
must be screened thoroughly in order to detect the virus with the help of nucleic acid amplification tests such
as Reverse transcription polymerase chain reaction (RTPCR). If a country or a particular region does not
have the facility to test the specimens, the specimens of the suspected individual should be sent to the
nearest reference laboratories per the list provided by WHO. 32
It is also recommended that the suspected patients be tested for the other respiratory pathogens by
performing the routine laboratory Investigation per the local guidelines, mainly to differentiate from other
viruses that include influenza virus, parainfluenza virus, adenovirus, respiratory syncytial virus, rhinovirus,
human vaccine that can produce cross-reactive antibodies. However, the success of such a vaccine relies
greatly on its ability to provide protection no! only against present versions of the virus but also the ones that
are likely to emerge in the future. This can be achieved by identifying antibodies that can recognize
relatively conserved epitopes that are maintained as such even after the occurrence of considerable variations
(362). Even though several vaccine clinical trials are being conducted around the world, pregnant women
have been completely excluded from these studies. Pregnant women are highly vulnerable to emerging
diseases such as COVID-19 due to alterations in the immune system and other physiological systems that are
associated with pregnancy. Therefore, in the event of successful vaccine development, pregnant women will
not get access to the vaccines (361). Hence, it is recommended that pregnant women be included in the
ongoing vaccine trials, since successful vaccination in pregnancy will protect the mother, fetus, and
newborn.
The heterologous immune effects induced by Bacillus Calmette Guérin (BCG) vaccination is a promising
strategy for controlling the COVID-19 pandemic and requires further investigations. BCG is a widely used
vaccine against tuberculosis in high-

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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.

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VACCINES
The strange coronavirus outbreak in the Chinese city of Wuhan, now termed COVID-1 9, and its rapid
transmission, threatens people around the world. Because of its pandemic nature, the National Institutes of
Health (NIH) and pharmaceutical companies are involved in the development of COVID-19 vaccines. Xu
Nanping, China's vice-minister of science and technology, announced that the first vaccine is expected to be
ready for clinical trials in China at the end of April 2020. 54 There is no approved vaccine and treatment for
COVID-19 infections.
Vaccine development is sponsored and supported by the Biomedical Advanced Research and Development
Authority (BARDA), a component of the Office of the Assistant Secretary for Preparedness and Response
(ASPR). Sanofi will use its egg-free, recombinant DNA technology to produce an exact genetic match to
proteins of the virus.55

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Initially, the epicenter of the SARS-CoV-2 pandemic was China, which reported a significant number of
deaths associated with COVID-19, with 84,458 laboratory-confirmed cases and 4,644 deaths as of 13 May
2020 (Fig. 4). As of 13 May 2020, SARS-CoV-2 confirmed cases have been reported in more than 210
countries apart from China (Fig. 3 and 4) (WHO Situation Report 114) (25, 64). COVID-19 has been
reported on all continents except Antarctica. For many weeks, Italy was the focus of concerns regarding the
large number of cases, with 221,216 cases and 30,911 deaths, but now, the United States is the country with
the largest number of cases, 1,322,054, and 79,634 deaths. Now, the United Kingdom has even more cases
(226,4671) and deaths (32,692) than Italy. A John HopkinS University web platform has provided daily
updates on the basic epidemiology of the COVID-19 outbreak

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assessed intrauterine vertical transmission of COVID-19 infection in nine infants born to infected mothers,
found that none of the infants tested positive for the virus. 45 Likewise, there was no evidence of intrauterine
infection caused by vertical transmission in the SARS and MERS epidemics.43
The CDC asserts that infants born to mothers with confirmed COVID-19 are considered persons under
investigation (PUI) and should be temporarily separated from the mother and isolated.46
7.1 Breastfeeding and infant care
The data available to date is limited and cannot confirm whether or not COVID-19 can be transmitted
through breast milk. 40 Assessing the presence of COVID-19 in breast milk samples from six patients showed
negative result. 45 The CDC points out that in case of a confirmed or suspected COVID-19 infection, the
decision of whether or how to start or continue breastfeeding should be made by the mother in collaboration
with the family and healthcare practitioners. 47 Careful precautions need to be taken by the mother to
prevent transmitting the disease to her infant through respiratory droplets during breastfeeding. This includes
wearing a facemask and practicing hand

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RED, indicating its potential as a therapeutic agent in the management of COVID-19. It can be used alone
or in combination with other effective neutralizing antibodies for the treatment and prevention of COVID-19
(202). Furthermore, SARSCoV-specific neutralizing antibodies, like m396 and CR3014, failed to bind the S
protein of SARS-CoV2, indicating that a particular level of similarity is mandatory between the RBDs of
SARS-CoV and SARS-CoV-2 for the cross-reactivity to occur.
Further assessment is necessary before confirming the effectiveness of such combination therapy. In
addition, to prevent further community and nosocomial spread of COVID-19, the post procedure risk
management program should not be neglected (309). Development of broad-spectrum inhibitors against the
human coronaviral pathogens will help to facilitate clinical trials on the effectiveness of such inhibitors
against endemic and emerging coronaviruses (203). A promising animal study revealed the protective effect
of passive immunotherapy with immune serum from MERS immune camels on mice infected with MERS-
CoV (204). Passive immunotherapy using convalescent plasma is another strategy that can be used for
treating COVID-19-infected, critically ill patients (205).

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explored targeting molecular dynamic simulations, evaluating their interaction with corresponding major
histocompatibility complex class I molecules. They potentially induce immune responses (176). The
recombinant vaccine can be designed by using rabies virus (RV) as a viral vector. RV can be made to
express MERS-CoV Sl protein on its surface so that an immune response is induced against MERS-CoV.
The RV vector-based vaccines against MERS-CoV can induce faster antibody response as well as higher
degrees of cellular immunity than the Gram-positive enhancer matrix (GEM) particle vector-based vaccine.
However, the latter can induce a very high antibody response at lower doses (167). Hence, the degree of
humoral and cellular immune responses produced by such vaccines depends upon the vector used.
Dual vaccines have been getting more popular recently. Among them, the rabies virus-based vectored
vaccine platform is used to develop vaccines against emerging infectious diseases. The dual vaccine
developed from inactivated rabies virus particles that express the MERS-CoV Sl domain of S protein was
found to induce immune responses for both MERS-CoV and rabies virus. The vaccinated mice were found
to be completely protected from challenge with MERS-CoV (169). The intranasal

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• All clinicians should keep themselves updated about recent developments including global spread of
the disease.
• Non-essential international travel should be avoided at this time.
• People should stop spreading myths and false information about the disease and try to allay panic and
anxiety of the public.
Conclusions
This new virus outbreak has challenged the economic, medical and public health infrastructure of China and
to some extent, of other countries especially, its neighbours. Time alone will tell how the virus will impact
our lives here in India. More so, future outbreaks of viruses and pathogens of zoonotic origin are likely to
continue. Therefore, apart from curbing this outbreak, efforts should be made to

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identified angiotensin receptor (ACE2) as the receptor through which the virus enters the respiratory mucosa
[11].
The basic case reproduction rate (BCR) is estimated to 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 HINI 2009 [2].
Clinical Features [8, 15-18]
The clinical features of COVID-19 are varied, ranging from asymptomatic state to acute respiratory distress
syndrome and multi organ dysfunction. The common clinical features include fever (not in all), cough, sore
throat, headache, fatigue, headache, myalgia and breathlessness.
Conjunctivitis has also been described. Thus, they are indistinguishable from

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variant group. The receptor-binding gene region appears to be very similar to that of the SARSCOV and it is
believed that the same receptor could be used for cell entry.
4.1 Virion structure and its genome
Coronaviruses are structurally enveloped, belonging to the positive-strand RNAviruses category that has the
largest known genomes of RNA. The structures of the coronavirus are more spherical in shape, but their
structure has the potential to modify their morphology in response to environmental conditions, being
pleomorphic. The capsular membrane which represents the outer envelope usually has glycoprotein
projection and covers the nucleus, comprising a matrix protein containing a positive-strand RNA. Since the
structure possesses 5'-capped and 3'-polyadenylated ends, it remains identical to the cellular mRNAs. 18 The
structure is comprised of hemagglutinin esterase (HE) (present only in some beta-coronaviruses), spike (S),
small membrane (E), membrane (M) and nucleocapsid (N), as shown (Figure 1). The envelope containing
glycoprotein is responsible for attachment to the host cell, which possesses the primary anti-genic epitopes
mainly those
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vitro antiviral potential of FAD-approved drugs, viz., ribavirin, penciclovir, nitazoxanide, nafamostat, and
chloroquine, tested in comparison tOgemdesivir and favlpiravir (broad-spectrum antiviral drugs) revealed
remdesivir and chloroquine to be highly effective against SARS-CoV-2 infection in vitro (194). Ribavirin,
penciclovir, and favipiravir might not possess noteworthy in vivo antiviral actions for SARS-CoV-2, since
higher concentrations of these nucleoside analogs are needed in vitro to lessen the viral infection. Both
remdesivir and chloroquine are being used in humans to treat other diseases, and such safer drugs can be
explored for assessing their effectiveness in COVID-19 patients.
Several therapeutic agents, such as lopinavir/ritonaur, chloroquine, and hydroxychloroquine, have been
proposed for the clinical management of COVID-19 (299). A molecular docking study, conducted in the
RNAdependent RNA polymerase (RdRp) of SARS-CoV-2 using different commercially available
antipolymerase drugs, identified that drugs such as ribavirin, remdesivir, galidesivir, tenofovir, and
sofosbuvir bind RdRp tightly, indicating their vast potential to be used against COVID-19 (305). A broad-
spectrum antiviral drug that was developed in the United States, tilorone dihydrochloride (tilorone),

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216 countries and regions from all six continents had reported more than 20 million cases ofCOVID-19, and
more than 733,000 patients had died2 High mortality 04 occurred especially when health-care resources
were overwhelmed. The USA is the country with the largest number of cases so far.
Although genetic evidence suggests that SARS-CoV-2 is a natural virus that likely originated in animals,
there is no conclusion yet about when and where the virus first entered humans. As some of the first
reported cases in Wuhan had no epidemiological link to the seafood market 22, it has been suggested that the
market may not be the initial source of human infection with SARS-CoV-2. One study from France detected
SARS-CoV-2 by PCR in a stored sample from a patient who had pneumonia at the end of 2019, suggesting
SARS-CoV-2 might have spread there much earlier than the generally known starting time of the outbreak
in France2 . However, this -individual early report cannot give a solid answer to the origin of SARS-CoV-2
and contamination, and thus a false positive result cannot be excluded. To address this highly controversial
issue, further retrospective investigations involving a larger number of banked samples from patients,
animals and environments need to be conducted worldwide with well-validated assays.
Genomics, phylogeny and taxonomy
As a novel beta coronavirus, SARS- CoV-2 shares 79% genome sequence identity with SARS-CoV and
50% with MERS-CoV24. Its genome organization is shared with other beta corona viruses. The six
functional
7.4 open reading frames (ORFs) are arranged in order from 04.5' to 3': replicase
(ORF1a/ORF1b), spike (S); envelope E), membrane (M) and nucleocapsid (N). In addition, seven putative
ORFs encoding accessory proteins are interspersed between the structural genes 25. Most of the proteins
encoded by SARS-CoV-2 have a similarity

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 SARS-CoV-2 invades the lung parenchyma, resulting in severe interstitial inflammation of the lungs. This
is evident on computed tomography (CT) images as ground-glass opacity in the lungs. This lesion initially
involves a single lobe but later expands to multiple lung lobes (118). The histological assessment of lung
biopsy samples obtained from COVID-19-infected patients revealed diffuse alveolar damage, cellular
fibromyxoid exudates, hyaline membrane formation, and desquamation of pneumocytes, indicative of acute
respiratory distress syndrome (119). It was also found that the SARS-CoV-2-infected patients often have
lymphocytopenia with or without leukocyte abnormalities. The degree of lymphocytopenia gives an idea
about disease prognosis, as it is found to be positively correlated with disease severity (118). Pregnant
women are considered to have a higher risk of getting infected by COVID-19. The coronaviruses can cause
adverse outcomes for the fetus, such as intrauterine growth restriction, spontaneous abortion, preterm
delivery, and perinatal death. Nevertheless, the possibility of intrauterine maternal-fetal transmission
(vertical transmission) of CoVs is low and was not seen during either the SARS- or MERS-C0V outbreak
(120). However,

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CONCLUDING REMARKS
Several years after the global SARS epidemic, the current SARS-C0V-2/COVID-19 pandemic has served as
a reminder of how novel pathogens can rapidly emerge and spread through the human population and
eventually cause severe public health crises. Further research should be conducted to establish animal
models for SARS-CoV-2 to investigate replication, transmission dynamics, and pathogenesis m humans.
This may help develop and evaluate potential therapeutic strategies against zoonotic COV epidemics.
Present trends suggest the occurrence of future outbreaks of CoVs due to changes in the climate, and
ecological conditions may be associated with human-animal contact. Live animal markets, such as the
Huanan South China Seafood Market, represent ideal conditions for interspecies contact of wildlife with
domestic birds, pigs, and mammals, which substantially increases the probability of interspecies
transmission of COV infections and could result in high risks to humans due to adaptive genetic
recombination in these viruses (323—325).
The COVID-19-associated symptoms are fever, cough, expectoration, headache, and myalgia or fatigue.
Individuals with asymptomatic and atypical

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range of hosts, producing symptoms and diseases ranging from the common cold to severe and ultimately
fatal illnesses, such as SARS, MERS, and, presently, COVID-19. SARS-C0V-2 IS considered one of the
seven members of the COV family that infect humans (3), and it belongs to the same lineage of CoVs that
causes SARS; however, this novel virus is genetically distinct. Until 2020, six CoVs were known to infect
humans, including human COV 229E (HC0V-229E), HC0V-NL63, HC0V-OC43, HC0VHKUI, SARS-
C0V, and MERS-C0V. Although SARS-C0V and MERS-C0V have resulted in outbreaks with high
mortality, others remain associated with mild upper-respiratory-tract illnesses
Newly evolved CoVs pose a high threat to global public health. The current emergence of COVID-19 is the
third COV outbreak in humans over the past 2 decades (5). It is no coincidence that Fan et al. predicted
potential SARS- or MERS-1ike COV outbreaks in China following pathogen transmission from bats (6).
COVID-19 emerged in China and spread rapidly throughout the country and, subsequently, to other
countries. Due to the severity of this outbreak and the potential of spreading on an international scale, the
WHO declared a global health emergency

Image 83
transmission risk (228). Considering the zoonotic links associated with SARS-CoV-2, the One Health
approach may play a vital role in the prevention and control measures being followed to restrain this
pandemic virus (3 17—319). The substantial importation of COVID-19 presymptomatic cases from Wuhan
has resulted in independent, self-sustaining outbreaks across major cities both within the country and across
the globe. The majority of Chinese cities are now facing localized outbreaks of COVID-19 (231). Hence,
deploying efficient public health interventions might help to cut the spread of this virus globally.
The occurrence of COVID-19 infection on several cruise ships gave us a preliminary idea regarding the
transmission pattern of the disease. Cruise ships act as a closed environment and provide an ideal setting for
the occurrence of respiratory disease outbreaks. Such a situation poses a significant threat to travelers, since
people from different countries are on board, which favors the introduction of the pathogen (320). Although
nearly 30 cruise ships from different countries have been found harboring COVID-19 infection, the major
cruise ships that were involved in

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specimens, like bronchoalveolar lavage fluid, sputum, nasal swabs, fibrobronchoscope brush biopsy
specimens, pharyngeal swabs, feces, and blood (246).
The presence of SARS-CoV-2 in fecal samples has posed grave public health concerns. In addition to the
direct transmission mainly occurring via droplets of sneezing and coughing, other routes, such as fecal
excretion and environmental and fomite contamination, are contributing to SARS-CoV-2 transmission and
spread (249—252). Fecal excretion has also been documented for SARS-CoV and MERS-CoV, along with
the potential to stay viable in situations aiding fecal-oral transmission. Thus, SARS-CoV-2 has every
possibility to be transmitted through this mode. Fecal-oral transmission of SARSCoV-2, particularly in
regions having low standards of hygiene and poor sanitation, may have grave consequences with regard to
the high spread of this virus. Ethanol and disinfectants containing chlorine or bleach are effective against
corona viruses (249—252). Appropriate precautions need to be followed strictly while handling the stools
of patients infected with SARS-CoV-2. Biowaste materials and sewage from hospitals must be adequately
disinfected, treated, and disposed of properly. The significance of frequent and good hand hygiene and

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SARS- or IVIERb-CoV outbreak (120). However, there has been concern regarding the impact of SARS-
CoV-2/COVID-19 on pregnancy. Researchers have mentioned the probability of in utero transmission of
novel SARS-CoV-2 from COVID19-infected mothers to their neonates in China based upon the rise in IgM
and IgG antibody levels and cytokine values in the blood obtained from newborn infants immediately post
birth; however, RT-PCR failed to confirm the presence of SARS-CoV-2 genetic material in the infants
(283). Recent studies show that at least in some cases, preterm delivery and its consequences are associated
with the virus. Nonetheless, some cases have raised doubts for the likelihood of vertical transmission
COVID-19 infection was associated with pneumonia, and some developed acute respiratory distress
syndrome (ARDS). The blood biochemistry indexes, such as albumin, lactate dehydrogenase, reactive
protein, lymphocytes (percent), and neutrophils (percent) give an idea about the disease severity in COVID-
19 infection (121). During COVID-19, patients may present leukocytosis, leukopenia with lymphopenia
(244), hypoalbuminemia, and an increase o of lactate dehydrogenase, aspartate transaminase, alanine
aminotransferase, bilirubin, and, especially, D-dimer
m • 1 11

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and deaths. The COVID-19 outbreak has also been associated with severe economic impacts globally
due to the sudden interruption of global trade and supply chains that forced multinational
companies to make decisions that led to significant economic losses (66). The recent increase in the number
of confirmed critically ill patients with COVID-19 has already surpassed the intensive care supplies, limiting
intensive care services to only a small portion of critically ill patients (67). This might also have contributed
to the increased case fatality rate observed in the COVID-19 outbreak.
Viewpoint on SARS-CoV-2 Transmission, Spread, and Emergence
The novel coronavirus was identified within 1 month (28 days) of the outbreak. This is impressively fast
compared to the time taken to identify SARSCOV reported in Foshan, Guangdong Province, China (125
days) (68). Immediately after the confirmation of viral etiology, the Chinese virologists rapidly released the
genomic sequence of SARS-CoV-2, which played a crucial role in controlling the spread of this newly
emerged novel coronavirus to other parts of the world (69). The possible origin of SARS-CoV-2 and the first
mode of

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suffering from novel SARS-CoV-2, with more than cases and 287,399 deaths across the globe. There is an
urgent need for a rational international campaign against the unhealthy food practices of China to encourage
the sellers to increase hygienic food practices or close the crude live-dead animal wet markets. There is a
need to modify food policies at national and international levels to avoid further life threats and economic
consequences from any emerging or reemerging pandemic due to close animal-human interaction (285).
Even though individuals of all ages and sexes are susceptible to COVID-19, older people with an underlying
chronic disease are more likely to become severely infected (80). Recently, individuals with asymptomatic
infection were also found to act as a source of infection to susceptible individuals (81). Both the
asymptomatic and symptomatic patients secrete similar viral loads, which indicates that the transmission
capacity of asymptomatic or minimally symptomatic patients is very high. Thus, SARS-CoV-2 transmission
can happen early in the course of infection (82). Atypical clinical manifestations have also been reported m
COVID-19 in which the only reporting symptom was fatigue. Such patients may lack respiratory signs, such
as fever, cough, and sputum (83). Hence, the clinicians

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The results of the studies related to SARS-CoV-2 viral loads reflect active replication of this virus m the
upper respiratory tract and prolonged viral shedding after symptoms disappear, Including via stool. Thus, the
current case definition needs to be updated along with a reassessment of the strategies to be adopted for
restraining the SARS-CoV-2 outbreak spread (248). In some cases, the viral load studies of SARS-CoV-2
have also been useful to recommend precautionary measures when handling specific samples, e.g., feces. In
a recent survey from 17 confirmed cases of SARS-CoV-2 infection with available data (representing days 0
to) 3 after onset), stool samples from nine cases (53%; days 0 to I l after onset) were positive on RT-PCR
analysis. Although the viral loads were lower than those of respiratory samples (range, 550 copies per ml to
1.21 x 105 copies per ml), this has essential biosafety implications (151).
The samples from 18 SARS-CoV-2-positive patients in Singapore who had traveled from Wuhan to
Singapore showed the presence of viral RNA in 1-4. stool and whole blood but not in by real-time RT-PCR
(288). Further, novel SARS-C0V-2 infections have been detected in a variety of clinical specimens, like
bronchoalveolar lavage fluid,

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From experience with several outbreaks associated with known emerging viruses, higher pathogenicity of a
virus is often associated with lower transmissibility. Compared to emerging viruses like Ebola virus, avian
H7N9, SARS-C0V, and MERS-C0V, SARS-C0V-2 has relatively lower pathogenicity and moderate
transmissibility (15). The risk of death among individuals infected with COVID-19 was calculated using the
infection fatality risk (IFR). The IFR was found to be in the range of 0.3% to 0.6%, which is comparable to
that of a previous Asian influenza pandemic (1957 to 1958) (73, 277).
Notably, the reanalysis of the COVID-19 pandemic curve from the initial cluster of cases pointed to
considerable human-to-human transmission. It is opined that the exposure history of SARS-CoV- 2 at
the Wuhan seafood market originated from human-to-human transmission rather than animal-to-human
transmission (74); however, in light of the zoonotic spillover in COVID-19, is too early to fully endorse this
idea (1). Following the initial infection, human-to-human transmission has been observed with a
preliminary Reproduction number (Ro) estimate of 1.4 to 2.5 (70, 75), and recently it is estimated to be 2.24
to 3.58 (76). In another study, the average reproductive number of

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The virus can remain viable on surfaces for days in favourable atmospheric conditions but
are destroyed in less than a minute by common disinfectants like sodium hypochlorite, hydrogen peroxide
etc. [13]. Infection is acquired either by inhalation of these droplets or touching surfaces contaminated by
them and then touching the nose, mouth and eyes. The virus is also present in the stool and contamination of
the water supply and subsequent transmission via aerosolization/feco-oral route is also hypothesized [6]. As
per current information, transplacental transmission from pregnant women to their fetus has not been
described [14]. However, neonatal disease due to postnatal transmission is described [14]. The incubation
period varies from 2 to angiotensin receptor 2

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Of those infected, 20% are in critical condition, 25% have recovered, and 3310 (3013 in China and 297 in
other countries) have died [2]. India, which had reported only 3 cases till 2/3/2020, has also seen a sudden
spurt in cases.
By 5/3/2020, 29 cases had been reported; mostly in Delhi, Jaipur and
Agra in Italian tourists and their contacts. One case was reported in an Indian who traveled back from
Vienna and exposed a large number of school children in a birthday party at a city hotel. Many of the
contacts of these cases have been quarantined.
These numbers are possibly an underestimate of the infected and dead due to limitations of surveillance
and testing. Though the SARS-CoV-2 originated from bats, the intermediary

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specifically in the respiratory tract will help to reduce virus-triggered immune pathologies in COVID-19
(209). The later stages of corona virus induced inflammatory cascades are characterized by the release of
proinflammatory interleukin-1 (IL-I) family members, such as IL-I and IL-33. Hence, there exists a
possibility that the inflammation associated with coronavirus can be inhibited by utilizing anti-inflammatory
cytokines that belong to the IL-I family (92). It has also been suggested that the actin protein is the host
factor that is involved in cell entry and pathogenesis of SARS-CoV-2. Hence, those drugs that modulate the
biological activity of thiS protein, like ibuprofen, might have some therapeutic application in managing the
disease (174). The plasma angiotensin 2 level was found to be markedly elevated in COVID-19 infection
and was correlated with viral load and lung injury. Hence, drugs that block angiotensin receptors may have
potential for treating COVID-19 infection (121). A scientist from Germany, named Rolf Hilgenfeld, has
been working on the identification of drugs for the treatment of coronaviral infection since the time of the
first SARS outbreak (19)
The SARS-CoV S2 subunit has a significant function in mediating virus fusion that provides entry into the
host cell. Heptad repeat 1 (HR 1) and heptad

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DIAGNOSIS OF SARS-C0V-2 (COVID19)

RNA tests can confirm the diagnosis of SARSCOV-2 (COVID-19) cases with real-time RT-PCR or next-
generation sequencing (148, 149, 245, 246). At present, nucleic acid detection techniques, like RTPCR, are
considered an effective method for confirming the diagnosis in clinical cases of COVID19 (148). Several
companies across the world are currently focusing on developing and marketing SARS-CoV-2-specific
nucleic acid detection kits. Multiple laboratories are also developing their own in-house RT-PCR. One of
them is the SARS-C0V-2 nucleic acid detection kit produced by Shuoshi Biotechnology (double
fluorescence PCR method) (150). Up to 30 March 2020, the U.S. Food and Drug Administration (FDA) had
granted 22 in vitro diagnostics Emergency Use Authorizations (EUAs), including for the RT-PCR diagnostic
panel for the universal detection of SARS-like betacoronauruses and specific detection of SARS-CoV-2,
developed by the U.S. CDC (Table 1) (258, 259).

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turtles, ducks, fish, Siamese crocodiles, and other animal meats without any fear of COVID-19. The Chinese
government IS encouraging people to feel they can return to normalcy. However, this could be a risk, as it
has been mentioned in advisories that people should avoid contact with live-dead animals as much as
possible, as SARS-CoV-2 has shown zoonotic spillover. Additionally, we cannot rule out the possibility of
new mutations in the same virus being closely related to contact with both animals and humans at the market
(284). In January 2020, China imposed a temporary ban on the sale of live dead animals in wet markets.
However, now hundreds of such wet markets have been reopened without optimizing standard food safety
and sanitation practices (286).
With China being the most populated country in the world and due to its domestic and international food
exportation policies, the whole world is now facing the menace of COVID-19, including China itself. Wet
markets of live-dead animals do not maintain strict food hygienic practices. Fresh blood splashes are
present everywhere, on the floor and tabletops, and such food customs could encourage many pathogens to
adapt, mutate, and jump the species barrier. As a result, the whole world is suffering from novel SARS-
CoV-2, with more than

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performance (Table 2) (80, 245, 246). The viral loads of SARS-CoV-2 were measured using N-gene specific
quantitative RT-PCR in throat swab and sputum samples collected from COVID-19-infected individuals.
The results indicated that the viral load peaked at around 5 to 6 days following the onset of symptoms, and it
ranged from 104 to 107 copies/ml during this time (151). In another study, the viral load was found to be
higher in the nasal swabs than the throat swabs obtained from COVID-19 symptomatic patients (82).
Although initially it was thought that viral load would be associated with poor outcomes, some case reports
have shown asymptomatic individuals with high viral loads (247). Recently, the viral load in nasal and throat
swabs of 17 symptomatic patients was determined, and higher viral loads were recorded soon after the onset
of symptoms, particularly in the nose compared to the throat. The pattern of viral nucleic acid shedding of
SARS-CoV-2-infected patients was similar to that of influenza patients but seemed to be different from that
of SARS-CoV patients. The viral load detected in asymptomatic patients resembled that of symptomatic
patients as studied in China, which reflects the transmission perspective of asymptomatic or symptomatic
patients having minimum signs and symptoms (82). Another study,

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in the epidemic strain (104). Transmission can also occur directly from the reservoir host to humans without
RBD adaptations. The bat coronavirus that is currently in circulation maintains speci IC "poised" spike
proteins that facilitate human infection without the requirement of any mutations or adaptations (105).
Altogether, different species of bats carry a massive number of coronaviruses around the world (106).
The high plasticity in receptor usage, along with the feasibility of adaptive mutation and recombination, may
result in frequent interspecies transmission of coronavirus from bats animals and humans (106). The
pathogenesis or most bat coronauruses IS unknown, as most of these viruses are not isolated and studied (4).
Hedgehog coronavirus HKU31, a Betacoronavirus, has been identified from amur hedgehogs in China.
Studies show that hedgehogs are the reservoir of Betacoronavirus, and there is evidence of recombination
(107).
The current scientific evidence available on MERS infection suggests that the significant reservoir host, as
well as the animal source of MERS infection in humans, is the dromedary camels (97). The infected
dromedary camels may not show any visible signs of infection. making it challenging to

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absence of this protein is related to the altered virulence of coronaviruses due to changes in morphology and
tropism (54). The E protein consists of three domains, namely, a short hydrophilic ammo terminal, a large
hydrophobic transmembrane domain, and an efficient C-terminal domain (51). The SARS-CoV-2 E protein
reveals a similar amino acid constitution without any substitution (16).
N Protein
The N protein of coronavirus is multipurpose. Among several functions, it plays a role in complex
formation with the viral genome, facilitates M protein interaction needed during vinon assembly, and
enhances the transcription efficiency of the virus (55, 56). It contains three highly conserved and distinct
domains, namely, an NTD, an RNA-binding domain or a linker region (LKR), and a CTD (57). The NTD
binds with the 3' end of the viral genome, perhaps via electrostatic interactions, and is highly diverged both
in length and sequence (58). The charged LKR is serme and arginine rich and is also known as the SR
(serine and arginine) domain (59). The LKR is capable of direct interaction with in vitro
RNA interaction and is responsible for cell signaling (60, 61). It also modulates the antiviral response of the
host by working as an antagonist for interferon

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snakes, and various other wild animals (20, 30, 79, 93, 124, 125, 287). Coronavirus infection is linked to
different kinds of clinical manifestations, varying from enteritis m cows and pigs, upper respiratory disease
in chickens, and fatal respiratory infections in humans (30).
Among the COV genera, Alphacoronavirus and Betacoronavirus infect mammals, while Gammacoronavirus
and Deltacoronavirus mainly infect birds, fishes, and, sometimes, mammals (27, 29, 106). Several novel
coronaviruses that come under the genus Deltacoronavirus have been discovered in the past from birds, like
Wigeon coronavirus HKU20, Bulbul HKUII, Munia coronavirus HKU13, white-eye coronavirus HKU16,
night-heron coronavirus HKU19, and common moorhen coronavirus HKU21, as well as from pigs (porcine
coronavirus HKU15) (6, 29). Transmissible gastroenteritis virus (TGEV), porcine epidemic diarrhea virus
(PEDV), and porcine hemagglutinating encephalomyelitis virus (PHEV) are some of the coronaviruses of
swine. Among them, TGEV and PEDV are responsible for causing severe gastroenteritis in young piglets
with noteworthy morbidity and mortality. Infection with PHEV also causes enteric infection but can cause
encephalitis due to its ability to infect the nervous

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Since knowledge about this virus is rapidly evolving, readers are urged to update themselves regularly.
History
Coronaviruses are enveloped positive sense RNA viruses ranging from 60 nm to 140 nm in diameter with
spike like projections on its surface giving it a
crown like appearance under the electron microscope; hence the name coronavirus [3]. Four corona viruses
namely HKUI, NL63, 229E and OC43 have been in circulation in humans, and generally cause mild
respiratory disease.
There have been two events in the past two decades wherein crossover of animal betacorona viruses to
humans has resulted in severe disease. The first such instance was in 2002—2003 when a

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that remdesivir has to be further evaluated for its efficacy in the treatment of COVID-19 infection in
humans. The broad-spectrum activity exhibited by remdesivir will help control the spread of disease in the
event of a new coronavirus outbreak.
Chloroquine is an antimalarial drug known to possess antiviral activity due to its ability to block virus-cell
fusion by raising the endosomal pH necessary for fusion. It also interferes with virusreceptor binding by
interfering with the terminal glycosylation of SARS-CoV cellular receptors, such as ACE2 (196). In a recent
multicenter clinical trial that was conducted in China, chloroquine phosphate was found to exhibit both
efficacy and safety in the therapeutic management of SARS-CoV-2-associated pneumonia (197). This drug
is already included in the treatment guidelines issued by the National Health Commission of the People's
Republic of China. The preliminary clinical trials using hydroxychloroquine, another aminoquinoline drug,
gave promising results. The COVID-19 patients received 600 mg of hydroxychloroquine daily along with
azithromycin as a single-arnv protocol. This protocol was found to be associated with a noteworthy
reduction in viral load. Finally, it resulted in a complete cure (271); however, the study comprised a small
population and, hence, the