fatigue.

Individuals with asymptomatic and atypical

clinical manifestations were also identified recently,
further adding to the complexity of disease
transmission dynamics. Atypical clinical
manifestations may only express symptoms such as
fatigue instead of respiratory signs such as fever,
cough,and sputum.In such cases,the clinician must
be vigilant for the possible occurrence of
asymptomatic and atypical clinical manifestations to
avoid the possibility of missed diagnoses.
The present outbreak caused by SARS-CoV-2
was,indeed,expected.Similar to previous outbreaks,
the current pandemic also will be contained shortly.
However,the real question is,how are we planning
to counter the next zoonotic CoV epidemic that is
likely to occur within the next 5 to 10 years or
perhaps sooner?Our knowledge of most of the bat
CoVs is scarce,as these viruses have not been
isolated and studied,and extensive studies on such
viruses are typically only conducted when they are
associated with specific disease outbreaks.The next
step following the control of the COVID-19 outbreak
in China should be focused on screening,
identification, isolation,and characterization of
CoVs present in wildlife species of China,
particularly in bats.Both in vitro and in vivo studies
(using suitable animal models)should be conducted
in Yunnan.This novel bat virus,denoted ‘RmYN02,
is 93.3%identical to SARS-CoV-2 across the
genome. In the long lab gene,it exhibits
97.2%identity to SARS-CoV-2,which is even higher
than for RaTG13 (REF²8).In addition to RaTG13 and
RmYN02,phyloge- netic analysis shows that bat
coronaviruses ZC45 and ZXC21 previously detected
in Rhinolophus pusillus bats from eastern China also
fall into the SARS-CoV-2 lineage of the subgenus
Sarbecovirus³(FIG.2).The dis- covery of diverse bat
coronaviruses closely related to SARS-CoV-2
suggests that bats are possible reservoirs of SARS-
CoV-2(REF₃7).Nevertheless,on the basis of current
findings,the divergence between SARS-CoV-2 and
related bat coronaviruses likely represents more than 20
years of sequence evolution,suggesting that these bat
coronaviruses can be regarded only as the likely evolu-
tionary precursor of SARS-CoV-2 but not as the direct
progenitor of SARS-CoV-2 (REF³).
Beyond bats,pangolins are another wildlife host
probablylinked with SARS-CoV-2.Multiple SARS-CoV-
2- related viruses have been identified in tissues of
Malayan pangolins smuggled from Southeast Asia into
southern China from 2017 to 2019.These viruses from
pangolins independently seized by Guangxi and
Guangdong pro- vincial customs belong to two distinct
sublineages³9-41.
The Guangdong strains,which were isolated or
sequenced by different research groups from smug-
gled pangolins,have 99.8%sequence identity with each
other²l.They are very closely related to SARS-CoV-
2, exhibiting 92.4%sequence similarity.Notably,the
RBD of Guangdong pangolin coronaviruses is highly
similar to that of SARS-CoV-2.The receptor-
binding motif (RBM;which is part of the RBD)of
these viruses has only one amino acid variation from
SARS-CoV-2,and
it is identical to that of SARS-CoV-2 in all five critical
07:28 ☑ 艹 ·

category A agents (cholera,plague).

Patients should be placed in separate
rooms or cohorted
together.Negative
pressure rooms are not generally
needed.The rooms and surfaces and
equipment should undergo regular
decontamination preferably with
sodium hypochlorite.Healthcare
workers should be provided with fit
tested N95 respirators and protective
suits and goggles.Airborne
transmission precautions should be
taken during aerosol generating
procedures such as intubation,suction
and tracheostomies.All contacts
including healthcare workers should
be monitored for development of
symptoms of COVID-19.Patients can be
discharged from isolation once they
are afebrile for atleast 3 d and have
two consecutive negative molecular
tests at 1 d sampling interval.This
recommendation is different from
pandemic flu where patients were
administration of the recombinant adenovirus-based
vaccine in BALB/c mice was found to induce long-
lasting neutralizing immunity against MERS spike
pseudotyped virus,characterized by the induction
of systemic IgG,secretory IgA,and lung-
resident memory T-cell
responses(177).Immunoinformatics methods have
been employed for the genome-wide screening of
potential vaccine targets among the different
immunogens of MERS-CoV(178).The N protein
and the potential B-cell epitopes of MERS- CoV
E protein have been suggested as
immunoprotective targets inducing both T-cell and
neutralizing antibody responses (178,179).
The collaborative effort of the researchers of
Rocky Mountain Laboratories and Oxford University
is designing a chimpanzee adenovirus-vectored
vaccine to counter COVID-19(180).The
Coalition for Epidemic Preparedness
Innovations(CEPI)has initiated three programs to
design SARS-CoV-2 vaccines (181).CEPI has a
collaborative project with Inovio for designing a
MERS-CoV DNA vaccine that could potentiate
effective immunity.CEPI and the University of
Queensland are designing a molecular clamp
vaccine platform for MERS-CoV and other
pathogens,which could assist in the easier
identification of antigens by the immune system
(181).CEPI has also funded Moderna to develop
a
07:27 艹·
ncbi.nlm.nih.gov/pmc/artii ①
glass opacities and sub segmental
consolidation.It is also abnormal in
asymptomatic patients/patients with
no clinical evidence of lower
respiratory tract involvement.In
fact, abnormal CT scans have been
used to
diagnose COVID-19 in suspect cases
with negative molecular diagnosis;
many of these patients had positive
molecular tests on repeat testing [22].

Differential Diagnosis [21]

The differential diagnosis includes all
types of respiratory viral infections
[influenza,parainfluenza,respiratory
syncytial virus (RSV),adenovirus,
human metapneumovirus,non COVID-
19 coronavirus],atypical organisms
(mycoplasma,chlamydia)and bacterial
infections.It is not possible to
differentiate COVID-19 from these
infections clinically or through routine
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 virion 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
serine 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 (IFN)and RNA
interference(62).Compared to that of SARS-
CoV,the N protein of SARS-CoV-2 possess
five amino acid mutations,where two are in the
intrinsically dispersed region (IDR;positions 25 and
26),one each in the NTD(position 103),LKR
(position 217),and CTD(position 334)(16).
1
nsps and Accessory Proteins

1
weeks,and the typical symptom occurrence
from incubation period to infection takes
an average of 12.5 days.29

6 CLINICAL DIAGNOSIS
The symptoms of COVID-19 remain very similar
to those of the other respiratory epidemics in
the past,which include SARS and MERS,but
here the range of symptoms includes mild
rhinitis to septic shock.Some intestinal
disturbances were reported with the other
epidemics,but COVID-19 was devoid of such
symptoms.When examined,unilateral or
bilateral involvement compatible with viral
pneumonia is observed in the patients,and
bilateral multiple lobular and sub-segmental
consolidation areas were observed in
patients hospitalised in the intensive care
unit.
Comorbid patients showed a more severe
clinical course than predicted from previous
epidemics.Diagnosis of COVID-19 includes the
complete history of travel and touch,with
laboratory testing.It is more preferable to
choose serological screening,which can help
to analyse even the asymptomatic infections;
several serological tests are in progress for
SARS-CoV-2. 14 ,30
health emergency on 31 January
2020;subsequently, on 11 March 2020,they
declared it a pandemic situation.At present,we
are not in a position to effectively treat
COVID-19,since neither approved vaccines nor
specific antiviral drugs for treating human CoV
infections are available(7-9).Most nations are
currently making efforts to prevent the further
spreading of this potentially deadly virus by
implementing preventive and control strategies.
In domestic animals,infections with CoVs are
associated with a broad spectrum of pathological
conditions.Apart from infectious bronchitis virus,
canine respiratory CoV,and mouse hepatitis virus,
CoVs are predominantly associated with
gastrointestinal diseases(10).The emergence of
novel CoVs may have become possible because of
multiple CoVs being maintained in their natural host,
which could have favored the probability of genetic
recombination(10).High genetic diversity and the
ability to infect multiple host species are a result of
high-frequency mutations in CoVs,which occur due
to the instability of RNA-dependent RNA
polymerases along with higher rates of homologous
RNA recombination(10, 11).Identifying the
origin of SARS-CoV-2 and the pathogen's evolution
will be
helpful for disease surveillance(12),development of
observed through both in vivo and in vitro
experiments.There is an enhanced nasal
secretion observed along with local oedema
because of the damage of the host
cell,which further stimulates the synthesis of
inflammatory mediators.In
addition,these reactions can induce
sneezing,difficulty
breathing by causing airway inhibition and
elevate mucosal temperature.These viruses,
when released,chiefly affect the lower
respiratory tract,with the signs and symptoms
existing clinically.Also,the virus further affects
the intestinal lymphocytes,renal cells,liver
cells and T-lymphocytes.Furthermore,the
virus
induces T-cell apoptosis,causing the reaction of
the T-cell to be erratic,resulting in the immune
system's complete collapse.24,25

5.1 Mode of transmission

In fact it was accepted that the original
transmission originated from a seafood
market, which had a tradition of selling live
animals,
where the majority of the patients had either
worked or visited,although up to now the
understanding of the COVID-19 transmission
risk remains incomplete.16 In addition,while
the newer patients had no exposure to the
market and still got the virus from the humans
present there,there is an increase in the
outbreak of
patients with COVID-19 can be found
on the WHO and CDC websites.67

16 CONCLUSION
The corona virus (COVID-19)spreads at an
alarming rate all over the world.The
outbreak of the virus has confronted the
world's
economic,medical and public health
infrastructure.Elderly and
immunocompromised patients also are
susceptible to the virus's mortal impacts.
Currently,there is no documented cure for the
virus and no vaccine has been created,although
some treatment protocols have been
promising. Therefore,the virus can be controlled
with the
appropriate prevention strategies.Also,
attempts have to be made to formulate
systematic strategies to prevent such
future zoonotic outbreaks.
comprised a small population and,hence, the
possibility of misinterpretation could arise.However,
in another case study,the authors raised concerns
over the efficacy of hydroxychloroquine-
azithromycin in the treatment of COVID-19 patients,
since no observable effect was seen when they were
used.In some cases,the treatment was discontinued
due to the prolongation of the QT interval
(307). Hence,further randomized clinical trials are
required
before concluding this matter.
Recently, another FDA-approved drug,
ivermectin,was reported to inhibit the in vitro
replication of SARS-CoV-2.The findings from this
study indicate that a single treatment of this drug
was able to induce an~5,000-fold reduction in the
viral RNA at 48 h in cell culture.(308).One of the
main disadvantages that limit the clinical
utility of
ivermectin is its potential to cause cytotoxicity.
However, altering the vehicles used in
the formulations,the pharmacokinetic properties can
be modified,thereby having significant control over
the systemic concentration of
ivermectin(338).Based on the pharmacokinetic
simulation,it was also found that ivermectin may
have limited therapeutic utility in managing
COVID-19, since the inhibitory concentration
that has to be achieved for effective
anti-SARS-CoV-2 activity is far higher than the
07:29 ☑

themselves while examining such

patients and practice hand
hygiene frequently.

·Suspected cases should be

referred to government designated
centres
for isolation and testing (in
Mumbai,at this time,it is Kasturba
hospital).Commercial kits for
testing are not yet available in
India.

·Patients admitted with severe

pneumonia and acute respiratory
distress syndrome should be
evaluated for travel history and
placed under contact and
droplet
isolation.Regular
decontamination of surfaces
should be done.They should be
tested for etiology using multiplex
PCR panels if logistics permit and
if no pathogen is identified,refer
the samples for testing for SARS-
CoV-2.
visible signs of infection,making it challenging to
identify animals actively excreting MERS-CoV that
has the potential to infect humans.However,they
may shed MERS-CoV through milk,urine,feces,
and nasal and eye discharge and can also be found in
the raw organs(108).In a study conducted
to evaluate the susceptibility of animal species
to MERS-CoV infection,llamas and pigs were found
to be susceptible,indicating the possibility of
MERS- CoV circulation in animal species
other than dromedary camels (109).
Following the outbreak of SARS in China,
SARS-CoV-like viruses were isolated from
Himalayan palm civets (Paguma larvata) and
raccoon dogs(Nyctereutes procyonoides)found in a
live-animal market in Guangdong,China. The
animal isolates obtained from the live-animal market
retained a 29-nucleotide sequence that was not
present in most of the human isolates (78).These
findings were critical in identifying the possibility of
interspecies transmission in SARS-CoV.The higher
diversity and prevalence of bat coronaviruses in this
region compared to those in previous reports indicate
a ] host/pathogen coevolution. SARS-like
coronaviruses also have been found circulating in the
Chinese horseshoe bat (Rhinolophus
sinicus)
populations.The in vitro and in vivo studies carried
viruses in nasal washes,saliva,urine and faeces for up
to 8 days after infection,and a few naive ferrets with only
indirect contact were positive for viral RNA,suggest-
ing airborne transmission78.In addition,transmission
of the virus through the ocular surface and prolonged
presence of SARS-CoV-2 viral RNA in faecal samples
were also documented101,102.Coronaviruses can persist
on inanimate surfaces for days,which could also be the
case for SARS-CoV-2 and could pose a prolonged riskof
infection103.These findings explain the rapid geographic
spread of COVID-19,and public health interventions to
reduce transmission will provide benefit to mitigate the
epidemic,as has proved successful in China and several
other countries,such as South Korea⁸9,104,105.

Diagnosis
Early diagnosis is crucial for controlling the spread of
COVID-19.Molecular detection ofSARS-CoV-2 nucleic
acid is the gold standard.Many viral nucleic acid
detec- tion kits targeting ORF1b (including
RdRp),N,E or Sgenes are commercially availablell,106-
109.The detection time ranges from several minutes to
hours depending on the technology106,107,109-ll1.The
molecular detection can be affected by many
factors.Although SARS-CoV-2 has been detected from
a variety of respiratory sources, including throat
swabs,posterior oropharyngeal saliva, nasopharyngeal
swabs,sputum and bronchial fluid, the viral load is
higher in lower respiratory tract sam-
ples¹1,96,112-115.In addition,viral nucleic acid was also
found in samples from the intestinal tract or blood even
when respiratory samples were negativell6.Lastly,viral
load may already drop from its peak level on disease
onset?6,97.Accordingly,false negatives can be common
when oral swabs and used,and so multiple detection
methods should be adopted to confirm a COVID-
19 diagnosisl⁷,118.Other detection methods were
there- fore used to overcome this problem.Chest
CT was used to quickly identify a patient when the
capacity of molecular detection was overloaded in
Wuhan.Patients
 Recently,95 full-length genomic sequences of
SARAS-CoV-2 strains available in the National
Center for Biotechnology Information and GISAID
databases were subjected to multiple-sequence
alignment and phylogenetic analyses for studying
variations in the viral genome(260).All the
viral strains revealed high homology of
99.99%(99.91% to 100%)at the nucleotide
level and 99.99% (99.79%to 100%)at the
amino acid level.Overall variation was found to be
low in ORF regions,with 13 variation sites
recognized in la,1b,S,3a,M,8, and N
regions.Mutation rates of 30.53%(29/95)and
29.47%(28/95)were observed at nt 28144 (ORF8)
and nt 8782(ORFla)positions,respectively.Owing
to such selective mutations,a few specific regions
of SARS-CoV-2 should not be considered for
designing primers and probes.The SARS-CoV-2
reference sequence could pave the way to study
molecular biology and pathobiology,along with
developing diagnostics and appropriate prevention
and control strategies for countering SARS-CoV-2
(260).
Nucleic acids of SARS-CoV-2 can be detected
from samples(64)such as bronchoalveolar
lavage fluid,sputum,nasal swabs,fiber bronchoscope
brush biopsy specimen,pharyngeal
swabs,feces,blood, and urine, with different
levels of diagnostic performance (Table 2)
(80,245,246).The viral loads
a polybasic cleavage site (RRAR),which enables effec-
tive cleavage by furin and other proteases²?.Such an
S1-S2 cleavage site is not observed in all related viruses
belonging to the subgenus Sarbecovirus,except for a
similar three amino acid insertion (PAA)in RmYN02,
a bat-derived coronavirus newly reported
from Rhinolophus malayanus in
China⁸(FIG.3a).Although the insertion in RmYN02
does not functionally represent a polybasic cleavage
site,it provides support for the notion that this
characteristic,initially considered unique to SARS-
CoV-2,has been acquired naturally²8.A structural study
suggested that the furin-cleavage site can reduce the
stability of SARS-CoV-2 S protein and facilitate the
conformational adaption that is required for the binding
of the RBD to its receptor².Whether the higher trans-
missibility of SARS-CoV-2 compared with SARS-CoV
is a gain of function associated with acquisition of the
furin-like cleavage site is yet to be demonstrated?6.
An additional distinction is the accessory gene
orf8 ofSARS-CoV-2,which encodes a novel protein
showing only 40%amino acid identity to ORF8 of
SARS-CoV.
Unlike in SARS-CoV,this new ORF8 protein does
not contain a motif that triggers intracellular stress
pathways²5.Notably,a SARS-CoV-2 variant with a
382-nucleotide deletion covering the whole of ORF8 has
been discovered in a number of patients in Singapore,
which resembles the 29-or 415-nucleotide deletions in
the ORF8 region observed in human SARS-CoV
variants from the late phase of the 2002-2003
D C
outbreak₃0.Such ORF8 deletion may be indicative of
human adaptation after cross-species transmission
from an animal host.

D C
(181).CEPI has also funded Moderna to develop
a vaccine for COVID-19 in partnership with
the Vaccine Research Center(VRC)of the
National Institute of Allergy and Infectious Diseases
(NIAID), part of the National Institutes of Health
(NIH)(182). By employing mRNA vaccine
platform technology,a vaccine candidate
expressing SARS-CoV-2 spike protein is likely to
go through clinical testing in the coming
months(180).On 16 March 2020,Jennifer Haller
became the first person outside China to
receive an experimental vaccine, developed by
Moderna,against this pandemic virus.Moderna,
along with China's CanSino Biologics,became the
first research group to launch small clinical trials of
vaccines against COVID-19. Their study is
evaluating the vaccine's safety and ability to trigger
immune responses (296).
Scientists from all over the world are trying hard
to develop working vaccines with robust protective
immunity against COVID-19.Vaccine candidates,
like mRNA-1273 SARS-CoV-2 vaccine,INO-4800
DNA coronavirus vaccine,and adenovirus type
5 vector vaccine candidate(Ad5-nCoV),are a
few examples under phase I clinical trials,while
self-
amplifying RNA vaccine,oral recombinant COVID-
19 vaccine, BNT162,plant-based COVID-19
vaccine,and li-Key peptide COVID-19 vaccine are
this emerging virus will establish a niche in humans
and coexist with us for a long timel⁶6.Before
clinically approved vaccines are widely available,there
is no bet- ter way to protect us from SARS-CoV-2
than personal preventive behaviours such as social
distancing and wearing masks,and public health
measures,including active testing,case tracing and
restrictions on social gatherings.Despite a flood of
SARS-CoV-2 research published every week,current
knowledge of this novel coronavirus is just the tip
of the iceberg.The animal origin and cross-species
infection route of SARS-CoV-2 are yet to be
uncovered.The molecular mechanisms of SARS-
CoV-2 infection pathogenesis and virus-host
07:28 ☑ 艹 ·

mask and practice cough hygiene.

Caregivers should be asked to wear a
surgical mask when in the same room
as patient and use hand hygiene
every
15-20 min.

The greatest risk in COVID-19 is

transmission to healthcare workers.In
the SARS outbreak of 2002,21%of
those affected were healthcare workers
[31].Till date,almost 1500 healthcare
workers in China have been infected
with 6 deaths.The doctor who first
warned about the virus has died too.It
is important to protect healthcare
workers to ensure continuity of care
and to prevent transmission of
infection to other patients.While
COVID-19 transmits as a droplet
pathogen and isplaced in Category B of
infectious agents (highly pathogenic
H5N1 and SARS),by the China National
Health Commission,infection control
measures recommended are those for
Abstract
There is a new public health crises
threatening the world with the
emergence and spread of 2019 novel
coronavirus (2019-nCoV)or the severe
acute respiratory syndrome
coronavirus 2(SARS-CoV-2).The virus
originated in bats and was transmitted
to humans through yet unknown
intermediary animals in Wuhan,Hubei
province,China in December 2019.
There have been around 96,000
reported cases of coronavirus disease
2019 (COVID-2019)and 3300 reported
deaths to date(05/03/2020).The disease
is transmitted by inhalation or contact
with infected droplets and the
incubation period ranges from 2 to 14
d.The symptoms are usually fever,
cough,sore throat,breathlessness,
fatigue,malaise among others.The
disease is mild in most people;in some
(usually the elderly and those with
co movbiditio l it mo r nwocwoce to
INTRODUCTION
Over the past 2 decades,coronaviruses(CoVs)
have been associated with significant disease
outbreaks in East Asia and the Middle East.The
severe acute respiratory syndrome(SARS)and the
Middle East respiratory syndrome (MERS)began to
emerge in 2002 and 2012,respectively.Recently,a
novel coronavirus, severe acute respiratory
syndrome coronavirus 2(SARS-CoV-2),causing
coronavirus disease 2019(COVID-19),emerged in
late 2019,and it has posed a global health threat,
causing an ongoing pandemic in many countries
and
territories (1).
Health workers worldwide are currently making
efforts to control further disease outbreaks caused by
the novel CoV(originally named 2019-nCoV),
which was first identified in Wuhan City,Hubei
Province,China,on 12 December 2019.On 11
February 2020,the World Health Organization
(WHO)announced the official designation for the
current CoV-associated disease to be COVID-19,
caused by SARS-CoV-2.The primary cluster of
patients was found to be connected with the Huanan
South China Seafood Market in Wuhan (2).CoVs
belong to the family Coronaviridae(subfamily
Coronavirinae),the members of which infect a broad
6.5 Specimen collection and
storage
A Nasopharyngeal and oropharyngeal swab
should be collected using Dacron or polyester
flocked swabs.It should be transported to
the laboratory at a temperature of 4°C and
stored in the laboratory between 4 and -70°℃
on the basis of the number of days and,in
order to
increase the viral load,both nasopharyngeal
and oropharyngeal swabs should be placed
in the same tube.Bronchoalveolar lavage and
nasopharyngeal aspirate should be collected
in a sterile container and transported similarly
to the laboratory by maintain a temperature
of 4℃.

Sputum samples,especially from the lower

respiratory tract,should be collected with the
help of a sterile container and
stored,whereas tissue from a biopsy or
autopsy should be
collected using a sterile container along with
saline.However,both should be stored in
the laboratory at a temperature that ranges
between 4 and -70°℃.Whole blood for
detecting the antigen,particularly in the first
week of illness,should be collected in a
collecting tube and stored in the laboratory
between 4 and-70°℃.Urine samples must also
be collected using a sterile container and
stored
infected by human beings.However,evidence of
cat- to-human transmission is lacking and
requires
further studies (332).Rather than waiting for
firmer
evidence on animal-to-human transmission,
necessary preventive measures are advised,as well
as following social distancing practices among
companion animals of different
households(331). One of the leading veterinary
diagnostic companies, IDEXX, has conducted
large-scale testing for COVID-19 in specimens
collected from dogs and cats.However,none of the
tests turned out to be positive( 334).
In a study conducted to investigate the potential
of different animal species to act as the intermediate
host of SARS-CoV-2,it was found that both ferrets
and cats can be infected via experimental inoculation
of the virus.In addition,infected cats efficiently
transmitted the disease to naive cats(329).SARS-
CoV-2 infection and subsequent transmission in
ferrets were found to recapitulate the clinical
aspects of COVID-19 in humans.The infected
ferrets also shed virus via multiple routes,such as
saliva,nasal washes,feces,and
urine,postinfection,making them an ideal animal
model for studying disease
transmission( 337).Experimental inoculation
was
also done in other animal species and found that the
dogs have low susceptibility,while the chickens,
therapeutics,and drug regimens to counter
emerging viruses( 161-163,280).Several attempts
are being made to design and develop vaccines
for CoV infection,mostly by targeting the spike
glycoprotein. Nevertheless, owing to extensive
diversity in antigenic variants,cross-protection
rendered by the vaccines is significantly
limited,even within the strains of a phylogenetic
subcluster(104).Due to the lack of effective
antiviral therapy and vaccines in the present
scenario,we need to depend solely on
implementing effective infection control measures to
lessen the risk of possible nosocomial transmission
(68).Recently,the receptor for SARS-CoV-2
was established as the human angiotensin-
converting enzyme 2 (hACE2),and the virus was
found to enter the host cell mainly through
endocytosis.It was also found that the major
components that have a critical role in viral
entry include PIKfyve,TPC2,and cathepsin
L.These findings are critical,since the
components described above might act as candidates
for vaccines or therapeutic drugs against SARS-
CoV-2 (293).
The majority of the treatment options and
strategies that are being evaluated for SARS-CoV-2
(COVID-19)have been taken from our previous
experiences in treating SARS-CoV,MERS-CoV,and
other emerging viral diseases.Several therapeutic
07:27 回 艹 ·

Prevention [21,30]

Since at this time there are no

approved treatments for this infection,
prevention is crucial.Several
properties of this virus make
prevention difficult namely,non-
specific features of the disease,the
infectivity even before onset of
symptoms in the incubation period,
transmission from asymptomatic
people,long incubation period,tropism
for mucosal surfaces such as the
conjunctiva,prolonged duration of the
illness and transmission even after
clinical recovery.

Isolation of confirmed or suspected

cases with mild illness at home is
recommended.The ventilation at
home should be good with sunlight to
allow for destruction of
virus.Patients should
be asked to wear a simple surgical
mask and practice cough hygiene.
lower respiratory tracts.Acute viral interstitial pneu-
monia and humoral and cellular immune responses
were observed⁸7.Moreover,prolonged virus shedding
peaked early in the course of infection in
asymptomatic macaques,and old monkeys showed
severer intersti- tial pneumonia than young monkeys?
6,which is similar to what is seen in patients with
COVID-19.In human ACE2-transgenic mice infected
with SARS-CoV-2,typ- ical interstitial pneumonia
was present,and viral anti- gens were observed
mainly in the bronchial epithelial cells,macrophages
and alveolar epithelia.Some human ACE2-transgenic
mice even died after infection70,71. In wide-type
mice,a SARS-CoV-2 mouse-adapted strain with
theN501Y alteration in the RBD of the S protein was
generated at passage 6.Interstitial pneumonia and
inflammatory responses were found in both young
and aged mice after infection with the mouse-adapted
strain'4.Golden hamsters also showed typical symptoms
after being infected with SARS-CoV-2 (REF??).In other
animal models,including cats and ferrets,SARS-CoV-2
could efficiently replicate in the upper respiratory tract
but did not induce severe clinical symptoms,78.As trans-
mission by direct contact and air was observed in infected
ferrets and hamsters,these animals could be used to
model different transmission modes of COVID-19
(REFS77-79).Animal models offer important information
for understanding the pathogenesis of SARS-CoV-2
infection and the transmission dynamics of SARS-
CoV-2,and are important to evaluate the efficacy of
antiviral therapeutics and vaccines.

Clinical and epidemiological features

It appears that all ages of the population are susceptible
to SARS-CoV-2 infection,and the median age of
infection is around 50 years°-13,60,80,81.However,clinical
manifesta- tions differ with age.In general,older men
(>60 years old)with co-morbidities are more likely
to develop severe respiratory disease that requires
hospitalization
prevailing chronic medical conditions such as
lung disease,heart failure,cancer,
cerebrovascular disease,renal disease,
diabetes,liver disease and
immunocompromising conditions and
pregnancy are risk factors for developing
severe llness.Management includes
implementation of prevention and control
measures and
supportive therapy to manage the
complications,together with advanced organ
support. 5

Corticosteroids must be avoided unless

specified for chronic obstructive pulmonary
disease exacerbation or septic shock,as it is
ikely to prolong viral replication as detected
in MERS-CoV patients.58

12 EARLY SUPPORTIVE
THERAPY AND MONITORING
Management of patients with suspected or
documented COVID-19 consists of ensuring
appropriate infection control and supportive
care.WHO and the CDC posted clinical
guidance for COVID-19.59

Immediate therapy of add-on oxygen must

be started for patients with severe acute
respiratory infection (SARl)and respiratory
primary anti-genic epitopes mainly those
recognised by neutralising antibodies.The spike
S-protein being in a spike form is subjected to a
structural rearrangement process so that
fusing
the outer membrane of the virus with the host-
cell membrane becomes easier.19,20 Recent
SARS-CoV work has also shown that the
membrane exopeptidase ACE enzyme
(angiotensin-converting enzyme)functions as
a COVID-19 receptor to enter the human cell.21
FIGURE 1
dt%csfir romphe heihertsedohion
hoy
were infected with SARS-CoV-2 (REF⁹).
The high transmissibility of SARS-CoV-2
may be attributed to the unique virological
features of SARS-CoV-2.Transmission of SARS-
CoV occurred mainly after illness onset and peaked
following dis- ease severity.However,the SARS-
CoV-2 viral load in upper respiratory tract samples
was already high- est during the first week of
symptoms,and thus the risk of pharyngeal virus
shedding was very high at the beginning of
infection⁶,97.It was postulated that undocumented
infections might account for 79%of documented
cases owing to the high transmissibility of the virus
during mild disease or the asymptomatic period⁹.A
patient with COVID-19 spreads viruses in liquid
droplets during speech.However,smaller and much
more numerous particles known as aerosol parti- cles
can also be visualized,which could linger in the air for
a long time and then penetrate deep into the lungs
when inhaled by someone else⁸-100.Airborne trans-
mission was also observed in the ferret experiments
mentioned above.SARS-CoV-2-infected ferrets shed
involved in the COVID-19 outbreak is of
great importance,because the strain on their mental
well- being will affect their
attention,concentration,and decision-making
capacity.Hence,for control of the COVID-19
outbreak,rapid steps should be taken to protect the
mental health of medical workers (229).
Since the living mammals sold in the wet
market are suspected to be the intermediate host of
SARS- CoV-2,there is a need for
strengthening the regulatory mechanism for wild
animal trade(13).
The total number of COVID-19 confirmed cases is
on a continuous rise and the cure rate is relatively
low,making disease control very difficult to achieve.
The Chinese government is making continuous
efforts to contain the disease by taking emergency
control and prevention measures.They have already
built a hospital for patients affected by this virus and
are currently building several more for
accommodating the continuously increasing infected
population( 230).The effective control of
SARS- CoV-2/COVID-19 requires high-level
interventions like intensive contact tracing,as
well as the quarantine of people with suspected
infection and the isolation of infected
individuals.The implementation of rigorous control
and preventive measures together might control
the Ro number and reduce the
transmission risk(228).Considering the
zoonotic
4 VIROLOGY
Coronaviruses,a family of viruses within the
nidoviruses superfamily,are further classified
according to their
genera,alpha-,beta-,gamma- and
deltacoronaviruses (a-,β-,γ-and δ-).
Among those,alpha and beta species are
capable of contaminating only mammals,
whereas the other two genera can infect
birds and could also infect mammals.13,14
Two of these genera belong to human
coronaviruses (HCoVs):a-
coronaviruses,which comprise
human coronavirus 229E(hcov229E)and
human coronavirus NL63(hcovNL63),and β-
coronaviruses,which are human
coronavirus HKU1,human coronavirus
OC43,MERS-COV (known as Middle East
respiratory syndrome coronavirus)and
SARS-CoV(referred to as
severe acute respiratory syndrome
coronavirus).15

The severe acute respiratory syndrome CoV-

2 (SARS-CoV-2)is now named novel COVID-19
(coronavirus disease 2019).16 Genome
sequencing and phylogenetic research
revealed that the COVID-19-causing coronavirus
is a
beta-coronavirus that belongs to the same
subtypes as SARS virus,but still exists in a
variant group.The receptor-binding gene region
07:23 回 艹 ·
had>95%homology with the bat
coronavirus and>70%similarity with
the SARS-CoV.Environmental samples
from the Huanan sea food market also
tested positive,signifying that the virus
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 fuelled 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
07:25 ☑ 艹 ·
epidemic progresses,commercial tests
will become available.

Other laboratory investigations are

usually non specific.The white cell
count is usually normal or low.There
may be lymphopenia;a lymphocyte
count <1000 has been associated with
severe disease.The platelet count is
usually normal or mildly low.The CRP
and ESR are generally elevated but
procalcitonin levels are usually
normal.A high procalcitonin level may
indicate a bacterial co-infection.The
ALT/AST,prothrombin time,creatinine,
D-dimer,CPK and LDH may be
elevated
and high levels are associated with
severe disease.

The chest X-ray (CXR)usually shows

bilateral infiltrates but may be normal
in early disease.The CT is more
sensitive and specific.CT imaging
generally shows infiltrates,ground
glass opacities and sub segmental
might be lower.Further genetic analysis is required
between SARS-CoV-2 and different strains of
SARS-CoV and SARS-like(SL)CoVs to
evaluate the possibility of repurposed vaccines
against COVID-19.This strategy will be helpful
in the scenario of an outbreak,since much time
can be saved,because preliminary
evaluation,including in vitro studies,already would
be completed for such
vaccine candidates.
Multiepitope subunit vaccines can be considered
a promising preventive strategy against the ongoing
COVID-19 pandemic.In silico and advanced
immunoinformatic tools can be used to develop
multiepitope subunit vaccines.The vaccines that are
engineered by this technique can be further evaluated
using docking studies and,if found effective,then
can be further evaluated in animal
models(365). Identifying epitopes that have the
potential to become a vaccine candidate is critical
to developing an effective vaccine against
COVID-19. The immunoinformatics approach
has been used for recognizing essential
epitopes of cytotoxic T lymphocytes and B
cells from the surface glycoprotein of
SARS-CoV-2.Recently,a few epitopes have been
recognized from the SARS-CoV- 2 surface
glycoprotein. The selected epitopes
explored targeting molecular dynamic simulations,
major problem associated with this diagnostic kit
is that it works only when the test subject has an
active
infection,limiting its use to the earlier stages of
infection.Several laboratories around the world are
currently developing antibody-based diagnostic
tests against SARS-CoV-2 (157).
Chest CT is an ideal diagnostic tool
for identifying viral pneumonia.The sensitivity of
chest CT is far superior to that of X-ray
screening.The chest CT findings associated
with COVID-19- infected patients include
characteristic patchy infiltration that later
progresses to ground-glass opacities( 158).Early
manifestations of COVID-19 pneumonia might
not be evident in X-ray chest radiography. In
such situations,a chest CT examination can
be performed,as it is considered highly specific
for COVID-19 pneumonia(118). Those patients
having COVID-19 pneumonia will exhibit the
typical ground-glass opacity in their chest CT
images (154). The patients infected with
COVID-19 had elevated plasma angiotensin 2 levels.
The level of angiotensin 2 was found to be linearly
associated with viral load and lung injury,indicating
its potential as a diagnostic biomarker(121).The
chest CT imaging abnormalities associated with
COVID-19 pneumonia have also been observed even
in asymptomatic patients. These abnormalities
anti-SARS-CoV-2 activity is far higher than
the maximum plasma concentration achieved
by administering the approved
dose(340).However, ivermectin,being a host-
directed agent,exhibits antiviral activity by
targeting a critical cellular process of the
mammalian cell.Therefore,the administration of
ivermectin,even at lower doses, will reduce the
viral load at a minor level.This slight decrease will
provide a great advantage to the immune
system for mounting a large-scale antiviral
response against SARS-CoV-2(341).Further,a
combination of ivermectin and hydroxychloroquine
might have a synergistic effect,since ivermectin
reduces viral replication,while hydroxychloroquine
inhibits the entry of the virus in the host cell
(339). Further,in vivo studies and randomized
clinical control trials are required to
understand the mechanism as well as the
clinical utility of this
promising drug.
Nafamostat is a potent inhibitor of MERS-CoV
that acts by preventing membrane fusion.
Nevertheless,it does not have any sort of inhibitory
action against SARS-CoV-2 infection
(194). Recently,several newly synthesized
halogenated triazole compounds were
evaluated, using fluorescence resonance
energy transfer(FRET)-
based helicase assays,for their ability to inhibit
and SARS,along with adopting and strengthening
a few precautionary measures owing to the
unknown
nature of this novel virus(36, 189).Presently,the
main course of treatment for severely affected
SARS-CoV-2 patients admitted to hospitals includes
mechanical ventilation,intensive care unit(ICU)
admittance, and symptomatic and supportive
therapies.Additionally,RNA synthesis inhibitors
(lamivudine and tenofovir disoproxil fumarate),
remdesivir,neuraminidase inhibitors,peptide (EK1),
anti-inflammatory drugs, abidol, and Chinese
traditional medicine (Lianhuaqingwen and
ShuFengJieDu capsules)could aid in COVID-19
treatment.However,further clinical trials are being
carried out concerning their safety and efficacy (7).
It might require months to a year(s)to design and
develop effective drugs,therapeutics,and vaccines
against COVID-19,with adequate evaluation and
approval from regulatory bodies and moving to the
bulk production of many millions of doses at
commercial levels to meet the timely demand of
mass populations across the globe(9).Continuous
efforts are also warranted to identify and assess
viable drugs and immunotherapeutic regimens
that revealed proven potency in combating other
viral agents similar to SARS-CoV-2.
COVID-19 patients showing severe signs are
 The pathogenesis of SARS-CoV-2 infection in
humans manifests itself as mild symptoms to
severe respiratory failure.On binding to epithelial
cells in the respiratory tract,SARS-CoV-2 starts
replicating and migrating down to the airways and
enters alveo- lar epithelial cells in the lungs.The rapid
replication of SARS-CoV-2 in the lungs may trigger a
strong immune response.Cytokine storm syndrome
causes acute res- piratory distress syndrome and
respiratory failure,which is considered the main cause
of death in patients with
COVID-19 (REFS6061).Patients of older age (>60 years)
and with serious pre-existing diseases have a greater
risk of developing acute respiratory distress
syndrome and death⁶2-64(FIG.4).Multiple organ
failure has also been reported in some COVID-19
cases,13.65.
Histopathological changes inpatients with COVID-19
occur mainly in the lungs.Histopathology analyses
showed bilateral diffused alveolar damage,hyaline
membrane formation,desquamation of pneumocytes
and fibrin deposits in lungs of patients with severe
COVID-19.Exudative inflammation was also shown
in some cases.Immunohistochemistry assays detected
SARS-CoV-2 antigen in the upper airway,bronchiolar
epithelium and submucosal gland epithelium,as well
as in type Iand type I pneumocytes,alveolar
macrophages and hyaline membranes in the
lungs³.60,66,67.
Animal models used for studying SARS-CoV-
2 infection pathogenesis include non-human
primates (rhesus macaques,cynomolgus
monkeys,marmosets and African green
monkeys),mice(wild-type mice(with mouse-adapted
virus)and human ACE2-transgenic or human
ACE2-knock-in mice),ferrets and golden
hamsters³,48,68-74.In non-human primate animal mod-
els,most species display clinical features similar to
those of patients with COVID-19,including virus
shedding, virus replication and host responses to
SARS-CoV-2 infection⁶9,72.73.For example,in the
rhesus macaque model,high viral loads were detected
in the upper and
appeared asymptomatic⁴5.Another serological study
detected SARS-CoV-2 neutralizing antibodies in cat
serum samples collected in Wuhan after the COVID-
19 outbreak,providing evidence for SARS-CoV-2
infection in cat populations in Wuhan,although the
potential of SARS-CoV-2 transmission from cats to
humans is currently uncertain⁴6.

Receptor use and pathogenesis

SARS-CoV-2 uses the same receptor as SARS-CoV,
angiotensin-converting enzyme 2(ACE2)l1.47.Besides
human ACE2 (hACE2),SARS-CoV-2 also recognizes
ACE2 from pig,ferret,rhesus monkey,civet,cat,pan-
golin,rabbit and dog',43,48,49.The broad receptor usage
of SARS-CoV-2 implies that it may have a wide host
range,and the varied efficiency of ACE2 usage in differ-
ent animals may indicate their different susceptibilities
to SARS-CoV-2 infection.The Sl subunit of a corona-
virus is further divided into two functional domains,
an N-terminal domain and a C-terminal domain.
Structural and biochemical analyses identified a
211 amino acid region (amino acids 319-529)at the S1
C-terminal domain of SARS-CoV-2 as the RBD,which
has a key role in virus entry and is the target of neu-
tralizing antibodies5051 (FIG.3a).The RBM mediates con-
tact with the ACE2 receptor (amino acids 437-507 of
SARS-CoV-2 S protein),and this region in SARS-CoV-2
differs from that in SARS-CoV in the five residues crit-
considerable protection in mice against a
MERS- CoV lethal challenge.Such antibodies may
play a crucial role in enhancing protective
humoral responses against the emerging CoVs
by aiming appropriate epitopes and functions of
the S protein. The cross-neutralization ability of
SARS-CoV RBD- specific neutralizing MAbs
considerably relies on the resemblance between
their RBDs;therefore, SARS-CoV RBD-specific
antibodies could cross- neutralized SL
CoVs,i.e.,bat-SL-CoV strain WIV1 (RBD with
eight amino acid differences from SARS- CoV)but
not bat-SL-CoV strain SHC014 (24 amino acid
differences)(200).
Appropriate RBD-specific MAbs can be
recognized by a relative analysis of RBD of
SARS- CoV-2 to that of SARS-CoV,and cross-
neutralizing SARS-CoV RBD-specific MAbs could
be explored for their effectiveness against COVID-
19 and further need to be assessed
clinically. The U.S. biotechnology company
Regeneron is attempting to recognize potent and
specific MAbs to combat COVID-19.An ideal
therapeutic option suggested for SARS-CoV-
2(COVID-19)is the combination therapy
comprised of MAbs and the drug remdesivir
(COVID-19)( 201).The SARS-CoV-specific
human
MAb CR3022 is found to bind with SARS-CoV-2
RBD,indicating its potential as a therapeutic agent
 07:25 回 艹 ·

consolidation.It is also abnormal in

asymptomatic patients/patients with
no clinical evidence of lower
respiratory tract involvement.In fact,
abnormal CT scans have been used to
diagnose COVID-19 in suspect cases
with negative molecular diagnosis;
many of these patients had positive
molecular tests on repeat testing [22].

Differential Diagnosis [21]

The differential diagnosis includes all
types of respiratory viral infections
[influenza,parainfluenza,respiratory
syncytial virus (RSV),adenovirus,
human metapneumovirus,non COVID-
19 coronavirus],atypical organisms
(mycoplasma,chlamydia)and bacterial
infections.It is not possible to
differentiate COVID-19 from these
infections clinically or through routine
lab tests.Therefore travel history
becomes important.However,as the
epidemic spreads.the travel history
recovered patients and used for plasma transfusion
twice in a volume of 200 to 250ml on the day of
collection( 310).At present,treatment for sepsis
and ARDS mainly involves antimicrobial
therapy,source control,and supportive
care.Hence,the use of therapeutic plasma
exchange can be considered an option in
managing such severe conditions.Further
randomized trials can be designed to investigate its
efficacy( 311).

Potential Therapeutic Agents

Potent therapeutics to combat SARS-CoV-2
infection include virus binding molecules,molecules
or inhibitors targeting particular enzymes implicated
in replication and transcription process of the virus,
helicase inhibitors,vital viral proteases and
proteins, protease inhibitors of host cells,
endocytosis inhibitors, short interfering RNA
(siRNA), neutralizing antibodies,MAbs against
the host receptor,MAbs interfering with the
S1 RBD, antiviral peptide aimed at S2,
and natural drugs/medicines( 7,166,186).The S
protein acts as the critical target for developing
CoV antivirals,like inhibitors of S protein and S
cleavage,neutralizing antibodies,RBD-ACE2
blockers,siRNAs,blockers of the fusion core,and
proteases (168).
All of these therapeutic approaches have revealed
nsps and Accessory Proteins
Besides the important structural proteins,the
SARS-CoV-2 genome contains 15 nsps,nspl to
nsp10 and nsp12 to nsp16,and 8 accessory
proteins (3a,3b,p6,7a,7b,8b,9b,and
ORF14)(16).All these proteins play a specific role in
viral replication (27).Unlike the accessory proteins
of SARS-CoV, SARS-CoV-2 does not contain 8a
protein and has a longer 8b and shorter 3b
protein(16).The nsp7, nsp13,envelope,matrix,and
p6 and 8b accessory proteins have not been
detected with any amino acid substitutions
compared to the sequences of other coronaviruses
(16).
The virus structure of SARS-CoV-2 is depicted in
Fig.2.

Spike glycoprotein (S)

(required for the entry of the
infectious virion particlei
Membrane protein (M)
(most abundant viral pi
[
[
Major protei

Envelope glycoprotein (E)

(smallest among the major
structural proteins)

Nucleocapsid protein (N)

+single-stranded positive
sense RNA genome

Lipid bilayer
FIG 2 SARS-CoV-2 virus structure.
 The comprehensive sequence analysis of the
SARS-CoV-2 RNA genome identified that the CoV
from Wuhan is a recombinant virus of the bat
coronavirus and another coronavirus of unknown
origin.The recombination was found to have
happened within the viral spike glycoprotein,which
recognizes the cell surface receptor.Further analysis
of the genome based on codon usage identified the
snake as the most probable animal reservoir of
SARS-CoV-2( 143).Contrary to these
findings, another genome analysis proposed that
the genome of SARS-CoV-2 is 96%identical to bat
coronavirus, reflecting its origin from bats(63).The
involvement of bat-derived materials in causing
the current outbreak cannot be ruled out.High risk
is involved in the production of bat-derived
materials for TCM practices involving the
handling of wild bats.The use of bats for TCM
practices will remain a severe risk for the
occurrence of zoonotic coronavirus epidemics in
the future (139).
Furthermore,the pangolins are an endangered
species of animals that harbor a wide variety of
viruses, including coronaviruses (144). The
coronavirus isolated from Malayan pangolins (Manis
javanica)showed a very high amino acid identity
with COVID-19 at E(100%),M(98.2%),N
(96.7%),and S genes (90.4%).The RBD of S protein
by the University of Oxford.In a randomized
controlled phase I/II trial,it induced neutralizing
antibodies against SARS-CoV-2 in all 1,077
participants after a second vaccine dose,while its
safety profile was acceptable as well¹63.The NIAID
and Moderna co-manufactured
mRNA-1273,a lipid nanoparticle-formulated mRNA
vaccine candidate that encodes the stabilized prefusion
SARS-CoV-2 S protein.Its immunogenicity has been
confirmed by a phase I trial in which robust neutralizing
antibody responses were induced in a dose-dependent
manner and increased after a second
dosel⁶4.Regarding inactivated vaccines,a successful
phase I/II trial involv- ing 320 participants has been
reported in China.The whole-virus COVID-19 vaccine
had a low rate of adverse reactions and effectively
induced neutralizing antibody production⁶5.The
verified safety and immunogenicity support
advancement of these vaccine candidates to phase
III clinical trials,which will evaluate their efficacy in
protecting healthy populations from SARS-CoV-2
infection.

Future perspectives
COVID-19 is the third highly pathogenic human coro-
navirus disease to date.Although less deadly than
SARS and MERS,the rapid spreading of this highly
conta- gious disease has posed the severest threat to
global health in this century.The SARS-CoV-2
outbreak has lasted for more than half a year now,and
it is likely that
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-
 studies carried
out on the isolated virus confirmed that there is a
potential risk for the reemergence of SARS-
CoV infection from the viruses that are
currently circulating in the bat population(105).

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
respiratory infection (SARl)and respiratory
distress,shock or hypoxaemia.Patients with
SARI 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).59

Patients'clinical deterioration is closely

observed with SARl;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.60
Generally,such patients give way to their
primary illness to
secondary complications like sepsis or
multiorgan system failure.48
in asymptomatic patients.These abnormalities
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
07:25 回 艹 ·
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].

Diagnosis [21]
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 historw or those with confrmed
countries.Large-scale screening programs might
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
Even though a high similarity has been
reported 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 of
nsp2 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 ORF8,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
 COVID-19 patients showing severe signs are
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
SplitsTree phylogeny analysis.

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
trimeric S1 locates itself on top of the trimeric S2
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
wearing a facemask and practising 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.42

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.48,49 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 hospitalisation,11-
31%of them
required admission to the intensive care
unit, and 4-11%died.50
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 identity⁹.The
repeated occurrence of SARS-CoV-2-related
coronavirus infec- tions 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
organs⁰.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 identi- cal 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.42).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.
07:25 M ⊙ 艹 ·

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 ACE₂receptors
on the
respiratory mucosa [11].

Disease in neonates,infants and

children has been also reported to be
significantly milder than their adult
counterparts.In a series of 34 children
admitted to a hospital in Shenzhen,
China between January 19th and
February 7th,there were 14 males and
20 females.The median age was 8y 11
mo and in 28 children the infection
was linked to a family member and 26
07:23 ☑ 艹 ·

and Middle East respiratory syndrome

coronavirus (MERS-CoV),but has
lower fatality.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 eve view about
07:28
U
☑ 艹 · U 1

(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-19 for 2 wks 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
dogs have low susceptibility,while the chickens,
ducks,and pigs are not at 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 rate,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 SARS-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).
07:27 回 艹 ·

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 co-
infections 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
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.
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-
CoVZC45 and bat-SL-CCoVZ)
differs from that in SARS-CoV in the five residues
crit- ical for ACE2 binding,namely
Y455L,L486F,N493Q, D494S and
T501N²(FIG.3b,c).Owing to these residue
changes,interaction of SARS-CoV-2 with its receptor
stabilizes the two virus-binding hotspots on the surface
ofhACE2(REF5⁰)(FIC.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 ena- bles better contact with the N-
terminal helix of hACE2 (REF50).Biochemical data
confirmed that the structural features of the SARS-
CoV-2 RBD has strengthened its hACE2 binding
affinity compared with that of SARS-CoV50,52,53.
Similarly 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
furin754,55.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 cumu-
lative 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 conforma-
tional states50,51,58,59.A lying-down conformation of
the SARS-CoV-2 S protein may not be in favour of
receptor binding but is helpful for immune evasion⁵ .
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-1b¹43,144.The Randomized Evaluation of
COVID-19 Therapy (RECOVERY)trial,a national clin-
ical trial programme 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 atotal of 1,596 patients
45.Nevertheless,
wrought havoc in China and caused a pandemic
situation in the worldwide population,leading to
disease outbreaks that have not been controlled to
date,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-CoVs(26).SARS-CoV-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 lbats, 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(A)tail (30).The
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
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(Ro)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 an 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,
possible origin of SARS-CoV-2 and
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 ).
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.63-6!
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 lopinavirand 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

15 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
hospitalisation.Interim
recommendations on home management
of patients with COVID-19 can be found on
fever,cough,and sputum(83).Hence,the 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
respectively¹40.However,this study did not include
a control arm,and most of the trials offavilavir were
based on a small sample size.For more reliable
assess- ment 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-CoV¹41,142.Alone,the combination of
lopinavir
07:23 回 艹 ·
such instance was in 2002-2003 when a
new coronavirus of the β 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 HongKong
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
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
COVID- 19 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
07:27 回 艹 ·
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
 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-CoV-2
(COVID-19). Bats are recognized as a possible
natural reservoir host of both SARS-CoV and
MERS-CoV 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 HCoV-229E and HCoV-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
 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-CoV-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
and MERS (17, 279).The recently emerging
SARS-CoV-2 has wrought havoc in China and
caused a pandemic
situation in the worldwide nonulation leadino to
mice,and hDPP4-Tg mice(transgenic for expressing
hDPP4) for MERS-CoV 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-CoV2/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-CoV)(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, iradiological, and pathological
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.34-3E

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
 We also predict the possibility of another
outbreak,as predicted by Fan et al.(6).Indeed,the
present outbreak caused by SARS-CoV-2 (COVID-
19)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 ).
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
syndrome⁶061.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 mechan- ical
ventilation and by one fifth in patients receiving
oxygen.By contrast,no benefit was found in patients
without respiratory supportl46.
Tocilizumab and sarilumab,two types of interleukin-
6 (IL-6)receptor-specific antibodies previously used
to treat various types of arthritis,including
rheumatoid arthritis,and cytokine release
syndrome,showed effec- tiveness in the treatment of
severe COVID-19 by atten- uating the cytokine storm
in a small uncontrolled trial⁴7. Bevacizumab is an
anti-vascular endothelial growth
factor(VEGF)medication that could potentially reduce
pulmonary oedema inpatients 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 (REF.148).
as an entry receptor while exhibiting an RBD similar
to that of SARS-CoV(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
SARS- CoV and MERS-CoV,the efficiency of
SARS-CoV- 2 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-CoV 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 (84).
07:23 ☑ 艹 ·

the SARS-CoV.Environmental
samples from the Huanan sea food
market also
tested positive,signifying that the virus
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 fuelled 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
07:25 回 艹 ·

of persistent local transmission or

contact with patients with similar
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/
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
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 muta- tion make up a single subclade labelled as
clade S³334. Currently,however,the available sequence
data are not sufficient to interpret the early global
transmission his- tory 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 alphacoronavi-
ruses 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!¹I).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.!I).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
bats³5.Another related coronavirus has been reported
more recently in a Rhinolophus malayanus bat sampled
in Yinnan Thic novel hat viruc denoted‘RmYN∩?’
into the host cell.Heptad repeat 1(HR1)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-CoV identified that the S2
subunits are highly conserved in these CoVs.The
HR1 and HR2 domains showed 92.6%and 100%
overall identity,respectively(210).From
these findings, we can confirm the
significance of
COVID-19 HR1 and HR2 and their vital role in host
cell entry.Hence,fusion inhibitors target the HR1
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).
 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
(IBV,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
virion a corona or crown-like
appearance.Functionally it is required for the
entry of the infectious virion 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,S1 and S2(43).The first one,S1,helps
in host receptor binding,while the second
one,S2,accounts for fusion.The former(S1)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
S1 CTD contains the receptor-binding motif
(RBM).In each coronavirus spike protein,the
trimeric S1 locates itself on top of the trimeric S2
responsible for MERS-CoV and SARS-
CoV(3).The newly emerged SARS-CoV-2 is a
group 2B coronavirus (2).The genome
sequences of SARS- CoV-2 obtained from patients
share 79.5%sequence
similarity to the sequence of SARS-CoV(63).
As of 13 May 2020,a total of 4,170,424
confirmed cases of COVID-19(with 287,399
deaths) have been reported in more than 210
affected
countries worldwide(WHO Situation Report 114
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?3.
It has overwhelmingly surpassed SARS and MERS in
terms of both the number of infected people and the
spatial range ofepidemic areas.The ongoing outbreak
of COVID-19 has posed an extraordinary threat to
global public health⁴5.In this Review,we summarize
the cur- rent 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 epide- miological 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*.Similarly to patients with SARS and
MERS,these patients showed symptoms of viral
pneumonia,including fever,cough
only a matter of time before another zoonotic
coronavirus results in an epidemic by jumping the
so-called species barrier (287).
The host spectrum of coronavirus increased when
a novel coronavirus,namely,SW1,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 calls 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
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.3/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-19 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
animal species is necessary to prevent the
possibility of virus spread and initiation of an
outbreak due to
zoonotic spillover (1).
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
susceptible individuals.Hence,hand hygiene is
equally as important as the use of appropriate PPE,
like face masks,to break the transmission cycle of
the virus;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
07:29

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 travel history of all patients
with
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
10 RECOMBINANT SUBUNIT
VACCINE
Clover Biopharmaceuticals is producing a
recombinant subunit vaccine based on
the trimeric S-protein of COVID-19.55 The
oral recombinant vaccine is being
expanded by Vaxart in tablet
formulation,using its
proprietary oral vaccine platform.

11 CLINICAL MANAGEMENT
AND TREATMENT
In severe COVID-19 cases,treatment 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 lsolation 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
Coronaviruses in Humans SARS,MERS,
and COVID-19
Coronavirus infection in humans 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
 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
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 January'5.On 30 January,the WHO
declared the novel coronavirus outbreak a public health
emergency of inter- national concern⁶.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'(REF.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. In the following
couple of weeks,all outdoor activities and gatherings
were restricted,and public facilities were closed in most
cities as well as in countrysidel⁸.Owing to these
measures,the daily number of new cases in China
started to decrease steadily'° .
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 countries⁸.The high transmission
efficiency of SARS-CoV-2 and the abun- dance of
international travel enabled rapid worldwide spread
of COVID-19.On 11 March 2020,the WHO
officially characterized the global COVID-19 out-
break as a pandemic²0.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 dash-
board ofthe Center for System Science and
Engineering at Johns Hopkins University,as of 11
August 2020,
system( 30).
Bovine coronaviruses(BoCoVs)are known to
infect several domestic and wild
ruminants(126). BoCoV 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 canine respiratory
coronavirus in Betacoronavirus,affecting the enteric
and respiratory tract,respectively(129,
130).IBV,
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
major CoVs associated with disease manifestations
like enteritis,
hepatitis,and respiratory infections (10,133).
Swine acute diarrhea syndrome coronavirus
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
SARS- CoV-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).
Inhibition ofvirus entry. SARS-CoV-2 uses ACE2 as
the receptor and human proteases as entry
activators;sub- sequently it fuses the viral membrane
with the cell mem- brane 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 respira-
tory 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-
nosis of or accelerate SARS-CoV-2 clearance
inpatients with mild to moderate COVID-
19(REFS¹24,125).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 postoper- ative 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 (wild- type 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 cells47.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.
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
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 remdesivir
in
treating the patients with COVID-
19,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-19.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-
19.62

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
07:25 M ⊙ 艹 ·
1

Epidemiology and Pathogenesis

[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 in
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 infected
droplets can spread 1-2 m and deposit
vaccine that can produce cross-reactive antibodies.
However,the success of such a vaccine relies greatly
on its ability to provide protection not 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-
07:24 ⊙ ●

ncbi.nlm.nih.gov/pmc/artic
①
exponentially in other countries
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
07:24 ⊙ ●

ncbi.nlm.nih.gov/pmc/artic
①
testing.Though the SARS-CoV-2
originated from bats,the intermediary
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-19.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 remdesiviris effective in treating
the Middle
East respiratory syndrome coronavirus
(MERS- CoV),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
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 amino acid sequences of SARS-CoV-
2 and the SARS/SARS-like
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 amino 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
virological, 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
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 diverges l.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 transcrip-
tion 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 horse- shoe bat coronavirus isolates
(RaTG13,RmYN02,ZC45 and ZXC21)as well as novel
coronaviruses recently iden-
tified in pangolins,which group parallel to SARS-CoV
(96.7%),and S genes (90.4%).The RBD of S
protein in CoV isolated from pangolin was almost
identical (one amino acid difference)to that of
SARS-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-CoV.COVID-19 is also
suspected of having a similar mode of origin.Hence,
to prevent the occurrence of another zoonotic
spillover (1),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 SARS- related 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
Furthermore,SARS-CoV-2 is genetically distinct
from SARS-CoV(79%similarity)and MERS-CoV
(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 ).
07:27 回 艹 ·
1

been used based on the experience

with SARS and MERS.In a historical
control study inpatients with SARS,
patients treated with lopinavir-
ritonavir 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 from
Wuhan,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]
6.1 Laboratory testing for
coronavirus disease 2019 (COVID-
19)in suspected human cases
The assessment of the patients with COVID-19
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 (RT-
PCR).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
07:23 回 艹
·
tuou uny uiu uiuuily uiu uiuouvviul
comorbidities),it may progress to
pneumonia,acute respiratory distress
syndrome(ARDS)and multi organ
dysfunction.Many people are
asymptomatic.The case fatality rate is
estimated to range from 2 to 3%.
Diagnosis is by demonstration of the
virus in respiratory secretions by
special molecular tests.Common
laboratory findings include normal/
low white cell counts with elevated
C-
reactive protein(CRP).The
computerized tomographic chest scan
is usually abnormal even in those
with
no symptoms or mild disease.
Treatment is essentially supportive;
role of antiviral agents is yet to be
established.Prevention entails home
isolation of suspected cases and those
with mild illnesses and strict
infection
control measures at hospitals that
include contact and droplet
precautions.The virus spreads faster
than ite two ancestore tho SARS CoW
severe illness,to minimise the risk of
exposure to COVID-19 during outbreaks.53

9 VACCINES
The strange coronavirus outbreak in the
Chinese city of Wuhan,now termed COVID-19,
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
 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
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 (PUl)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 practising
hand
RBD,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,SARS-
CoV-specific neutralizing antibodies,like m396 and
CR3014,failed to bind the S protein of SARS-
CoV- 2,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
postprocedure 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 ).
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 S1 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 S1 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
07:29 、

·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 tryy to allay 1

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
o uthreak efforts should be made to
07:25 ●
ncbi.nlm.nih.gov/pmc/arti
①
identified angiotensin receptor 2
(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 H1N12009 [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
othov vocnivoto wr infootiono Iu o o nlheot
variant group.The receptor-binding gene
region appears to be very similar to that of the
SARS- CoV and it is believed that the same
receptor
would be used for cell entry.17

4.1 Virion structure and its

genome
Coronaviruses are structurally enveloped,
belonging to the positive-strand RNA viruses
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
vitro antiviral potential of FAD-approved drugs,viz.,
ribavirin,penciclovir,nitazoxanide,nafamostat,and
chloroquine,tested in comparison to remdesivir and
favipiravir (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/ritonavir, chloroquine, and
hydroxychloroquine,have been proposed for
the clinical management of COVID-19
(299).A
molecular docking study,conducted in the RNA-
dependent 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),
216 countries and regions from all six continents had
reported more than 20 million cases of COVID-19,and
more than 733,000 patients had died?.High
mortality 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?,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
France²3.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 inves- tigations 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 betacoronavirus,SARS-CoV-2 shares
79%genome sequence identity with SARS-CoV and
50%with MERS-CoV²4.Its genome organization is
shared with other betacoronaviruses.The six functional
open reading frames (ORFs)are arranged in order from
5'to 3':replicase (ORFla/ORF1b),spike (S),envelope
(E),membrane (M)and nucleocapsid (N).In addition,
seven putative ORFs encoding accessory proteins are
interspersed between the structural genes²5.Most of
the proteins encoded by SARS-CoV-2 have a similar
with SARS and MERS(117).
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-CoV outbreak(120).However,
CONCLUDING REMARKS
Several years after the global SARS
epidemic, the current SARS-CoV-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 in 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
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-CoV-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
(HCoV-229E),HCoV-NL63,HCoV-OC43,HCoV-
HKU1,SARS-CoV,and MERS-CoV.Although
SARS-CoV and MERS-CoV have resulted in

outbreaks with high mortality, others remain

associated with mild upper-respiratory-tract
illnesses
(4).
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-like
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 eme: oenc January 2020·subsequently
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 (317-319). 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 the COVID-19
outbreaks are the Diamond Princess, Grand
Princess,Celebrity Apex,and Ruby Princess.The
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 SARS-
CoV-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
coronaviruses (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
SARS-or MERS-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 COVID- 19-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
postbirth;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(240-243).
COVID-19 infection was associated with
pneumonia,and some developed acute respiratory
distress syndrome(ARDS).The blood biochemistry
indexes,such as albumin,lactate dehydrogenase,C-
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 of
lactate dehydrogenase, aspartate transaminase,
alanine
aminotransferase,bilirubin,and,especially,D-dimer
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 SARS-
CoV 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
suffering from novel SARS-CoV-2,with more than
4,170,424 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 in 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
 The results of the studies related to SARS-CoV-2
viral loads reflect active replication of this virus in
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 13 after onset),
stool samples from nine cases(53%;days 0 to 11
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
1.21×10⁵copies 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 stool and whole blood but not in
urine by real-time RT-PCR (288). Further,
novel SARS-CoV-2 infections have been detected
in a variety of clinical
specimens, like bronchoalveolar lavage fluid,
 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-CoV, and MERS-CoV,SARS-CoV-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
pointedl 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
07:25 回 艹 ·
uiupieo uaii spieau ia iii anu uepusil
on surfaces.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
post
natal transmission is described [14].
The incubation period varies from 2 to
14 d [median 5 d].Studies have
identified angiotensin receptor 2
(ACE )oc tho vocontov tbvoncb rrbicl
07:24 M
◎艹 ·

ncbi.nlm.nih.gov/pmc/artii ①
exponentially in other countries
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
specifically in the respiratory tract will help to
reduce virus-triggered immune pathologies in
COVID-19( 209).The later stages of
coronavirus- induced inflammatory cascades are
characterized by the release of proinflammatory
interleukin-1(IL-1) family members,such as IL-1
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-1 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(HR1)and heptad
DIAGNOSIS OF SARS-CoV-2 (COVID-
19)
RNA tests can confirm the diagnosis of
SARS- CoV-2 (COVID-19)cases with real-time RT-
PCR or next-generation
sequencing(148,149,245,246).At
present,nucleic acid detection techniques,like RT-
PCR,are considered an effective method for
confirming the diagnosis in clinical cases of COVID-
19( 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-CoV-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 betacoronaviruses
and specific detection of SARS-CoV-2,developed
by the U.S.CDC(Table 1)(258,259).
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
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,
 tations tnat resulted
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 specific“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 to animals and
humans (106).The pathogenesis of most
bat
coronaviruses 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
nfection.making nging to
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 amino 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 virion 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
serine 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
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 in 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 coronavirus HKU11,
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
07:23 回 艹 ·
article gives a bira's eye view about
this new virus.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 HKU1,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
1
such instance was in 2002-2003 when a

1
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 virus-
receptor 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-arm 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
4.2 Viral replication
Usually replication of coronavirus occurs
within the cytoplasm and is closely associated
with
endoplasmic reticulum and other cellular
membrane organelles.Human coronaviruses
are thought to invade cells,primarily through
different receptors.For 229E and
OC43,amino peptidase-N(AP-N)and a sialic
acid containing receptor,respectively,were
known to function in this role.After the virus
enters the host cell and uncoating process
occurs,the genome is transcribed,and
then,translated.A
characteristic feature of replication is that all
mRNAs form an enclosed group of typical 3'
ends;only the special portions of the
5'ends are translated.In total,about 7
mRNAs are
produced.The shortest mRNA codes and
the others can express the synthesis of
another
genome segment for nucleoprotein.At the
cell membrane,these proteins are collected
and genomic RNA is initiated as a mature
particle type by burgeoning from internal cell
membranes, 22,23
5 PATHOGENESIS
Coronaviruses are tremendously precise and
mature in most of the airway epithelial cells
as observed through both in vivo and in vitro
route warrants the introduction of negative fecal
viral
nucleic acid test results as one of the additional
discharge criteria in laboratory-confirmed cases of
COVID-19( 326).
The COVID-19 pandemic does not have
any novel factors,other than the genetically
unique pathogen and a further possible
reservoir.The cause and the likely future outcome
are just repetitions of our previous interactions
with fatal coronaviruses. The only difference is the
time of occurrence and the genetic distinctness of
the pathogen involved. Mutations on the RBD
of CoVs facilitated their capability of infecting
newer hosts, thereby expanding their reach to
all corners of the world (85).This is a potential
threat to the health of both animals and
humans.Advanced studies using Bayesian
phylogeographic reconstruction identified
the most probable origin of SARS-CoV-2 as the
bat
SARS-like coronavirus, circulating in the
Rhinolophus bat family( 86).
Phylogenetic analysis of 10 whole-genome
sequences of SARS-CoV-2 showed that they
are related to two CoVs of bat origin,namely,bat-
SL- CoVZC45 and bat-SL-CoVZXC21,which
were reported during 2018 in China(17).It was
reported that SARS-CoV-2 had been confirmed to
use ACE2
as an entry receptor while exhibiting an RBD
similar
 07:24 回 艹 ·
extenaea to otner ciies oi hupel
province.Cases of COVID-19 in
countries outside China were reported
in those with no history of travel to
China suggesting that local human-to-
human transmission was occurring in
these countries [9].Airports in
different countries including India put
in screening mechanisms to detect
symptomatic people returning from
China and placed them in isolation
and testing them for COVID-19.Soon it
was
apparent that the infection could be
transmitted from asymptomatic people
and also before onset of symptoms.
Therefore,countries including India
who evacuated their citizens from
Wuhan through special flights or had
travellers returning from
China,placed all people symptomatic
or otherwise in
isolation for 14 d and tested them for
the virus.
Cases continued to increase
exponentially and modelling studies
been controlled by adopting appropriate and strict
prevention and control measures,and patients for
clinical trials will not be available.The newly
developed drugs cannot be marketed due to the lack
of end users.

Vaccines
The S protein plays a significant role in
the induction of protective immunity against SARS-
CoV by mediating T-cell responses and
neutralizing antibody production(168).In the past
few decades, we have seen several attempts to
develop a vaccine
against human coronaviruses by using S protein as
the target(168, 169).However,the
developed
vaccines have minimal application,even among
closely related strains of the virus,due to a lack of
cross-protection.That is mainly because of the
extensive diversity existing among the different
antigenic variants of the virus (104). The
contributions of the structural proteins,like spike
(S), matrix (M),small envelope (E), and
nucleocapsid(N)proteins,of SARS-CoV to induce
protective immunity has been evaluated by
expressing them in a recombinant parainfluenza
virus type 3 vector(BHPIV3).Of note,the result
was conclusive that the expression of M,E,or N
proteins without the presence of S protein would not
and chest discomfort,and in severe cases dyspnea and
bilateral lung infiltration⁶7.Among the first 27
docu- mented hospitalized patients,most cases were
epidemi- ologically linked to Huanan Seafood
Wholesale Market. a wet market located in downtown
Wuhan,which sells not only seafood but also live
animals,including poultry and wildlife⁴8.According to
a retrospective study,the onset of the first known case
dates back to 8 December
2019(REF9.On 31 December,Wuhan Municipal Health
Commission notified the public of a pneumonia
out- break of unidentified cause and informed the
World Health Organization (WHO)°(FIG.1).
By metagenomic RNA sequencing and virus isola-
tion from bronchoalveolar lavage fluid samples from
patients with severe pneumonia,independent teams
of Chinese scientists identified that the causative agent
ol this emerging disease is a betacoronavirus that had
never been seen before⁶,10,1.On 9 January 2020,the
result ol this etiological identification was publicly
announced (FIG.1).The first genome sequence of the
novel coro- navirus was published on the
Virological website on 10 January,and more nearly
complete genome sequences determined by different
research institutes were then released via the
GISAID database on 12 January?. Later,more
patients with no history of exposure tc Huanan
Seafood Wholesale Market were identified. Several
familial clusters of infection were reported. and
nosocomial infection also occurred in health-care
facilities.All these cases provided clear evidence foi
human-to-human transmission of the new virus4,12-14
As the outbreak coincided with the approach of the
lunar New Year,travel between cities before the festival
facilitated virus transmission in China.This novel coro-
navirus pneumonia soon spread to other cities in
Hubei province and to other parts of China.Within 1
month.
of plasma cytokines,which suggests an
immunopatho- logical process caused by a cytokine
storm6086.87.In this cohort of patient,around
2.3%people died within a median time of 16 days
from disease onset⁹,86.Men older than 68 years had a
higher risk of respiratory fail- ure,acute cardiac injury
and heart failure that led to death,regardless ofa
history of cardiovascular disease*6 (FIG.4).Most
patients recovered enough to be released from hospital
in 2 weeks⁹80 (FIG.4).
Early transmission of SARS-CoV-2 in Wuhan in
December 2019 was initially linked to the Huanan
Seafood Wholesale Market,and it was suggested
as the source of the
outbreak⁹22,50.However,community transmission
might have happened before that⁸.Later, ongoing
human-to-human transmission propagated the
outbreak°.It is generally accepted that SARS-CoV-2 is
more transmissible than SARS-CoV and MERS-CoV;
however,determination of an accurate reproduction
number(R0)for COVID-19 is not possible yet,as many
asymptomatic infections cannot be accurately accounted
for at this stage⁸9.An estimated R0 of 2.5(ranging
from 1.8 to 3.6)has been proposed for SARS-CoV-2
recently, compared with 2.0-3.0 for SARS-
CoV⁰.Notably,most of the SARS-CoV-2 human-to-
human transmission early in China occurred in
family clusters,and in other countries large outbreaks
also happened in other set- tings,such as migrant
worker communities,slaughter- houses and meat
packing plants,indicating the necessity of isolating
infected people⁹,1291-93.Nosocomial transmis- sion was
not the main source of transmission in China because
of the implementation of infection control
measures in clinical settings.By contrast,a high risk
of nosocomial transmission was reported in some
other
countries have a fragile health system that can be
crippled in the event of an outbreak.Effective
management of COVID-19 would be difficult for
low-income countries due to their inability to
respond rapidly due to the lack of an efficient health
care system(65).Controlling the imported cases is
critical in preventing the spread of COVID-19 to
other countries that have not reported the disease
until now.The possibility of an imported case of
COVID-19 leading to sustained human-to-human
transmission was estimated to be 0.41.This can be
reduced to a value of 0.012 by decreasing the mean
time from the onset of symptoms to hospitalization
and can only be made possible by using intense
disease surveillance systems (235).The
silent importations of infected individuals
(before the
manifestation of clinical signs)also contributed
significantly to the spread of disease across the
major cities of the world.Even though the travel ban
was implemented in Wuhan(89),infected
persons who traveled out of the city just
before the imposition of the ban might have
remained undetected and resulted in local
outbreaks(236). Emerging novel diseases like
COVID-19 are difficult to contain within the
country of origin,since globalization has led to
a world without borders.
Hence,international collaboration plays a vital role
Inhibition of virus replication. Replication inhibitors
include remdesivir(GS-5734),favilavir (T-705),riba-
virin,lopinavir and ritonavir.Except for lopinavir and
ritonavir,whichinhibit 3CLpro,the other three all target
RdRp¹28135(FIG.5).Remdesivir has shown activity against
SARS-CoV-2 in vitro and in vivo'28,136.A clinical
study revealed a lower need for oxygen support in
patients with COVID-19 (REF.137).Preliminary
results of the Adaptive COVID-19 Treatment
Trial(ACTT)clinical trial by the National Institute of
Allergy and Infectious Diseases(NIAID)reported that
remdesivir can shorten the recovery time in
hospitalized adults with COVID-19 by a couple days
compared with placebo,but the differ- ence in
mortality was not statistically significant³8.The FDA
has issued an emergency use authorization for rem-
desivir for the treatment of hospitalized patients with
severe COVID-19.It is also the first approved option by
the European Union for treatment of adults and adoles-
cents with pneumonia requiring supplemental oxygen.
Several international phase III clinical trials are contin-
uing to evaluate the safety and efficacy of remdesivir
for
the treatment of COVID-19.
Favilavir (T-705),which is an antiviral drug devel-
oped in Japan to treat influenza,has been approved in
China,Russia and India for the treatment of COVID-
19. A clinical study in China showed that favilavir
signif- icantly reduced the signs of improved
disease signs on chest imaging and shortened the
time to viral clearancel39.A preliminary report in
Japan showed rates of clinical improvement of
73.8%and 87.8%from the start offavilavir therapy
inpatients with mild COVID-19 at 7 and 14
days,respectively,and 40.1%and 60.3% in patients
with severe COVID-19 at 7 and 14 days,
samples obtained from lower respiratory
tracts. Hence,based on the viral load,we can
quickly
evaluate the progression of infection(291).In
addition to all of the above findings,sequencing and
phylogenetics are critical in the correct identification
and confirmation of the causative viral agent and
useful to establish relationships with previous
isolates and sequences,as well as to know,especially
during an epidemic,the nucleotide and amino acid
mutations and the molecular divergence.The rapid
development and implementation of diagnostic tests
against emerging novel diseases like COVID-19
pose significant challenges due to the lack of
resources and logistical limitations associated with
an outbreak(155).
SARS-CoV-2 infection can also be confirmed by
isolation and culturing.The human airway epithelial
cell culture was found to be useful in isolating
SARS-CoV-2(3). The efficient control of
an outbreak depends on the rapid diagnosis of
the disease.Recently,in response to the
COVID-19 outbreak, 1-step quantitative real-
time reverse transcription-PCR assays were
developed that detect the ORF1b and N regions
of the SARS-CoV-2 genome( 156).That assay
was found to achieve the rapid detection of
SARS-CoV-2.Nucleic acid-based
assays offer high accuracy in the diagnosis of SARS-
 We assessed the nucleotide percent
similarity using the MegAlign software
program,where the
similarity between the novel SARS-CoV-2 isolates
was in the range of 99.4%to 100%.Among the other
Serbecovirus CoV sequences,the novel SARS-CoV-
2 sequences revealed the highest similarity to bat-
SL-CoV,with nucleotide percent identity ranges
between 88.12 and 89.65%.Meanwhile,earlier
reported SARS-CoVs showed 70.6 to
74.9% similarity to SARS-CoV-2 at the
nucleotide level. Further,the nucleotide percent
similarity was 55.4%, 45.5%to
47.9%,46.2%to 46.6%,and 45.0%to
46.3% to the other four
subgenera,namely,
Hibecovirus, Nobecovirus, Merbecovirus, and
Embecovirus,respectively.The percent similarity
index of current outbreak isolates indicates a close
relationship between SARS-CoV-2 isolates and
bat- SL-CoV,indicating a common
origin.However, particular pieces of evidence
based on further complete genomic analysis of
current isolates are necessary to draw any
conclusions,although it was ascertained that the
current novel SARS-CoV-2 isolates belong to the
subgenus Sarbecovirus in the diverse range of
betacoronaviruses.Their possible ancestor was
hypothesized to be from bat CoV
strains,wherein bats might have played a crucial role
in harboring this class of viruses.
 Currently,our knowledge on the animal origin of
SARS-CoV-2 remains incomplete to a large part.The
reservoir hosts of the virus have not been clearly
proven. It is unknown whether SARS-CoV-2 was
transmitted to humans through an intermediate host
and which animals may act as its intermediate
host.Detection of RaTG13,RmYN02 and pangolin
coronaviruses implies that diverse coronaviruses
similar to SARS-CoV-2 are circulating in wildlife.In
addition,as previous stud- ies showed
recombination as the potential origin of some
sarbecoviruses such as SARS-CoV,it cannot be
excluded that viral RNA recombination among different
related coronaviruses was involved in the evolution of
SARS-CoV-2.Extensive surveillance of SARS-CoV-2-
related viruses in China,Southeast Asia and other
regions targeting bats,wild and captured pangolins and
other wildlife species will help us to better understand
the zoonotic origin of SARS-CoV-2.
Besides wildlife,researchers investigated the sus-
ceptibility of domesticated and laboratory animals
to SARS-CoV-2 infection.The study demonstrated
exper- imentally that SARS-CoV-2 replicates
efficiently in cats and in the upper respiratory tract
of ferrets,whereas dogs,pigs,chickens and ducks
were not susceptible to SARS-CoV-2 (REF₄3).The
susceptibility of minks was documented by a report
from the Netherlands on an outbreak of SARS-
CoV-2 infection in farmed minks. Although the
symptoms in most infected minks were
mild,some developed severe respiratory distress
and died of interstitial pneumonia**.Both virologi-
cal and serological testing found evidence for natural
SARS-CoV-2 infection in two dogs from households with
human cases of COVID-19 in HongKong,but the
dogs
proteins without the presence of S protein would not
confer any noticeable protection,with the absence of
detectable serum SARS-CoV-neutralizing antibodies
(170).Antigenic determinant sites present over S
and N structural proteins of SARS-CoV-2 can
be explored as suitable vaccine candidates (294).In
the Asian population,S,E,M,and N proteins of
SARS- CoV-2 are being targeted for developing
subunit vaccines against COVID-19 (295).
The identification of the immunodominant region
among the subunits and domains of S protein is
critical for developing an effective vaccine against
the coronavirus.The C-terminal domain of the S1
subunit is considered the immunodominant region of
the porcine deltacoronavirus S protein
(171). Similarly,further investigations are
needed to determine the immunodominant
regions of SARS-
CoV-2 for facilitating vaccine development.
However,our previous attempts to develop a
universal vaccine that is effective for both SARS-
CoV and MERS-CoV based on T-cell epitope
similarity pointed out the possibility of cross-
reactivity among coronaviruses(172).That can
be made possible by selected potential vaccine
targets that are common to both viruses.SARS-
CoV-2 has been reported to be closely related to
SARS-CoV (173,174).Hence,knowledge and
understanding of
07:23 M
◎艹 ·

Origin and Spread of COVID-19

[1,2,6]

In December 2019,adults in
Wuhan, capital city of Hubei
province and a
major transportation hub of China
started presenting to local hospitals
with severe pneumonia of unknown
cause.Many of the initial cases had
a
common exposure to the Huanan
wholesale seafood market that also
traded live animals.The
surveillance system(put into place
after the SARS
outbreak)was activated and
respiratory samples of patients were
sent to reference labs for etiologic
investigations.On December 31st 2019,
China notified the outbreak to the
World Health Organization and on
1st January the Huanan sea food
market was closed.On 7th January
the virus
was identified as a coronavirus that
had>95%homology with the bat
paiucuiaily 1 Uals.DUirn vlrodllUI lu vivO SLuUI 互 CS
(using suitable animal models)should be conducted
to evaluate the risk of future epidemics.Presently,
licensed antiviral drugs or vaccines against SARS-
CoV,MERS-CoV,and SARS-CoV-2 are lacking.
However,advances in designing antiviral drugs and
vaccines against several other emerging diseases will
help develop suitable therapeutic agents against
COVID-19 in a short time.Until then,we must rely
exclusively on various control and prevention
measures to prevent this new disease from becoming
a pandemic.
understanding of the lung inflammation associated
with this infection (24).
SARS is a viral respiratory disease caused by a
formerly unrecognized animal CoV that originated
from the wet markets in southern China after
adapting to the human host,thereby enabling
transmission between humans(90). The SARS
outbreak reported in 2002 to 2003 had 8,098
confirmed cases with 774 total deaths(9.6%)
(93). The outbreak severely affected the Asia
Pacific region,especially mainland China (94).Even
though the case fatality rate (CFR)of
SARS-CoV-2 (COVID-19)is lower than that of
SARS-CoV,there

exists a severe concern linked to this outbreak due

to its epidemiological similarity to influenza
viruses (95, 279).This can fail the public health
system, resulting in a pandemic (96).
MERS is another respiratory disease that was
first reported in Saudi Arabia during the year 2012.
The disease was found to have a CFR of around 35%
(97).The analysis of available data sets suggests that
the incubation period of SARS-CoV-2,SARS-CoV,
and MERS-CoV is in almost the same range.The
longest predicted incubation time of SARS-CoV-2 is
14 days.Hence,suspected individuals are isolated
for 14 days to avoid the risk of further spread
(98).
Even though a high similarity has been reported
encircled with an envelope containing viral
nucleocapsid. The nucleocapsids in CoVs are
arranged in helical symmetry,which reflects an
atypical attribute in positive-sense RNA viruses (30).
The electron micrographs of SARS-CoV-2 revealed
a diverging spherical outline with some degree of
pleomorphism,virion diameters varying from 60 to
140 nm,and distinct spikes of 9 to 12 nm,giving the
virus the appearance of a solar corona (3).The CoV
genome is arranged linearly as 5'-leader-UTR-
replicase-structural genes (S-E-M-N)-3' UTR-
poly(A)(32).Accessory genes,such as 3a/b,4a/b,
and the hemagglutinin-esterase gene (HE),are also
seen intermingled with the structural genes(30).
SARS-CoV-2 has also been found to be arranged
similarly and encodes several accessory proteins,
although it lacks the HE,which is characteristic of
some betacoronaviruses (31).The positive-sense
genome of CoVs serves as the mRNA and is
translated to polyprotein la/lab(ppla/lab)(33).A
replication-transcription complex (RTC)is formed in
double-membrane vesicles (DMVs)by nonstructural
proteins(nsps),encoded by the polyprotein gene
(34).Subsequently,the RTC synthesizes a nested set
of subgenomic RNAs(sgRNAs)via discontinuous
transcription( 35).
cat and camels,respectively,act as amplifier hosts
(40,41).
Coronavirus genomes and subgenomes encode
six ORFs(31).The majority of the 5'end is occupied
by ORFla/b,which produces 16 nsps.The two
polyproteins,ppla and pplab,are initially produced
from ORFla/b by a-1 frameshift between ORFla
and ORF1b(32).The virus-encoded proteases cleave
polyproteins into individual nsps(main protease
[Mpro],chymotrypsin-like protease [3CLpro],and
papain-like proteases [PLPs])(42).SARS-CoV-2
also encodes these nsps,and their functions have
been elucidated recently (31).Remarkably, a
difference between SARS-CoV-2 and other CoVs
is the identification of a novel short putative
protein within the ORF3 band,a secreted protein
with an alpha helix and beta-sheet with six strands
encoded by ORF8(31).
Coronaviruses encode four major structural
proteins,namely,spike(S),membrane (M),envelope
(E),and nucleocapsid(N),which are described
in
detail below.

S Glycoprotein
 Coronavirus S protein is a large,multifunctional
class I viral transmembrane protein.The size of this
 The interferon response is one of the major innate
immunity defences against virus invasion.Interferons
induce the expression of diverse interferon-stimulated
genes,which can interfere with every step of virus
replication.Previous studies identified type I interfer-
ons as a promising therapeutic candidate for SARS¹49.
In vitro data showed SARS-CoV-2 is even more sen-
sitive to type I interferons than SARS-CoV,suggesting
the potential effectiveness of type I interferons in the
early treatment of COVID-19 (REF150.In China,vapor
inhalation of interferon-a is included in the COVID-19
treatment guidelinel⁵.Clinical trials are ongoing across
the world to evaluate the efficacy of different therapies
involving interferons,either alone or in combination
with other agents¹52.

Immunoglobulin therapy. Convalescent plasma treat-

ment is another potential adjunctive therapy for
COVID-19.Preliminary findings have suggested
improved clinical status after the treatment153,154.The
FDA has provided guidance for the use of COVID-19
convalescent plasma under an emergency investigational
new drug application.However,this treatment may have
adverse effects by causing antibody-mediated enhance-
ment of infection,transfusion-associated acute lung
injury and allergic transfusion reactions.
Monoclonal antibody therapy is an effective
immuno- therapy for the treatment of some viral
infections in select patients.Recent studies reported
specific mon- oclonal antibodies neutralizing SARS-
CoV-2 infection
helicase activity.
Among the evaluated compounds,4-(cyclopent-
1-en-3-ylamino)-5-[2-(4-
iodophenyl)hydrazinyl]-4H-1,2,4-triazole-3-thiol and
4-(cyclopent-1-en-3-ylamino)-5-[2-(4-
chlorophenyl)hydrazinyl]-4H-1,2,4-triazole-3-thiol
were found to be the most potent.These compounds
were used for in silico studies,and molecular
docking was accomplished into the active binding
site of MERS-CoV helicase nsp13(21).Further
studies are required for evaluating the therapeutic
potential of these newly identified compounds in the
management of COVID-19 infection.

Passive Immunization/Antibody Therapy/MAb

Monoclonal antibodies (MAbs)may be helpful
in the intervention of disease in CoV-
exposed individuals.Patients recovering from SARS
showed robust neutralizing antibodies against
this CoV infection( 164).A set of MAbs aimed at
the MERS- CoV S protein-specific
domains,comprising six specific epitope groups
interacting with receptor- binding,membrane
fusion,and sialic acid-binding sites,make up
crucial entry tasks of S protein(198, 199).Passive
immunization employing weaker and strongly
neutralizing3 antibodies provided considerable
protection in mice against a MERS-
or even die,whereas most young people and children
have only mild diseases (non-pneumonia or mild
pneumonia)or are asymptomatic³81,82.Notably,the risk
of disease was not higher for pregnant
women.However, evidence of transplacental
transmission of SARS-CoV-2 from an infected
mother to a neonate was reported, although it was
an isolated case⁸384.On infection,the most common
symptoms are fever,fatigue and dry
cough¹3,60,80,81.Less common symptoms include
sputum
production,headache,haemoptysis,diarrhoea,anorexia,
sore throat,chest pain,chills and nausea and vomiting in
studies of patients in Chinal3,60,80,81.Self-reported
olfac- tory and taste disorders were also reported by
patients in Italy.Most people showed signs of diseases
after an incubation period of 1-14 days(most
commonly around 5 days),and dyspnoea and
pneumonia developed within a median time of 8 days
from illness onset".
In a report of 72,314 cases in China,81%of the
cases were classified as mild,14%were severe cases that
required ventilation in an intensive care unit (ICU)and
a 5%were critical (that is,the patients had
respiratory failure,septic shock and/or multiple organ
dysfunction or failure)⁸6.On admission,ground-glass
opacity was the most common radiologic finding on
chest computed tomography(CT)l3,60,80,81.Most
patients also developed marked lymphopenia,similar to
what was observed in patients with SARS and
MERS,and non-survivors devel- oped severer
lymphopenia over timel3,60,80,81.Compared with non-
ICU patients,ICU patients had higher levels
 To assess the genetic variation of different
SARS- CoV-2 strains,the 2019 Novel Coronavirus
Resource of China National Center for
Bioinformation aligned 77,801 genome sequences of
SARS-CoV-2 detected glob- ally and identified a total of
15,018 mutations,including 14,824 single-nucleotide
polymorphisms(BIGD)³¹ . In the S protein,four
amino acid alterations,V483A, L455I,F456V and
G476S,are located near the binding interface in the
RBD,but their effects on binding to the host receptor
are unknown.The alteration D614G in the S1 subunit
was found far more frequently than other S variant
sites,and it is the marker of a major subclade of SARS-
CoV-2(clade G).Since March 2020,SARS-CoV-2
variants with G614 in the S protein have replaced the
original D614 variants and become the dominant form
circulating globally.Compared with the D614 variant,
higher viral loads were found in patients infected with
the G614 variant,but clinical data suggested no signif-
icant link between the D614G alteration and disease
severity³?.Pseudotyped viruses carrying the S protein
with G614 generated higher infectious titres than viruses
carrying the S protein with D614,suggesting the altera-
tion may have increased the infectivity of SARS-CoV-
2
(REF³2).However,the results of in vitro experiments
based on pseudovirus models may not exactly reflect
natural infection.This preliminary finding should be
validated by more studies using wild-type SARS-CoV-2
variants to infect different target cells and animal
models.Whether this amino acid change enhanced
virus transmissibil- ity is also to be
determined.Another marker mutation for SARS-CoV-
2 evolution is the single-nucleotide
 A suspected case of COVID-19 infection is said
to be confirmed if the respiratory tract aspirate or
blood samples test positive for SARS-CoV-2 nucleic
acid using RT-PCR or by the identification of SARS-
CoV-2 genetic sequence in respiratory tract aspirate
or blood samples (80).The patient will be
confirmed as cured when two subsequent oral swab
results are negative( 153).Recently,the live virus
was detected in the self-collected saliva of patients
infected with COVID-19.These findings were
confirmative of using saliva as a noninvasive
specimen for the diagnosis of COVID-19
infection in suspected individuals( 152).It has
also been observed that the initial screening of
COVID-19 patients infected with RT-PCR may give
negative results even if they have chest CT findings
that are suggestive of infection. Hence,for the
accurate diagnosis of COVID-19,a combination of
repeated swab tests using RT-PCR and CT
scanning is required to prevent the possibility
of false-negative results during disease screening(
154).RT-PCR is the most widely used test for
diagnosing COVID-19.However,it has some
significant limitations from the clinical perspective,
since it will not give any clarity regarding disease
progression.Droplet digital PCR(ddPCR)can be
used for the quantification of viral load in the
samples obtained from lower respiratory tracts.
adaptive evolution,close monitoring of the viral
mutations that occur during subsequent human-to-
human transmission is warranted.

M Protein
The M protein is the most abundant viral
protein present in the virion particle,giving a
definite shape to the viral envelope (48). It
binds to the nucleocapsid and acts as a
central organizer of coronavirus
assembly(49).Coronavirus M proteins are highly
diverse in amino acid contents but maintain
overall structural similarity within different genera(
50).The M protein has three transmembrane
domains,flanked by a short amino terminus outside
the virion and a long carboxy terminus inside the
virion( 50).Overall,the viral scaffold is
maintained
by M-M interaction.Of note,the M protein
of SARS-CoV-2 does not have an amino
acid
substitution compared to that of SARS-CoV(16).

E Protein
The coronavirus E protein is the most
enigmatic and smallest of the major structural
proteins(51).It plays a multifunctional role in the
pathogenesis, assembly,and release of the
virus(52).It is a small integral membrane
polypeptide that acts as a
viroporin(ion channel)(53).The inactivation or
Animal Models and Cell Cultures
For evaluating the potential of vaccines and
therapeutics against CoVs,including SARS-CoV,
MERS-CoVs,and the presently emerging SARS-
CoV-2,suitable animal models that can mimic the
clinical disease are needed(211, 212 ).Various
animal models were assessed for SARS-and MERS-
CoVs,such as mice,guinea pigs,golden Syrian
hamsters,ferrets,rabbits,nonhuman primates like
rhesus macaques and marmosets,and
cats(185, 213-218).The specificity of the virus
to hACE2 (receptor of SARS-CoV)was found
to be a significant barrier in developing
animal models. Consequently,a SARS-CoV
transgenic mouse model has been developed by
inserting the hACE2 gene into the mouse
genome(219).The inability of MERS-CoV to
replicate in the respiratory tracts of
animals(mice,hamsters,and ferrets)is another
limiting factor.However,with genetic engineering,a
288-330+/+MERS-CoV genetically modified mouse
model was developed and now is in use for the
assessment of novel drugs and vaccines against
MERS-CoV( 220).In the past,small animals
(mice or hamsters)have been targeted for being
closer to a humanized structure,such as mouse
DPP4 altered with human
DPP4(hDPP4),hDPP4-transduced
mice,and hDPP4-Tg mice(transgenic for expressing
assays offer high accuracy in the diagnosis of
SARS- CoV-2,but the current rate of spread limits
its use
due to the lack of diagnostic assay kits.This will
further result in the extensive transmission of

COVID-19,since only a portion of suspected cases

can be diagnosed.In such situations,conventional
serological assays, like enzyme-linked
immunosorbent assay(ELISA),that are specific to
COVID-19 IgM and IgG antibodies can be used as
a high-throughput alternative(149).At
present,there is no diagnostic kit available for
detecting the SARS- CoV-2 antibody(150).The
specific antibody profiles of COVID-19 patients
were analyzed,and it was found that the IgM
level lasted more than 1 month, indicating a
prolonged stage of virus replication in SARS-CoV-
2-infected patients.The IgG levels were found to
increase only in the later stages of the
disease.These findings indicate that the specific
antibody profiles of SARS-CoV-2 and SARS-CoV
were similar(325).These findings can be utilized
for the development of specific diagnostic tests
against COVID-19 and can be used for rapid
screening Even though diagnostic test kits are
already available that can detect the genetic
sequences of SARS-CoV- 2( 95),their availability
is a concern,as the number of COVID-19 cases
is skyrocketing(155, 157).A
major problem associated with this diagnostic kit is
require sedatives,analgesics, and even muscle
relaxation drugs to prevent ventilator-related lung
injury associated with human-machine
incoordination( 122).The result obtained from
a clinical study of four patients infected with
COVID- 19 claimed that combination
therapy using lopinavir/ritonavir, arbidol, and
Shufeng Jiedu capsules (traditional Chinese
medicine)was found to be effective in managing
COVID-19 pneumonia (193).It is difficult to
evaluate the therapeutic potential of a drug or a
combination of drugs for managing a disease based
on such a limited sample size.Before choosing the
ideal therapeutic agent for the management of
COVID-19,randomized clinical control studies
should be performed with a sufficient
study population.

Antiviral Drugs
Several classes of routinely used antiviral drugs,
like oseltamivir(neuraminidase inhibitor),acyclovir,
ganciclovir,and ribavirin,do not have any effect on
COVID-19 and,hence,are not recommended
(187). Oseltamivir,a neuraminidase inhibitor,has
been explored in Chinese hospitals for treating
suspected COVID-19 cases,although proven
efficacy against SARS-CoV-2 is still lacking for
this drug (7).The in
vitro antiviral potential of FAD-approved drugs,viz.,
07:24 回 艹 ·

Cases continued to increase

exponentially and modelling studies
reported an epidemic doubling time of
1.8 d [10].In fact on the 12th of
February,China changed its definition
of confirmed cases to include patients
with negative/pending molecular
tests but with clinical,radiologic and
epidemiologic features of COVID-19
leading to an increase in cases by
15,000 in a single day [6].As of
05/03/202096,000 cases worldwide
(80,000 in China)and 87 other
countries and 1 international
conveyance(696,in the cruise ship
Diamond Princess parked off the
coast of Japan)have been reported
[2].It is important to note that while
the
number of new cases has reduced in
China lately,they have increased
exponentially in other countries
including South Korea,Italy and Iran.
1: DF / 1 ] ]
Of those infected,20%are in critical

1: DF / 1 ] ]
high commercial value,since they are used in
traditional Chinese medicine(TCM).Therefore,the
handling of bats for trading purposes poses a
considerable risk of transmitting zoonotic CoV
epidemics( 139).
Due to the possible role played by farm and wild
animals in SARS-CoV-2 infection,the WHO,in
their novel coronavirus (COVID-19)situation report,
recommended the avoidance of unprotected contact
with both farm and wild animals(25).The
live- animal markets,like the one in
Guangdong,China, provides a setting for animal
coronaviruses to amplify and to be transmitted
to new hosts,like humans( 78).Such markets can
be considered a critical place for the origin
of novel zoonotic diseases and have
enormous public health significance in the
event of an outbreak.Bats are the reservoirs for
several viruses;hence,the role of bats in the present
outbreak cannot be ruled out (140).In a
qualitative study conducted for evaluating the
zoonotic risk factors among rural communities of
southern China, the frequent human-animal
interactions along with the low levels of
environmental biosecurity were identified as
significant risks for the emergence of zoonotic
disease in local communities (141,142).
The comprehensive sequence analysis of the
other emerging viral diseases.Several therapeutic
and preventive strategies, including vaccines,
immunotherapeutics,and antiviral drugs,have been
exploited against the previous CoV outbreaks
(SARS-CoV and MERS-CoV)(8, 104, 164-
167).
These valuable options have already been evaluated
for their potency,efficacy,and safety,along with
several other types of current research that will fuel
our search for ideal therapeutic agents against
COVID-19(7,9,19,21,36).The primary cause of
the unavailability of approved and commercial
vaccines,drugs,and therapeutics to counter the
earlier SARS-CoV and MERS-CoV seems to owe to
the lesser attention of the biomedicine and
pharmaceutical companies,as these two CoVs did
not cause much havoc,global threat,and panic like
those posed by the SARS-CoV-2 pandemic(19).
Moreover, for such outbreak situations, the
requirement for vaccines and therapeutics/drugs
exists only for a limited period,until the outbreak
is
controlled.The proportion of the human population
infected with SARS-CoV and MERS-CoV was
also much lower across the globe,failing to attract
drug and vaccine manufacturers and
producers.Therefore, by the time an effective drug
or vaccine is designed against such disease
outbreaks,the virus would have
been controlled by adopting appropriate and strict
pieces of evidence are available that link NSAID
uses with the occurrence of respiratory and
cardiovascular adverse effects. Hence, as a
cautionary approach,it is better to recommend the
use of NSAIDs as the first-line option for managing
COVID-19 symptoms (302). The use of
corticosteroids in COVID-19 patients is still a matter
of controversy and requires further systematic
clinical studies.The guidelines that were put forward
to manage critically ill adults suggest the use of
systemic corticosteroids in mechanically ventilated
adults with ARDS(303).The generalized use
of corticosteroids is not indicated in COVID-
19,since
there are some concerns associated with the use of
corticosteroids in viral pneumonia.Stem cell therapy
using mesenchymal stem cells(MSCs)is another
hopeful strategy that can be used in clinical cases
of COVID-19 owing to its
potential immunomodulatory capacity. It may
have a
beneficial role in attenuating the cytokine storm that
is observed in severe cases of SARS-CoV-2

infection,thereby reducing mortality.Among the

different types of MSCs,expanded umbilical cord
MSCs can be considered a potential therapeutic
agent that requires further validation for managing
critically ill COVID-19 patients (304).
Repurposed broad-spectrum antiviral drugs
significance of frequent and good hand hygiene
and sanitation practices needs to be given due
emphasis (249-252).Future explorative research
needs to be conducted with regard to the fecal-oral
transmission of SARS-CoV-2, along with
focusing on environmental investigations to find
out if this virus could stay viable in situations
and atmospheres
facilitating such potent routes of transmission.The
correlation of fecal concentrations of viral RNA with
disease severity needs to be determined,along with
assessing the gastrointestinal symptoms and the
possibility of fecal SARS-CoV-2 RNA detection
during the COVID-19 incubation period or
convalescence phases of the disease (249-252).
The lower respiratory tract sampling techniques,
like bronchoalveolar lavage fluid aspirate,are
considered the ideal clinical materials,rather than
the throat swab,due to their higher positive rate on
the nucleic acid test (148).The diagnosis of
COVID- 19 can be made by using upper-
respiratory-tract specimens collected using
nasopharyngeal and oropharyngeal
swabs.However,these techniques are associated
with unnecessary risks to health care workers
due to close contact with patients(152).
Similarly,a single patient with a high viral load was
reported to contaminate an entire endoscopy room by
shedding the virus,which may remain viable for at
vaccine,and li-Key peptide COVID-19 vaccine are
under preclinical trials(297).Similarly,the
WHO, on its official website,has mentioned a
detailed list of COVID-19 vaccine agents that
are under consideration.Different phases of trials
are ongoing for live attenuated virus
vaccines,formaldehyde alum inactivated
vaccine,adenovirus type 5 vector vaccine,LNP-
encapsulated mRNA vaccine,DNA plasmid
vaccine,and S protein,S-trimer,and Ii-Key peptide
as a subunit protein vaccine,among others
(298).The process of vaccine development
usually takes approximately ten years,in the
case of inactivated or live attenuated
vaccines,since it involves the generation of long-
term efficacy data. However,this was brought
down to 5 years during the Ebola emergency for
viral vector vaccines.In the urgency associated with
the COVID-19 outbreaks, we expect a vaccine by
the end of this year (343). The development of
an effective vaccine against COVID-19 with
high speed and precision is the combined result
of advancements in computational biology,gene
synthesis,protein engineering,and the invention of
advanced manufacturing platforms
(342).
The recurring nature of the coronavirus
outbreaks calls for the development of a pan-
coronavirus
vaccine that can produce cross-reactive antibodies.
in vitro and in vivol55-158.Compared with convalescent
plasma,which has limited availability and cannot be
amplified,monoclonal antibodies can be developed in
larger quantities to meet clinical requirements.Hence,
they provide the possibility for the treatment and pre-
vention of COVID-19.The neutralizing epitopes of
these monoclonal antibodies also offer important infor-
mation for vaccine design.However,the high cost and
limited capacity of manufacturing,as well as the prob-
lem of bioavailability,may restrict the wide application
of monoclonal antibody therapy.

Vaccines
Vaccination is the most effective method for a long-term
strategy for prevention and control of COVID-19
in the future.Many different vaccine platforms
against SARS-CoV-2 are in development,the strategies
of which include recombinant vectors,DNA,mRNA in
lipid nano- particles,inactivated viruses,live attenuated
viruses and protein subunits59-161.As of 2 October
2020,~174 vac- cine candidates for COVID-19 had
been reported and 51 were in human clinical
trials(COVID-19 vaccine and therapeutics
tracker).Many of these vac- cine candidates are in
phase II testing,and some have
already advanced to phase III trials.A randomized
double-blinded phase II trial of an adenovirus type 三
vectored vaccine expressing the SARS-CoV-2 Sprotein,
developed by CanSino Biologicals and the Academy of
Military Medical Sciences of China,was conducted in
603 adult volunteers in Wuhan.The vaccine has proved
to be safe and induced considerable humoral and cel-
lular immune response in most recipients after a single
immunization¹62.Another vectored vaccine,ChAdOxl,
07:28 回 艹 ·
pandemic flu where patients were
asked to resume work/school once
afebrile for 24 h or by day 7 of illness.
Negative molecular tests were not a
prerequisite for discharge.

At the community level,people should

be asked to avoid crowded areas and
postpone non-essential travel to places
with ongoing transmission.They
should be asked to practice cough
hygiene by coughing in sleeve/tissue
rather than hands and practice
hand
hygiene frequently every 15-20 min.
Patients with respiratory symptoms
should be asked to use surgical masks.
The use of mask by healthy people in
public places has not shown to protect
against respiratory viral infections
and
is currently not recommended by
WHO.However,in China,the public
has been asked to wear masks in public
and especially in crowded places and
large scale gatherings are prohibited
(entertainment parks etc).China is also
07:25 回 艹 ·
including IL2,IL7,IL10,GCSF,IP10,
MCP1,MIP1A,and TNFa [15].The
median time from onset of symptoms
to dyspnea was 5 d,hospitalization 7
d
and acute respiratory distress
syndrome (ARDS)8 d.The need for
intensive care admission was in 25-
30%of affected patients in published
series.Complications witnessed
included acute lung injury,ARDS,
shock and acute kidney injury.
Recovery started in the 2nd or 3rd wk.
The median duration of hospital stay
in those who recovered was 10
d.Adverse outcomes and death are
more common
in the elderly and those with
underlying co-morbidities (50-75%of
fatal cases).Fatality rate in
hospitalized
adult patients ranged from 4 to 11%.
The overall case fatality rate is
estimated to range between 2 and 3%
[2].
Interestingly,disease in patients
outside Hubei province has been
prevent further spread of disease at mass
gatherings, functions remain canceled in the
affected cities,and persons are asked to work from
home(232).Hence,
it is a relief that the current outbreak of COVID-19
infection can be brought under control with the
adoption of strategic preventive and control
measures along with the early isolation of
subsequent cases in the coming days.Studies also
report that since air traffic between China and
African countries increased many times over in the
decade after the SARS outbreak,African countries
need to be vigilant to prevent the spread of novel
coronavirus in Africa(225).Due to fear of
virus spread,Wuhan City was completely shut
down (233).The immediate control of the
ongoing COVID-19 outbreaks appears a
mammoth task, especially for developing
countries,due to their inability to allocate
quarantine stations that could screen infected
individuals'movements (234).Such
underdeveloped countries should divert their
resources and energy to enforcing the primary level
of preventive measures,like controlling the entry of
individuals from China or countries where the
disease has flared up,isolating the infected
individuals,and quarantining individuals with
suspected infection.Most of the sub-Saharan African
countries have a fragile health system that can be
having proven uses against other viral pathogens can
be employed for SARS-CoV-2-infected patients.
These possess benefits of easy accessibility and
recognized pharmacokinetic and pharmacodynamic
activities,stability,doses,and side effects(9).
Repurposed drugs have been studied for treating
CoV infections, like lopinavir/ritonavir, and
interferon-1β revealed in vitro anti-MERS-CoV
action.The in vivo experiment carried out in the
nonhuman primate model of common marmosets
treated with lopinavir/ritonavir and interferon beta
showed superior protective results in treated animals
than in the untreated ones(190).A combination
of these drugs is being evaluated to treat MERS
in humans (MIRACLE trial)(191).These two
protease inhibitors(lopinavir and ritonavir),in
combination with ribavirin,gave encouraging clinical
outcomes in SARS patients,suggesting their
therapeutic values (165).However,in the current
scenario,due to the lack of specific therapeutic
agents against SARS- CoV-2,hospitalized patients
confirmed for the disease are given supportive
care,like oxygen and fluid therapy,along with
antibiotic therapy for managing secondary
bacterial infections (192).
Patients with novel coronavirus or COVID-
19
pneumonia who are mechanically ventilated often
require sedatives.analgesics.and even muscl e
between 4 and-70°℃.Urine samples must also
be collected using a sterile container and
stored in the laboratory at a temperature that
ranges between 4 and-70°℃ .32

7 PREGNANCY
Currently,there is a paucity of knowledge and
data related to the consequences of COVID-
19 during pregnancy.40-42 However,pregnant
women seem to have a high risk of
developing severe infection and complications
during the
recent 2019-nCoV outbreak.41-43 This
speculation was based on previous available
scientific reports on coronaviruses during
pregnancy (SARS-CoV and MERS-CoV)as well
as the limited number of COVID-19 cases.41-43
Analysing the clinical features and outcomes
of 10 newborns (including two sets of twins)in
China,whose mothers are confirmed cases of
COVID-19,revealed that perinatal infection with
2019-nCoV may lead to adverse outcomes for
the neonates,for example,premature labour,
respiratory distress,thrombocytopenia with
abnormal liver function and even death.44 It
is still unclear whether or not the COVID-19
infection can be transmitted during
pregnancy to the foetus through the
transplacental
route.42 A recent case series report,which
assessed intrauterine vertical transmission of
13 CONVALESCENT PLASMA
THERAPY
Guo Yanhong,an official with the National
Health Commission (NHC),stated that
convalescent plasma therapy is a significant
method for treating severe COVID-19 patients.
Among the COVID-19 patients currently
receiving convalescent plasma therapy in the
virus-hit Wuhan,one has been discharged
from hospital,as reported by Chinese science
authorities on Monday,17th February 2020
in Beijing.The first dose of convalescent
plasma
from a COVID-19 patient was collected on 1st
and 9th February 2020 from a severely ill
patient who was given treatment at a hospital
in Jiangxia District in Wuhan.The presence of
the virus in patients is minimised by the
antibodies in the convalescent
plasma.Guiqiang stated
that donating plasma may cause minimal
harm to the donor and that there is nothing to
be
worried about.Plasma donors must be
cured patients and discharged from
hospital.Only
plasma is used,whereas red blood cells (RBC),
white blood cells (WBC)and blood platelets are
transfused back into the donor's body.Wang
alleged that donor's plasma will totally
improve to its initial state after one or 2 weeks
from the day of plasma donation of around 200
to 300 millilitres. 61
rates, disease outbreaks, community spread,
clustered transmission events,hot spots,and
superspreader potential of SARS-CoV-2/COVID
warrant full exploitation of real-time disease
mapping by employing geographical information
systems(GIS),such as the GIS software Kosmo 3.1,
web-based real-time tools and dashboards,apps,and
advances in information technology (356-
359). Researchers have also developed a few
prediction tools/models,such as the prediction
model risk of bias assessment
tool(PROBAST) and critical appraisal and data
extraction for systematic reviews of prediction
modeling studies(CHARMS),which could aid in
assessing the possibility of getting infection and
estimating the prognosis in patients; however,such
models may suffer from bias issues and,
hence,cannot be considered completely
trustworthy,which necessitates the development of
new and reliable predictors (360).

VACCINES,THERAPEUTICS,AND
DRUGS
Recently emerged viruses,such as Zika,Ebola,
and Nipah viruses,and their grave threats to
humans have begun a race in exploring the
designing and developing of advanced
vaccines,prophylactics,
therapeutics,and drug regimens to counter emerging
asympwiauu ui sympuiiauu paucins
naving
minimum signs and symptoms(82).Another
study, conducted in South Korea,related to SARS-
CoV-2 viral load,opined that SARS-CoV-2
kinetics were significantly different from those of
earlier reported CoV infections,including SARS-
CoV (253).SARS- CoV-2 transmission can
occur early in the viral infection
phase;thus,diagnosing cases and isolation attempts
for this virus warrant different strategies than
those needed to counter SARS-CoV.Studies are
required to establish any correlation between SARS-
CoV-2 viral load and cultivable virus.Recognizing
patients with fewer or no symptoms,along with
having modest detectable viral RNA in the
oropharynx for 5 days,indicates the requirement of
data for assessing SARS-CoV-2 transmission
dynamics and updating the screening procedures in
the clinics (82).
07:27 M ◎艹 ·

ncbi.nlm.nih.gov/pmc/artii ①
[median 17 d].In the case series of
children discussed earlier,all children
recovered with basic treatment and
did
not need intensive care [17].

There is anecdotal experience with use

of remdeswir,a broad spectrum anti
RNA drug developed for Ebola in
management of COVID-19 [27].More
evidence is needed before these drugs
are recommended.Other drugs
proposed for therapy are arbidol (an
antiviral drug available in Russia and
China),intravenous immunoglobulin,
interferons,chloroquine and plasma
of patients recovered from COVID-19
[21,
28,29].Additionally,recommendations
about using traditional Chinese herbs
find place in the Chinese guidelines
[21].
Prevention [21,30]
there,there is an increase in the outbreak of
this virus through human-to-human
transmission,with the fact that it has become
widespread around the globe.This confirms
the fact similar to the previous
epidemics,including SARS and MERS,that this
coronavirus exhibited potential human-to-
human transmission,as it was recently
declared a pandemic by WHO.26 Respiratory
droplets are the major carrier for
coronavirus transmission.Such droplets can
either stay in the nose or mouth or enter the
lungs via the inhaled air.Currently,it is known
that COVID-19's transmission from one person
to another also occurs through touching
either an infected surface or even an
object.With the current scant awareness of the
transmission
systems however,airborne safety measures
with a high-risk procedure have been
proposed in many countries.Transmission
levels,or the rates from one person to
another,reported
differ by both location and interaction with
involvement in infection control.It is stated
that even asymptomatic individuals or those
individuals in their incubation period can act
as carrier of SARS-CoV2.27,28 With the data
and
evidence provided by the CDC,the usual
incubation period is probably 3 to 7
days, sometimes being prolonged up to
even 2
weeks,and the typical symptom occurrence
 Based on molecular characterization,SARS-
CoV-2 is considered a new
Betacoronavirus
belonging to the subgenus Sarbecovirus (3).A few
other critical zoonotic viruses(MERS-related
CoV and SARS-related CoV)belong to the same
genus.
However,SARS-CoV-2 was identified as a distinct
virus based on the percent identity with other
Betacoronavirus;conserved open reading frame la/b
(ORFla/b)is below 90%identity(3).An overall
80%nucleotide identity was observed between
SARS-CoV-2 and the original SARS-CoV,along
with 89%identity with ZC45 and ZXC21 SARS-
related CoVs of bats(2,31, 36).In
addition,82% identity has been observed between
SARS-CoV-2 and human SARS-CoV Tor2 and
human SARS-CoV BJ012003(31).A sequence
identity of only 51.8% was observed between
MERS-related CoV and the recently emerged
SARS-CoV-2(37).Phylogenetic analysis of the
structural genes also revealed that SARS-CoV-2
is closer to bat SARS-related CoV.
Therefore,SARS-CoV-2 might have originated from
bats,while other amplifier hosts might have played a
role in disease transmission to humans (31).Of
note, the other two zoonotic CoVs(MERS-related
CoV and SARS-related CoV)also originated from
bats
(38,39).Nevertheless,for SARS and
MERS,civet
and other SARSr-CoVs(FIG.2).Using sequences of
five conserved replicative domains in pplab(3C-like
protease (3CLpro),nidovirus RNA-dependent RNA
polymerase (RdRp)-associated
nucleotidyltransferase (NiRAN), RdRp,zinc-binding
domain (ZBD)and HEL1),the Coronaviridae
Study Group of the International Committee on
Taxonomy of Viruses estimated the pairwise
patristic distances between SARS-CoV-2 and known
coronaviruses,and assigned SARS-CoV-2 to the
existing species SARSr-CoVl7.Although phyloge-
netically related,SARS-CoV-2 is distinct from all other
coronaviruses from bats and pangolins in this species.
The SARS-CoV-2 S protein has a full size of
1,273 amino acids,longer than that of SARS-CoV
(1,255 amino acids)and known bat SARSr-CoVs
(1,245-1,269 amino acids).It is distinct from the S pro-
teins of most members in the subgenus Sarbecovirus,
sharing amino acid sequence similarities of 76.7-
77.0%with SARS-CoVs from civets and
humans,
 The exploration of fully human
antibodies (human single-chain antibodies;
HuscFvs) or humanized nanobodies(single-
domain antibodies; sdAb,VH/VHH) could aid
in blocking virus replication,as these agents can
traverse the virus- infected cell membranes
(transbodies)and can interfere with the biological
characteristics of the replicating virus
proteins.Such examples include transbodies to the
influenza virus,hepatitis C virus, Ebola virus,and
dengue virus(206).Producing similar
transbodies against intracellular proteins of
coronaviruses,such as papain-like proteases (PLpro),
cysteine-like protease (3CLpro),or other nsps,which
are essential for replication and transcription of the
virus,might formulate a practical move forward for a
safer and potent passive immunization approach for
virus-exposed persons and rendering therapy to
infected patients.
In a case study on five grimly sick
patients having symptoms of severe pneumonia
due to COVID-19,convalescent plasma
administration was found to be helpful in
patients recovering successfully.The convalescent
plasma containing a SARS-CoV-2-specific
ELISA(serum)antibody titer higher than 1:1,000
and neutralizing antibody titer more significant
than 40 was collected from the
recovered patients and used for plasma transfusion
with COVID-19 showed typical features on initial CT,
including bilateral multilobar ground-glass opacities
with a peripheral or posterior distribution'18,119.Thus,
it has been suggested that CT scanning combined
with repeated swab tests should be used for
individu- als with high clinical suspicion of COVID-
19 but who test negative in initial nucleic acid
screening⁸.Finally, SARS-CoV-2 serological tests
detecting antibodies to N or S protein could
complement molecular diagnosis, particularly in late
phases after disease onset or for retro- spective
studies¹16,120,121.However,the extent and dura- tion of
immune responses are still unclear,and available
serological tests differ in their sensitivity and specific-
ity,all of which need to be taken into account when
one is deciding on serological tests and
interpreting their results or potentially in the future
test for T cell
responses.

Therapeutics
To date,there are no generally proven effective
thera- pies for COVID-19 or antivirals against SARS-
CoV-2, although some treatments have shown some
benefits in certain subpopulations of patients or for
certain end points (see later).Researchers and
manufacturers are conducting large-scale clinical
trials to evaluate var- ious therapies for COVID-
19.As of 2 October 2020, there were about 405
therapeutic drugs in development for COVID-19,and
nearly 318 in human clinical trials
(COVID-19 vaccine and therapeutics tracker).In the
following sections,we summarize potential therapeutics
against SARS-CoV-2 on the basis of published
clinical data and experience.
aminotransferase,bilirubin,and,especially,D-dimer
(244).Middle-aged and elderly patients with
primary chronic diseases,especially high blood
pressure and diabetes,were found to be more
susceptible to respiratory failure and, therefore,
had poorer prognoses.Providing respiratory
support at early stages improved the disease
prognosis and facilitated recovery (18).The ARDS in
COVID-19 is due to the occurrence of cytokine
storms that results in exaggerated immune
response,immune regulatory network
imbalance,and,finally,multiple-organ failure(
122).In addition to the exaggerated
inflammatory response seen in patients with
COVID-19 pneumonia,the bile duct epithelial cell-
derived hepatocytes upregulate ACE2 expression in
liver tissue by compensatory proliferation that might
result in hepatic tissue injury(123).

CORONAVIRUSES IN ANIMALS AND

ZOONOTIC LINKS—A BRIEF
VIEWPOINT
Coronavirus can cause disease in several
species of domestic and wild animals,as well as
humans (23).The different animal species that are
infected with CoV include
horses,camels,cattle,swine,dogs,
cats,rodents,birds,ferrets, minks,bats,rabbits,
snakes,and various other wild
animals(20,30,79,
another study,the average reproductive number of
COVID-19 was found to be 3.28, which is
significantly higher than the initial WHO estimate of
1.4 to 2.5 (77).It is too early to obtain the exact Ro
value,since there is a possibility of bias due to
insufficient data.The higher Ro value is indicative of
the more significant potential of SARS-CoV-2
transmission in a susceptible population.This is not
the first time where the culinary practices of China
have been blamed for the origin of novel coronavirus
infection in humans.Previously,the animals present
in the live-animal market were identified to be the
intermediate hosts of the SARS outbreak in China
(78).Several wildlife species were found to
harbor potentially evolving coronavirus strains
that can
overcome the species barrier (79).One of the main
principles of Chinese food culture is that live-
slaughtered animals are considered more nutritious
(5).
After 4 months of struggle that lasted from
December 2019 to March 2020,the COVID-19
situation now seems under control in China.The wet
animal markets have reopened,and people have
started buying bats,dogs,cats,birds,scorpions,
badgers,rabbits,pangolins(scaly anteaters),minks,
soup from palm civet,ostriches,hamsters,snapping
turtles,ducks,fish,Siamese crocodiles,and other
developed for rapid and colorimetric detection of this
virus (354).RT-LAMP serves as a
simple,rapid,and sensitive diagnostic method that
does not require sophisticated equipment or
skilled personnel(349). An interactive web-based
dashboard for tracking SARS-CoV-2 in a real-time
mode has been designed (238).A smartphone-
integrated home-based point- of-care
testing(POCT)tool,a paper-based POCT
combined with LAMP,is a useful point-of-care
diagnostic( 353).An Abbott ID Now COVID-
19 molecular POCT-based test,using isothermal
nucleic acid amplification technology,has been
designed as a point-of-care test for very rapid
detection of SARS-CoV-2 in just 5 min(344).A
CRISPR-based SHERLOCK(specific high-
sensitivity enzymatic reporter
unlocking)diagnostic for rapid detection of SARS-
CoV-2 without the requirement of specialized
instrumentation has been reported to be very useful
in the clinical diagnosis of COVID-19(360).A
CRISPR-Cas12-based lateral flow assay also has
been developed for rapid detection of SARS-CoV-2
(346).Artificial intelligence,by means of a
three- dimensional deep-learning model, has
been developed for sensitive and specific
diagnosis of COVID-19 via CT images (332).
 Tracking and mapping of the rising incidence
rates, disease outbreaks, community spread,
 All of these therapeutic approaches have revealed
both in vitro and in vivo anti-CoV potential.
Although in vitro research carried out with these
therapeutics showed efficacy,most need appropriate
support from randomized animal or human trials.
Therefore,they might be of limited applicability and
require trials against SARS-CoV-2 to gain practical
usefulness.The binding of SARS-CoV-2 with ACE2
leads to the exacerbation of pneumonia as a
consequence of the imbalance in the renin-
angiotensin system (RAS).The virus-induced
pulmonary inflammatory responses may be reduced
by the administration of ACE inhibitors(ACEI)and
angiotensin type-1 receptor(AT1R)(207).
Several investigations have suggested the use of
small-molecule inhibitors for the potential control of
SARS-CoV infections.Drugs of the FDA-approved
compound library were screened to identify four
small-molecule inhibitors of MERS-CoV
(chlorpromazine, chloroquine, loperamide, and
lopinavir)that inhibited viral replication.These
compounds also hinder SARS-CoV and human
CoVs( 208).Therapeutic strategies involving the
use of specific antibodies or compounds that
neutralize cytokines and their receptors will help to
restrain the host inflammatory responses.Such
drugs acting
specifically in the respiratory tract will help to
shedding the virus,which may remain viable for at
least 3 days and is considered a great risk for
uninfected patients and health care
workers(289). Recently,it was found that the anal
swabs gave more positive results than oral swabs in
the later stages of infection( 153).Hence,clinicians
have to be cautious while discharging any
COVID-19-infected patient based on negative oral
swab test results due to the possibility of fecal-
oral transmission.Even though the viral loads in
stool samples were found to be less than those
of respiratory samples, strict precautionary
measures have to be followed while handling stool
samples of COVID-19 suspected or infected
patients (151). Children infected with SARS-
CoV-2 experience only a mild form of illness and
recover immediately after treatment.It was
recently found that stool samples of SARS-CoV-2-
infected children that gave negative throat swab
results were positive within ten days of negative
results. This could result in the fecal-oral

transmission of SARS-CoV-2 infections,especially

in children(290).Hence,to prevent the fecal-
oral transmission of SARS-CoV-2,infected
COVID-19 patients should only be considered
negative when they test negative for SARS-CoV-
2 in the stool
sample.
 Swine acute diarrhea syndrome coronavirus
(SADS-CoV)was first identified in suckling piglets
having severe enteritis and belongs to the genus
Alphacoronavirus (106). The outbreak was
associated with considerable scale mortality of
piglets(24,693 deaths)across four farms in China
(134).The virus isolated from the piglets was
almost identical to and had 95%genomic
similarity with horseshoe bat(Rhinolophus
species)coronavirus HKU2,suggesting a bat origin of
the pig virus (106, 134, 135).It is also
imperative to note that the SADS-CoV outbreak
started in Guangdong province, near the location
of the SARS pandemic origin (134).Before this
outbreak,pigs were not known to be infected
with bat-origin coronaviruses.This indicates that
the bat-origin coronavirus jumped to pig by
breaking the species barrier.The next step of this
jump might not end well,since pigs are
considered the mixing vessel for influenza A viruses
due to their ability to be infected by both human and
avian influenza A viruses (136).
Similarly,they may act as the mixing vessel
for coronaviruses,since they are in frequent contact
with both humans and multiple wildlife
species. Additionally,pigs are also found to be
susceptible to infection with human SARS-CoV
and MERS-CoV,
making this scenario a nightmare(109, 137).It
is