WHO Travel Recommendations in Response to 2019-nCoV (Novel Coronavirus) Outbreak

What is 2019-nCoV (Novel Coronavirus)? How Should You Protect Yourself from Coronaviruses? How Could You Prevent 2019-nCoV Outbreak Using Herbal Medicine

The Appearance of 2019-nCoV (Novel Coronavirus)

China’s Hubei Province (Wuhan City) witnessed numerous pneumonia cases on 31st Dec 2019 (World Health Organization, 2020). These cases proved to be highly complicated and troublesome since the clinicians and scientists could not match the virus configuration with any of the previously known virus structures. The pathophysiology, etiology, and mode of transmission of the coronaviruses were not initially known to the medical community. The Chinese health care sector tracked a new virus on 7th January 2020 that matched with several viruses’ families related to MERS, SARS, and the common cold. The scientists named this newly diagnosed coronavirus as 2019-nCoV. The Chinese medical community in coordination with WHO initiated the search to understand the specificities of 2019-nCoV in the context of challenging its transmission across the globe.

The Basics of Coronaviruses

The coronaviruses primarily attack the human respiratory system that leads to the development of pulmonary manifestations based on the disease conditions including SARS-CoV (Severe Acute Respiratory Syndrome) and MERS-CoV (Middle East Respiratory Syndrome). The zoonotic nature of coronaviruses facilitates their transmission from animals to healthy individuals. The clinical evaluations have affirmed the transmission of coronaviruses from dromedary camels and civet cats to healthy individuals. The commonly reported symptoms of coronavirus include breathing problems, shortness of breath, cough, and fever. The coronavirus infections potentially elevate the risk of serious comorbidities including kidney failure, severe acute respiratory syndrome, avian influenza, and pneumonia (World Health Organization, 2020). The infected patients remain highly predisposed to debility and death in a range of scenarios. The general preventive measures to challenge coronavirus transmission frequency include the adoption of appropriate hand washing techniques and other hygiene measures. The utilization of protective facial masks is also recommended to reduce the risk of infection transmission after sneezing and coughing. The appropriate cooking of eggs and meat is also recommended to control the transfer of coronaviruses from animals to healthy people. Most importantly, healthy people must avoid closely contacting with suspected patients or individuals affected by respiratory symptoms of the cold (including sneezing and coughing).

The Wuhan 2019-nCoV (Novel Coronavirus) Outbreak – An Overview

China’s Wuhan city witnessed pneumonia in many individuals and scientists could not identify its immediate cause and predisposing factors (Hui et al., 2020). However, they epidemiologically correlated the transmission of 2019-nCoV with living animals in the Human Seafood Wholesale Market. Eventually, the Chinese medical community configured surveillance interventions after recognizing the serious public health threat posed by 2019-nCoV. The novel infection detection strategy for 2019-nCoV is based on the provision of PCR (polymerase chain reaction) tests. WHO has recognized the genome sequence of 2019-nCoV in the context of its high similarity with SARS-CoV. The GenBank sequences of 2019-nCoV are publicly available at NCBI (2020). The individuals exposed to wildlife/farm animals including bats, snakes in the Huanan seafood wholesale market experience an elevated risk of contacting coronaviruses. 2019-nCoV is a recombinant type virus having the configuration of a coronavirus of unknown origin and bat coronavirus. The recombinant character of 2019-nCoV is driven by the interaction between cell surface receptor and viral spike glycoprotein. Furthermore, the RSCU bias of the snake makes it an active source of 2019-nCoV. Research findings reveal spike glycoprotein’s homologous recombination pattern as the preliminary cause of coronavirus cross-infection from animals to the human populations (Ji, Wang, Zhao, Zai, & Li, 2020).

The latest WHO report describes 2-14 days incubation period of 2019-nCoV (WHO, 2020). However, the scientific community yet appears clueless of the duration (after infection) of 2019-nCoV transmission to healthy individuals. 2798 cases of 2019-nCoV have been confirmed so far on a global scale. China has witnessed 2741 2019-nCoV infected patients and identified 5794 individuals suspecting their coronavirus infection status. 2019-nCoV reportedly appears to be a severe disease condition leading to the development of critical and debilitating symptoms in 461 Chinese individuals until date. China has so far reported 80 deaths from 2019-nCoV infection. However, 37 patients have been diagnosed with 2019-nCoV outside of China in 11 nations. The traveling of people from these countries to China has become the sole reason for their contact with the epidemiological link of coronaviruses. The countries including Japan, the Republic of Korea, Vietnam, Singapore, Australia, Malaysia, Thailand, Nepal, USA, Canada, and France have officially reported 2019-nCoV infection cases within their territories.

Symptoms of 2019-nCoV/ Novel Coronavirus Infection

2019-nCoV transmission reportedly leads to the development of respiratory manifestations including the following symptoms.

1.    Dyspnea/breathing difficulty

2.    Flu-like symptoms including headache, sore throat, and coughing

3.    Fever

However, the physicians require carefully watching other pneumonia-related symptoms and signs in patients suspected with novel coronavirus infection (American Lung Association, 2020). These symptoms/signs include the following manifestations.

1.    Confusion

2.    Vomiting

3.    Nausea

4.    Fatigue

5.    Debility

6.    Weakness or reduced energy

7.    Chest pain

8.    Shallow or rapid breathing

9.    Sweating

10.  Shaking chills

11.  Expectoration of blood and/or yellow mucus

12.  Greenish colored cough

These symptoms could lead to the occurrence of serious debility and/or death if left untreated in clinical settings.

Laboratory Testing of Novel Coronavirus (2019-nCoV) Infection

The diagnostic interventions for 2019-nCoV detection include the following measures (World Health Organization, 2020).

1.    Analysis of Respiratory Material: The respiratory assessment reciprocates with the laboratory analysis of endotracheal aspirate or sputum. The specimen analysis from the upper respiratory tract is considered as a weak measure to evaluate the establishment and progression of 2019-nCoV. The development of progressive disease; however, reciprocates with a positive specimen from the lower respiratory tract.

2.    Serological Testing: Blood serum analysis also helps in affirming the presence of 2019-nCoV in the suspected human host. However, a serum negative finding does not necessarily rule out the occurrence of novel coronavirus infection. The positive finding elevates the risk of co-infection along with the progression of the novel coronavirus. Clinicians recommend repeated testing and sampling for confirming 2019-nCoV infection in the suspected cases.

The following specimens are usually collected to investigate respiratory infection after their suspected exposure to novel coronavirus.

1.    Urine sample

2.    Whole blood sample (for antigen evaluation)

3.    Convalescent and acute serum samples

4.    Lung tissue sample through autopsy or biopsy

5.    Sputum from the lower respiratory tract

6.    Nasal wash/nasopharyngeal aspirate

7.    Endotracheal aspirate

8.    Bronchoalveolar lavage

9.    Oropharyngeal and nasopharyngeal swabs for viral load assessment

PCR assay is a recommended measure to affirm novel coronavirus cases after acquiring positive findings from the above-mentioned tests. The case definition of 2019-nCoV does not rely on the reported occurrence of comorbid respiratory infection from a conventional respiratory pathogen. The endemic nature of coronaviruses warrants the development of a pan-coronavirus assay for the systematic amplification of virus sequences. The final confirmation and characterization of coronaviruses require the assessment of non-conserved regions through amplicon sequencing. Some of the other serious variants of coronaviruses recognized through these diagnostic interventions include beta-coronaviruses HCoV-OC43, HCoV-HKU1, HCoV-NL63, and HCoV-229E. The biosafety measures warrant the utilization of powered air-purifying respirator, eye protectors (face shields/goggles), gloves, full-sleeved gowns, waterproof aprons, and fluid resistant dresses by the laboratory teams to minimize their risk for 2019-nCoV exposure. Furthermore, systematic utilization of decontamination procedures and safe specimen handling interventions is highly needed during sample(s) transport to restrict the transmission of deadly coronaviruses to the healthy population.

Preventive Measures for Novel Coronavirus (2019-nCoV) Infection

High compliance with the following safety tips is of paramount importance for reducing the transmission of coronaviruses infections from animals to humans or from diseased patients to healthy individuals (WHO, 2020).

1.    The avoidance of uncooked/under-cooked animal food is highly needed in the context of improving food safety practices. For example, people must refrain from using raw meat or consuming unpasteurized milk. Most importantly, the cooks and food processing professionals must practice caution while managing animal organs to effectively reduce the frequency of cross-contamination.

2.    People should avoid visiting locations affected by the onset and transmission of coronavirus infections. They must wear gloves and face masks while making direct contact with live animals and/or their products.

3.    Patients affected with cough, shortness of breath, fever, or difficulty in breathing must immediately contact their treatment providers and avoid interacting with healthy individuals in the absence of protective clothing.

4.    The patients affected with cough and fever should avoid living in proximity to 2019-nCoV infected locations, must not contact healthy individuals, and undertake screening measures to rule out their exposure to the deadly virus.

5.    The frequent utilization of water, soap, and alcohol-based hand-rub are highly recommended for washing hands in the context of reducing the risk of infection transmission.

6.    People must wash their hands after sneezing, coughing, and administering care to diseased individuals.

7.    Washing of hands is also recommended before, during, and after food preparation.

8.    People should adopt healthy eating habits and must wash their hands before eating and after utilizing urinals or toilets.

9.    The visible dirt on hands must not be ignored and require cleaning through elevated compliance with hand-washing habits.

10.  The careful handling of animal waste products is highly needed to challenge the frequency of cross-infection.

11.  The utilization of tissue papers during sneezing and coughing is highly recommended for the common masses. People must use closed bins for disposing of their nasal mucus.

12.  People must not spit at public places and utilize toilets and private locations for expectorating their respiratory wastes.

13.  The professionals at meat shops must utilize different knives and chopping boards for processing cooked food items or raw meat. They must frequently wash their hands while contacting cooked and/or raw food materials.

14.  People must avoid contacting or eating dead or sick animals.

15.  The appropriate handling and thorough cooking of meat items are highly recommended to reduce the risk of 2019-nCoV transmission.

16.  People should limit their visits to wet markets and must adopt safe hand hygiene practices while contacting or touching animals or their products.

17.  People must refrain from contacting the mouth, nose, and eyes of animals in the wet markets. They must not touch spoiled or dead animals and stay away from fluids, waste products, and stray animals.

18.  The professionals in the wet market must practice caution and use protective equipment or clothing while handling animal products and/or animals. They should also wash their protective coverings at isolated locations per day and must not carry them to their homes. They should avoid their family members’ exposure to their work shoes and soiled clothing.

19.  The workers at the wet market must regularly disinfect their equipment several times per day.

20.  People must refrain from traveling to coronaviruses outbreak locations. Most importantly, patients infected with fever and cough should not travel to new locations. The experience of difficulty breathing, cough, and fever by any individual requires prompt reporting to the health care facility. The infected patients must share their travel history with the concerned physician. The occurrence of respiratory symptoms and/or fever during travel also requires prompt reporting to the crew for receiving immediate medical attention.

Treatment Recommendations by World Health Organization (WHO) for Novel Coronavirus (2019-nCoV) Infection

1.    The administration of empiric antibiotics is highly recommended for infected patients based on their reported clinical manifestations (World Health Organization, 2020). The patients suspected for 2019-nCoV must receive empiric antibiotics within a duration of 1-hour following the conformation of sepsis. The empiric diagnosis must include sepsis or healthcare-associated/community-acquired pneumonia. The animal influenza virus transmission and travel history affirmation of the suspected patients warrant the administration of neuraminidase inhibitors in the health care setting. The de-escalation of empiric therapy is highly recommended based on clinical judgment in the context of animal influenza virus exposure.

2.    The patients affected with shock require receiving supplemental oxygen therapy at the rate of 5 liters per minute following the reporting of shock, hypoxemia, and respiratory distress in the context of severe acute respiratory infection (SARI). The ultimate goal of oxygen therapy is based on acquiring an oxygen saturation level of 90% in the suspected patients (World Health Organization, 2020). However, the administration of oxygen therapy to pregnant women is based on the oxygen saturation level target of 92%-95%.

3.    Fluid resuscitation is the preferred therapeutic option for SARI patients (World Health Organization, 2020). However, since fluid therapy for an extended duration adversely impacts oxygen saturation level, the physicians must mechanically ventilate the infected patients following the reporting of respiratory complications.

4.    The physicians must not administer systemic corticosteroids to the patients suspected for 2019-nCoV on a routine basis (World Health Organization, 2020). This is because long-term administration of systemic corticosteroids potentially increases the risk for delayed viral clearance, diabetes, psychosis, and avascular necrosis. The utilization of steroids for respiratory management of 2019-nCoV patients should only reciprocate following the affirmation of comorbid conditions and their clinical complications.

5.    The physicians must actively coordinate with 2019-nCoV patients and their caretakers to acquire information regarding prognosis and comorbidities in the context of developing holistic person-centered therapies and life-saving treatments (World Health Organization, 2020).

6.    The physicians must actively monitor the clinical condition of 2019-nCoV patients in the context of configuring safe supportive therapies based on the reporting of sepsis and progressive respiratory failure (World Health Organization, 2020).

Herbal/Unani Treatment for Novel Coronavirus/2019-nCoV Infection

No standard, scientifically proven, or approved herbal formulation is available to date for treating the cases of 2019-nCoV infection. However, Unani Medicine offers potential remedies for the management of breathing complications, fever, and cough in infected patients. The physicians should administer these formulations along with other recommended therapies for obtaining the desired treatment advantage. Some of the significant Unani drugs along with their dosages and pharmaceutical actions for respiratory and immune system management are mentioned as under.

Qurs Humma

Recommended Dosage: 2-tablets both times a day

Treatment Advantage/Pharmaceutical Action: Reduces fever

Qurs Tabasheer Kafoori

Recommended Dosage: 2-tablets both times a day

Treatment Advantage/Pharmaceutical Action: Reduces fever

Sharbat Neelofar

Recommended Dosage: 25-ml per day

Treatment Advantage/Pharmaceutical Action: Strengthens blood circulation, improves fluid balances and reduces fever

Jawarish Anarain

Recommended Dosage: 5-gram per day

Treatment Advantage/Pharmaceutical Action: Relieves dehydration while strengthening the overall function of liver and stomach

Kalonji/Black Seed Oil

Recommended Dosage: 5ml admixed with warm milk (twice daily)

Treatment Advantage/Pharmaceutical Action: Antiseptic and inflammatory actions of black seed oil assist in reducing fever and infectious manifestations

Lauq Sapistan Khayar Shambari

Recommended Dosage: 10gram admixed with warm water (3-4 times per day)

Treatment Advantage/Pharmaceutical Action: Helps in relieving the symptoms including cough and breathing difficulty

Khamira Marwareed Banuskha Kalan

Recommended Dosage: 2grams per day with warm milk

Treatment Advantage/Pharmaceutical Action: Helps in improving the immune system of the predisposed or infected patients

Note: The concerned patients must consult qualified/certified physicians/treatment providers in the context of deciding the appropriate pharmacotherapy for treating their 2019-nCoV Infection.

Other Supportive Measures for the Management of Novel Coronavirus (2019-nCoV) Infection

The health care professionals, home care providers, patients, and family members or caretakers must effectively comply with the following measures for the systematic management of Novel Coronavirus (2019-nCoV) Infection (World Health Organization, 2020).

1.    The health care professionals and/or caretakers must proactively inform the hospital setting regarding the arrival of the patient infected with respiratory symptoms.

2.    The diseased patient must wear a protective covering over his/her face while traveling to the health care facility.

3.    The patient must avoid using public transport while moving to the health care setting for medical attention. The suspected patient should preferably use a private vehicle or ambulance (with opened windows) while traveling to the medical facility.

4.    The diseased person must practice hand hygiene measures and maintain a distance of at least one meter from other healthy people during travel. Similarly, the caregivers and family members of the patient must also comply with the appropriate hand hygiene measures.

5.    The surfaces of the vehicle used during transportation of the infected patient require disinfection through a standard bleach solution.

6.    The infected patient should receive the appropriate ventilation during his/her stay in the hospital setting.

7.    The caretakers must not frequently visit the patient and only one healthy person should perform the duty of accomplishing the personalized health care requirements.

8.    The utilization of tightly fitted (disposable) medical masks by the family member or caretaker and health care professionals is highly warranted to reduce the risk of cross-contamination.

9.    The attending persons must not reuse the facial mask in any condition. They should also comply with hand hygiene measures while handling their masks during patient management.

10.  The visitors must perform hand hygiene intervention before and after visiting the hospital setting.

11.  The personal protective equipment, masks, tissues, and gloves require placement in a separately lined container for their disposal or decontamination (as applicable).

12.  The caretakers must not share bed linen, clothes, towels, drinks, dishes, eating utensils, cigarettes, toothbrushes, and eatables with infected patients. The cleaning of utensils should be performed through water and detergent for their re-use. The selection of a strong detergent is highly recommended for cleaning bed linens, clothes, and towels of the infected patients.

References

American Lung Association. (2020). Pneumonia Symptoms and Diagnosis. Retrieved from https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/pneumonia/symptoms-and-diagnosis.html

Hui, D. S., Azhar, E. I., Madani, T. A., Ntoumi, F., Kock, R., Dar, O., . . . Petersena, E. (2020). The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health — The latest 2019 novel coronavirus outbreak in Wuhan, China. International Journal of Infectious Diseases, 91, 264-266. Retrieved from https://www.ijidonline.com/article/S1201-9712(20)30011-4/fulltext

Ji, W., Wang, W., Zhao, X., Zai, J., & Li, X. (2020). Homologous recombination within the spike glycoprotein of the newly identified coronavirus may boost cross-species transmission from snake to human. Journal of Medical Virology. doi:10.1002/jmv.25682

NCBI. (2020). 2019-nCoV Sequences (Wuhan coronavirus). Retrieved from GenBank: https://www.ncbi.nlm.nih.gov/genbank/2019-ncov-seqs/?utm campaign=wuhan nCoV&utm source=insights&utm medium=referral

WHO. (2020). Novel Coronavirus(2019-nCoV). Geneva: World Health Organization. Retrieved from https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200127-sitrep-7-2019--ncov.pdf

World Health Organization. (2020). Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) nfection is suspected: Interm guidance . Geneva : WHO.

World Health Organization. (2020). Home care for patients with suspected novel coronavirus (nCoV) infection presenting with mild symptoms and management of contacts: Interim guidance. Geneva : WHO .

World Health Organization. (2020). Laboratory testing for 2019 novel coronavirus (2019-nCoV) in suspected human cases: Interim guidance. Geneva: WHO. Retrieved from https://www.who.int/health-topics/coronavirus/laboratory-diagnostics-for-novel-coronavirus

World Health Organization. (2020). Novel Coronavirus. Retrieved from https://www.who.int/emergencies/diseases/novel-coronavirus-2019