Coronavirus in 2020: What We Know

Coronavirus graphic lo resGraphic representation of the structure of a coronavirus by Roger Harris/Science Source. Members of this viral family have been responsible for a variety of human respiratory and gastrointestinal syndromes, including the current epidemic that emerged from Wuhan, China. The current coronavirus outbreak is a fast-moving story with an unknown trajectory.

The dramatic response by the Chinese government and the international community—total quarantine of major cities, closure of a 2,600-mile border between China and Russia, cancellation of thousands of international flights to and from China—is unprecedented in the history of public health.

There’s no question that 2019-nCoV, as the virus has been called—can spread from human to human, and that it can be lethal.

As of this writing on February 18, 2020, there were 73,332 confirmed cases worldwide—all but 804 are in China—and 1,873 deaths, according to the World Health Organization (WHO). A CNN report puts the global caseload over 75,000 and the death toll over 2,000.

These numbers are changing daily, as are the diagnostic criteria for what officially constitutes a “case.” Given the political sensitivity of the epidemic, it is difficult to determine the accuracy and reliability of the counts.

There are 15 confirmed cases in the US, 8 of which are in people who had recently traveled to China. Nearly 200 Americans living in Wuhan—the epicenter of the current outbreak—were evacuated to and quarantined in California.

The Federal government has suspended entry of all foreign nationals who have visited China. Delta, United, and American airlines have suspended all service to and from China. Many other nations have also suspended travel in the hope of containing the spread.

Regional Outbreak, Global Shockwaves

The shutdowns have had profound impact on trade and financial markets worldwide, leaving some sectors of the Chinese economy in a stand-still, and  adding fear of plague to an already volatile political and economic landscape.

Companies with the dietary supplements and natural products industry are feeling the shockwaves. Many ingredients and raw materials for supplements are grown, produced,Coronavirus spreadA) Cumulative number of confirmed cases of 2019 novel coronavirus as of Jan 28, 2020, in Wuhan, in mainland China (including Wuhan), and outside mainland China. (B) Major routes of outbound air and train travel originating from Wuhan during the 2019 Chinese lunar new year season. Darker and thicker edges represent greater numbers of passengers. International outbound air travel (yellow) constituted 13·5% of all outbound air travel, and the top 40 domestic (red) outbound air routes constituted 81·3% (Wu JT et al. Lancet Jan 31, 2020). or processed in China. Industry executives say they expect significant supply chain disruptions.

Late in January, The Lancet published the world’s first detailed case analysis—an in-depth look at 99 PCR-confirmed cases of infection with 2019-nCoV from Wuhan, the outbreak’s epicenter. Eleven of these 99 were fatal. The journal is making all of its current and future content on coronavirus free and open-access.

The editors of The Lancet lauded the Chinese government for its swift response.

“China has quickly isolated and sequenced the virus and shared these data internationally. The lessons from the SARS epidemic—where China was insufficiently prepared to implement infection control practices—have been successfully learned. By most accounts, Chinese authorities are meeting international standards and isolating suspected cases and contacts, developing diagnostic and treatment procedures, and implementing public education campaigns.”

Restraint or Censure?

Tedros Ghebreyesus, Director-General of the World Health Organization, also praised China for its transparency, data sharing, and rapid response.

However, a New York Times article on February 1, contends that the Chinese government refused to acknowledge the outbreak for weeks, squelching open discourse and reprimanding concerned scientists until the situation became untenable and the government had no choice but to act.

One physician, ophthalmologist Li Wenliang, who posted about an emerging coronavirus on December 30, was accused by Wuhan police for “rumor-mongering” and “severely disrupting social order.” Dr. Li has since died of the viral syndrome, now officially known as COVID-19. He likely was exposed to the virus while treating a patient at Wuhan Central Hospital, where he worked. His death triggered worldwide outcry.

The censure of Dr. Li and other outspoken doctors is not surprising, nor is it unprecedented. Epidemics are bad news that no government wants to face. During the 1918 worldwide flu epidemic—coming as it did during World War I—leaders in France, Germany, the UK, and the US, all censored information about the risks in an effort to maintain military morale.

The current coronavirus hit right before the Chinese Lunar New Year—a peak travel and commerce period, and also a season for annual Peoples’ Congresses (government conventions). No doubt, China’s leaders were tempted to downplay the situation for as long as possible.

Furthermore, repeated public health false alarms pose the risk of the “Cry Wolf” effect, blunting active responses when they are truly needed. Extreme reactions to news of a new pathogen can herald dire economic consequences, as well as civil rights violations against those infected, or suspected of being infected.

Putting things in perspective, the Global Burden of Disease study estimated that air pollution accounts for upward of 4 million deaths per year globally. Yet it does not trigger drastic government containment efforts, suspension of travel, or public panic. One can’t help but wonder why there is political will to lockdown major cities, close international borders, and prohibit travel in response to an infectious disease, but indifference and inaction in response to environmentally-induced illness.

The WHO formally declared COVID-19 a Public Health Emergency of International Concern (PHEIC) on January 30, after two rounds of deliberation, and with wording meant to mollify China:

“The Committee emphasized that the declaration of a PHEIC should be seen in the spirit of support and appreciation for China, its people, and the actions China has taken on the frontlines of this outbreak, with transparency, and, it is to be hoped, with success,” says WHO’s official statement.  

"Let me be clear, this declaration is not a vote of no confidence in China," said WHO’s Dr. Ghebreyesus, during a press conference in Geneva.

Given the social, political, and fiscal implications, the decision to hit the global panic button needs to be made carefully. In comments on the Wuhan case series, Dr. Chen Wang and colleagues stress the need to balance urgency with restraint.

A 2% Fatality Rate

“In emerging viral infection outbreaks the case-fatality ratio is often overestimated in the early stages because case detection is highly biased towards the more severe cases. As further data on the spectrum of mild or asymptomatic infection becomes available…the case-fatality ratio is likely to decrease.”

That said, they acknowledge that the 1918 flu epidemic had a case-fatality ratio of roughly 5%, yet killed millions worldwide. “There is no room for complacency,” writes Dr. Wang.

Using WHO’s figures, the current case-fatality rate is somewhere in the range of 2-3%, but the virus can spread quickly.

Time will tell whether COVID-19 will become the global scourge that officials fear, or whether it will end up as a significant but limited footnote in the annals of public health, like Zika, Ebola, and infections that made sudden news, then receded.

Though more than 95% of all cases are in China, US public health authorities are clearly concerned. Early in February, the Centers for Disease Control and prevention began sending rapid-response test kits to roughly 200 state-level centers around the country. The reverse transcriptase polymerase chain reaction (RT-PCR) test utilizes samples obtained via nasal or oral swabs, and gives diagnostic results within 4 hours. But the test kit rollout has been plagued by faulty reagents.

Big Questions

At this point, there are more questions about COVID-19 than answers: What is the velocity of spread? Will the case-fatality rate increase or decrease over time? Is it seasonal? Are current antiviral drugs effective? Are there especially vulnerable subpopulations? Do simple interventions—paper surgical masks, frequent hand-washing, chemical hand sanitizers—provide meaningful protection?

The case series report by Nanshen Chen and colleagues at the Tuberculosis & Respiratory Department, Wuhan Jinyintan Hospital, sheds some light, as do studies of earlier coronavirus outbreaks like SARS and MERS.

Origin & Transmission: The epicenter for COVID-19 appears to be the Huanan Seafood Wholesale Market in Wuhan, one of the many “wet” markets throughout China where vendors sell fish, seafood, poultry, fish, reptiles, and wild game—some of it live.

The scientific consensus is that the virus is zoonotic, though the specific animal source has yet to be determined.

While it is true that SARS-CoV and MERS-CoV originated in bats (but were transmitted to humans via civets and camels), experts dismiss claims, widely circulated on social media, that bat soup was the vector for animal-to-human transmission of COVID-19. Likewise, they give no credence to the idea that it is the result of lab experiments gone wrong.

Nearly half (49 of 99) of the Jinyintan Hospital cases had histories of exposure to the Huanan wet market, which has notoriously poor sanitation and environmental control. Of these, 47 were salesmen, market managers, or others with long and frequent engagements in the market. Two others were Huanan market shoppers.

Family clusters and detection of infected individuals far from Huanan market, or from Wuhan itself, were the initial indicators of human-to-human transmission.

Mortality: Among the Jinyintan cases, 17 of 99 (17%) developed acute respiratory distress. Twenty-three required intensive care, and 11 (11%) died of multiple organ failure. Coronavirus TEMColor-enhanced transmission electron micrograph (TEM) of human coronavirus particles. Approx viral diameter 80-160 nm. (James Cavallini / Science Source)Early case fatality estimates from Chinese researchers range from 14.6% on the high end to 3% on the low end.

These estimates will likely change in the coming months as more cases are tracked for longer periods. Whether the number goes up or down remains to be seen. For the first weeks of February, the rate seemed to be settling in the range of 2% to 3%.

At its peak, the coronavirus in the 2003 SARS epidemic had an estimated mortality rate of just over 10%, with an official tally of 774 deaths among 8,098 infected individuals. MERS-CoV caused 449 deaths between 2012 and 2015, with an estimated case fatality rate of 35%.

2019-nCoV is clearly a serious pathogen, but so far, its case-fatality rate is on the low side. It is not an instant death sentence for all who get infected.

Putting things in perspective, the Global Burden of Disease study estimated that air pollution accounts for upward of 4 million deaths per year globally. Yet it does not trigger drastic government containment efforts, suspension of travel, or public panic. One can’t help but wonder why there is political will to lockdown major cities, close international borders, and prohibit travel in response to an infectious disease, but indifference and inaction in response to environmentally-induced illness.

Symptoms & Lab Findings: Chen and colleagues report that fever (83%), cough (82%), and shortness of breath (31%) were the most common symptoms among their 99 patients. Other symptoms included muscle ache (11%), confusion (9%), headache (8%), sore throat (5%), rhinorrhea (4%), chest pain (2%), diarrhea (2%), nausea and vomiting (1%).

Radiographically, 75% of patients had bilateral pneumonia, and 14% showed “multiple mottling and ground-glass opacity.” One had pneumothorax.

They report that 43 patients had abnormal liver function tests, particularly elevated ALT and AST levels. Thirty-eight had high neutrophil counts, and 35 had abnormally low lymphocyte numbers. In the 73 patients tested, nearly all had elevated C-reactive protein levels.

Chen’s team tested for nine other common respiratory pathogens associated with pneumonia. Aside from coronavirus, they found no other viruses. One patient was infected with Acinetobacter baumannii, Klebsiella pneumoniae, and Aspergillus flavus. Three had Candida albicans, and one had Candida glabrata.

Patient Characteristics: The average age of the infected individuals was 55.5 years, with a range of 21-82 years. Two thirds (67) were male.

Notably, half of the infected patients had prior and longstanding chronic conditions, including cardiovascular and cerebrovascular diseases (40%), endocrine disorders (13%), and gastrointestinal diseases (13%). Twelve had diabetes.

The first two deaths in this case cohort were men in their 60s, who had long histories of smoking.

The high prevalence of preexistent chronic disease observed in this cohort is similar to what investigators reported during the MERS-CoV epidemic.

“Our results suggest that 2019-nCoV is more likely to infect older adult males with chronic comorbidities as a result of the weaker immune functions of these patients.” Chen and colleagues cite age, obesity, and presence of one or more chronic disorders as factors associated with increased risk of death from COVID-19.

Treatment: There are no specific antiviral drugs or vaccines known to be effective against coronaviruses in humans. None the less, the Jinyintan clinicians treated 75 of the 99 patients with oseltamivir (75 mg every 12 h, orally), ganciclovir (0·25 g every 12 h, intravenously), and lopinavir and ritonavir tablets (500 mg twice daily, orally). The treatment duration ranged from 3 to 14 days (median 3 days). Chen and colleagues have not disclosed estimates of the efficacy of these treatments.

Though only 5 of the 99 patients had other non-viral co-infections, the clinical team opted to treat 70 of them with antibiotics (25 received a single drug, 45 got a combination of antibiotics). They drew from a wide range of drugs: cephalosporins, quinolones, carbapenems, and others.

At the time of the Lancet publication, 31 of the 99 patients had been discharged, 11 had died, and 57 were still hospitalized.

Shanghai people in masks lo resResidents of Shanghai, like millions of people worldwide, attempt to protect themselves from COVID-19 by using paper or cloth surgical masks. There's little evidence that these types of masks are prophylactic. (Photo: Edwin Rmsberg /VWPics/UIG/Science Source)Prevention: The public health dialog thus far has largely been about containment of 2019-nCoV: quarantining of infected individuals; restrictions on travel; bans on trade and sale of wild game, and stockpiling of pharmaceuticals, medical supplies, and personal protective equipment.

Many experts are also calling for fast-track R&D efforts on coronavirus vaccines and novel antiviral drugs. “Vaccine platforms should be accelerated for real-time deployment in the event of a second wave of infections,” writes Joseph Wu of the University of Hong Kong’s Li Ka Shing School of Public Health.

As far as individual protection, official recommendations are simplistic. The WHO advises the following:

  • Frequent hand-washing with soap and running water
  • Frequent use of alcohol-based hand sanitizers
  • Covering mouth and nose with a tissue or flexed elbow when coughing or sneezing
  • Avoid spitting in public
  • Seek medical care for any fever, cough, or respiratory symptoms
  • Minimize or avoid shopping in “wet” markets that sell live animals
  • Minimize contact with livestock
  • Eat only thoroughly cooked food; minimize consumption of raw animal products

There is additional guidance for workers in high-risk environments (“wet markets in China and Southeast Asia”), like use of protective gowns, gloves, and masks. Protection guidelines for medical professionals, hospitals, and clinics more or less echo those issued by WHO in response to MERS.

Fabric Placebos

Though millions of people in China and around the world have begun wearing paper surgical masks in public, there’s scant evidence they will block this virus. Likewise, washable cloth masks are really just fabric placebos, according to a recent National Public Radio report.

The only masks likely to offer meaningful protection are the tight-fitting N95 respirator masks, of the sort used in infectious disease units. When used properly, they block 95% of small airborne particles like viruses, but they’re impractical for general public use.

Beyond the calls for new vaccines, public health officials worldwide have paid little attention to individual immune system strength, overall health status, or ways to strengthen these through nutrition, herbal medicine, and other non-invasive interventions. That seems like a glaring oversight, given that half the Jinyintan cases were in people with preexisting chronic conditions strongly associated with lifestyle factors

Beyond the calls for new vaccines, public health officials worldwide have paid little attention to the matter of individual immune system strength, overall health status, or ways to strengthen these through nutrition, herbal medicine, and other non-invasive interventions.

That seems like a glaring oversight, given that half the Jinyintan Hospital cases were in people with preexisting chronic conditions that are strongly associated with lifestyle factors, and that having a chronic disease is associated with a higher risk of death when infected with coronavirus.

It is unlikely that herbal extracts and nutraceuticals hold drug-like “cures” for coronavirus. Four leadng supplement industry trade organizations--American Herbal Products Association (AHPA), Council for Responsible Nutrition (CRN), Consumer Healthcare Products Association (CHPA), and the United Natural Products Alliance (UNPA)--stressed that point in a joint statement on February 11.

"While research supports the use of certain dietary supplements to maintain immune system health, we are not aware of clinical research that demonstrates using a dietary supplement specifically to prevent or to treat the novel coronavirus. Even if research is conducted and published on the topic, the law that regulates dietary supplements... prohibits marketers in the United States from promoting any dietary supplement product that makes disease prevention or treatment claims."

That said, there are a number of herbs that have shown in vitro antiviral activity against some forms of coronavirus. One that stands out is Oregano.Oregano

In vitro work done during the 2002-03 SARS epidemic show that carvacrol-rich oregano oil is both virustatic and virucidal against the coronavirus thought to cause SARS (see Oregano Oil Proves Effective Against Coronavirus).

Other studies have shown oregano oil—alone or in combination with other terpene rich herbs—to inhibit the growth of H1N1, HSV, and other human viral pathogens (Brochot A, et al. Microbiology Open. 2017. Toujani MM, et al. Phytother Res. 2018. Sanchez C, et al. Int J Food Microbiol. 2015).

There has yet to be a human clinical trial of oregano oil to confirm or refute the observations from basic research. And as the joint industry position paper has stated, even if a company or agency were to sponsor such studies, the Dietary Supplements Health and Education Act (DSHEA) would prohibit supplement makers from advertising the data.

But given the dearth of conventional drug therapies for coronavirus infections, the possibility that this herb might be useful should not be categorically dismissed.

It is unlikely that herbal extracts and nutraceuticals hold drug-like “cures” for coronavirus. But there are a number of herbs that have shown in vitro antiviral activity against some forms of coronavirus. One that stands out is Oregano.

In his excellent 2013 book, Herbal Antivirals, herbalist Stephen Harrod Buhner goes into great depth about the mechanisms by which viruses attach to and infect human cells, and the diverse plant substances that can inhibit viral attachment and proliferation.

Buhner points out that the virus that triggers SARS attaches to the Angiotensin-Converting Enzyme 2 (ACE-2) on the surfaces of lung, lymph and splenic epithelium. A number of herbs, including Licorice, Chinese Skullcap, Horse Chestnut, Polygonium, Elder, and Cinnamon contain compounds that block coronavirus attachment to ACE-2.

He also notes that Kudzu, Skullcap, Angelica, Astragalus, and cordyceps mushrooms can down-regulate TGF-β, IL-1β, and other cytokines involved in the inflammatory cytokine storm that characterizes SARS.

Buhner’s book, rooted in traditional use and long personal experience, includes guidelines and recipes for the use of herbs to strengthen immunity to viral infections while down-regulating inflammation.

 

Ginger Tea

Juice one to two pounds of fresh ginger root (dried ginger powder is ineffective), preferably organic.

Pour 3-4 ounces of the juice in a mug; refrigerate the rest

Add the juice of one quarter of a lime, a large tablespoon of honey, an eighth teaspoon of cayenne pepper, and 6 ounces of hot water.

Stir well.

Drink 4-6 cups per day.

 

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