COVID-19 Coronavirus Disease 2019
COVID-19 term is derived from “CO”rona”VI”rus “D”isease 20″19” it is caused due to Novel Coronavirus also known as 2019-nCoV or SARS-CoV-2. It is commonly known as Wuhan Coronavirus or Wuhan Sea Food Market Pneumonia Virus is an enveloped positive sense, single strand, RNA Coronavirus with a neucleocapsid of helical symetry which can infect and spread through human to human transmission causing flu like illness officially termed by WHO as Covid-19 where “Co” represents CORONA, “vi”represents virus, “d” stands for disease and “19” stands for year of first outbreak 2019.
Novel Coronavirus 2019-nCoV or SARS-CoV-2 Classification
Novel Coronavirus belongs to
- Realm -Riboviria
- Phylum -Incertia Sedis
- Order -Nidoviralis
- Family -Coronaviridae
- Genus -Beta Corona virus
- Sub Genus -Serbecovirus,
- Virus -2019nCoV or SARS-CoV-2
Coronavirus strands that affect humans
Coronaviruses infects mammals and birds there are total 7 known strands that infect humans including 2019nCoV, first 2 strands were detected in 1960’s
- Human coronavirus 229E (HCoV-229E)
- Human coronavirus OC43 (HCoV-OC43)
- Human coronavirus NL63 (HCoV-NL63, New Haven coronavirus)
- Human coronavirus HKU1
- Middle East respiratory syndrome coronavirus (MERS-CoV), previously known as novel coronavirus 2012 and HCoV-EMC.
- Novel coronavirus (2019-nCoV). This is the strain that causes COVID-19 disease in humans
The first outbreak of the Novel Coronavirus or 2019nCoV in humans was confirmed and notified to WHO by China on 31/12/2019, when patients from Wuhan province of China were suffering with virus related non specific flu like illness from around 8/12/2019 then later the genome was sequenced to confirm this absolutely new and novel strain of coronavirus 2019-nCoV or SARS-CoV-2
Within three months of first reported case on 8/12/2019 the coronavirus outbreak that had first started from Wuhan in China had now reached more than 66 countries including India, Thailand, Japan, South Korea, Italy, Iran, Germany, Taiwan, Hong Kong, USA, Vietnam, Singapore etc. claiming more than 3100+ deaths of estimated 100000+ infected as on 8/3/2020. The death toll is constantly rising, in subsequent two months that is by 8/6/2020 almost 6.5 million got infected and almost 4lac deaths.
It will take some time to estimate mortality rate but it seems to be around 2%. Old people and people with other pre-existing disease condition are at higher risk of succumbing to death. With increasing death rate rises steeply with upto 50-70% death rate in symptomatic patients above 60 with hypertension or diabetes or other complications.
Most of the initial cases were from Huanan seafood market so epizootic origin is suspected.Outbreak of this particular strain of coronavirus is for the first time, So its new for human immune system. As the time lapses the affected community will start developing certain immunity against it, which will slow down the progress of transmission and epidemic as time lapses. Also with time and better understanding of virus and its epidemic, the health authorities will be more efficient in containing the disease and its epidemic.
There is a split between science community where in a group suggests that it has originated from snake where as other claims that snake cannot be the probable the reservoir and is probably from mammal reservoir mostly the bats as the genome sequencing shows 96% resemblance of bat coronavirus and 2019-nCoV.
It is postulated that homologous recombination of Clad A bat viruses “CoVZC45 and CoVZXC21” with some unknown Beta-CoV may have formed 2019nCoV
Human to human transmission of novel coronavirus was confirmed till mid January And the damage was done till then. The virus had started spreading at pace unmatched by any other disease witnessed in past 100 yrs.
PATHOGENESIS OF COVID-19 or Novel Coronavirus 2019 Infection
Still the pathogenesis is not been clearly understood but data and study results are fast pouring in and now we have some basic understanding about but there are many missing gaps and needs to be understood and filled up soon.
The disease causing agent and its full geneome was sequence in December 2019-January 2020, soon after initial outbreak.It was found that the disease causing agent was a virus which had 70% genomic resemblence to SARS-CoV and 50% genomic resemblence to MERS- CoVand they termed it as Novel Coronavirus 2019 or 2019nCoV or SARS-CoV-2 and disease caused by this virus was termed as COVID-19.
Inoculation of 2019nCoV
From initial studies it seems that 2019nCoV attaches to the receptors of Angiotensin Converting Enzyme 2 (ACE2) through an endocytosis process trigerred with the help of spike protein present on surface envelop of the virus . Which are present good quantity on lymphocytes, macrophages, epithelial linning of respiratory mucosa, lungs alveoli, enodthelium of blood vessels, gastrointestinal tract and are also expressed by vital organ like heart and kidneys, which we see getting affected in this disease.
Multiplication and Spread of 2019nCoV
Virus not only has capability to attach to ACE2 receptors of upper respiratory tract and inoculate the cells but also has capability to actively replicate in upper-respiratory tract tissue which was demonstrated by isolating virus from swabs of upper respiratory tract with presence of Sub-Genomic mRNA (sgRNA) in cells of upper respiratory tract. There is tropism of upper respiratory tract and shedding of virus.
All of the above factors explains us fast and easy transmission of virus even in early stage of disease as compared to SARS-CoV and MERS-CoV.
Virus predominantly infects through upper-respiratory in majority cases and then gradually by 3-4 days it involves lower respiratory tract and then by second week there is wide spread invasion into bloodvessels and major vital organs like heart, kidneys with general viremia.
Immune Reaction Towards 2019nCoV Infection and Its Consequences
Its not only virus that causes damage to system but also the body’s immune response against the virus is causing damage to the body which is observed by excessive production of early proinflamatory mediators like Interlukine 6 (IL6) Tumour Necrosis Factor (TNF) Interlukine 1 (IL1), presence of inflamatory infiltrate in lungs. Reduced blood level of T-Lymphocytes and B-Lymphocytes although direct due to viral attack on these cells but also is attributed to redistritbution by immune respone which is demonstrated by presence of comparative more number of T-cell and B-cells at inflamatory sites.
The Cytokine Storm Postulate
There is much evidence to suggest that the initial immune response driven against virus causes activation of coagulation pathway which results in excessive production of early proinflamatory mediators which accumulate overtime leading to vascular hyperpermeability and micro-coagulations resulting from disturbed procoagulant-anticoagulant axis balance due to overt inflamatory response.
Thrombin, known for its primary role in coagulation by activation of platelets and conversion of fibrinogen to fibrin, also has multiple cellular effects that may enhance inflamatory response through Protinase-Activated Receptors(PARs).
Thrombin production is tightly controlled by negative feedback loops and physiological anti-coagulants like Tissue Pathway Factor Inhibitor, Antithrombin III and Protein 3. Inflamatory process can significantly reduce the concentration of anti-coagulants this deviates the fine balance of axis between procoagulant-anticoagulant balance that causes multiple micro-coagulations disseminated intravascular clots and multiple organ failure.
SIGNS AND SYMPTOMS of COVID-19
It shows symptoms that of severe respiratory tract infection giving rise to pneumonia with some gastrointestinal symptoms like other coronavirus infection, Its symptoms are much related to 2003 SARS Epidemic caused due to SARS-CoV.
Most of the patients remain asymptomatic and never get detected many show mild to moderate symptoms this forms the vast majority.
COVID 19 CLINICAL PRESENTATION
- Almost 98% symptomatic cases of 2019-nCoV(Covid-19) infection presents with Fever
- Dry Coughing is present in almost 82% of symptomatic cases.
- Of all the cases sputum production is seen in 25-30% cases and Hemoptysis in upto 5% of all the cases.
- Fatigue is observed in almost 70% cases approaching medical care
- Muscle-aches (myalgia) in almost 44% of all the cases.
- Headaches in almost 13% of all the cases
- Diarrhoea experienced in 10% cases
- Vomitting seen in 10% of all the patients
- Almost 55% of all the cases will develop shortness of breath after 3-8days of initial general symptoms.
- Almost 20% of all the the cases seem to progress into severe disease with respiratory distress symptoms within a day or two of developing shortness of breath.
- Few patients go into shock and may develop cardiac arythmias.
- Of all the cases less than 5-10%(approx) will die due to complications, mostly those who are elderly children or have other prevailing disease condition like diabetes, cardiac diseases, cancer etc.
- X – ray and CT scan shows bilateral Lungs involvement with Ground Glass Opacities, grey white consolidated patches.
- Leucopenia -Low WBC count especially lymphocytes – lymphopenia.
- Increased Neutrophil to Lymphocytes Ratio(NLR)
- Increased D. Dimer
- Reduced Prothrombin time
- Reduction in bleeding and clotting time.
Window period of 2019-nCoV ranges between 2-14days. It takes 2-14 days for symptoms to appear post exposure to virus. Note the patient of 2019 nCoV (Covid-19) can spread infection to others even during this window period l, that is, even before any symptoms starts appearing after first inoculation of 2019-nCoV into body or even any test to decisively test positive.
After window period is over and the symptoms starts appearing the following pattern is seen in progression of clinical symptoms commonly found in most cases.
DAY 1-2 Initially on first 1-2 days patient will show mild fatigue malaise and heaviness of head with mild rise in temperature, few will show a peculiar symptom of Olfactory loss- loss of taste and smell(usually this type of presentation shows mild disease form and has has good prognosis).
DAY 2-3 Gradually the temperature will increase from 2-3rd day with mild irritation in throat.In many this symptom will stop increasing at this stage and will remain mild symptomatic throughout the course of disease, in rest it will progress with fever exceeding 100F, bodyaches, joint pains, weakness
DAY3-4 Fever continues to relapse with dry cough a very few minority might start showing development of shortness of breath even at this early stage.
DAY4-6 Loose motion is frequently encountered on once or twice between 4th and 6thday(in few minority it has appeared right on day one of initial symptoms) this might bring in weakness and exhaustion in patients and those with high fever may be drained even more by accompanying diarrhoea. Few might go into respiratory distress at this stage.
DAY 7–8 From 7th day onwards in few patients fever starts subsiding a bit but in many it persists and few go into respiratory distress.
DAY 8-9 Now 8th-9th days are important to observe as from here on majority patient’s immune system will develop sufficient immunity and resistance against virus and fight it off from the body and recover. Their fever breaks away and they start feeling better with weakness leaving their body but in few cases there is no recovery at this stage such patients progresses into critical stage either fever continues or breathlessness sets this is when the patient needs be urgently shifted to ICU.
- Patients with co-morbidity like Diabetes Mellitus, Cardiovascular or Kidney diseases, Immuno-compromised, Organ failure, Asthma Bronchitis, Chronic Obstructive Pulmonary Disease(COPD),Cancer, Autoimmune diseases, Severe anaemia, etc.
- Greater severity of pneumonia at presentation.
- Elderly patients – Older the age greater the risk.
- Radio-opacities and/or pulmonary infiltrates on X-ray findings
- Neutrophil to Lymphocyte ratio (NLR) of more than 3.13
- SPO2 level below 95%
- Increased BUN or Serum Creatinine
- Increased Liver enzymes SGOT SGPT, Bilirubin
- Any neurological event
- Increased D Dimer
- Increased LDH
- Reduced bleeding time
- Reduced Clotting time
- Reduced Prothrombin time
- Transeminated intravascular clot.
There are two types of testing approach one is direct test and indirect test.
1) DIRECT TEST :-
Throat Swab for RT-PCR for SARS CoV-2
detects viral protein through Polymerase Chain Reaction PCR it is gold standard test as it amplifies/enhances virus protein to detectable levels and give most accurate results possible as we are directly detecting virus. But it is comparatively more costly and time consuming. Still it’s recomended as rapid antibody tests(indirect tests) that are available till date are too inaccurate to rely
2) INDIRECT TEST :-
Blood Test for Antibodies IgM and IgG against SARS CoV-2
Herebwe are not directly detecting the virus but we try to find out antibodies formed against 2019-nCoV/ SRAS CoV-2 virus. It is comparatively rapid in nature but not accurate. Presence of antibodies – IgM and IgG against SARS CoV-2 are indicators of past or active
Interpretation of blood test for diagnosis of Covid 19
- RT-PCR -ve, IgM -ve & IgG -ve Means No current, No past infection or may be window period.
- RT-PCR +ve, IgM -ve & IgG -ve means early infection no immune response developed
- RT-PCR +ve, IgM+ve & IgG -ve suggests infection with early acute phase immune response developed.
- RT-PCR +ve, IgM +ve & IgG +ve means later stage of infection with with longer lasting immune response developed.
- RT-PCR +ve, IgM -ve & IgG +ve suggests acute phase of infection is recovered and virus is being neutralised and strong immunity is being developed.
- RT-PCR -ve, IgM-ve & IgG +ve means infection has completely resolved and there is nonvirus in body and patient is non infectiois and has developed certain immunity towards virus for quite some time.
Time Line of Sensitivity of various Laboratory Investigations for Covid 19.
Day 0: Infected (innoculation)
Upto Day 5: Onset of symptoms(variable 2-21days, with 11.2days average)
Day 7: IgM positive – (from Day 7 toDay 21)
Day 14: IgG positive
Day 21: IgM disappears
Days 1-28: SARS CoV2 RNA & Antigens will be positive
Day 28: SARS CoV2 RNA & Antigens disappears
Disease Progression, Antibodies, Viral load, and Infectivity
Day 0 -Day 7: Window Period, Asymptomatic, Only PCR positive in this Phase, negligible Viral load on day 0-1 but viral load starts increasing very speedily and within a couple of days patient from mildly infectious on day 0 and 1, becomes considerably infectious and infectivity keeps increasing with each passing and in no time patient becomes highly infectious by the end of this period.
Day 7- Day 21: Symptomatic, both PCR and IgM Positive, Patient is highly infectious.
Day 14- Day 21: Decline Phase, PCR, IgM and IgG positive, Patient is highly infectious.
Day 21- Day 28: Convalescence Phase,IgM negative, IgG positive, PCR on declining count, Patient is still infectious.
After day 28: most of the patients are recovered and also PCR turns negative,so they are not infectious, IgG remains elevated,
Chest CT scan along with clinical picture and other blood tests like D.Dimer, CBC, NLR, ABG, CRP and ESR, LDH is also very important tool to give direction in diagnosis especially during pandemic when resources are less for RT-PCR. CT scan pattern may help to establish provisional diagnosis, during pandemic, which later can be confirmed by RT-PCR.
PREVENTION OF NOVEL CORONAVIRUS INFECTION DURING TIMES OF COVID-19 PANDEMIC
COVID 19 is caused by 2019-nCoV also called SARS-CoV-2. It is a highly contagious virus. The virus can spread even through casual contacts and proximity.
Current studies suggests that virus can survive on surfaces like glass, plastic, metals etc for may be up to 9days and in fecal material for may be upto weeks of which studies are still going on for confirmation.
It has spread to infect more than 63,00,000 person worldwide within a very short span of just 5months since its outbreak. Time and again most of the types of Coronavirus have proven themselves to have potential to create global pandemic claiming many lives within no time. Looking at the scale of pandemic and potential of 2019nCoV virus to spread very fast and claim lacs of lives in no time has spread panic and concern throughout the world as fast increase in cases of COVID-19 has overwhelmed the healthcare system even of the best country of the world with doctors finding them helpless against the disease and its scale and so almost all the major countries of the world have implimented partial or complete lockdown and social distancing norms to contain and slow down the spread of virus.
- Keep distance from infected person, at least 6 feet of distance is recomended
- Wear masks in public places
- Avoid traveling to area affected with 2019-nCoV epidemic
- Quatrantine patients traveling from COVID-19 epidemic regions.
- Avoid contact with person known to have came in contact with any person infected with 2019-nCoV or travel history from affected area.
- Report any case of cough, cold, fever or symptoms of flu to health authorities found in all the regions where cases of SARS-CoV-2 also called 2019-nCoV is prevailing.
- Person staying in affected regions should stay within their home and avoid any public places as much as possible.
- While moving out in affected region, wear removable and easily washable overcoats, wear disposable gloves, protective eye wears.
- Touching with bare hands to public handle, buttons, walls curtains and other objects in public places in affected region should be avoided.
- When in public place, try to prefer option with open air and lesser crowd then in enclosed public premises.
- Dont use public transport unless its unavoidable.
- Stay away from sewage channels and fecal material.
- Prefer food prepared at home that too fully cooked and avoid uncooked raw food.
- Avoid gathering and meeting people during times of epidemic.
- Avoid hand shakes and close proximity with other people during epidemic.
- Maintain healthy lifestyle and nutrition, food rich in Zinc, Iron and Vitamin C is recomended
- Keep all rooms highly ventilated.
- Sanitize your hands frequently almost every 1-2hours, wash hands at least for 20seconds at a time.
- People with long hairs should keep hair in such a way that it doesn’t come in contact with potentially infected objects in public places e.g. handle on seat back on buses and trains.
- Eat nutritious food, daily yoga and exercise sufficient exposure to sunlight, timely meal sleep and exercise helps boost health and immunity to prevent and fight the disease.
When and how to use mask correctly is explained and demonstrated in the video below by WHO
HOMOEOPATHIC MEDICINE ARSENICUM ALBUM 30 PREVENTIVE MEDICINE AGAINST CORONAVIRUS DURING COVID -19 PANDEMIC
Expert committee of MINISTRY OF AYUSH, GOVT OF INDIA has identified Arsenicum Album 30 as Genus Epidemicus for immunity enhancement during COVID-19 pandemic and has recomended issuing public notice regarding the same. It has also recomended registered homeopathic practioners of India to suggest identified COVID-19 Genus Epidemicus Arsenicum Album 30 to people as immunity enhancement during the COVID 19 pandemic.
As per Ministry of Ayush, Govt of India Circular:-
Central Council for research in Homeopathy and Ministry of Ayush on its 64th Scientific Advisory Board meeting date 28th January 2020, recomended that Arsenicum Album 30 could be taken as prophylactic medicine against coronavirus infection in following prescribed dose
- One Dose of Arsenicum Album 30 on Empty Stomach For 3 Consecutive Days
- The Dose Should Be Repeated After One Month Following The Same Schedule.
Other Precautions that needs to be followed during homeopathic medication
- Do not eat or drink anything at least for 1 hour after taking medicine. Plain water or milk at room temperature could be consumed during this one hour if required.
- Brush Teeth at least one hour before or after taking this doses i.e one hour interval prior and after the dose.
- Avoid Uncooked Onion, Uncooked Garlic and Coffee atleast for 5 days when you start medicines.
Homeopathic Medicines Indicated For COVID-19 Novel Coronavirus Infection
As per my view other than basic symptomatic supportive treatment and available regular conventional allopathic treatment, homeopathic medicines can be used in conjunction, as per indication under guidance and observation of both qualified homeopathic physician and allopathic physician.
Few of the Homeopathic medicines that can be useful in treatment of COVID-19 that is SARS-CoV-2 infection also called 2019 novel coronavirus infection are listed below.
Initial stage of fever or first day of symptoms in patients much fear and anxiety. Also this medicine can be used for patients having psychological problems of fear fright and anxiety due to COVID-19 pandemic and lockdown psychological effects.
This remedy may prove useful for heaviness of head, fever and bodyaches in COVID-19
This is wonderful drug used since ages to treat respiratory complaints be it asthma, allergic rhinitis, viral respiratory infections or bacterial respiratory infections. Arsenic is consumed by mountaineers since ages which helps them to survive in higher altitudes in low oxygen environment it shall work well in any stage of Covid 19 infection. Itcan also be brought into service in patirnt with breathlessness and respiratory distress. Arsenicum Album acts not only on respiratory sphere but also gastrointestinal sphere which should cover the sptom of diarrhoea that many Covid-19 patients present along with respiratory and general symptoms. It should work well in Covid 19 patients with weakness where the patient is mentally restless but physically too weak to move.
USE OF ARSENICUM ALBUM AS HOMEOPATHIC GENUS EPIDEMICUS TO ENHANCE IMMUNITY AGAINST CORONA VIRUS DURING COVID-19 PANDEMIC
ARSENICUM ALBUM 30 is being identified as Genus Epidemicus and is suggested by Ministry of Ayush, Government of India under consultation of Central Council For Research in Homeopathy that it could be taken as prophylactic against Coronavirus infection one dose every morning on empty stomach for three consecutive days and same protocol should be repeated after a month of the epidemic still prevails in the region.
Cytokine-Storm is associated with increased capalilary permeability and disemminated intravascular coagulation due to overproduction of early-proinflamatory cytokines causing imbalance in procoagulant-anticoagulant balance causing microcoagualations in complicated cases of COVID19.
Arnica Montana is commonly used medicine in homeopathy to dissolve internal clots by stimulating body’s natural pathways to dissolve clots and in inverse concentration un-homeopathically it is also used to form clots stop to stop bleeding. So Arnica Montana has both the type of effects procoagulant and anticoagulant depending on what concentartion and repetition its uses. So with correct homeopathically succussed dilution and correct posology it may prove useful in such acute life threatening situation condition of sudden cytokine storm which causes dissemminated intravascular coagulations with damaged leaky hyperpermeable capillaries .
This medicine works well in cases who are living in region where days are hot and nights are cold. dry coughing, shortness of breath, fever, body aches, muscle aches are some of the symptoms covered by bryonia in COVID-19 patients. Master Hahnemann recommends bryonia alba in epidemics during summer season affecting respiratory system.
Camphora made from camphor can be used in terminally ill COVID-19 patient with gross signs of circulatory insufficiency, cyanosis, hypoxia and this should be the first medicine brought in immediately administered in cases of sudden collapse. Typically it has to be used in higher potency as recomended by some homeopaths.
Agaricus muscarius typically used in homeopathy for frosbite and cyanosis of extrimities can prove beneficial in terminally ill COVID-19 patients with signs of cyanosis and bluish discolouration of extremities like finger and toes this homeopathic medicine should be called in for service.
crategus oxyacantha may prove of great service in COVID-19 patients having cardiac complaints and high lipid profile having circulatory distress and disseminated intravascular coagulations crategus should be thought of is complimentary and supportive medicine.
Aspidosperma Quebracho successfully used in homeopthic mother tincture form since ages for treatment of acute exacerbations of asthma and cardiac asthma may prove useful in COVID-19 patients those who have reduced oxygen saturation arising out of pulmonary congestion, increased nitrogenous waste in blood which are usually excreted by kidney, pulmonary thrombus. It may help by stimulating respiratory centers and clearing temporary obstructions in lungs thus improving oxygen saturation of blood.
Antimonium Tartaricum shall prove useful for COVID-19 patients living in region with high humidity near sea-shores works wonders in relieving rattling cough with thick mucous especially in aged.
Kalium Bichromicum is very commonly used medicine in homeopathy which is helpful in getting rid of thick stringy ropy mucous it may prove of great service in COVID-19 cases with accumulation of thick mucous difficult to bring up.
Justicia Adhatoda also known as Vasaka in indian medicine and iss used in Ayurveda since ages. It is a great expectorant if used in lower potency preferably in homeopathic mother tincture form.