another study, the average reproductive nu1nber 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 R0 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
07:27 (Ml 0 ·•
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
•
:25
07
(Ml 0 ·•
··
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 ACE 2 receptors 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 8 y 11 mo and
in 28 children the inf ection
was
linked to a fam
. ily member and 26
•
07:25 (Ml 0 ·. • i
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°/o) or had mild
disease. No severe or critical cases were
seen. The most common
symptoms were fever (50°/o) and cough
(38°/o). 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
tr:::i vPl h i stnrv nr th nsP '"Ti th rnn fi rm Prl
•
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
eel I entry.17
4.1 Vi rion structure and its
genome
Coronaviruses are structurally enveloped,
belonging to the positive-strand RNA viruses category
I
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-genie epitopes mainly those
The p athogenesis of SARS- CoV-2 infection in
humans manifests itself as mild symptoms to severe
respirator y 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
COVID- 19the main cause of death in patients with
(REFS60 61 . 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 cases9,13,65• Histopathological
changesin patients 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.
Immunohistochemi stry assays detected SARS-CoV-2
antigen in the upper airway, bron chiolar epithelium and
submucosal gland epithelium , as well as in type I and type
II
andpneumocytes, alveolar macrophages
hyaline membranes in the lungs13 60 66 67•
, , ,
An imal models used for studyin g SARS- CoV-2
infection pathogenesis include n on-human pri mates
(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
48 68 74
hamsters43• •
-• 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 response s to SARS-CoV-2
' 73
infection69 72'
• For example, in the rhesus macaque
model, high viral loads were detected in the upper and
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, I-step quantitative real-time
reverse transcription-PCR assays were developed that
detect the ORFlb 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-
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 siDrnti on in the 'Vorl dwi de nonulation
leading to
The exploration of fully human antibodies (human
single-chain antibodies; HuscFvs) or humanized
nanobodies (single-domain antibodies; sdAb, VHNHH)
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
f urthermore, SARS-Co V-2 1s 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).
4 VI ROLOGY
Coronaviruses, a family of viruses within the
nidoviruses superfamily, are further classified
according to their genera, alpha-, beta-, gamma and
deltacoronaviruses (a-, -, y- and o-).
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
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
h n c ontro l ·o hy ,c opting appror ! • nc 1 •
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
Princess , Celebrity Apex , and Ruby Princess. 1he
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 (R0) 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 coronav1rus predecessors,
COVID-19 has an R0 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 ,
d:Sy 111p lUllld ll\,; Ul :sy 1111'lUllldll\,; pa.uc;1u:s lld v 111
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).
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 COVI D-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 COVI D-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
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
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 1s evidence of recombination (107).
The current scientific evidence available on MERS
infection suggests that the significant reservoir host, as
well as the animal source of MERS infection in humans,
is the dromedary camels (97). The infected dromedary
camels may not show any visible signs of infection.
makin g it cbaJJ en ging to
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-CoVZXC2 D (f jg. D.
in vitro and in vivo 155
-
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 n eutralizing epitop es 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 subunits 159
161 • As of 2 October 2020, -174 vac
cine candidates for COV ID -19 had been repo rted and
51 were in hum an clinical trials (COVID-19 vaccine
and therapeutics tracker ). Many of these vac cine candidates
are in phase II testing, and some have already advan ced to
phase III trials. A ran domi1°rl double-blinded phase II trial
of an adenovirus type vectored vaccine expressing the SARS-
CoV-2 S protein, 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
162• Another vectored vaccine, ChAdOx l,
immunization
it had spread massively to all 34 provinces of China. The
number of confirmed cases suddenly increased , with
thousan ds of new cases diagnosed daily during late
January 15
•
On 30 January, the WHO declared the novel
coronavirus outbreak a public health emergency of inter
•
national concern 16
On 11 February, the International
)
Committee on Taxonomy of Viruses named the novel
coronavirus 'SARS-CoV-217 . ', and the WHO named the
disease 'COVID- 19' (REF.
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 countryside18
•
Owing to
•
these measures, the daily number of new cases in China
started to decrease steadily19
However, despite the declining trend in China, the
international spread of COVID-19 accelerated from late
February. Large clusters of infection have been reported
from an increasing number of countries 18
•
The high
transmission efficiency of SARS-CoV-2 and the abun dance
of international travel enabled rapid worldwide spread of
COVID-19. On 11 March 2020, the WHO officially
characterized the global COV ID-19 out break as a
20• Since March, while COVID-19 in China has
pandemic
become effectively controlled, the case numbers in Europe,
the USA and other regions have jumped sharply. According
to the COVID-19 dash board of the Center for System
Science and Engineering at Johns Hopkins Un iversity, as
of 11 August 2020,
