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The situation is dynamic and subject
to new discoveries and changes.
Data are up to 15/May/2013.
 Coronaviruses are important human and
animal pathogens.
 Up to 1/3 of community acquired upper
respiratory tract infections in adults.
 Play a role in severe respiratory tract
infections in both adults and children.
 They were first identified in the 1960s,
and were named after the crown-like
projections on the surface of the virus.
 Members of nidovirus family.
 Replicate using a nested set of mRNAs.
 Human coronaviruses are classified into 2
genera:
oAlpha: HCoV-229E and HCoV-NL63
oBeta: HCoV-HKU1, HCoV-OC43, nCoV, and
the SARS coronavirus
 Coronaviruses are medium-
sized, enveloped, positive-stranded RNA
viruses.
 Have the largest known viral RNA
genomes, with a length of 27 to 32 kb.
 The genome encodes four or five
structural proteins, S, M, N, HE, and E.
 Replication of viral RNA occurs in the host cytoplasm by
a unique mechanism in which RNA polymerase binds to a
leader sequence and then detaches and reattaches at
multiple locations, allowing for the production of a nested
set of mRNA molecules
Proteins Function
M (Membrane glycoprotein) Budding, envelope formation
S (Spike glycoprotein) R. binding, cell fusion, as Ag
HE (Hemagglutinin-acetylesterase gp) Beta, adsorption to host cell
N (Nucleocapsid phosphoprotein) Ribonucleoprotein
E (envelope) Unknown function
 The novel coronavirus (nCoV; also abbreviated as HCoV-
EMC), has been classified through sequencing as a
betacoronavirus.
 Closely related to several bat coronaviruses.
 Dipeptidyl peptidase 4 (DPP4; also known as CD26), which
is present on the surfaces of human non-ciliated bronchial
epithelial cells, is a functional receptor for nCoV.
 nCoV appears to infect several other human cell
lines, including lower (but not upper)
respiratory, kidney, intestinal, and liver cells, as well as
histiocytes.
 nCoV can also infect non-human primate, porcine, bat, and
rabbit cell lines
Epidemiology
So far …
On 19 Apr 2012, Jordan: outbreak of pneumonia in the Zarqa Public
Hospital’s ICU. 7 nurses, 1 doctor and 1 brother of a nurse were among
the 11 affected. In Nov 2012, testing of stored samples from two died
patients of this cluster confirmed novel coronavirus infection
22/Sep/2012: UK: 49 yrs previously healthy Qatari male.
Travel history to KSA
23/Nov/2012: 3 cases in KSA, 2 died, 1 survived, 2 are family members
1 case in Qatar.
28/Nov/2012: 1 case in KSA, died.
Oct 2012: KSA: A family member of the 2 earlier cases in Nov.
11/Feb/2013: UK: Critically ill male, with travel history to Pakistan and KSA.
Later he died.
13/Feb/2013: UK: Relative of the patient reported 2 days earlier, no travel
history, no comorbidities.
Later he died.
16/Feb/2013: UK: Relative of the other 2 UK cases.
Mild
21/Feb/2013: KSA: Sporadic case, died.
6/Mar/2013: KSA: Sporadic case, no contact with other reported cases, and
no travel history.
Died.
12/Mar/2013: KSA: Sporadic case, no contact with other reported cases, and
no travel history.
Died.
23/Mar/2013: KSA: Relative of the patient reported on 12/Mar
Mild, Recovered.
26/Mar/2013: Germany: 73 yrs Male, from Abu-Dhabi hospital.
2/May/2013: KSA: 7 cases, no travel history, no animal contact, not relatives
or cluster.
3/May/2013: KSA: 3 cases, same region, 2 are family members, critical
condition.
6/May/2013: KSA: 3 cases, 2 died, 1 in critical condition.
8/May/2013: France: immunocompromised, travel history to Dubai.
9/May/2013: KSA: 2 cases, both with comorbidities, both recovered.
Same cluster
12/May/2013: France: 1 case, shared a room with the other French case
14/May/2013: KSA: 4 cases, all with comorbidities, 1 died, 1 recovered, 2 in
critical condition.
15/May/2013: KSA: 2 cases, a male in critical condition, a female in stable
condition.
 From September 2012 to 15/May/2013 WHO has been
informed of 40 laboratory confirmed cases.
 Of whom 20 died.
30
 The incubation period is currently considered
to be up to ten days.
 The mode of transmission is currently unknown.
Coronaviruses typically spread like other
respiratory infections such as influenza.
 The two clusters in Saudi Arabia and Jordan raise
the possibility of limited human-to-human
transmission, but could also be explained by
exposure to a common source.
 It is possible that some infections occur via
intermittent zoonotic transmission or an
environmental source.
 All patients presented generally as pneumonia
with symptoms of fever, cough, shortness of
breath and breathing difficulties.
 Some cases have had acute kidney injury.
 Other clinical manifestations that have been
reported (in one patient each) are pericarditis
and DIC.
 Two cases presented with mild respiratory
illness.
 Pulmonary parenchymal disease.
 Evidence of consolidation.
 Localized infiltrates and increased
interstitial markings.
 Patient under investigation:
 Considered for evaluation:
 Probable case:
 Confirmed case:
 Testing for the novel coronavirus is undertaken only
when there is clinical or epidemiological evidence
that nCOV may be the cause in an individual or
cluster of patients.
 To avoid the inappropriate use of scarce resources,
the generation of false positives and the risk of
overwhelming the health system by unnecessary
activation of hospital-based and public health
response teams.

 Routine confirmation of of nCOV will be based on
detection of unique sequences of viral RNA by real-
time reverse-transcriptase polymerase chain reaction
(RT-PCR) and sequencing.
 Laboratories with the appropriate experience and
containment facilities, may attempt to isolate the
virus in cell culture, not routine.
 A number of RT-PCR assays that are specific for nCOV have
been developed and published. Currently described tests include:
o Upstream of the E protein gene (upE)
o open reading frame 1b (ORF 1b) gene
o open reading frame 1a (ORF 1a) gene.
 The assay for the upE target is considered highly sensitive, with
the ORF 1a assay considered of equal sensitivity.
 The ORF 1b assay is considered less sensitive than the ORF 1a
assay but may be more specific.
 Other target sites on the nCOV genome suitable for sequencing
to aid confirmation: RNA-dependent RNA polymerase (RdRp)
and nucleocapsid (N) protein genes.
 As with other CoVs, no antiviral agents are recommended for the
treatment of nCoV infection.
 The WHO has issued recommendations for the management of
severe respiratory infections suspected to be caused by nCoV.
 Patient under investigation for nCOV.
 Severe pneumonia, ARDS.
 Sepsis, septic shock.
 Initiate infection prevention and control measures.
 Collect specimens for laboratory testing.
 Empiric antimicrobials to treat suspected pathogens including
community acquired pathogens.
 Conservative fluid management if there is no evidence of shock
Permissive hypercapnia, PEEP, double triggering, deep
sedation, prolonged inspiratory time.
Neuromuscular block, prone, recruitment maneuvers.
Thank you…

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Novel Coronavirus spotlight

  • 1.
  • 2. The situation is dynamic and subject to new discoveries and changes. Data are up to 15/May/2013.
  • 3.
  • 4.  Coronaviruses are important human and animal pathogens.  Up to 1/3 of community acquired upper respiratory tract infections in adults.  Play a role in severe respiratory tract infections in both adults and children.  They were first identified in the 1960s, and were named after the crown-like projections on the surface of the virus.
  • 5.  Members of nidovirus family.  Replicate using a nested set of mRNAs.  Human coronaviruses are classified into 2 genera: oAlpha: HCoV-229E and HCoV-NL63 oBeta: HCoV-HKU1, HCoV-OC43, nCoV, and the SARS coronavirus
  • 6.  Coronaviruses are medium- sized, enveloped, positive-stranded RNA viruses.  Have the largest known viral RNA genomes, with a length of 27 to 32 kb.  The genome encodes four or five structural proteins, S, M, N, HE, and E.
  • 7.  Replication of viral RNA occurs in the host cytoplasm by a unique mechanism in which RNA polymerase binds to a leader sequence and then detaches and reattaches at multiple locations, allowing for the production of a nested set of mRNA molecules Proteins Function M (Membrane glycoprotein) Budding, envelope formation S (Spike glycoprotein) R. binding, cell fusion, as Ag HE (Hemagglutinin-acetylesterase gp) Beta, adsorption to host cell N (Nucleocapsid phosphoprotein) Ribonucleoprotein E (envelope) Unknown function
  • 8.
  • 9.  The novel coronavirus (nCoV; also abbreviated as HCoV- EMC), has been classified through sequencing as a betacoronavirus.  Closely related to several bat coronaviruses.  Dipeptidyl peptidase 4 (DPP4; also known as CD26), which is present on the surfaces of human non-ciliated bronchial epithelial cells, is a functional receptor for nCoV.  nCoV appears to infect several other human cell lines, including lower (but not upper) respiratory, kidney, intestinal, and liver cells, as well as histiocytes.  nCoV can also infect non-human primate, porcine, bat, and rabbit cell lines
  • 11. On 19 Apr 2012, Jordan: outbreak of pneumonia in the Zarqa Public Hospital’s ICU. 7 nurses, 1 doctor and 1 brother of a nurse were among the 11 affected. In Nov 2012, testing of stored samples from two died patients of this cluster confirmed novel coronavirus infection
  • 12. 22/Sep/2012: UK: 49 yrs previously healthy Qatari male. Travel history to KSA
  • 13. 23/Nov/2012: 3 cases in KSA, 2 died, 1 survived, 2 are family members 1 case in Qatar.
  • 14. 28/Nov/2012: 1 case in KSA, died.
  • 15. Oct 2012: KSA: A family member of the 2 earlier cases in Nov.
  • 16. 11/Feb/2013: UK: Critically ill male, with travel history to Pakistan and KSA. Later he died.
  • 17. 13/Feb/2013: UK: Relative of the patient reported 2 days earlier, no travel history, no comorbidities. Later he died.
  • 18. 16/Feb/2013: UK: Relative of the other 2 UK cases. Mild
  • 20. 6/Mar/2013: KSA: Sporadic case, no contact with other reported cases, and no travel history. Died.
  • 21. 12/Mar/2013: KSA: Sporadic case, no contact with other reported cases, and no travel history. Died.
  • 22. 23/Mar/2013: KSA: Relative of the patient reported on 12/Mar Mild, Recovered.
  • 23. 26/Mar/2013: Germany: 73 yrs Male, from Abu-Dhabi hospital.
  • 24. 2/May/2013: KSA: 7 cases, no travel history, no animal contact, not relatives or cluster.
  • 25. 3/May/2013: KSA: 3 cases, same region, 2 are family members, critical condition.
  • 26. 6/May/2013: KSA: 3 cases, 2 died, 1 in critical condition.
  • 27. 8/May/2013: France: immunocompromised, travel history to Dubai.
  • 28. 9/May/2013: KSA: 2 cases, both with comorbidities, both recovered. Same cluster
  • 29. 12/May/2013: France: 1 case, shared a room with the other French case
  • 30. 14/May/2013: KSA: 4 cases, all with comorbidities, 1 died, 1 recovered, 2 in critical condition.
  • 31. 15/May/2013: KSA: 2 cases, a male in critical condition, a female in stable condition.
  • 32.  From September 2012 to 15/May/2013 WHO has been informed of 40 laboratory confirmed cases.  Of whom 20 died. 30
  • 33.
  • 34.
  • 35.
  • 36.  The incubation period is currently considered to be up to ten days.
  • 37.  The mode of transmission is currently unknown. Coronaviruses typically spread like other respiratory infections such as influenza.  The two clusters in Saudi Arabia and Jordan raise the possibility of limited human-to-human transmission, but could also be explained by exposure to a common source.  It is possible that some infections occur via intermittent zoonotic transmission or an environmental source.
  • 38.  All patients presented generally as pneumonia with symptoms of fever, cough, shortness of breath and breathing difficulties.  Some cases have had acute kidney injury.  Other clinical manifestations that have been reported (in one patient each) are pericarditis and DIC.  Two cases presented with mild respiratory illness.
  • 39.  Pulmonary parenchymal disease.  Evidence of consolidation.  Localized infiltrates and increased interstitial markings.
  • 40.
  • 41.  Patient under investigation:
  • 42.  Considered for evaluation:
  • 45.
  • 46.  Testing for the novel coronavirus is undertaken only when there is clinical or epidemiological evidence that nCOV may be the cause in an individual or cluster of patients.  To avoid the inappropriate use of scarce resources, the generation of false positives and the risk of overwhelming the health system by unnecessary activation of hospital-based and public health response teams.
  • 47.
  • 48.  Routine confirmation of of nCOV will be based on detection of unique sequences of viral RNA by real- time reverse-transcriptase polymerase chain reaction (RT-PCR) and sequencing.  Laboratories with the appropriate experience and containment facilities, may attempt to isolate the virus in cell culture, not routine.
  • 49.  A number of RT-PCR assays that are specific for nCOV have been developed and published. Currently described tests include: o Upstream of the E protein gene (upE) o open reading frame 1b (ORF 1b) gene o open reading frame 1a (ORF 1a) gene.  The assay for the upE target is considered highly sensitive, with the ORF 1a assay considered of equal sensitivity.  The ORF 1b assay is considered less sensitive than the ORF 1a assay but may be more specific.  Other target sites on the nCOV genome suitable for sequencing to aid confirmation: RNA-dependent RNA polymerase (RdRp) and nucleocapsid (N) protein genes.
  • 50.
  • 51.
  • 52.  As with other CoVs, no antiviral agents are recommended for the treatment of nCoV infection.  The WHO has issued recommendations for the management of severe respiratory infections suspected to be caused by nCoV.
  • 53.  Patient under investigation for nCOV.  Severe pneumonia, ARDS.  Sepsis, septic shock.  Initiate infection prevention and control measures.  Collect specimens for laboratory testing.  Empiric antimicrobials to treat suspected pathogens including community acquired pathogens.  Conservative fluid management if there is no evidence of shock
  • 54.
  • 55.
  • 56. Permissive hypercapnia, PEEP, double triggering, deep sedation, prolonged inspiratory time. Neuromuscular block, prone, recruitment maneuvers.
  • 57.
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  • 61.
  • 62.