International Academic Research Journal of Internal Medicine & Public Health ISSN Print : 2709-3301 | ISSN Online : 2709-331X Frequency : Bi-Monthly Language : English Origin : Kenya Website : https://www.iarconsortium.org/journal-info/iarjimph

Review Article Disease (Covid-19) Outbreak: A Narrative Review of Current Knowledge Article History Abstract: are a diverse group of viruses infecting many different animals, and they can cause mild to severe respiratory infections in humans. In 2002 and 2012, Received: 29.01.2021 respectively, two highly pathogenic coronaviruses with zoonotic origin, severe acute Revision: 07. 02.2021 respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome Accepted: 18.02.2021 coronavirus (MERS-CoV), emerged in humans and caused fatal respiratory illness, making Published: 28.02.2021 emerging coronaviruses a new public health concern in the twenty-first century. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly transmissible and Author Details pathogenic coronavirus that emerged in late 2019 and has caused a pandemic of acute 1 2 Dr. Shaik Kareemulla* , P. Tejaswini , S. , named ‗coronavirus disease 2019‘ (COVID-19), which threatens human Yaseen Vamaliya2, S. Yasmeen2 and K. health and public safety. The disease is transmitted by inhalation or contact with infected Chaithanya Bharathi2 droplets and the incubation period ranges from 2 to 14 days. The symptoms are usually Author’s Affiliations fever, cough, sore throat, breathlessness, fatigue, malaise among others. The disease is mild in most people; in some (usually the elderly and those with comorbidities), it may progress 1Associate professor, Department of Pharmacy to pneumonia, acute respiratory distress syndrome (ARDS) and multi organ dysfunction. practice, P. Rami Reddy Memorial College of Many people are asymptomatic. The case fatality rate is estimated to range from 2 to 3%. Pharmacy, Kadapa, Andhra Pradesh, India Diagnosis is by demonstration of the virus in respiratory secretions by special molecular tests. Common laboratory findings include normal/ low white cell counts with elevated C- 2Pharm D Intern, Department of Pharmacy practice, reactive protein (CRP). In this Review, we describe the basic virology of SARS-CoV-2, P. Rami Reddy Memorial College of Pharmacy, current knowledge of clinical, epidemiological and pathological features of COVID-19 and Kadapa, Andhra Pradesh, India treatment approaches for SARS-CoV-2 infection. Corresponding Author* Dr. Shaik Kareemulla Keywords: Pandemic, 2019-nCOV, SARS-CoV-2, COVID-19, bat-SL-CoV, RT-PCR. How to Cite the Article: Dr. Shaik Kareemulla, P. Tejaswini, S. Yaseen Vamaliya, S. Yasmeen & K. Chaithanya History of Coronavirus: Bharathi (2021): Coronavirus Disease (Covid- Coronaviruses were first discovered in the 1930s when an acute 19) Outbreak: A Narrative Review of Current respiratory infection of domesticated chickens was shown to be caused Knowledge. Int Aca. Res. J Int. Med. Pub. by Infectious Bronchitis Virus (IBV). In 1931, Arthur Schalk and M.C. Hlth. 2(1)15-24. Hawn described new respiratory infection of chickens in North Dakota. Copyright @ 2021: This is an open-access article The infection of new-born chicks was characterized by gasping and distributed under the terms of the Creative Commons Attribution license which permits listlessness. The chicks' mortality rate was 40–90%. Fred Beaudette and unrestricted use, distribution, and reproduction Charles Hudson six years later successfully isolated and cultivated the in any medium for non commercial use infectious bronchitis virus (Dos Santos, W. G. 2020). In the 1940s, two (NonCommercial, or CC-BY-NC) provided the more animal coronaviruses i.e., Mouse Virus (MHV) original author and source are credited. and Transmissible Gastro Enteritis Virus (TGEV) were isolated. It was not realized at the time that these three different viruses were related. Human coronaviruses were discovered in the 1960s. They were isolated using two different methods in United Kingdom and United States. E.C. Kendall, Malcom Byone, and David Tyrrell working at the Unit of the British Medical Research Council isolated from a boy a novel common cold virus B814. The virus was unable to cultivate using standard techniques which had successfully cultivated , adenoviruses and other known common cold viruses. In 1965, Tyrrell and Byone successfully cultivated the novel virus serially by passing it through organ culture of human embryonic trachea. The new cultivating method was introduced to the lab by Bertil Hoorn. The isolated virus when intranasally inoculated into volunteers caused a cold and was inactivated by ether which indicates that it had a lipid envelope. Around the same time, Dorothy Hamre and John Procknow at the isolated a novel cold virus 229E from medical students, which they grew in kidney tissue culture. The novel virus 229E, like the virus strain B814, when inoculated into volunteers caused a cold and was inactivated by ether. The two novel strains B814 and 229E were subsequently imaged by electron microscopy in 1967 by Scottish virologist Almeida at St. Thomas Hospital in London. Almeida through electron microscopy was able to show that B814 and 229E were morphologically related by their distinctive club-like spikes and were morphologically related to IBV (Chaplin, S. 2020). A research group at the National Institute of Health the same year was able to isolate another member of this new group of viruses using organ culture and named the virus strain OC43 (OC means organ culture). Like B814, 229E, and IBV, the novel cold virus OC43 had distinctive club-like spikes when observed under electron microscope. The IBV-like novel cold viruses were also morphologically related to the mouse hepatitis virus. This new group of IBV-like viruses came in existence, known as Coronaviruses. The coronavirus strain B814 was lost. It is not known that which human coronavirus was present. Other human coronaviruses have been identified, including SARS-CoV in 2003, HCoV NL63 in 2004, HCoV

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HKU1 in 2005, MERS-CoV in 2012, and SARS-CoV-2 in 2019. There also been a large number of animal coronaviruses identified since the 1960s.

Transmission electron micrograph of organ cultured coronavirus OC43

Origin of Coronavirus: coronavirus of the species Beta coronavirus1 and Many human coronaviruses have their origin in subgenus Embecovirus was originated in rodents and bats. The human coronavirus NL63 shared a common not in bats. In the 1790s, equine coronavirus diverged ancestor with a bat coronavirus (ARCoV.2) between from the bovine coronavirus after a cross-species jump. 1190 and 1449 CE. The Later in the 1890s, human coronavirus OC43 diverged shared a common ancestor with a bat coronavirus from bovine coronavirus after another cross-species (GhanaGrp1 Bt CoV) between 1686 and 1800 spillover event (Guo, Y. R. et al., 2020). It is CE. More recently, alpaca coronavirus and human speculated that the flu pandemic of 1890 may have been coronavirus 229E diverged before 1960. MERS-CoV caused by this spillover event, not by the influenza emerged in humans from bats through the intermediate virus, because of related timing, neurological symptoms host of camels. MERS-CoV, related to several bat and unknown causative agent of the pandemic. Besides coronavirus species, appears to have diverged from causing respiratory infections, human coronavirus SARS-CoV in 1986. A possible path of evolution of OC43 is also suspected of playing a role in neurological SARS coronavirus and keen bat coronaviruses is that diseases. In the 1950s, the human coronavirus OC43 SARS-related coronaviruses coevolved in bats for a began to diverge into its long time (Shereen, M. A. et al., 2020). The ancestors present genotypes. Phylogenetically, mouse hepatitis of SARS-CoV first infected leaf-nose bats of the virus (), which infects the mouse's genus Hipposideridae; subsequently, they spread to liver and central nervous system is related to human horseshoe bats in the species Rhinolophidae, then coronavirus OC43 and bovine coronavirus (Dhama, K. to Asian palm civets and finally to humans. Unlike et al., 2020). other strains such as beta coronaviruses, bovine

Microbiology of Coronavirus:

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Coronaviruses are large, roughly spherical particles expertise and hypotheses. Thus, there are different with bulbous surface projections. The average diameter criteria for testing, hospitalization and estimating of of the virus particles is around 125 nm. The diameter of cases making it difficult to calculate the number of the envelope is 85 nm and the spikes are 20 nm long. people affected by epidemic. Based on the data, the estimated case fatality ratio among medically attended The envelope of the virus in electron micrographs patients is approximately 2%. By 19th July 2020, based appears as a distinct pair of electron-dense shells (shells on the WHO reports, we have globally 1,40,07,791 that are relatively opaque to the electron beam used to confirmed cases and 5,97,105 deaths, distributed as scan the virus particle). The viral envelope consists of follows: Western Pacific Region 1.7 billion cases and a lipid bilayer, in which the membrane (M), envelope 3649 deaths, European Region 26,84,223 cases and (E) and spike (S) structural proteins are anchored. The 6,01,934 deaths, South East Asia Region 1,61,441 cases ratio of E:S:M in the lipid bilayer is approximately and 1,44,664 deaths, Eastern Mediterranean Region 1:20:300. On average a coronavirus particle has 74 6,76,508 cases and 4,18,955 deaths, Region of the surface spikes. A subset of coronaviruses (specifically Americas 75,93,083 cases and 6,01,934 deaths and in the members of subgroup A) also have the Africa region 2,00,000 cases and 5,600 deaths a shorter spike-like surface protein called hemagglutinin (Srivastava, N. et al., 2020). esterase (HE). The coronavirus surface spikes are homotrimers of S protein, which is composed of S1 Risk factors: and S2 subunit. The homotrimeric S protein is a class I Age, race/ethnicity, gender, some medical fusion protein which mediates the receptor conditions (HIV, AIDS), use of certain binding and membrane fusion between the virus and medications(corticosteroids), poverty and crowding, host cell (Sharma, A. et al., 2019). The S1 subunit certain occupations, pregnancy, chronic kidney forms the head of the spike and has the receptor binding diseases, chronic obstructive pulmonary disease, domain. The S2 subunit forms the stem which anchors weakened immune system because of organ transplant, the spike in the viral envelope and on protease obesity, serious heart conditions such as heart failure or activation enables fusion. The E and M proteins are coronary artery disease, sickle cell anemia, diabetes, important in forming the viral envelope and maintaining moderate to severe asthma, disease that affect blood its structural shape. Inside the envelope, there is vessels and blood flow to the brain, cystic fibrosis, high the nucleocapsid, which is formed from multiple copies blood pressure, dementia, liver diseases, smoking and of the nucleocapsid (N) protein binds to the positive thalassemia (Zheng, Z. et al., 2020). sense single stranded RNA genome in a continuous beads on a string type conformation. The Modes of transmission: lipid bilayer envelope, membrane proteins, and Contact and droplet transmission, airborne nucleocapsid protect the virus when it is outside the transmission, fomite transmission. Other modes of host cell. transmission include serum or plasma transmission, blood transmission, breast feeding (Shereen, M. A. et Epidemiology of Coronavirus: al., 2020). The COVID-19 epidemic expanded in early December from Wuhan, China‘s 7th most populous Clinical manifestations: city, throughout China and was then exported to a Loss of taste or smell, fever, cough, tiredness, growing number of countries. The first confirmed case shortness of breath or difficulty breathing, muscle of COVID-19 outside China was diagnosed on 13th aches, chills, sore throat, runny nose, headache, chest January 2020 in Bangkok (Thailand). On 2nd of March pain, nausea, vomiting, diarrhoea, fatigue, new 2020, 67 territories outside mainland China had confusion, inability to wake or stay awake, bluish lips reported 8565 confirmed cases of COVID-19 with 132 or face, repeated shaking with chills, blocked nose, deaths, as well as significant community transmission sputum or coughed up mucus and saliva, abdominal occurring in several countries worldwide, including Iran pain (Huang, C. et al., 2020). and Italy and it was declared as global pandemic by the WHO on 11th of March 2020. The number of Pathogenesis of COVID 19: confirmed cases is constantly increasing worldwide and Virus Entry and Spread: SARS-CoV-2 is transmitted after Asian and European regions, a steep increase in predominantly via respiratory droplet, contact, and potential cases is currently (31 March 2020) being observed in in fecal-oral. Primary viral replication is presumed to occur in low-income countries. It is problematic to quantify the mucosal epithelium of upper respiratory tract (nasal cavity and pharynx), with further multiplication in lower respiratory exact size of this pandemic as it would necessary to tract and gastrointestinal mucosa, giving rise to a mild count all cases including severe cases, symptomatic viremia. Few infections are controlled at this point and remain cases and mild ones (Dawood, F. S. et al., asymptomatic. Some patients have also exhibited non- 2020). Unfortunately, to date, there is not a global and respiratory symptoms such as acute liver and heart injury, standard response to the pandemic and each country is kidney failure, diarrhea, implying multiple organ facing the crisis based on their own possibilities, involvement. ACE2 is broadly expressed in nasal mucosa,

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Dr. Shaik Kareemulla, et al., Int Aca. Res. J Int . Med. Pub. Hlth; Vol-2, Iss- 1 (Jan-Feb, 2021): 15-24 bronchus, lung, heart, esophagus, kidney, stomach, bladder, could be observed in both lungs. Multinucleated and ileum, and these human organs are all vulnerable to syncytial cells with atypical enlarged pneumocytes SARS-Co 2. Recently, potential pathogenicity of the SARS- characterized by large nuclei, amphophilic granular CoV-2 to testicular tissues has also been proposed by cytoplasm, and prominent nucleoli were identified in clinicians, implying fertility concerns in young patients (Jin, the intra-alveolar spaces, indicating viral cytopathic-like Y. et al., 2020). changes. These pulmonary pathological findings Pathological findings: The first report of extremely resemble those seen in SARS and MERS. pathological findings from a severe COVID-19 showed Moderate microvascular steatosis and mild lobular and pulmonary bilateral diffuse alveolar damage with portal activity were observed in liver biopsy specimens, cellular fibro myxoid exudates. The right lung showed which might be caused by either SARS-CoV-2 evident desquamation of pneumocytes and hyaline infection or drug use. In addition, only a few interstitial membrane formation, indicating acute respiratory mononuclear inflammatory infiltrates were found in the distress syndrome. The left lung tissue displayed heart tissue, which means that SARS-CoV-2 might not pulmonary edema with hyaline membrane formation, directly impair the heart. Massive mucus secretion in both lungs was found in death cases with COVID-19, suggestive of early-phase acute respiratory distress syndrome (ARDS). Interstitial mononuclear which was different from SARS and MERS (Yang, M. inflammatory infiltrates, dominated by lymphocytes, et al., 2020).

Postulated pathogenesis of SARS-CoV-2 infection

Acute Respiratory Distress Syndrome (ARDS): It disorders and acute lung injury. In fatal cases of human is a life-threatening lung condition that prevents enough SARS-CoV, MERS-CoV, and SARS-CoV-2 infections, oxygen from getting to the lungs and into the individuals exhibit severe respiratory distress requiring circulation, accounting for mortality of most respiratory

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Dr. Shaik Kareemulla, et al., Int Aca. Res. J Int . Med. Pub. Hlth; Vol-2, Iss- 1 (Jan-Feb, 2021): 15-24 mechanical ventilation, and the histopathology findings coughing up sputum in a special cup or a swab is also support ARDS (Xu, Z. et al., 2020). used to take a sample from nose. . Blood test: Blood sample is taken from a vein in Cytokine storm: Clinical findings showed the arm. exuberant inflammatory responses during SARS-CoV-2  Rapid diagnostic tests based on antigen infection, further resulting in uncontrolled pulmonary detection: A rapid test has also been started for the inflammation, likely a leading cause of case fatality. COVID-19, which involves taking samples from Rapid viral replication and cellular damage, virus- the nose, throat, and lungs. Rapid diagnostic test induced ACE2 down regulation and shedding, and (RDT) of a sample of the respiratory tract of a antibody dependent enhancement (ADE) are person helps to detect the viral proteins (antigens) responsible for aggressive inflammation caused by related to COVID-19 virus. SARS-CoV-2, as concluded in a recently published  Rapid diagnostic tests based on host antibody review article. A possible underlying mechanism of detection: This test detects the presence of antibody-dependent enhancement (ADE) has been antibodies in the blood of COVID-19 infected proposed recently. ADE, a well-known virology people. The strength of antibody response depends phenomenon, has been confirmed in multiple viral on several factors like age, medications, infections, infections. ADE can promote viral cellular uptake of and severity of disease etc. (Pascarella, G. et al., infectious virus–antibody complexes following their 2020). interaction with Fc receptors (FcR), FcγR, or other receptors, resulting in enhanced infection of target cells. Naso-pharyngeal swab test: The interaction of FcγR with the virus-anti-S protein-  A nasal swab is collected from a patient at a neutralizing antibodies (anti-S-IgG) complex may hospital or other testing site. facilitate both inflammatory responses and persistent  The swab is placed into a tube that contains liquid viral replication in the lungs of patients (Mustafa, M. I. media. Some of the media is transferred to a et al., 2020). special, barcoded tube provided by the Broad Institute‘s Genomics Platform. Immune dysfunction: Peripheral CD4 and CD8 T  The tube is sent to the Board Institute Clinical cells showed reduction and hyperactivation in a severe Research Sequencing Platform, a CLIA-certified patient. High concentrations of proinflammatory CD4 T clinical lab, where it is unpacked in a clean room cells and cytotoxic granules CD8 T cells were also and registered in the laboratory‘s electronic system determined, suggesting antiviral immune responses and for verification and tracking. overactivation of T cells. Additionally, several studies  Within a safety hood in the lab, an automated have reported that lymphopenia is a common feature of liquid handling machine transfers the liquid from COVID-19, suggestive of a critical factor accounting each barcoded tube into one well of a 96-well plate. for severity and mortality. This allows dozens of individual samples to be processed at once. Diagnostic parameters of COVID-19:  The liquid handling machine extracts any viral These are different types of coronavirus tests RNA from the samples. . Swab Test: In this case, a special swab is used to  Automating this step speeds up the RNA take a sample from your nose or throat. extraction, allowing for up to 2000 tests to be . Nasal aspirate: In this case, a saline solution will processed each day. be injected into nose and, then a sample is taken  Each plate is inserted into one of four high- with a light suction. throughput quantitative polymerase chain reaction . Tracheal aspirate: In this case, a thin tube with a (qPCR) machines. torch, also known as a bronchoscope, is put into  Inside the qPCR machine, a fluorescent dye that mouth to reach lungs from where a sample is sticks to viral complementary DNA is mixed with collected. each sample. The machine measures the fluorescent . Sputum Test: Sputum is thick mucus that gets signal, which indicates the presence of the COVID- accumulated in the lungs and comes out with a 19 virus. cough. During this test, individual required  Results are sent to hospital and physicians through a secure network (Susanna Hamilton et al., 2019).

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Diagrammatic representation of nasopharyngeal swab test

Reverse Transcription Polymerases Chain Reaction throat and multiply in the lungs. In the second (RT-PCR): week, sputum or deep airways collection is  Polymerase chain reaction (PCR) is a process preferred. that amplifies (replicates) a small, well-defined  Collecting saliva may be as effective as nasal and segment of DNA many hundreds of thousands of throat swabs although this is not certain. Sampling times, creating enough of it for analysis. Test saliva may reduce the risk for health care samples are treated with certain chemicals that professionals by eliminating close physical allow DNA to be extracted. Reverse interaction. It is also more comfortable for the transcription converts RNA into DNA. patient. Quarantined people can collect their own  Reverse transcription polymerase chain samples. A saliva test's diagnostic value depends reaction (RT-PCR) first uses reverse transcription on sample site (deep throat, oral cavity, or salivary to obtain DNA, followed by PCR to amplify that glands) (Abbasi, J. 2020). DNA, creating enough to be analyzed. RT-PCR can thereby detect SARS-CoV-2, which contains only Treatment for COVID-19: RNA. The RT-PCR process generally requires a It has been over six months since the first case of few hours. corona virus was detected in China's Wuhan province.  Real-time PCR (qPCR) provides advantages More than half a million people across have since lost including automation, higher-throughput and more their lives to the killer disease. reliable instrumentation. It has become the  Azithromycin: This must be the most widely preferred method. prescribed and misused antibiotic in this pandemic.  The combined technique has been described as Azithromycin, as with all other antibiotics, does not real-time RT-PCR or quantitative RT-PCR and is work in viral infections. Antibiotics are only sometimes abbreviated qRT-PCR rRT-PCR or RT- warranted in patients who have evidence of a qPCR, although sometimes RT-PCR or PCR are secondary bacterial infection as some hospitalized used. The Minimum Information for Publication of patients will have in the later stages of their Quantitative Real-Time PCR Experiments (MIQE) disease. guidelines propose the term RT-Qpcr, but not all  Blood Thinners: Hospitalized Covid-19 patients authors adhere to this Samples can obtained by have been observed to have a very high incidence various methods, including a nasopharyngeal of blood clots. There is current global consensus swab, sputum (coughed up material), throat that all hospitalized Covid-19 patients will benefit swabs, deep airway material collected via suction from blood thinners injected daily just under their catheter or saliva. Drosten et al.,. remarked that for skin (like insulin injections). Though there is sound 2003 SARS, "from a diagnostic point of view, it is mechanistic reasoning, randomized controlled trials important to note that nasal and throat swabs seem are awaited. less suitable for diagnosis, since these materials  Favipiravir: This is an oral antiviral drug which contain considerably less viral RNA than sputum, was fast tracked by the Indian Drug Controller but and the virus may escape detection if only these is not yet approved in the EU or US. Its use should materials are tested.‘‘ be restricted to mild or moderate infections only.  The likelihood of detecting the virus depends on Available data to support its use is sparse but collection method and how much time has passed Indian trials have just been completed and the since infection. According to Drosten tests results are awaited. performed with throat swabs are reliable only in the first week. Thereafter the virus may abandon the 20

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 Hydroxychloroquine sulphate: We now have the surface spike protein and can potentially bock compelling data from multiple large clinical trials the infection. including WHO‘s SOLIDARITY and the UK‘s  Miscellaneous “cures”: The state machinery has RECOVERY trials to categorically say: HCQS been used to distribute unproven herbal and does not work. Ayurvedic potions (Ukalo), homeopathic drops  Convalescent Plasma: Our blood is composed of (Arsenicum album), and ―treatments‖ peddled by cells and plasma. Plasma from those who have god-men. Anecdotes and observations do not recovered from Covid-19 carries naturally acquired constitute scientific evidence. In the absence of antibodies and when transfused to critically ill evidence generated from rigorously vetted clinical patients with Covid-19, may help improve trials, the distribution of these substances must be outcomes. This form of therapy is being used condemned. Pushing unproven and supposedly across the globe and trials to access its efficacy are harmless ―treatments‖ and distributing them to under way. hundreds of thousands is not only disingenuous,  Remdesivir: An intravenously administered but provides people false hope, and risks them antiviral medication, it has been shown to be lowering their guard (Das, S. et al., 2020). effective in well-designed studies. It seems to shorten recovery time and hospital stay but does Precautions: not reduce the chance of death. It is currently to be Until a COVID-19 vaccine is developed, it's crucial used only in hospitalized patients with severe to slow the spread of the COVID-19 virus and protect disease. individuals at increased risk of severe illness, including  Steroids: Current evidence shows older adults and people of any age with underlying that dexamethasone can reduce deaths by one- health conditions. To reduce the risk of infection: third in patients with severe Covid-19 infection  Avoid large events and mass gatherings. who need oxygen therapy or ventilators.  Avoid close contact (within about 6 feet, or 2  Methyprednisolone is another steroid being used meters) with anyone who is sick or has by Indian doctors to handle moderate to severe symptoms. covid-19 cases.  Stay home as much as possible and keep  Tocilizumab: This drug is an injection originally distance between yourself and others. used in patients with rheumatoid arthritis. It is  Wash your hands often with soap and water for being widely used to counter the severe at least 20 seconds, or use an alcohol-based inflammation (cytokine storm) that occurs in some hand sanitizer that contains at least 60% Covid-19 patients. Its use can increase the risk of alcohol. bacterial infections, and it must therefore be used  Wear a cloth face covering in public spaces, with caution, if at all, in carefully selected patients. such as the grocery store, where it's difficult to  Itolizumab: Biocon's Hospital-only, Injectible avoid close contact with others, especially if drug earlier approved for the treatment of Psoriasis. you're in an area with ongoing community Has got Emergency Use Authorisation for spread. Only use nonmedical cloth masks — treatment of moderate to severe COVID-19 surgical masks and N95 respirators should be patients. Approval based on 30 patients‘ clinical reserved for health care providers. trial where 20 patients were out on Itolizumab, 10  Cover your mouth and nose with your elbow or randomised on standard care. a tissue when you cough or sneeze. Throw  Arbidol: This antiviral was tested along with the away the used tissue. drug lopinavir/ritonavir as a treatment for COVID-  Avoid touching your eyes, nose and mouth. 19. Researchers reported in mid-April that the two  Avoid sharing dishes, glasses, bedding and drugs didn‘t improve the clinical outcomes for other household items if you're sick. people hospitalized with mild to moderate cases of  Clean and disinfect high-touch surfaces, such as COVID-19. doorknobs, light switches, electronics and  Heparin: a common anti-coagulant drug this is counters, daily. used in treating covid -19 patients. The SARS- CoV2 virus works by using its spike protein to  Stay home from work, school and public areas attach to human cells and begin infection. if you're sick (Cascella, M. et al., 2020). According to recent findings, heparin can bind with

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Environmental cleaning and disinfection:  Environmental decontamination.  Cleaning of medical equipment.  Cleaning soiled bedding, towels and clothes from patients with COVID-19.  Cleaning and disinfection of occupied patient rooms.  Cleaning and disinfection after patient discharge and transfer.  Prevent environment contamination: contain respiratory secretions.

Respiratory hygiene/etiquette:  Reduces the spread of microorganisms that cause respiratory infections (colds, flu).  Turn head away from others when coughing/sneezing  Cover the nose and mouth with a tissue.  If tissues are used, discard immediately into the trash  Cough/sneeze into sleeve if no tissue is available  Clean hands with soap, water or alcohol based products. Do not spit here and there (Tobaiqy, M. 2020).

Herd immunity:

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Herd immunity occurs when a large portion of a amount of infection could also lead to serious community (the herd) becomes immune to a disease, complications and millions of deaths, especially among making the spread of disease from person to person older people and those who have chronic conditions unlikely. As a result, the whole community becomes (Randolph, H. E., & Barreiro, L. B. 2020). protected not just those who are immune. Often, a percentage of the population must be capable of getting Role of clinical pharmacist in reducing disease a disease in order for it to spread. This is called a transmission: threshold proportion. If the proportion of the population 1) Be a role model and educate others about infection that is immune to the disease is greater than this prevention basics. threshold, the spread of the disease will decline. This is 2) Provide sound guidance to patients and customers. known as the herd immunity threshold (John, T. J., & 3) Offer strategies for symptom management for Samuel, R.2000). patients with minor viral illnesses. 4) Direct people to reliable resources. How is herd immunity achieved? 5) Keep up to date on the situation as it evolves. There are two paths to herd immunity for COVID- 6) Develop guidance for providing pharmacy services. 19 — vaccines and infection. 7) Create formulary manuals and medicine news to assist clinicians in better. Vaccines: 8) Establish drug registration research. A vaccine for the virus that causes COVID- 9) Establish evidence-based drug evaluation and 19 would be an ideal approach to achieving herd guideline. immunity. Vaccines create immunity without causing 10) Remote inpatient order review and dispensing. illness or resulting complications. Herd immunity 11) Tele-pharmaceutical care in fangcang shelter makes it possible to protect the population from a hospital. disease, including those who can't be vaccinated, such 12) Develop individual treatment with as newborns or those who have compromised immune multidisciplinary team. systems. Using the concept of herd immunity, vaccines 13) Telehealth counselling and patient education have successfully controlled deadly contagious diseases (Gross, A. E., & MacDougall, C. 2020). such as smallpox, polio, diphtheria, rubella and many others. People who object to vaccines often live in the cknowledgement: same neighborhoods or attend the same religious A services or schools. If the proportion of vaccinated The authors of the study would like to express their people in a community falls below the herd immunity sincere thanks to Dr. S Nelson Kumar, (Principal), M. threshold, exposure to a contagious disease could result Venkata Subbaiah, (HOD), P. Gowtham Kumar Reddy in the disease quickly spreading. Measles has recently & S. Padmakar, (faculty members), department of resurged in several parts of the world with relatively pharmacy practice of P. Rami reddy Memorial College low vaccination rates, including the United States. of Pharmacy, Kadapa, Andhra Pradesh. Opposition to vaccines can pose a real challenge to herd immunity. Declaration of Conflicting Interests: The author(s) declared no potential conflicts of Natural infection: interest with respect to the research, authorship, and/or However, there are some major problems with publication of this article. relying on community infection to create herd immunity to the virus that causes COVID-19. First, it isn't yet Conflict of Interest: clear if infection with the COVID-19 virus makes a The authors declare no conflict of interest person immune to future infection. REFERENCES: Research suggests that after infection with some 1. Abbasi, J. (2020). The promise and peril of coronaviruses, reinfection with the same virus though antibody testing for COVID-19. Jama, 323(19), usually mild and only happening in a fraction of people 1881-1883. is possible after a period of months or years. Further 2. Cascella, M. et al., (2020). features, evaluation and research is needed to determine the protective effect of treatment coronavirus (covid-19), 4th july, 2020. antibodies to the virus in those who have been infected. 3. Chaplin, S. (2020). Covid-19: A brief history and Even if infection with the COVID-19 virus creates treatments in the development, Steve Chaplin, long-lasting immunity, a large number of people would published online 21st May 2020. have to become infected to reach the herd immunity 4. Das, S. et al., (2020). covid-19 treatment: A threshold. Experts estimate that in the U.S, 70% of the lowdown on possible cure and drugs being used, population more than 200 million people would have to 18th july, 2020. recover from COVID-19 to halt the epidemic. If many people become sick with COVID-19 at once, the health care system could quickly become overwhelmed. This

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