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Journal of Infection and Public Health xxx (2020) xxx–xxx
Contents lists available at ScienceDirect
Journal of Infection and Public Health
journal homepage: http://www.elsevier.com/locate/jiph
The outbreak of the novel severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2): A review of the current global status
1
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Q2
Mbarka Bchetnia a , Catherine Girard a , Caroline Duchaine b,c , Catherine Laprise a,∗
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a
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b
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c
Université du Québec à Chicoutimi (UQAC), Département des sciences fondamentales, Centre intersectoriel en santé durable, Saguenay, Canada
Centre de recherche, Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval (IUCPQ-UL), Québec, Canada
Département de biochimie, de microbiologie et de bioinformatique, Université Laval, Québec, Canada
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8
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a r t i c l e
i n f o
a b s t r a c t
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Article history:
Received 10 May 2020
Received in revised form 13 July 2020
Accepted 21 July 2020
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Keywords:
SARS-CoV-2
COVID-19
Emergence
Transmission
Prevention
Treatment
23
Contents
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There is currently an ongoing worldwide pandemic of a novel virus belonging to the family of CoroQ3 naviruses (CoVs) which are large, enveloped, plus-stranded RNA viruses. Coronaviruses belong to the
order of Nidovirales, family of Coronavirinae and are divided into four genera: alphacoronavirus, betacoronavirus, gammacoronavirus and deltacoronavirus. CoVs cause diseases in a wide variety of birds and
mammals and have been found in humans since 1960. To date, seven human CoVs were identified including the alpha-CoVs HCoVs-NL63 and HCoVs-229E and the beta-CoVs HCoVs-OC43, HCoVs-HKU1, the
Q4 severe acute respiratory syndrome-CoV (SARS-CoV), the Middle East respiratory syndrome-CoV (MERSCoV) and the novel virus that first appeared in December 2019 in Wuhan, China, and rapidly spread to
213 countries as of the writing this paper. It was officially named severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) by the international committee on taxonomy of viruses (ICTV) and the disease’s name is COVID-19 for coronavirus disease 2019. SARS-CoV-2 is very contagious and is capable of
spreading from human to human. Infection routes include droplet and contact, and aerosol transmission
is currently under investigation. It is associated with a respiratory illness that may cause severe pneumonia and acute respiratory distress syndrome (ARDS). SARS-CoV-2 became an emergency of international
concern. As of July 12, 2020, the virus has been responsible for 12,698,995 confirmed cases and 564,924
deaths worldwide and the number is still increasing. Up until now, no specific treatment has yet been
proven effective against SARS-CoV-2. Since the beginning of this outbreak, several interesting papers on
SARS-CoV-2 and COVID-19 have been published to report on the phylogenetic evolution, epidemiology,
pathogenesis, transmission as well as clinical characteristics of COVID-19 and possible treatments agents.
This paper is a systematic review of the available literature on SARS-CoV-2. It was performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and aims
to help readers access the latest knowledge surrounding this new infectious disease and to provide a
reference for future studies.
© 2020 The Author(s). Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for
Health Sciences. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Inclusion and exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Data extraction and synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
SARS-CoV-2 emergence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Clinical features and pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
∗ Corresponding author.
E-mail address: catherine laprise@uqac.ca (C. Laprise).
https://doi.org/10.1016/j.jiph.2020.07.011
1876-0341/© 2020 The Author(s). Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Bchetnia M, et al. The outbreak of the novel severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2): A review of the current global status. J Infect Public Health (2020), https://doi.org/10.1016/j.jiph.2020.07.011
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SARS-CoV-2 transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
SARS-CoV-2 structure and cells infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
SARS-CoV-2 diagnosis tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
SARS-CoV-2 treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Antiviral agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Chloroquine and hydroxychloroquine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Antibodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Convalescent plasma transfusion (CP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Global SARS-CoV-2 prevention measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Competing interests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Ethical approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Author contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Uncited reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
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Introduction
Coronaviruses (CoV) are the largest known RNA viruses. Their
size varies from 65 to 125 nm in diameter and their nucleic acid
genome is single-stranded RNA, size ranging from 26 to 32 kb in
35
36Q5 length [1]. Since 1960, six coronaviruses have been found to cause
diseases in humans; SARS-CoV-2 is the seventh one, after SARS-CoV
37
and MERS-CoV [2]. While HKU1, NL63, OC43 and 229E are associ38
ated with mild symptoms in humans, SARS-CoV, MERS-CoV, and
39
SARS-CoV-2, belonging to the betacoronavirus genus, cause severe
40
to deadly pneumonia in humans [3]. Fever, dry cough, difficulty
41
breathing and fatigue usually accompany this pneumonia [4,5]. The
42
fatality rates of SARS-CoV, MERS-CoV and SARS-CoV-2 are 9.5%,
43
34.4%, and 2.3% respectively [6]. COVID-19 shows some particu44
lar pathogenic, epidemiological and clinical features which have
45
are not completely understood to date as well as its wide and high
46
transmission in the community versus nosocomial spread of SARS
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and MERS and its milder infection and low mortality compared to
48
the severe phenotype and higher mortality caused by the two oth49
ers viruses [7]. To date, no therapeutic or vaccines were approved
50
against any of the known human coronaviruses and only protec51
tive measures were put in place. Based on the current published
52
literature, we summarize in this paper the origin of this novel virus
53
and its life cycle, the clinical characteristics of the disease, the possi54
ble transmission routes, the pathogenesis, the prevention measures
55
and the undergoing treatments of this emerging infectious
56
disease.
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Inclusion and exclusion criteria
Inclusion and exclusion criteria were recorded following
PRISMA guidelines presented in the form of a PRISMA flow diagram (Fig. 1). Briefly, the retrieved literature was imported into
Endnote software (v. × 9.0) and screened for exclusion criteria.
First, duplicate literature was removed by Endnote, and then obviously inappropriate ones were eliminated based on the title and
abstract. Finally, remaining inappropriate entries were eliminated
by reading the full articles. The exclusion criteria for articles were
non-English studies, entries with only an abstract, those with no
relevant topic, and studies containing no useful or duplicated data
from previously published studies. The inclusion criteria are articles reporting confirmed SARS-CoV-2 positive patients, and studies
presenting original data as well as clear and precise end-point outcomes.
Data extraction and synthesis
The authors independently extracted important information
from each article fulfilling the inclusion criteria and reviewed each
paper to verify the accuracy and coherence of collected data. Arguments or disagreements were resolved following discussions. The
consensus extracted data were synthesized in the present paper.
Ethical approval was not required for this review of existing peerreviewed papers.
Results
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Methods
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Search strategy
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The present study was conducted following the PRISMA
guidelines [8]. We performed a systematic search for accessible
peer-reviewed and full articles published from December 2019 to
May 2020. The literature search was updated in July 2020 while
reviewing the paper prior to its resubmission. Articles for review
were selected from the following databases MEDLINE (PubMed),
Web of Science and Google Scholar. The search terms included combinations of “COVID-19, SARS-CoV-2, new coronavirus, emergence,
symptoms, multiplication cycle, transmission, diagnosis tests, prevention, and treatment”. Full-text versions of the included papers
were retrieved. The reference lists of relevant studies were also
assessed.
We identified 170 papers through PubMed, Web of science
and Google Scholar databases and 20 papers through reference
cross-check and internet research of conference abstracts. After
duplicate removal, a total of 130 papers were screened for relevance. Abstracts and titles screening identified 32 studies that met
the inclusion criteria. After the full-text analyses, 12 of these studies were excluded. Hence, twenty studies were eligible according
to our criteria and were included in this review (Fig. 1).
SARS-CoV-2 emergence
Coronaviruses have been described as causing several systemic
infections in their selected animal host [9]. However, some of
them can adapt dramatically and jump the species barrier by natural recombination causing epidemics or pandemics. Infection in
human often leads to severe clinical symptoms and high mortal-
Please cite this article in press as: Bchetnia M, et al. The outbreak of the novel severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2): A review of the current global status. J Infect Public Health (2020), https://doi.org/10.1016/j.jiph.2020.07.011
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Fig. 1. PRISMA flowchart of literature search strategy.
Fig. 2. Emergence of human coronaviruses: As of July 12, 2020, seven CoVs are known to be human pathogens including the alpha-CoVs HCoVs-NL63 (1200-1500) and
HCoVs-229E (1700-1800) and the beta-CoVs HCoVs-OC43 (1890), HCoVs-HKU1 (1950), severe acute respiratory syndrome-CoV (SARS-CoV) (2002), Middle East respiratory
syndrome-CoV (MERS-CoV) (2012) and the novel SARS-CoV-2 (2019).
Please cite this article in press as: Bchetnia M, et al. The outbreak of the novel severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2): A review of the current global status. J Infect Public Health (2020), https://doi.org/10.1016/j.jiph.2020.07.011
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Fig. 3. SARS-CoV-2 situation update worldwide: As of July 12, 2020, 12,698,995 cases of COVID-19 have been reported in the world including 564,924 deaths. The most
affected continent is the America with 6,685,097 confirmed cases and 286,796 deaths on this day (https://www.ecdc.europa.eu/).
Table 1
Comparative analysis of SARS-CoV, MERS-CoV, and SARS-CoV-2.
SARS-CoV
MERS-CoV
SARS-CoV-2
Emergency year
Emergency area
Number of infected countries
Animal reservoir
Intermediate host
incubation time in humans (days)
Caused disease
2002
Guangdong province, China
29
Bat
Palm civets
2–7
Severe acute respiratory syndrome
(SARS)
Malaise, diarrhea, cough, fever and
shortness of breath
8098
776
Angiotensin-converting enzyme 2
(ACE2)
Supportive care
2013
Arabian peninsula
27
Bat
Camels
2–14
Middle East respiratory syndrome
(MERS)
Pneumonia, acute respiratory distress
syndrome, renal failure
2254
858
Dipeptidyl peptidase 4 (DPP4)
2019
Wuhan, China
213
Bat
Unknown
2–14
Coronavirus disease 2019 (COVID-19)
Clinical symptoms
Number of infected patients
Number of deaths
Entry receptor in human cells
Used therapy
110
111
112
113
114
115
116
117
118
119
120
121
122
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Q1
Coronavirus
ity (https://www.who.int/emergencies/mers-cov/en/). We present
in Fig. 2 the appearance of the seven human coronaviruses over
the time (Fig. 2). In 2002, in Guangdong (China), the SARS-CoV
virus emerged and spread to the five continents infecting 8098
people and causing 774 deaths (9.5% of cases). In 2012, MERSCoV emerged in the Arabian Peninsula infecting 2494 people in
27 countries and causing 858 deaths (34.4% of cases) [10]. In late
December 2019, SARS-CoV-2 emerged in a seafood market (where
several wildlife species are sold including bats, rabbits, snakes, birds
and frogs) in Wuhan City, Hubei province, China [11]. As of July
12, 2020, this virus has been responsible for 12,698,995 confirmed
cases and 564,924 deaths worldwide (2.3%). SARS-CoV-2 spread
rapidly to 213 countries (at the time of revision), and the most
affected continents are the America and Europe with 6,685,097
Supportive care
Cough, fever and shortness of breath
3,646,304
252,425
Angiotensin-converting enzyme 2
(ACE2)
Supportive care
and 2,572,406 confirmed cases respectively since 31 December
2019 and as of July 12, 2020. In America, 286,796 persons were
died and 196,096 ones in Europe until this day (https://www.ecdc.
europa.eu/) (Fig. 3). On January 30, 2020, the World Health Organization (WHO) declared the SARS-CoV-2 epidemic as a public
health emergency of international concern [12]. On March 11, 2020,
the WHO issued an announcement of the change in COVID-19’s
status from an epidemic to pandemic disease. It was suggested
that MERS-CoV, SARS-CoV and SARS-CoV-2 originated from bats
[13]. Phylogenetic analyses showed that SARS-CoV-2, SARS-CoV
and SARS-like coronaviruses isolated in bats belong to a different
clade than MERS-CoV, with a complete genome nucleotide identity between SARS-CoV-2 and SARS-CoV of 79.5% and between
SARS-CoV-2 and bat SARS coronavirus (SARSr-CoV-RaTG13) of 96%
Please cite this article in press as: Bchetnia M, et al. The outbreak of the novel severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2): A review of the current global status. J Infect Public Health (2020), https://doi.org/10.1016/j.jiph.2020.07.011
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[14,13]. Palm civets and racoon dogs were identified as the likely
reservoir host fuelling spillover to humans for SARS-CoV [15,16],
while MERS-CoV’s intermediate host is unequivocally dromedary
camels [17,18]. For SARS-CoV-2, pangolins and snakes are thought
to be potential intermediate hosts but this requires further confirmation [19]. More evidence is needed to confirm the origin of
this novel virus and its transmission to humans, to understand the
best way to prevent and slow down its transmission and to better control of future zoonotic events. In Table 1, we summarize the
principal characteristics of SARS-CoV, MERS-CoV and SARS-CoV-2.
Briefly, bats seem to be the common natural origin of SARS-CoV-2,
SARS-CoV and MERS-CoV. The clinical features of the three viruses
are quite similar. However, unlike SARS-CoV and MERS-CoV, SARSCoV-2 is more contagious and spreads rapidly, currently affecting
more than 213 countries (https://www.who.int). SARS-CoV-2 uses
the SARS-CoV receptor angiotensin-converting enzyme 2 (ACE2)
on host target cells; however, MERS-CoV binds to the dipeptidyl
peptidase 4 receptor (DDP4) [20]. According to the latest studies,
SARS-CoV-2 has the highest number of casualties but its mortality rate is lower (2.3%) compared to SARS-CoV (9.5%) and MERS
(34.4%) [6]. Therefore, SARS-CoV-2 resembles both SARS-CoV and
MERS-CoV, but appears unique in its high transmission rates.
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Clinical features and pathogenesis
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COVID-19 is a highly contagious disease. Its clinical manifestations range from mild to severe but most infected cases present
a mild form of the disease and therefore have no severe clinical
features [21]. Based on current data, 81% of the cases exhibit mild
symptoms and 1.2% are asymptomatic (http://weekly.chinacdc.cn).
SARS-CoV-2 can spread rapidly in the community contrarily to
SARS CoV and MERS-CoV that have a higher mortality rate but a
stronger nosocomial than community transmissibility. This is likely
due to the fact that they cause a more severe clinical phenotype
than COVID-19 [6]. It was reported that COVID-19 average incubation period is 5.2 days (95% confidence interval (CI), 4.1–7.0) with
the 95th percentile at 12.5 days [22]. Another study estimated it
at 6.4 days (95% CI, 5.6–7.7) [23]. The median age of COVID-19
cases ranges from 49 to 57 years [6] and median time from the
first symptom to death is 14 days [24]. While a detailed clinical
landscape continues to be established, the most common clinical
symptoms of SARS-CoV-2 observed in patients were fever (87.9%),
cough (67.7%) and fatigue (38.1%), whereas diarrhea (3.7%) and
vomiting (5.0%) were occasional [24,25]. All patients had pneumonia and about half had dyspnea [26]. Some COVID-19 patients
showed arrhythmia, acute heart injury, impaired renal function
and abnormal liver function (50.7%) at admission [27,28]. In addition, there is evidence of ocular surface infection in patients with
COVID-19 as SARS-CoV-2 RNA was detected in eye secretions of
patients [29,30]. A retrospective case series study conducted on
214 infected patients from Wuhan showed that 78 (36.4%) patients
displayed neurologic manifestations [31]. Furthermore, diminished
ability to smell or taste observed in some patients [32,33] was
found to result from a neurotropic or neurovirulent viral infection
of the olfactory system [34]. The older population and individuals
with underlying health complications as cardiovascular diseases
and diabetes were reported to present the severe disease symptoms
[35]. Children were found less vulnerable than the elder population
[36,37]. Pregnant women may be more vulnerable to SARS-CoV-2
as this virus may alter the immune responses at the maternalfetal interface, and affect the well-being of mothers and infants
[38]. A retrospective study based on nine pregnant women infected
by COVID-19 showed no evidence of intrauterine vertical transmission between mothers and infants in the late pregnancy [39].
To avoid SARS-CoV-2 newborns infections after birth, immediate
prevention instructions should be implemented for these women
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and their neonates, including a 14-day isolation for newborns
and avoiding breast feeding during this period [40]. Laboratory
findings showed typical CT results including bilateral pulmonary
parenchymal ground glass and consolidated pulmonary opacities
sometimes with a rounded morphology and peripheral lung distribution [41]. Ground-glass-like lung images are probably due to the
severe inflammation of lung cells becoming unable to exchange carbon dioxide and oxygen after SARS-CoV-2 infection [42]. A recent
study showed that that SARS-CoV-2 could infect T cells explaining
the lymphocytopenia commonly found in COVID-19 patients [43].
It was also observed that most critically ill patients infected with
SARS-CoV-2 had elevated levels of inflammatory cytokines (IL-6
and IL-10) [44], indicating potential bacterial co-infection caused
by dysregulated immune system [45]. Moreover, Nguyen team,
by using in silico analysis, showed that genetic variability across
the three major histocompatibility complex (MHC) class I genes
(human leukocyte antigen [HLA] A, B, and C) may affect susceptibility to and severity of COVID-19 which need further experimental
investigation [46].
SARS-CoV-2 transmission
Understanding transmission pathways of SARS-CoV-2 has significant implications for intervention and prevention. It was
initially suggested that Chinese patients infected with SARS-CoV2 may have visited the seafood market in Wuhan City or may
have consumed infected animals. However, further investigation
revealed that some individuals contracted the COVID-19 without visiting the market. Indeed, an epidemiological study in early
cases in this city showed that only 22% of patients were directly
exposed to the marketplace, 32% of cases were in close contact
with the suspected cases and 51% had no contact with either source
[47]. This suggests a human-to-human transmission of the virus
and an ability to propagate, resulting in disease clusters from a
single index patient [48,49]. The WHO estimated the reproductive number (R0) of SARS-CoV-2 to range between 2 and 2.5,
which is higher than SARS (1.7–1.9) and MERS (<1). This suggests that SARS-CoV-2 has a higher pandemic potential [50,51].
Three transmission ways of SARS-CoV-2 in humans were proposed with incubation times of 2–14 days: 1) contact with liquid
droplets produced by infected patients and/or 2) close contact with
infected individuals and 3) contact with surfaces and material contaminated with SARS-CoV-2 (https://www.cdc.gov/coronavirus/
2019ncov/about/transmission). In experimental setups, infectious
viruses could be detected up to 24 h on cardboard, up to 2–3 days
on plastic and stainless steel and up to 3 h post aerosolization
(van Doremalen et al. 2020). Certain scientists recently highlighted
another possible transmission route, the airborne transmission
through droplet nuclei (or aerosols), meaning the possibility of
the disease spreading in much smaller particles from exhaled air,
known as aerosols. They are suggesting that aerosols are also more
likely than droplets to be produced by talking and breathing and
might pose a higher probability of transmission than coughing and
sneezing [52]. In lab experiments, infectious SARS-CoV-2 particles
were detected in aerosols for 3 h [53]. Liu and colleagues at Wuhan
University collected samples of aerosols in and around hospitals
treating COVID-19 patients and found viral RNA from SARS-CoV2 on protective apparel and floor surface and their subsequent
resuspension. In this study, viral RNA concentration in aerosol samples was low (0–42 genomes/cubic metre of air) [54]. An American
team studied the presence of SARS-CoV-2 in air samples and surfaces from 11 isolation rooms of COVID-19 patients and showed
that many (63%) of air samples had evidence of viral contamination, with higher airborne virus concentration (2860 copies per
cubic metre of air) [55]. It is noteworthy to mention that infectious
viruses have not been recovered from aerosols in any study. In a
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Fig. 4. SARS-CoV-2 life cycle in infected cells and inhibition targets: SARS-CoV-2 begins its life cycle by binding of the S protein presented on the surface of the virus to
the cellular receptor ACE2 on the target cell. After receptor binding, the S protein changes conformation, facilitating viral envelope fusion with the infected cell membrane
through endocytosis. SARS-CoV-2 then releases its genetic material into the host cell. Genomic RNA is translated into viral replicase polyproteins pp1a and 1ab, which are
then cleaved into small products by viral proteinases. By discontinuous transcription, the polymerase produces a series of subgenomic mRNAs that are translated into viral
proteins. The positive-sense genomic RNA is then packaged into a ribonucleocapsid and is assembled into viral particles in the ER and Golgi apparatus where they undergo
maturation. Virions are finally transported via small vesicles and released out of the cell through exocytosis. Inhibition targets are presented in red.
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recently published paper, ten air samples of patient rooms with
confirmed COVID-19 cases in the largest clinical hospital in Iran
showed that all air samples were negative [56]. This may be because
of air sampling processes damaging the viruses or because the virus
does not resist easily to aerosolization process. Finally, given the
general scientific knowledge about aerosol long distance indoor
transport, aerosol scientists have proposed that airborne transmission of SARS-CoV-2 is most likely to occur in poorly ventilated
spaces [57].
SARS-CoV-2 structure and cells infection
SARS-CoV-2 RNA genome is 29.9 kb [58]. It contains 14 open
reading frames (ORFs), encoding 27 proteins. At the 5’-terminal
region of the genome, the ORF1 and ORF2 encode 15 non-structural
proteins important for virus multiplication. The 3’-terminal region
of the genome encodes functional structural proteins, namely spike
(S), envelope protein (E), membrane protein (M) and nucleocapsid
(N), plus 8 accessory proteins [59,58]. Phylogenetic and computational genomic analyses suggest that to enter in host’s cells,
SARS-CoV-2 shares the same human cell receptor with SARS-CoV
(ACE2), while MERS-CoV uses another (DPP4) [20]. ACE2 is an
ectoenzyme anchored to the plasma membrane of the cells of
several tissues, particularly in the lower respiratory tract, heart,
kidneys and gastrointestinal tract [60]. A structure model analysis shows that SARS-CoV-2 binds ACE2 with above 10 folds
greater affinity than SARS-CoV, and much higher than the threshold required for viral infection [61]. The Spike (S) protein (of
about 150 kDa) is the major antigen presented on the surface of
SARS-CoV-2. The S protein forms a transmembrane homotrimer
protruding from the viral surface to attach to the host cellular
receptor ACE2. S comprises two functional subunits: subunit S1
responsible for binding to the cell surface receptor ACE2 and subunit S2 responsible viral fusion to the cell membrane [62].
SARS-CoV-2 hijacks host cells (such as lung cells) by endocytosis
[63,64]. First, S protein binds to the cellular receptor ACE2 [65]. This
attachment is followed by activation of the S protein, which initiates fusion of the viral membrane with the membrane of the host
cell [10]. This fusion allows the virus to enter the cells [66]. SARSCoV-2 releases its genetic material into the cell cytoplasm where
it is translated into the viral replicase polyproteins pp1a and 1ab.
Pp1a and p1ab are then cleaved by viral proteinases to form functional non-structural proteins (NSPs) such as a helicase (Hel) and
the RNA-dependent RNA polymerase (RdRp) which is responsible
for replication of structural protein RNA [67]. The plus-stranded
RNA genome of SARS-CoV-2 will serve to synthetize subgenomic
Please cite this article in press as: Bchetnia M, et al. The outbreak of the novel severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2): A review of the current global status. J Infect Public Health (2020), https://doi.org/10.1016/j.jiph.2020.07.011
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negative-strand templates that serve as templates for mRNA synthesis. Structural proteins S1, S2, E, and M are then translated by
ribosomes that are bound to the endoplasmic reticulum (ER) [68].
Viral nucleocapsids (N) are assembled from genomic RNA, followed
by budding into the lumen of the endoplasmic reticulum (ER)–Golgi
intermediate compartment (ERGIC) [69]. The nucleocapsids fuse
with the virion precursor. Formed virions will then be transported
from the ER through the Golgi apparatus to the cell surface via small
vesicles and released from the cell through exocytosis [70] (Fig. 4).
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SARS-CoV-2 diagnosis tests
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Remdesivir, a nucleotide analog antiviral inhibitor that may
compete for RdRp, was designed for the Ebola virus and was with
efficient against MERS and SARS [80]. Remdesivir has been reported
to inhibit in vitro SARS-CoV-2 proliferation and therefore has clinical therapeutic potential [81]. Recently, Remdesivir was used in a
clinical trial including 53 COVID-19 patients. Results showed clinical improvement in 36 of the 53 patients (68%). However, this drug
needs to be used especially for patients not receiving invasive ventilation as the mortality rate was 18% when receiving ventilation,
compared to 5% when not receiving [82].
Chloroquine and hydroxychloroquine
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Diagnostic tests were developed rapidly after the start of the
SARS-CoV-2 outbreak allowing early recognition and detection
of this novel virus. Nasopharyngeal swabs are the recommended specimen for molecular analysis. As of 19 March
2020, the CDC made oropharyngeal, mid-turbinate, and nasal
swabs acceptable specimen types if nasopharyngeal swabs are
not available (https://www.cdc.gov/coronavirus/2019-nCoV/lab/
guidelines-clinical-specimens.html). Samples are collected from
the upper respiratory tract (oropharyngeal and nasopharyngeal)
and lower respiratory tract (endotracheal aspirate, expectorated
sputum, or bronchoalveolar lavage) of patients suspected SARSCoV-2 infection [71].
At the initial stage of the outbreak, identification of COVID19 cases mainly involved virus isolation from swabs and viral
nucleic acid detection by RT-PCR-based SARS-CoV-2 RNA detection in respiratory samples. Enzyme-linked immunosorbent assay
(ELISA) kits for detection of IgM and IgG antibodies against N
and other SARS-CoV-2 proteins have also recently been made
available. Several other diagnostic tests are developed to detect
other regions of the SARS-CoV-2 genome or targeting RdRp, Hel,
S, E and N genes [72]. Another easy-to-implement and accurate
CRISPR–Cas12-based lateral flow assay for detection of SARS-CoV-2
from respiratory swab RNA extracts in just 30 min is under development [73]. Currently there are 628 SARS-CoV-2 tests commercially
available or in development for the diagnosis of COVID-19 https://
www.finddx.org/covid-19/pipeline/.
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SARS-CoV-2 treatment
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To date, no vaccines or therapies have been approved to treat
any of the known human coronaviruses. The rapid global spread of
COVID-19 has emphasized the need for the development of new
coronavirus vaccines and therapeutics for this family of viruses.
Treatment will reduce the economic impact on the world as SARSCoV had a history of taxing the global economy 30 US $ to 100 US
$ billion [74]. Since the beginning of the COVID-19 outbreak, the
WHO has encouraged researchers all over the world to develop a
cure for this disease. Here we present some of these initiatives that
are still in early stages of development.
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Antiviral agents
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Randomized controlled trials were initiated and are being conducted for many antiviral agents. Lopinavir (LPV) was shown to
inhibit the protease activity of coronavirus in vitro and in animal
models and already used for SARS and MERS in combination with
ritonavir, another antiviral drug [75,76]. However, a recent trial
showed lopinavir-ritonavir has no treatment benefit for severely
infected patients by SARS-CoV-2 [77]. Ribavirin is a guanosine analogue, used to treat several viral infections including those caused
by the hepatitis C and respiratory syncytial viruses by targetting the
RdRp complex [78]. Messenger RNA (mRNA) vaccine technology is
also under development (in phase 1 clinical trial by the US National
Institute of Allergy and Infectious Diseases) [79].
Chloroquine is antimalarial and autoimmune disease drug. It
blocks viral infection by increasing endosomal pH limiting virus to
cell fusion as well as interfering with the glycosylation of cellular
receptor ACE2 [83]. Hydroxychloroquine is an analog of chloroquine. Both drugs have immunomodulatory effect and can supress
the immune response of IL-6 and IL-10 that have been reported
to be increased in response to SARS-CoV-2 [84]. Clinical controlled
trials have shown that chloroquine was proved to be effective in
the treatment of COVID-19 by reducing pneumonia exacerbation
and was included in the recommendations for the prevention and
treatments of SARS-CoV-2 [85].
Corticosteroids
Corticosteroids could supress lung inflammation but their use
for the treatment of COVID-19 lung injury is not supported by
clinical evidence as the clearance of viral infection is delayed
and also due to the occurrence of side complications [86,87]. The
WHO advises against the use of corticosteroids unless indicated for
another reason [72].
Antibodies
The spike protein S is the principal target of antibodies. The
SARS-CoV monoclonal antibody CR3022, a neutralizing antibody
previously isolated from a convalescent SARS patient, was identified to bind potently with this protein [88]. This antibody may be a
potential therapeutic candidate.
Convalescent plasma transfusion (CP)
Convalescent plasma transfusion (CP) therapy was successfully
used in the treatment of SARS, MERS and during the 2009 H1N1
pandemic with acceptable efficacy and safety [89–91]. It consists of
collecting convalescent plasma from patients 2 weeks after recovery, to ensure neutralisation and a high antibodies titer followed
by its administration to infected patients [92]. performed a pilot
study in three participating hospitals in China to explore the feasibility of CP treatment in 10 severe COVID-19 patients. They showed
that clinical symptoms significantly improved with the increase of
oxyhemoglobin saturation within 3 days, accompanied by rapid
neutralization of viremia [92]. Another study performed on an
uncontrolled case series of five critically infected patients, showed
improvement in their clinical symptoms [93]. Despite CP being an
effective way to improve survival rate of severely infected patients,
it does not permit the patient to acquire a SARS-CoV-2 immune
protection and the safety of plasma globulin products specific to
SARS-CoV-2 deserves further consideration [94].
Global SARS-CoV-2 prevention measures
Given the lack of available effective vaccine or treatments,
it is primordial to control the source of infection and cut off
Please cite this article in press as: Bchetnia M, et al. The outbreak of the novel severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2): A review of the current global status. J Infect Public Health (2020), https://doi.org/10.1016/j.jiph.2020.07.011
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the transmission route of SARS-CoV-2 by implementing robust
preventative measures against this virus. We know that close contacts and fomites are the most common ways of transmission for
SARS-CoV-2. Aerosol transmission is still controversial. The WHO
recommended several standard procedures for slowing the spread
of COVID-19 by raising awareness on the prevention and control of
the disease in the general population. The bulk of these strategies
involve restricting mass gathering by advising the population to be
confined and avoid close contact with anyone showing symptoms
of respiratory illness in order to decrease the risk of spreading by
breaking the transmission chain. Thus, many countries suspended
all types (cultural, social, religious, scientific, sporting, and political)
of mass gatherings and opted for videoconferences, and telecommuting. The WHO also recommended to maintain personal hygiene
especially regular hand washing with soap and water or hand
sanitizer containing at least 60% alcohol, a healthy lifestyle and
adequate nutritional intake [95]. Outside, people need to respect
minimum 2 m social distancing and it is preferred to wear protective masks. To limit aerosol transmission, it is important to keep
regular room ventilation and effective sanitization [24].
In the face of this pandemic, some countries showed good
COVID-19 curve control because they rapidly deployed intense case
finding measures to stop virus transmission. For example, South
Korea dramatically slowed the epidemic by performing more than
300 000 diagnostic tests (5,828.6 tests per million) in the 9 weeks
after the first case was described. Individuals who tested positive
were identified and isolated (2020). Singapore used a broad case
definition, aggressive contact tracing, and isolation by testing all
patients with pneumonia and influenza-like illnesses in primary
care settings and hospitals, severely sick patients in intensive care,
and deaths with a possible infectious disease [96]. Taiwan and Hong
Kong used similar strategies [97].
Conclusion
The international alert about the COVID-19 infection has helped
in the containment of SARS-CoV-2. At the date of writing, COVID19 showed promising signs of ending. Many countries seem to be
efficiently controlling this SARS-CoV-2 pandemic wave and have
considerably limited the mortality rate thanks to knowledge garnered in the past from SARS and MERS epidemics, allowing for the
rapid institution of more efficient preventive measures. However,
SARS-CoV-2 is far from being eradicated and many researchers predict novel waves in the future. That is why research efforts on
SARS-CoV-2 and COVID-19 need to be redoubled to discover efficient treatments as soon as possible. Several promising competitive
therapeutic options are currently under development all over the
world but require time to for validation and commercialization.
There is still much to learn about COVID-19 and it critical that scientist around the world collaborate and share information in order
to face this new global threat and to develop a suitable cure to
benefit all of humanity.
Funding
No funding sources.
Competing interests
None declared.
Ethical approval
Not required.
Author contributions
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The order of topics in the article was designed by Mbarka Bchetnia & Catherine Laprise. Mbarka Bchetnia performed the literature
review and writes the first version. Caroline Duchaine, Catherine
Girard & Catherine Laprise contributed to the content, revised and
approved the manuscript as well as this final version for publication.
Uncited reference
[98].
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Acknowledgements
Catherine Laprise (C.L) is the director of the Centre intersectoriel en santé durable de l’UQAC and the chair holder of the Canada
Research Chair tier 1 (CRC1) in the Environment and Genetics of
Respiratory Disorders and Allergies (www.chairs.gc.ca). Catherine
Laprise is one of the principal researchers of the Biobanque Québécoise de la COVID-19 (bqc19.ca). Caroline Duchaine is holder of the
Tier-1 Canada Research Chair on Bioaerosols. Mbarka Bchetnia is
professor under grant in the Laprise laboratory with the support of
CRC1.
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