Journal of

Clinical Medicine

Review
The COVID-19 Pandemic: A Comprehensive Review
of Taxonomy, Genetics, Epidemiology, Diagnosis,
Treatment, and Control
Yosra A. Helmy 1,2, * , Mohamed Fawzy 3, *, Ahmed Elaswad 4 , Ahmed Sobieh 5 ,
Scott P. Kenney 1 and Awad A. Shehata 6,7
1 Department of Veterinary Preventive Medicine, Ohio Agricultural Research and Development Center,
The Ohio State University, Wooster, OH 44691, USA; kenney.157@osu.edu
2 Department of Animal Hygiene, Zoonoses and Animal Ethology, Faculty of Veterinary Medicine, Suez Canal
University, Ismailia 41522, Egypt
3 Department of Virology, Faculty of Veterinary Medicine, Suez Canal University, Ismailia 41522, Egypt
4 Department of Animal Wealth Development, Faculty of Veterinary Medicine, Suez Canal University,
Ismailia 41522, Egypt; ahmed_elaswad@vet.suez.edu.eg
5 Department of Radiology, University of Massachusetts Medical School, Worcester, MA 01655, USA;
ahmadsobeih@gmail.com
6 Avian and Rabbit Diseases Department, Faculty of Veterinary Medicine, Sadat City University, Sadat 32897,
Egypt; dr_awadali_1@yahoo.com
7 Research and Development Section, PerNaturam GmbH, 56290 Gödenroth, Germany
* Correspondence: helmy.6@osu.edu (Y.A.H.); mohamed_mohamed4@vet.suez.edu.eg (M.F.)




Received: 18 March 2020; Accepted: 21 April 2020; Published: 24 April 2020


Abstract: A pneumonia outbreak with unknown etiology was reported in Wuhan, Hubei province,
China, in December 2019, associated with the Huanan Seafood Wholesale Market. The causative agent
of the outbreak was identified by the WHO as the severe acute respiratory syndrome coronavirus-2
(SARS-CoV-2), producing the disease named coronavirus disease-2019 (COVID-19). The virus is
closely related (96.3%) to bat coronavirus RaTG13, based on phylogenetic analysis. Human-to-human
transmission has been confirmed even from asymptomatic carriers. The virus has spread to at least
200 countries, and more than 1,700,000 confirmed cases and 111,600 deaths have been recorded, with
massive global increases in the number of cases daily. Therefore, the WHO has declared COVID-19 a
pandemic. The disease is characterized by fever, dry cough, and chest pain with pneumonia in severe
cases. In the beginning, the world public health authorities tried to eradicate the disease in China
through quarantine but are now transitioning to prevention strategies worldwide to delay its spread.
To date, there are no available vaccines or specific therapeutic drugs to treat the virus. There are
many knowledge gaps about the newly emerged SARS-CoV-2, leading to misinformation. Therefore,
in this review, we provide recent information about the COVID-19 pandemic. This review also
provides insights for the control of pathogenic infections in humans such as SARS-CoV-2 infection
and future spillovers.

Keywords: SARS-CoV-2; COVID-19; One Health; genetics; epidemiology; control; outbreak;

pneumonia; treatment; diagnosis; public health

1. Introduction
Coronaviruses are enveloped, single-strand RNA viruses that can infect a wide range of hosts
including avian, wild, domestic mammalian species, and humans. Coronaviruses are well known for
their ability to mutate rapidly, alter tissue tropism, cross the species barrier, and adapt to different

J. Clin. Med. 2020, 9, 1225; doi:10.3390/jcm9041225 www.mdpi.com/journal/jcm

J. Clin. Med. 2020, 9, 1225 2 of 29

epidemiological situations [1]. Six human coronaviruses have been reported since the 1960s; four of
them (OC43, 229E, NL63, and HKU1) cause mild illness similar to the common cold and gastrointestinal
tract infection. The other two, severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle
East respiratory syndrome coronavirus (MERS-CoV), have raised significant public health concerns
due to their zoonotic emergence and crossing of the species barrier, causing high pathogenicity and
mortality in humans [2]. SARS- and MERS-CoVs were reported to be transmitted from the main host
(bats) to palm civets or dromedary camels, respectively, then finally to humans [3–5]. Both SARS- and
MERS-CoVs were and are highly pathogenic, resulting in 8096 and 2519 human cases, with 9.6% and
34.3% fatality rate in 2003–2004 and 2012–present, respectively [6,7].
Several clusters of pneumonia cases of unknown causes were reported in Wuhan city, Hubei
province, China, in December 2019. By epidemiological investigations, most of these patients were
related to the Huanan Seafood Wholesale Market. The causative agent of this pneumonia was confirmed
as the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), previously named 2019 novel
coronavirus (2019-nCoV), and the diseases was termed coronavirus disease-2019 (COVID-19) [8,9].
Based on phylogenetic analysis, SARS-CoV-2 forms a distinct lineage with Bat-SARS-like coronaviruses
that belong to the order Nidovirales, family Coronaviridae, genus Betacoronavirus, and subgenus
Sarbecovirus [9]. SARS-CoV-2 shares 96.3%, 89%, and 82% nucleotide similarity with bat CoV RaTG13,
SARS-like CoV ZXC21, and SARS-CoV, respectively, which confirms its zoonotic origin [10,11].
At the beginning of the outbreak, scientists thought that the disease was initially only
transmitted from animals to humans, then only between people who are symptomatic, until
the first human-to-human transmission case from an asymptomatic carrier was documented in
Germany [10,12,13]. This is also now evidenced by cases of community spread in which no direct
links between current patients and suspected COVID-19 carriers can be made. As of 13 April 2020,
the disease has caused a worldwide pandemic in more than 200 countries, with more than 1,700,000
confirmed human cases and 111,600 deaths. As a result of the rapid spread of the virus, authorities
worldwide have begun limiting international and domestic travel and large gatherings at educational
institutions, restaurants, bars, etc.
SARS-CoV-2 is reported to be transmitted between humans through direct contact, aerosol droplets,
fecal–oral route, and intermediate fomites from both symptomatic and asymptomatic patients during
the incubation period [9,14]. The disease is characterized by fever, dry cough, dyspnea, and diarrhea
in 20–25% of patients who do not exhibit upper respiratory signs such as sneezing or sore throat [8,13].
In severe cases, the disease is characterized by pneumonia, metabolic acidosis, septic shock, and
bleeding [14,15].
Several control measures are being instituted by nations around the world to extinguish the
SARS-CoV-2 pandemic, including the issuance of travel advisories or even flight bans to and from
infected countries, strict quarantine measures and traveler screenings, implementation of mitigation
measures by healthcare specialists, application of social distancing measures for schools and popular
gatherings, strict personal hygiene such as frequent handwashing, and wearing face masks [16].
Currently, world public health authorities such as the Centers for Disease Control and Prevention
(CDC), World Health Organization (WHO), and other global partners are trying to control and prevent
the spread of SARS-CoV-2. Additionally, WHO issued a guide to managing the recent pandemic
including instructions for the rapid detection of the disease, emergency treatment, application of
prevention and control strategies, supportive therapy, and prevention of disease complications [15].
Due to misleading information that is circulating and knowledge gaps about the newly emerged
SARS-CoV-2, this review provides the most recent information about SARS-CoV-2, with emphasis
on (1) the current status of SARS-CoV-2 outbreaks, (2) evidence regarding its origin by phylogenetic
analysis, (3) epidemiological characteristics required for efficient control strategies, (4) diagnosis of
the disease, (5) current control strategies and effective therapies, and (6) challenges to control future
epidemics like those caused by coronaviruses. This review also provides insights for the control of
pathogenic infections in humans with novel coronaviruses and spillovers in the future.
J. Clin. Med. 2020, 9, 1225 3 of 29

2. History of Coronavirus Outbreaks

Coronaviruses have repeatedly evolved during the past 1000 years [17]. The first recovery of
coronaviruses involved the identification of illnesses in animals followed by the isolation of infectious
bronchitis virus (IBV) from chickens in 1937 [18] and murine hepatitis viruses (MHV) from mice
in 1949 [19]. Pigs were found to carry a transmissible gastroenteritis virus (TGEV) in the United
States in 1946 [19]. Human coronaviruses were first characterized in the 1960s from respiratory tract
infections [20]. The two first isolated viruses were B814 and 229E [21,22]. Since then, several other
coronavirus strains have been isolated from humans using tissue culture (OC16 and OC43) [23,24].
The number of identified coronaviruses has continued to increase significantly to include viruses of
several additional animal species such as calves, dogs, cats, bats, sparrows, rabbits, and turkeys [25].
In 2002–2003, SARS-CoV caused a disease outbreak with deaths in 29 countries, most cases
being in China and Hong Kong. The total number of reported cases was 8096, of which 774 died,
corresponding to a 9.6% fatality rate [6], before the disease died out in part due to strict quarantine
protocols. Based on the genome sequence, SARS-CoV appeared to be very closely related to another
virus from Himalayan palm civets, from which it may have emerged [3]. Later, civets were considered
an intermediate host for SARS-CoV, with bats as the natural host [5].
Hu et al. [26] conducted a five-year surveillance study of SARS-related coronaviruses isolated
from horseshoe bats in Yunnan province, China, where 11 SARS-like CoVs were identified. Genome
comparisons revealed high genetic diversity among these viruses in several genes, including S, ORF3,
and ORF8. Despite the differences in S protein sequences, all 11 SARS-like CoVs are still able to use the
same human angiotensin-converting enzyme-2 (hACE2) receptor, demonstrating a close relationship
with SARS-CoV. Therefore, SARS-CoV likely emerged through recombination of bat SARS-like CoVs
before infecting civets, from which the recombinant virus spread to humans, causing the SARS
epidemic [5,26].
Ten years later, MERS-CoV emerged in Middle Eastern countries where the virus was transmitted
to humans from dromedary camels [27]. As of January 2020, MERS-CoV has resulted in 2519
laboratory-confirmed cases and 866 deaths (34.3% fatality rate), with more than 80% of the cases
reported from Saudi Arabia [7]. The human and camel MERS-CoV strains share more than 99%
identity with variations (substitutions) located in the S, ORF3, and ORF4b genes [28]. Phylogenetically,
MERS-CoV is very close to bat coronaviruses HKU4 and HKU5 [29]. A comprehensive analysis of
the evolutionary relationships indicated that MERS-CoV may have originated from bats as a result of
recombination events within ORF1ab and S genes [30,31]. To gain access into the cell, MERS-CoV uses
the human dipeptidyl peptidase 4 (DPP4) receptor [32]. This is also the case for MERS-related CoVs
isolated from bats in China, whose spike proteins are able to bind to the same receptor as MERS-CoV,
confirming the possibility of a bat origin for MERS-CoV [33].
In December 2019, SARS-CoV-2 emerged in Wuhan City, China, causing severe respiratory illness
and mortality (see the epidemiology section). Early studies reported that it may have evolved from bats,
as revealed by phylogenetic analysis [9] and its high identity (96.3%) with the bat coronavirus RaTG13.

3. Coronavirus Taxonomy
Coronaviruses are enveloped, icosahedral symmetric particles, approximately 80–220 nm in
diameter containing a non-segmented, single-strand, positive-sense RNA genome of about 26–32 kb
in size [34]. Coronaviruses (CoVs) are one of the largest groups of viruses that belong to the order
Nidovirales, suborder Cornidovirineae, and family Coronaviridae. Coronaviridae is classified into two
subfamilies, namely, Letovirinae and Orthocoronavirinae. Letovirinae includes the Alphaletovirus genus,
while Orthocoronaviridae is further classified on the basis of phylogenetic analysis and genome structure
into four genera: Alphacoronavirus (αCoV), Betacoronavirus (βCoV), Gammacoronavirus (γCoV), and
Deltacoronavirus (δCoV), which contain 17, 12, 2, and 7 unique species, respectively (ICTV 2018). The
most recent classification of the Coronaviridae is shown in Table 1. Corona in Latin means crown, and
this name was attributed to the virus due to the presence of spike projections from the virus envelope
J. Clin. Med. 2020, 9, 1225 4 of 29

that give it the shape of a crown under the electron microscope; Nido means nest and refers to the
ability of the viruses of this order to make a nested set of subgenomic mRNA [25,35].
Coronaviruses infect a wide range of wild and domestic animals; α- and βCoVs infect mammals,
while γ- and δCoVs primarily infect birds (Table 1). A human coronavirus (HCoV) was first isolated in
1960 from hospitalized patients who suffered from common cold symptoms and was named B814 [36].
So far, the seven different HCoVs that infect humans are 229E, NL63, which belong to α CoVs, and
HKU1, OC43, SARS, MERS, SARS-CoV-2, which belong to βCoVs. In 2002–2003, a pandemic caused by
SARS-CoV (lineage B βCoV) originated in China [37]. In the Middle East, MERS-CoV (lineage C βCoV)
emerged in 2012 [27]. In 2019, a newly emerged SARS-CoV-2, closely related to bat SARS-related
CoVs, was clustered with lineage B βCoV. Chan et al. [13] demonstrated that SARS-CoV-2 represents a
distinct lineage in the subgenus Sarbecovirus (previously, lineage 2b of βCoV) [38].
J. Clin. Med. 2020, 9, 1225 5 of 29

Table 1. Classification of Coronaviridae according to the International Committee of Taxonomy of Viruses (ICTV), with special emphasis on reservoir host, zoonotic
importance, and major epidemics.

Accession
Family Subfamily Genus Subgenus Species Abbreviations Reservoir Host Zoonotic [39]
Numbers
Letovirinae Alphaletovirus Milecovirus Microhyla letovirus 1 No
Colacovirus Bat coronavirus CDPHE15 BtCoV-CDPHE15 NC_022103.1 Bats No
Bat coronavirus HKU10 BtCoV-HKU10 NC_018871.1 Bats No
Decacovirus Rhinolophus ferrumeguinum
BtRfCoV-HuB13 KJ473807.1 Bats No
alphacoronavirus HuB-2013
Duvinacovirus Human coronavirus 229E HCoV-229E NC_002645.1 Human No
Luchacovirus Lucheng Rn rat coronavirus LRNV NC_032730.1 Rats No
Ferret coronavirus FRCoV NC_030292.1 Ferrets No
Minacovirus
Mink coronavirus 1 MCoV NC_023760.1 Minks No
Miniopetrus batcoronavirus 1 BtMiCoV-1 EU420138.1 Bats No
Orthocoronavirinae

Minunacovirus Miniopetrus batcoronavirus

BtMiCoV-HKU8 EU420139.1 Bats No
Coronaviridae

HKU8
Alphacoronavirus
Myotis ricketti
Mytacovirus BtMy-Sax11 NC_028811.1 Bats No
alphacoronavirus Sax-2011
Nyctalus velutinus
Nyctacovirus BtNy-Sc13 NC_028833.1 Bats No
alphacoronavirus SC-2013
Porcine epidemic diarrhea
PEDV NC_003436.1 Pigs No
virus
Pedacovirus
Scotophilus bat coronavirus
BtScCoV-512 NC_009657.1 Bats
512
Rhinolophus bat coronavirus BtRhCoV-HKU2
Rhinacovirus NC_009988.1 Bats and pigs Yes
HKU2 (SADS)
Human coronavirus NL63 HCoV-NL63 NC_005831.2 Human No
Setracovirus NL63-related bat coronavirus
BtKYNL63 NC_032107.1 Bats No
strain BtKYNL63-9b
TGEV NC_038861.1 Porcines, No
Tegacovirus Alphacoronavirus 1 CCoV KP_849472.1 canines, No
FeCoV JQ_408980.1 felines No
J. Clin. Med. 2020, 9, 1225 6 of 29

Table 1. Cont.

Accession
Family Subfamily Genus Subgenus Species Abbreviations Reservoir Host Zoonotic [39]
Numbers
HCoV-OC43 NC_006213.1 Human No
Betacoronavirus 1 BCoV NC_003045.1 Bovines No
ECoV EF_446615.1 Equines No
China Rattus coronavirus
Embecovirus RtCoV-HKU24 NC_026011.1 Rats No
HKU24
Human coronavirus HKU1 HCoV-HKU1 NC_006577.2 Human No
Murine coronavirus MHV NC_001846.1 Mouse No
Rabbit coronavirus HKU14 RbCoV HKU14 JN_874559 Rabbits No
Bat Hp-betacoronavirus
Hibecovirus BtHpCoV-ZJ13 NC_025217.1 Bats No
Zhejiang2013
Hedgehog coronavirus 1 EriCoV-1 NC_039207.1 Hedgehog No
Middle East respiratory
Betacoronavirus Human, camels,
syndrome-related MERSr-CoV NC_019843.3 Yes
and bats
Merbecovirus coronavirus
Pipistrellus bat coronavirus
BtPiCoV-HKU5 NC_009020.1 Bats No
HKU5
Tylonycteris bat
BtTyCoV-HKU4 NC_009019.1 Bats No
coronavirus HKU4
Roussetus bat coronavirus
BtEoCoV-GCCDC1 NC_030886.1 Bats No
GCCDC1
Nobecovirus
Roussetus bat coronavirus
BtRoCoV-HKU9 MG762674.1 Bats No
HKU9
Severe acute respiratory
Human, palm
Sarbecovirus syndrome-related SARSr-CoV NC_004718.3 Yes
civets, and bats
coronavirus
Unclassified
Pangolin coronavirus Pangolin-CoV NA_606875.1 Pangolins No
Betacoronavirus
J. Clin. Med. 2020, 9, 1225 7 of 29

Table 1. Cont.

Accession
Family Subfamily Genus Subgenus Species Abbreviations Reservoir Host Zoonotic [39]
Numbers
Beluga whale coronavirus
Cegacovirus BWCoV-SW1 NC_010646.1 Whale No
Gammacoronavirus SW1
Igacovirus Avian coronavirus IBV NC_001451.1 Birds No
Wigeon coronavirus
Andecovirus WiCoV-HKU20 NC_016995.1 Birds No
HKU20
Bulbul coronavirus HKU11 BuCoV-HKU11 NC_011547.1 Birds No
Coronavirus HKU15 PoCoV-HKU15 NC_039208.1 Pigs No
Buldecovirus Munia coronavirus HKU13 MuCoV-HKU13 NC_011550.1 Birds No
Deltacoronavirus
White-eye coronavirus
WECoV-HKU13 NC_016991.1 Birds No
HKU16
Night heron coronavirus
Herdecovirus NHCoV-HKU19 NC_016994.1 Birds No
HKU19
Common moorhen
Moordecovirus CMCoV-HKU21 NC_016996.1 Birds No
coronavirus HKU21
Human coronaviruses (HCoVs) are in bold, while major epidemic-causing mammalian and avian viruses are in red.
J. Clin. Med. 2020, 9, 1225 8 of 29

Additionally, other coronaviruses have caused pandemic diseases in domestic and wild mammals
and birds, leading to high mortality rates and severe economic losses. These viruses include IBV
in chickens [40], Beluga whale coronavirus SW1 (BWCoV-SW1) [41], bat coronaviruses CDPHE15
and HKU10 (ICTV 2018), porcine epidemic diarrhea virus (PEDV), TGEV, and sudden acute diarrhea
syndrome (SADS-CoV) [42].

4. SARS-CoV-2 Genome Organization

Since the emergence of SARS-CoV-2 in Wuhan City, China, in December 2019, many laboratories
have been working on sequencing the genome of the causative agent. As of 14 April 2020, there are a
total of 7655 complete genomes from 67 countries in the Global Initiative on Sharing All Influenza Data
(GISAID) database [43] (Table 2). A reference genome is now available in the NCBI genome database
(29,903 nucleotide, Reference Sequence: NC_045512.3) [44]. To date, there are a total of 875 sequences
including one RefSeq sequence and 768 complete genomes at NCBI.

Table 2. Number of completed genomes, partial sequences, or incomplete genomes of severe acute
respiratory syndrome coronavirus-2 (SARS-CoV-2) from different countries submitted to the Global
Initiative on Sharing All Influenza Data (GISAID) as of 14 April 2020.

Partial
Number of Complete
Country Sequences/Incomplete Total
Genomes
Genomes
Algeria, Argentina, Czech
Republic, Greece, Hungary, Saudi 3* 0 3*
Arabia, Slovenia
Australia 391 0 391
Austria 21 0 21
Belarus, Columbia, Pakistan,
2* 0 2*
Thailand, Turkey
Belgium 322 0 322
Brazil 36 0 36
Cambodia, Ecuador, Lithuania,
Mexico, Nepal, Nigeria, Panama, 1* 0 1*
Poland, South Africa, Sweden
Canada 129 0 129
Chile 7 0 7
China 346 47 393
Congo 42 0 42
Denmark, Mexico 9* 0 9*
Finland 40 0 40
France 204 0 204
Georgia 13 0 13
Germany 64 0 64
Ghana 15 0 15
Hong Kong 64 26 90
Iceland 601 0 601
India 32 1 33
Indonesia, Philippines 0 4* 4*
Iran 1 23 24
Ireland, South Korea 13 * 0 13 *
Italy 39 5 44
Japan 102 1 103
Kuwait, New Zealand, Vietnam 8* 0 8*
J. Clin. Med. 2020, 9, 1225 9 of 29

Table 2. Cont.

Partial
Number of Complete
Country Sequences/Incomplete Total
Genomes
Genomes
Latvia 5 0 5
Russia, Slovakia, Estonia 4* 0 4*
Luxembourg 86 0 86
Malaysia 7 3 10
Netherlands 585 0 585
Norway 29 0 29
Peru 1 1 2
Portugal 100 0 100
Senegal 23 0 23
Singapore 37 0 37
South Africa 6 0 6
Spain 105 0 105
Switzerland 52 0 52
Taiwan 22 0 22
United Kingdom 2540 1 2541
USA 1467 2 1469
Total 7655 118 7773
Available at: https://www.gisaid.org/, * Numbers are for each country.

SARS-CoV-2 is a monopartite, single-stranded, and positive-sense RNA virus with a genome size
of 29,903 nucleotides, making it the second-largest known RNA genome. The virus genome consists of
two untranslated regions (UTRs) at the 50 and 30 ends and 11 open reading frames (ORFs) that encode
27 proteins (Table 3).

Table 3. SARS CoV-2 genes and encoded polyproteins.

Gene Length Protein Length

Gene From To Protein
(Nucleotide) (Amino Acid)
50 UTR 1 265 265 Untranslated –
pp1ab 7096
orf1ab 266 21,555 21,290
pp1a 4405
S 21,563 25,384 3822 S 1273
orf3a 25,393 26,220 828 orf3a 275
E 26,245 26,472 228 E 75
M 26,523 27,191 669 M 222
orf6 27,202 27,387 186 orf6 61
orf7a 27,394 27,759 366 orf7a 121
orf7b 27,756 27,887 132 orf7b 43
orf8 27,894 28,259 366 orf8 121
N 28,274 29,533 1260 N 419
orf10 29,558 29,674 117 orf10 38
30 UTR 29,675 29,903 229 Untranslated –

The first ORF (ORF1/ab) constitutes about two-thirds of the virus genome, encoding 16
non-structural proteins (NSPS), while the remaining third of the genome encodes 4 structural proteins
and at least 6 accessory proteins. The structural proteins are spike glycoprotein (S), matrix protein (M),
envelope protein (E), and nucleocapsid protein (N), while the accessory proteins are orf3a, orf6, orf7a,
orf7b, orf8, and orf10, as shown in Figure 1 [2,13,38,45].
J.J.Clin.
Clin.Med.
Med.2020,
2019,9,8,1225
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Figure 1. Genome organization of SARS CoV-2 and its encoded proteins. The orf1ab gene constitutes
Figure 1. Genome organization of SARS CoV-2 and its encoded proteins. The orf1ab gene constitutes
two-thirds of the genome, encodes a total of 16 non-structural proteins (NSPs) within the pp1ab gene, as
two-thirds of the genome, encodes a total of 16 non-structural proteins (NSPs) within the pp1ab gene,
shown in yellow, which are nsp1 (180 aa), nsp2 (638 aa), nsp3 (1945 aa), nsp4 (500 aa), nsp5 (306 aa),
as shown in yellow, which are nsp1 (180 aa), nsp2 (638 aa), nsp3 (1945 aa), nsp4 (500 aa), nsp5 (306
nsp6 (290 aa), nsp7 (83 aa), nsp8 (198 aa), nsp9 (113 aa), nsp10 (139 aa), nsp11 (13 aa), nsp12 (932 aa),
aa), nsp6 (290 aa), nsp7 (83 aa), nsp8 (198 aa), nsp9 (113 aa), nsp10 (139 aa), nsp11 (13 aa), nsp12 (932
nsp13 (601 aa), nsp14 (527 aa), nsp15 (346 aa), and nsp16 (298 aa). The other third of SARS CoV-2
aa), nsp13 (601 aa), nsp14 (527 aa), nsp15 (346 aa), and nsp16 (298 aa). The other third of SARS CoV-2
includes four genes (in green) that encode four structural proteins (S, M, E, N), and six accessory genes
includes four genes (in green) that encode four structural proteins (S, M, E, N), and six accessory
(in blue) that encode six accessory proteins (orf3a, orf6, orf7a, orf7b, orf8, and orf10).
genes (in blue) that encode six accessory proteins (orf3a, orf6, orf7a, orf7b, orf8, and orf10).
The 50 UTR and 30 UTR of SARS CoV-2 are comprised of 265 and 229 nucleotides, respectively.
The 5′UTR and 3′UTR of SARS CoV-2 are comprised of 265 and 229 nucleotides, respectively.
Orf1ab is 21,290 nucleotides and encodes either replicase proteins pp1a of 4405 amino acids (aa)
Orf1ab is 21,290 nucleotides and encodes either replicase proteins pp1a of 4405 amino acids (aa)
(nsp1–nsp11) or pp1ab of 7096 aa (nsp1–nsp16), according to ribosomal frameshift. Of these proteins,
(nsp1–nsp11) or pp1ab of 7096 aa (nsp1–nsp16), according to ribosomal frameshift. Of these
(1) nsp1 suppresses the antiviral host response, (2) nsp3 is a papain-like protease, (3) nsp5 is a 3CLpro
proteins, (1) nsp1 suppresses the antiviral host response, (2) nsp3 is a papain-like protease, (3) nsp5
(3C-like protease domain), (4) nsp7 makes a complex with nsp8 to form a primase, (5) nsp9 is responsible
is a 3CLpro (3C-like protease domain), (4) nsp7 makes a complex with nsp8 to form a primase, (5)
for RNA/DNA binding activity, (6) nsp12 is an RNA-dependent RNA polymerase (RdRp), (7) nsp13
nsp9 is responsible for RNA/DNA binding activity, (6) nsp12 is an RNA-dependent RNA
is confirmed as a helicase, (8) nsp14 is a 30 –50 exonuclease (ExoN), 9) nsp15 is a poly(U)-specific
polymerase (RdRp), (7) nsp13 is confirmed as a helicase, (8) nsp14 is a 3′–5′ exonuclease (ExoN), 9)
endoribonuclease (XendoU). The remaining nsps are involved in transcription and replication of the
nsp15 is a poly(U)-specific endoribonuclease (XendoU). The remaining nsps are involved in
viral genome [13,46,47].
transcription and replication of the viral genome [13,46,47].
5. Comparative Phylogenetic Analysis of SARS-CoV-2
5. Comparative Phylogenetic Analysis of SARS-CoV-2
Single-stranded RNA viruses exhibit a faster biological mutation rate due to the lack of proofreading
Single-stranded RNA viruses exhibit a faster biological mutation rate due to the lack of
activity of viral RNA polymerases [48]; however, unlike other mutation-prone RNA viruses, with the
proofreading activity of viral RNA polymerases [48]; however, unlike other mutation-prone RNA
exception of the Arenaviridae family, CoVs do have limited proofreading capabilities, with the nsp14
viruses, with the exception of the Arenaviridae family, CoVs do have limited proofreading
protein allowing for the enhanced genome size of CoV family members [49].
capabilities, with the nsp14 protein allowing for the enhanced genome size of CoV family members
Recombination is another mechanism of evolution in coronaviruses [50]. A high recombination
[49].
frequency was demonstrated in murine hepatitis virus during mixed infection, where the majority
Recombination is another mechanism of evolution in coronaviruses [50]. A high recombination
offrequency
viruses recovered after three passages were recombinants [51]. Recombination was also reported
was demonstrated in murine hepatitis virus during mixed infection, where the majority of
for MERS-CoV and SARS-CoV.
viruses recovered after three passages Seven putative recombination
were recombinants [51]. regions were detected
Recombination was alsoin reported
ORF1ab andfor
SMERS-CoV
protein between
and SARS-CoV. Seven putative recombination regions were detected in ORF1ab and[52].
SARS-CoV and six other coronaviruses by in silico analysis of their genomes S
Similarly, bioinformatic analysis of MERS-CoV genomic data revealed 28 recombinant
protein between SARS-CoV and six other coronaviruses by in silico analysis of their genomes [52]. sequences from
humans andbioinformatic
Similarly, camels [53]. Recombination
analysis of MERS-CoVin SARS-CoV-2
genomicisdata
not yet clearly28
revealed understood.
recombinant Initial studies
sequences
suggested
from humans that itand
may have occurred
camels in the courseinofSARS-CoV-2
[53]. Recombination SARS-CoV-2isevolution [9], while
not yet clearly other researchers
understood. Initial
excluded the possibility of recombination based on a full genome evolutionary analysis
studies suggested that it may have occurred in the course of SARS-CoV-2 evolution [9], while other investigating
putative recombination
researchers excluded the events [11]. of recombination based on a full genome evolutionary analysis
possibility
To better understand
investigating the evolution
putative recombination of SARS-CoV-2,
events [11]. we performed a phylogenetic analysis of 45
representative coronaviruses from 18 countries including
To better understand the evolution of SARS-CoV-2, we SARS-CoV,
performedSARS-CoV-2,
a phylogeneticHCoV, bat of
analysis SARS
45
CoV, bat SARS-like CoV, and MERS-CoV. The viral genomes were obtained
representative coronaviruses from 18 countries including SARS-CoV, SARS-CoV-2, HCoV, bat SARS from the GISAID and
 CoV, bat SARS-like CoV, and MERS-CoV. The viral genomes were obtained from the GISAID and
NCBI databases. Multiple sequence alignment was performed using kalign 3 [54]. A phylogenetic
tree was constructed based on whole-genome sequences (coding sequences of all genes) in IQ-TREE,
using the maximum likelihood method, ultrafast bootstrap approximation, and ModelFinder [55,56].
The tree was drawn to scale, with branch lengths measured in the number of substitutions per site.
J. Clin. Med. 2020, 9, 1225 11 of 29
The bootstrap values were determined by 1,000 replicates. The tree was visualized in MEGA X [57]
(Figure 2).
In the analysis
NCBI databases. we performed,
Multiple sequenceall SARS-CoV-2
alignment wassamples fromusing
performed the 18 countries
kalign clustered
3 [54]. together
A phylogenetic
and were close to bat SARS or SARS-like coronaviruses, with Wuhan bat CoV RaTG13
tree was constructed based on whole-genome sequences (coding sequences of all genes) in IQ-TREE, being the
closest
using thevirus.
maximumIn addition, MERS-CoV
likelihood method,and human
ultrafast CoV HKU1
bootstrap were very distant
approximation, from SARS-CoV-2
and ModelFinder [55,56].
(Figure 2). Within MERS-CoV samples, the South China MERS-NL13892 clustered
The tree was drawn to scale, with branch lengths measured in the number of substitutions separately from
per site.
other MERS-CoVs. The two bat SARS-like CoVs (bat-SL-CoVZC45 and bat-SL-CoVZXC21) were the
The bootstrap values were determined by 1,000 replicates. The tree was visualized in MEGA X [57]
second closest viruses from bats to SARS-CoV-2 (Figure 2). All SARS-CoVs from China, Canada,
(Figure 2).
England, and the US were in a single cluster.

Figure 2. Phylogenetic tree based on the complete genome sequences of 45 selected coronaviruses from
18 countries including the SARS-CoV-2, SARS-CoV, HCoV, bat SARS, SARS-like CoV, and MERS-CoV.
The tree was constructed in IQ-TREE using the maximum likelihood method, ModelFinder, and
ultrafast bootstrap approximation (1000 replicates). The tree is drawn to scale, with branch lengths
(numbers below the branches) measured in the number of substitutions per site. Branch lengths less
than 0.3 are not shown. Numbers above the branches represent the percentage of replicate trees in
which the associated viruses clustered together in the bootstrap test. The tree is rooted with two human
coronavirus species from the genus Alphacoronavirus as an outgroup (HCoV-229E and HCoV-NL63).
J. Clin. Med. 2020, 9, 1225 12 of 29

In the analysis we performed, all SARS-CoV-2 samples from the 18 countries clustered together
and were close to bat SARS or SARS-like coronaviruses, with Wuhan bat CoV RaTG13 being the
closest virus. In addition, MERS-CoV and human CoV HKU1 were very distant from SARS-CoV-2
(Figure 2). Within MERS-CoV samples, the South China MERS-NL13892 clustered separately from
other MERS-CoVs. The two bat SARS-like CoVs (bat-SL-CoVZC45 and bat-SL-CoVZXC21) were the
second closest viruses from bats to SARS-CoV-2 (Figure 2). All SARS-CoVs from China, Canada,
England, and the US were in a single cluster.
Zhou et al. [9] conducted a phylogenetic analysis of SARS-CoV-2 against previously identified
coronaviruses based on their whole-genome sequences, main structural protein genes, and
non-structural protein genes. SARS-CoV-2 clustering was different depending on whether the
whole genome or specific genes were used in the analysis. For example, SARS-CoV-2 clustered with
the members of the subgenus Sarbecovirus including the SARS-CoV (79.5% identical) that caused the
global pandemic in 2003 and other bat SARS-like viruses (96% identical at the whole-genome level),
but the topological position within the Sarbecoviruses changed when individual genes (ORF1ab, S, E,
M, and N) were used for clustering [2,9].

6. SARS-CoV-2 Mutations and Their Effects

Based on the whole-genome sequence alignment, SARS-CoV-2 shares 89% identity with bat
SARS-like CoVZXC21, 82% with SARS-CoV, and 96.3% with bat CoV RaTG13 [11,13]. Alignment of the
predicted protein sequences of SARS-CoV-2 to those of SARS-CoV or SARS-like coronaviruses revealed
a total of 380 amino acid substitutions between these viruses [2]. These amino acid substitutions were
distributed as follows: 348 mutations in nonstructural proteins (ORF1ab, 3a, 3b, 7a, 7b, 9b, and ORF14),
27 in S protein, and 5 in N protein. No amino acid substitutions were detected in E or M proteins,
indicating that E and M proteins are highly conserved among these viruses.
It has been reported that SARS-CoV-2 uses the same cellular receptor, hACE2, as SARS-CoV to
gain entry into the cell [9,58,59]. The analysis of the receptor-binding domains (RBD) of SARS-CoV and
SARS-CoV-2 S protein revealed similar binding affinities [60]. Wu et al. [2] found a total of 27 amino
acid substitutions in the S protein but not in the receptor-binding motif (RBM) that directly interacts
with hACE2, which may affect host tropism. These 27 substituted residues were distributed as follows:
17 in the S1 subunit [6 in the RBD and 6 in the subdomain (SD)] and 10 in the S2 subunit. Wan et al. [58]
reported similarity in the spike protein RBD, including RBM, of both SARS-CoV and SARS-CoV-2,
in addition to the presence of several residues in SARS-CoV-2 RBM that favor the interaction with
human ACE2. These results agree with the genomic analysis of SARS-CoV-2, according to which the S2
subunit of the spike protein shares 99% identity with those of two bat SARS-like CoVs (SL-CoVZXC21
and ZC45) and of human SARS-CoV [13]. While the SARS-CoV-2 S2 subunit was conserved, the S1
subunit shares an overall 70% identity with those of bat and human SARS-CoV. The RBD core domain
of S1 is highly conserved, with most of the amino acid differences located in the external subdomain
that is responsible for the direct interaction with host receptors [13]. Investigators have also reported
the presence of a polybasic cleavage site and predicted O-linked glycans that are unique to SARS-CoV-2
S protein. Differences in SARS-CoV-2 S protein and the high contagious nature of this virus suggest
that SARS-CoV-2 has evolved via natural selection for binding to human ACE2 receptor [61].
ORF3b also differs in SARS-CoV-2. ORF3b deletion mutations in SARS-CoV do not affect viral
replication in vitro [62]. ORF3b may play a role in viral pathogenicity in addition to its inhibitory
effects on interferon (IFN) expression and signaling [63,64]. Recently, a novel short putative protein
was identified in ORF3b of SARS-CoV-2 [13]; however, the function of this novel protein is still not
known. SARS-CoV-2 ORF8 is closer to those of bat SARS CoV ZXC21 and ZC45 and distant from that
of human SARS-CoV [13].
J. Clin. Med. 2020, 9, 1225 13 of 29

7. Genetic Diversity of SARS-CoV-2

The assessment of genetic diversity among 86 complete or semi-complete genomes of SARS-CoV-2
viruses revealed three deletions in the genome of isolates from Japan, USA, and Australia in addition to
many other substitution mutations. The deletion mutations were in the ORF1ab gene (3-nucleotide and
24-nucleotide deletion) and at the 30 end of the genome (10-nucleotide deletion). Of the 93 substitution
mutations, 42 changed the amino acid sequence of structural and non-structural proteins [65]. The 3-
and 24-nucleotide deletions in ORF1ab are expected to reduce the protein sequence by 1 and 8 amino
acid residues, respectively, without changing the reading frame, but the functional effects have yet to
be investigated.
The alignment of SARS-CoV-2 reference S protein gene against all SARS-CoV-2 sequenced genomes
from China, USA, Japan, Australia, and Taiwan revealed 99.97–100% identity, with 100% query coverage
(also confirmed by our phylogenetic analysis, Figure 2), while the identity and coverage for SARS-CoV
S protein gene were 74.5% and 91%, respectively. Also, the S protein gene from bat SARS and SARS-like
coronavirus isolates shared 76.5–83% identity with that of SARS-CoV-2. This agrees with previous
conclusions regarding the evolutionary analysis of SARS-CoV-2 [11,44]. In the phylogenetic analysis we
performed, SARS-CoV-2 viruses were in the same cluster regardless of the geographic region (Figure 2).
These results strongly suggest the possibility of a recent common ancestor for all SARS-CoV-2 or the
transmission of the same virus strain across countries.

8. Epidemiology of COVID-19
The outbreak of COVID-19 originated from Wuhan City, Hubei province, in China. Fifty-five
percent of the infected cases before 1 January 2020 were linked to the Huanan Seafood Wholesale
Market. However, the first human-to-human case of SARS-CoV-2 infection reported on 1 December
2019 did not have any exposure to this market [66,67]. In mid-January 2020, SARS-CoV-2 spread to
other provinces of China due to the Spring Festival travel season. SARS-CoV-2 was transmitted from
China to other countries via international travelers. On 13 January 2020, the first case of SARS-CoV-2
infection was confirmed outside China in Thailand, and on 16 January 2020 the first infected case was
confirmed in Japan. These cases were also linked to the Huanan Seafood Wholesale Market. By 25
January 2020, the number of confirmed cases had risen to 2062, including 2,016 in China, Thailand,
Hong Kong, Macau, Australia, Malaysia, Singapore, France, Japan, South Korea, Taiwan, the US,
Vietnam, Nepal, and Sweden. On 30 January 2020, China reported a sharp rise in the number of
infected cases, with the presence of infection in more than 18 countries. Therefore, WHO declared the
SARS-CoV-2 outbreak to be a Public Health Emergency of International Concern [68].
As of 16 March 2020, more than 150 countries and territories have been affected, with major
outbreaks in central China, South Korea, Italy, Iran, France, and Germany [69]. There were 167,511
confirmed cases of SARS-CoV-2 infections, with 6606 deaths and about 8% estimated mortality rate.
More than 73% of these cases have been reported in mainland China [69]. At this time, the number of
global cases has shown a drastic increase within a short time, confirmed cases and deaths in China
have not increased too much, while confirmed cases and deaths in other countries have drastically
increased (Table 4). The number of confirmed cases increased from 2798 to 17,391 in one week (between
27 January and 3 February), and the number of infected countries doubled (from 12 to 24). Due to the
rapid increase of the number of infected cases and infected countries, the WHO declared SARS-CoV-2
a pandemic on 11 March 2020 and on 13 March 2020, the WHO declared Europe to be the new center
of the pandemic due to the massive increase of confirmed cases there [70]. On 23 March 2020, Italy
reported the highest number of deaths (5560) followed by China (3276), Spain (1720), and Iran (1685).
One week later (30 March 2020), the global map of COVID-19 had changed. For example, the highest
number of cases was reported in the USA (122,653 cases; 2112 deaths) followed by Italy (97,689 cases;
10,781 deaths), China (82,447 cases; 3310 deaths), Spain (78,797 cases; 6528 deaths), Germany (57,298
cases; 455 deaths), France (39,642 cases; 2602 deaths), and Iran (38,309 cases; 2640 deaths). As of 6 April
2020, there were 1,210,956 confirmed cases of SARS-CoV-2 infection (most of the cases, 307,318, were in
J. Clin. Med. 2020, 9, 1225 14 of 29

the USA) and 67,594 deaths (most of the deaths, 15,889, were in Italy). One week later (13 April 2020),
the number of confirmed cases of SARS-CoV-2 increased 1.7 times (up to 524,514 confirmed cases),
and the number of deaths increased 2.5 times (up to 20,444 deaths) in the USA alone. The number of
confirmed cases, deaths, and infected countries are shown in Table 4.

Table 4. Number of confirmed cases, deaths, and infected countries inside and outside China
weekly [69].

Number of Cumulative Confirmed Cases Cumulative Number of Deaths

Date Infected Countries Outside Outside
and Territories Globally China Globally China
China China
13 December–6
1 44 44 0 0 0 0
January
13 January 2 45 44 1 1 1 0
20 January 4 282 279 3 6 6 0
27 January 12 2798 2741 37 80 80 0
3 February 24 17,391 17,238 153 362 361 1
10 February 25 40,554 40,235 319 910 909 1
17 February 26 71,429 70,635 794 1775 1772 3
24 February 30 79,331 77,262 2069 2618 2595 23
2 March 65 88,948 80,174 8774 3043 2915 128
9 March 105 109,577 80,904 28,673 3809 3123 686
16 March 152 167,511 81,077 86,434 6606 3218 3388
23 March 195 332,930 81,601 251,329 14,509 3267 11,242
30 March 204 693,282 82,447 610,835 33,106 3310 29,796
6 April 210 1,210,956 83,005 1,127,951 67,594 3340 64,254
13 April 213 1,773,084 83,597 1,689,487 111,652 3351 108,301

8.1. Source of Infection and Evolution of SARS-CoV-2

The origins of more than 75% of coronavirus infections are considered zoonotic, i.e., animals
are the main source of the outbreaks. For example, SARS-CoV was transmitted from palm civets
to humans, and MERS-CoV from dromedary camels to humans. Bats are currently considered a
reservoir for all human coronaviruses, as mentioned above [5,71]. Many coronaviruses are circulating
in animals but have not yet infected humans. The type of animal that SARS-CoV-2 originated from
is still unclear. At the beginning of the outbreak in Wuhan, China, many patients were linked to
the Huanan Seafood Wholesale Market, suggesting animal-to-person spread. After retrospectively
studying case reports, the number of patients that did not have exposure to animal markets has risen,
indicating person-to-person spread was also occurring at that time [66]. SARS-CoV-2 is closely related
to bat coronaviruses and SARS-CoV [8]. A group of researchers reported early in the outbreak that
the novel SARS-CoV-2 has the highest similarity of codon usage bias with snakes [72,73]; however,
this method to determine initial host origins is dubious. Interestingly, researchers also reported one
amino acid difference in the receptor-binding domain of the S protein of Pangolin-CoV compared to
that of SARS-CoV-2, suggesting that pangolins might play a role as an intermediate host (Xiao et al.,
data currently under review). Another group of researchers reported that the virus originated from
bats based on the genome sequence of SARS-CoV-2, which is 96% identical to bat coronavirus RaTG13.
There were speculations that SARS-CoV-2 is a laboratory-engineered CoV and leaked directly from a
laboratory in Wuhan where a bat CoV (RaTG13) was recently reported. However, there is no evidence
to support this allegation [74]. Recently, a group of researchers found that SARS-CoV-2 replicates
poorly in dogs, pigs, chickens, and ducks but efficiently in ferrets and cats [75]. Scientists are still
trying to find the main source of the disease outbreak and identify the definitive intermediate hosts.

8.2. Mode of SARS-CoV-2 Transmission to Humans: Transmission Dynamics and Virus Persistence
Both established (SARS-CoV, MERS-CoV) and novel (SARS-CoV-2) coronaviruses were reported to
spread from an infected person to a non-infected person through direct or indirect contact. SARS-CoV-2
infection was reported to be transmitted directly from person to person like most respiratory viruses
 J. Clin. Med. 2019, 8, x FOR PEER REVIEW 8 of 30
J. Clin. Med. 2020, 9, 1225 15 of 29
8.2. Mode of SARS-CoV-2 Transmission to Humans: Transmission Dynamics and Virus Persistence
Both established (SARS-CoV, MERS-CoV) and novel (SARS-CoV-2) coronaviruses were
via close contact
reported towith
spreadan from
infected person person
an infected or through
to a respiratory
non-infected droplets (aerosol)
person through produced
direct when an
or indirect
infected
contact. SARS-CoV-2 infection was reported to be transmitted directly from person to person like can
person coughs or sneezes. These droplets can be inhaled to reach the lung. The virus
be indirectly transmitted
most respiratory via via
viruses touching a surface
close contact withoranan objectperson
infected that was previously
or through contaminated
respiratory droplets with
(aerosol)
the virus produced
and then whenthe
touching anface,
infected person
eyes, coughs
or mouth or and
[76] sneezes. Thesevia
possibly droplets can be inhaled
the fecal–oral routeto[77,78].
reach the lung.
Asymptomatic The(during
carriers virus canthe
be indirectly
incubation transmitted
period ofvia thetouching a surface
virus) and or anafter
patients objectrecovery
that was from
previously contaminated with the virus and then touching the face, eyes, or mouth [76] and possibly
the acute form of the disease are also considered a potential source of virus transmission to healthy
via the fecal–oral route [77,78]. Asymptomatic carriers (during the incubation period of the virus)
personsand
[10,12]. Interestingly, human coronaviruses are able to survive on steel, metal, wood, aluminum,
patients after recovery from the acute form of the disease are also considered a potential source
paper, of
glass,
virusplastic, ceramic,
transmission disposable
to healthy gowns,
persons andInterestingly,
[10,12]. surgical gloves
human for coronaviruses
2–9 days. High are temperature
able to
(≥30 ◦ C) can reduce
survive themetal,
on steel, persistence
wood, period,
aluminum,while low glass,
paper, temperature
plastic, (4
◦ C) increases the persistence time
ceramic, disposable gowns, and
up to 28 days [79].
surgical glovesTransmission of the
for 2–9 days. High virus vertically
temperature (≥30 °C)from mother
can reduce topersistence
the fetus or via breast
period, milk
while has not
low
temperature (4 °C) increases the persistence time up to 28 days [79]. Transmission
been confirmed yet [80]. The transmission cycle of coronavirus among animals and humans is shown of the virus
vertically
in Figure 3. from mother to fetus or via breast milk has not been confirmed yet [80]. The transmission
cycle of coronavirus among animals and humans is shown in Figure 3.

Figure 3. The transmission cycle of coronaviruses including MERS-CoV, SARS-CoV, and SARSCoV-2.
Figure 3. The transmission cycle of coronaviruses including MERS-CoV, SARS-CoV, and
The transmission
SARSCoV-2.of thetransmission
The virus to humans occurs
of the virus to by directoccurs
humans contact
by with
directinfected animals.
contact with The
infected continuous
animals.
line represents directline
The continuous transmission.
represents direct transmission.

8.3. Risk
8.3.Factors for SARS-CoV-2
Risk Factors Infection
for SARS-CoV-2 and
Infection andTheir
Their Assessment
Assessment
There There
are many factors
are many thatthat
factors affect SARS-CoV-2
affect SARS-CoV-2 transmission
transmission and and spread.
spread. These
These factors
factors include,
include,
but arebut
notarelimited
not limited to: travel
to: (1) (1) travel
to to
or or contactwith
contact with individuals
individuals whowho have
haverecently visited
recently Wuhan,
visited Wuhan,
China,China,
or otheror other
placesplaces experiencingananoutbreak;
experiencing outbreak; (2)
(2) close
closecontact
contactwith
withpersons
personswhowho
are diagnosed
are diagnosed
positive
positive for thefordisease,
the disease,
suchsuch as healthcareworkers
as healthcare workers caring
caring for
forpatients with
patients SARS-CoV-2;
with SARS-CoV-2; (3) contact
(3) contact
with droplets and secretions (produced by sneezing or coughing) from an infected person and eating
with droplets and secretions (produced by sneezing or coughing) from an infected person and eating
or handling wild animals native to China such as bats. Additionally, the risk of infection is higher for
or handling wildand
the elderly animals nativesuffering
for patients to Chinafrom suchpre-existing
as bats. Additionally,
illnesses such the risk of infection
as cardiovascular is higher
disease,
for thehypertension,
elderly and diabetes,
for patients suffering from pre-existing illnesses such as cardiovascular
and chronic respiratory disease [66]. The reported fatality rate based on age
disease,
hypertension,
is 14.8% for people ˃80 years of age, 8% for people between 70 and 79 years, 3.6% for people betweenage is
diabetes, and chronic respiratory disease [66]. The reported fatality rate based on
14.8% for people
60 and >80 years
69 years, of people
1.3% for age, 8% for people
between between
50 and 59 years,70 andfor
0.4% 79people
years,between
3.6% for40people
and 49 between
years, 60
and 69 years, 1.3% for people between 50 and 59 years, 0.4% for people between 40 and 49 years, 0.2%
for people between 10 and 39 years; no fatalities have been reported for children under 10 years of age.
Notably, the fatality rate is higher in males (2.8%) than in females (1.7%) [81,82].

8.4. Clinical Characteristics and Susceptibility of SARS-CoV-2 Infection in Humans

The estimated incubation period of the novel coronavirus ranges from 2 to 14 days. However,
some cases had an incubation period of 21, 24, or 27 days [83]. The complete clinical picture of
J. Clin. Med. 2020, 9, 1225 16 of 29

SARS-CoV-2 is still unclear. The disease begins with flu-like symptoms that include fever, fatigue,
dry cough, sore throat, shortness of breath, headache, chest tightness, chest pain, and muscle pain.
Some of SARS-CoV-2 patients have runny nose, nausea, vomiting, and diarrhea [84]. People can be
infected without showing symptoms, which allows the virus to spread more effectively from person to
person. Complications can occur due to COVID-19 leading to severe infections, such as pneumonia
(infection of the lungs), kidney failure, and death [8]. The mild phase of the disease can last up to
2 weeks, while severe or critical disease lasts approximately 3 to 6 weeks (this analysis was conducted
on 55,924 confirmed cases). Additionally, the time from the disease onset to the development of severe
disease is one week, while the time from the onset of symptoms to death ranges from 2 to 8 weeks [82].
Based on the data analysis of 72,314 confirmed cases of SARS-CoV-2 in Wuhan City, China, by 11
February, 80.9% of the cases were mild with flu-like symptoms, and patients recovered at home, 13.8%
were severe with pneumonia and shortness of breath, 4.7% were critical with respiratory failure and
septic shock resulting in organs failure, and approximately 2% of the cases were fatal [85]. Another
study was conducted on 99 hospitalized patients, and symptoms were classified as follow: fever (83%),
cough (82%), shortness of breath (31%), muscle ache (11%), confusion (9%), headache (8%), sore throat
(5%), runny nose (4%), chest pain (2%), diarrhea (2%), and nausea and vomiting (1%) [8].

9. Diagnosis of SARS-CoV-2 Infection

The rapid diagnosis of SARS-CoV-2 infection is the cornerstone of disease control. It depends on
several criteria including case history, clinical symptoms, serology, molecular diagnosis, and computed
tomography (CT) imaging. On 2 March 2020, WHO published interim guidance for laboratory testing of
suspected human cases, with precautions for specimen collection, packing, shipment, and amplification
of nucleic acid to detect viral genes (N, E, S, and RdRp) [82]. SARS-CoV-2 uses the same cell entry
receptor, hACE2, as SARS-CoV. Therefore, oral swabs, bronchoalveolar lavage fluid (BALF), blood, as
well as anal swabs are the best samples used for virus diagnosis [86]. A proper diagnosis depends
primarily on the factors described below.

9.1. Epidemiological History

The strict monitoring of case history in clinically suspicious patients is considered the first step
in the early diagnosis of SARS-CoV-2 infection. Clinically suspicious patients are those who suffer
from fever and lower respiratory tract infection symptoms (for details, see the clinical characteristics
section) and reside within or have traveled to endemic regions or had close contact with a confirmed
or suspected case. Additionally, SARS-CoV-2 can be transmitted by symptomatic and asymptomatic
patients especially to the high-risk group mentioned above (for details, see the risk assessment
section) [13].

9.2. Laboratory Diagnosis

The blood profiles of patients suffering from SARS-CoV-2 infection revealed the following:
(1) increased C-reactive protein and erythrocytes, (2) increased myohemoglobin, liver enzymes, and
muscle enzymes, with a high level of D-dimer in severe cases, and (3) normal or decreased white blood
cell counts and lymphocytes in the early stage of the disease, with advanced lymphocytopenia in
severe cases [13]. In ICU patients, high levels of plasma granulocyte colony-stimulating factor (GCSF),
IP10, IL2, IL7, IL10, TNF-α, and MIP1a were reported [38].

9.3. Virus Detection

Electron microscope examination of SARS-CoV-2 revealed the typical coronavirus morphology.
Further, SARS-CoV-2 was successfully isolated from human respiratory epithelial cells or BALF
samples of infected patients using Huh7 cells and Vero E6 cells. The isolated strain was confirmed by
immunofluorescent antibody techniques using the cross-reactive nucleoprotein (NP) antibody. Serum
 J. Clin. Med. 2019, 8, x FOR PEER REVIEW 10 of 30

9.3. Virus Detection

J. Clin. Med.Electron microscope examination of SARS-CoV-2 revealed the typical coronavirus morphology.17 of 29
2020, 9, 1225
Further, SARS-CoV-2 was successfully isolated from human respiratory epithelial cells or BALF
samples of infected patients using Huh7 cells and Vero E6 cells. The isolated strain was confirmed
neutralization tests (SNT) using
by immunofluorescent Vero
antibody E6 cells were
techniques usingconducted to confirm
the cross-reactive the neutralization
nucleoprotein activity in
(NP) antibody.
Serum neutralization
IgG-positive viral samplestests (SNT) using Vero E6 cells were conducted to confirm the neutralization
[87].
activity in IgG-positive viral samples [87].
9.4. Serological and Molecular Diagnosis
9.4. Serological and Molecular Diagnosis
IgM and IgG ELISA detection kits using bat SARSr-CoV Rp3 NP were developed with no
IgM and
cross-reaction IgG ELISA
against humandetection kits using
coronaviruses bat SARSr-CoV
except SARSr-CoVRp3 NPUsing
[80]. were developed with notools,
these serological
cross-reaction against human coronaviruses except SARSr-CoV [80]. Using these serological tools,
viral antibody titers were increased in SARS-CoV-2-infected patients [38]. The procedures of ELISA for
viral antibody titers were increased in SARS-CoV-2-infected patients [38]. The procedures of ELISA
the determination of SARS-CoV-2 IgG were described before [86]. Nucleic acid detection is the main,
for the determination of SARS-CoV-2 IgG were described before [86]. Nucleic acid detection is the
fastest, andfastest,
main, most sensitive test for the
and most sensitive testdiagnosis of SARS-CoV-2
for the diagnosis infection.
of SARS-CoV-2 Recently,
infection. two two
Recently, nested RT-PCR
nested
and two real-time
RT-PCR RT-PCR
and two assays
real-time haveassays
RT-PCR been have
developed with successful
been developed detection
with successful of the first
detection 25first
of the positive
cases25ofpositive
infection in Japan
cases [88]. Three
of infection in Japanreal-time RT-PCR
[88]. Three techniques
real-time RT-PCRhave been designed
techniques have beenbased on the E,
designed
RdRp,based
and N ongenes
the E, [89].
RdRp,Also,
and N scientists
genes [89].established molecular
Also, scientists detection
established tools for
molecular SARS-CoV-2
detection tools forbased
on theSARS-CoV-2
S gene [86].based on the S gene [86].

9.5. Radiological
9.5. Radiological Diagnosis
Diagnosis
ChestChest
X-rayX-ray examination
examination in early
in the the early
stagestage ofdisease
of the the disease
showsshows interstitial
interstitial changes
changes and and
multiple
multiple small plaque shadows. Chest CT scans play an important role in the diagnosis of acute
small plaque shadows. Chest CT scans play an important role in the diagnosis of acute respiratory
respiratory disease syndrome (ARDS) and pneumonia as well as in the early detection of lung
disease syndrome (ARDS) and pneumonia as well as in the early detection of lung parenchymal
parenchymal abnormalities in patients at risk and provide an impression of secondary infection
abnormalities
(Figure 4). in patients at risk and provide an impression of secondary infection (Figure 4).

Figure
Figure 4. Lung
4. Lung ofofaa51-year-old
51-year-old male
malepatient with
patient a history
with of hepatitis
a history C and symptoms
of hepatitis of dry cough
C and symptoms of dry
and shortness of breathing for three weeks. No recent travel or known contacts
cough and shortness of breathing for three weeks. No recent travel or known contacts with with infected
infected
subjects. Axial (A) and coronal computed tomography (CT) (B) of chest without contrast revealed
subjects. Axial (A) and coronal computed tomography (CT) (B) of chest without contrast revealed
bilateral peribronchial and subpleural consolidative opacities noted throughout both lungs (green
bilateral peribronchial and subpleural consolidative opacities noted throughout both lungs (green
arrow). There were scattered nodular consolidative opacities in a peribronchial distribution (orange
arrow). There were scattered nodular consolidative opacities in a peribronchial distribution (orange
arrow). The patient tested positive for SARS-CoV-2 RNA.
arrow). The patient tested positive for SARS-CoV-2 RNA.
Assessing these lungs parenchymal abnormalities conveys disease severity to clinicians. Using
Assessing these lungs
artificial intelligence parenchymal
models abnormalities
in the future may be conveys
useful indisease severity totoclinicians.
mass screening, allow riskUsing
artificial intelligence
prioritization andmodels
help to in the future
minimize may be useful
turnaround in mass
time [90]. Pan etscreening, to allowa risk
al. [91] conducted prioritization
retrospective
and help
studytotominimize
elaborate turnaround timeof[90].
the time course lung Pan et al.during
changes [91] conducted a retrospective
recovery from study
infection. They to elaborate
described
the time course of lung changes during recovery from infection. They described findings using
international standard nomenclatures such as ground-glass opacity (GGO), consolidation, and crazy
paving patterns. They established a semi-quantitative scoring system of 5 grades to quantify the degree
of involvement based on an area ranging from 0% to >75%. The total score ranged from 0 to 25 (max),
and involvement was subpleural, random, or diffuse. They found that in early stages (0–4 days after the
onset of symptoms), GGO was the main finding in lower lung lobes; in progressive stages (5–8 days), the
progression of lung disease involved three patterns of ground-glass, consolidation, and crazy paving,
J. Clin. Med. 2020, 9, 1225 18 of 29

while in peak stages (9–13 days), dense consolidation became the prevalent feature; in absorption
stages (>14 days), GGO was detected with no crazy paving and resolution of consolidations [91]. More
than 75% of SARS-CoV-2-affected patients suffered from bilateral lung involvement, and 71% have
multilobe involvement. CT examinations of 21 patients showed 29% consolidation and 86% GGO in
the chest [8,9,92,93]. Another study examined 51 cases by CT and reported that 77% showed pure
GGO, 75% exhibited GGO with reticular and/or interlobular septal thickness, 59% had GGO with
consolidation, while 55% revealed pure consolidation. Bilateral lung involvement was reported in 86%
of cases; in 80% of the cases the posterior part of the lung was involved, while in 86%, the periphery
was involved [94].

10. Control and Treatment of COVID-19 Infection

In January 2020, the WHO issued guidance for the clinical management of SARS when SARS-CoV-2
infection was suspected. In this guidance, the start of emergency treatments, immediate implementation
of prevention and control strategies, early supportive therapy and prevention of SARS-CoV-2
complications were described in detail [15]. So far, there are no approved specific antiviral drugs for
SARS-CoV-2 infection. Therefore, preventive measures and inactivation of the virus are essential to stop
and control the spread of the disease. Human coronaviruses can be inactivated using 0.5% hydrogen
peroxide, 62–71% ethanol, 0.1% sodium hypochlorite, 0.7–1% formaldehyde, 2% glutaraldehyde, or
0.23% povidone iodine within 1 minute. Other disinfectants such as 0.02% chlorhexidine digluconate,
0.55% orthophtalaldehyde, or 0.05–0.2% benzalkonium chloride are less effective [79].
In light of the urgent clinical demand, many drugs are approved to be used for clinical trials against
SARS-CoV-2 infection, such as lopinavir/ritonavir, arbidol, interferon-alpha, favipiravir, chloroquine
phosphate, darunavir/cobicistat, oseltamivir, and methylprednisolone. The most used antiviral
drugs [95] are summarized in Table 5.
Generally, coronaviruses are not sensitive to current antiviral drugs, and high concentrations
of drugs effective on these viruses cannot be used in vivo. Therefore, combinations of
different therapies have been used for the treatment of coronavirus infections [96]. Some drug
combinations that could be successful for the treatment of SARS-CoV-2 patients are lopinavir and
ritonavir [97,98], lopinavir/ritonavir plus arbidol [99], and ribavirin and interferon [100,101]. The use
of anti-inflammatory drugs such as glucocorticoids, IL-6 antagonist, janus kinase inhibitors (JAK), and
choloroquine/hydrocholoroquine in SARS-CoV-2 patients is a dilemma, especially in patients suffering
from an impaired immune system. Balancing the risk–benefit ratio is a critical issue. Corticosteroids
may delay the elimination of the virus and increase the risk of secondary infection. In addition, drugs
targeting pro-inflammatory cytokines can only inhibit specific inflammatory factors and thus may not
be very effective in curbing the cytokine storm (excessive and uncontrolled release of pro-inflammatory
cytokines). Moreover, some anti-inflammatory drugs such as JAK block INF-α production, which is
important in fighting the virus [102].
Additionally, fecal transplantation was approved for clinical trials as a therapeutic option for
SARS-CoV-2-related pneumonia based on the promising results obtained from fecal microbiota
transplantation in patients suffering from antibiotic-associated diarrhea, active ulcerative colitis, and
other viral infections [103–106]. Recently, it was found that intestinal microbiota-derived IFN in lung
stroma confers protection against viral diseases such as avian influenza and respiratory syncytial
virus [103]. Moreover, based on historical records of the effect of antiviral herbs on SARS and influenza
H1N1, Chinese herbal formulas could be an alternative approach for the prevention of SARS-CoV-2 in
a high-risk population [107], if no scientifically based therapeutics are available. It was found that
Sambucus formasana Nakai exhibited a strong antiviral effect against human coronavirus NL63 [108].
J. Clin. Med. 2020, 9, 1225 19 of 29

Table 5. Summary of drugs/treatments registered for clinical trials against SARS-CoV-2.

Drug/Treatment Mode of Action Antiviral Activity against COVID-19-Related Viruses References

- Provided good results against SARS-CoV decreased
Lopinavir/Ritonavir Protease inhibitor the viral load significantly and provided good results in [97,98,109]
COVID-19 patients
- Used for the treatment of influenza viruses in Russia
and China
Arbidol Inhibits membrane fusion - Lopinavir/ritonavir plus arbidol combination [102,110]
improved significantly the conditions of patients
suffering from COVID-19 pneumonia
- Opinavir/ritonavir plus interferon combination was
Inhibits many stages of virus replication: viral
used for the treatment of HIV infection
Interferon therapy entry, transcription, replication, translation, [99–101]
- Ribavirin and interferon combination was used for the
assembly
treatment of patients infected with MERS-CoV
- Demonstrated an inhibitory effect on all influenza
subtypes including neuraminidase- and M2
Inhibits viral RNA polymerase and mRNA
Favipiravir inhibitor-resistant strains [111–113]
capping
- Showed inhibitory effects against Arenaviruses,
Bunyaviruses, and Filoviruses
Increases pH in host cell lysosomes and - Exhibited a promising antiviral effect against
negatively influences virus–receptor binding, SARS-CoV-2 in vitro
Chloroquine [114]
as well as interferes with the glycosylation of - Improved COVID-19-pneumonia patients and
cellular receptors of SARS-CoV shortened the course of the disease
- Used against a wide range of RNA viruses such as
A monophosphoramidate of adenosine Filoviridae, Paramyxoviridae, Pneumoviridae, and
Remdesivir prodrug that incorporates into nascent viral Coronaviridae; used successfully in COVID-19 [115]
RNA chains causing pre-mature termination treatment in the United States and showed no adverse
events
- Used for the treatment of MERS-CoV in experimental
Darunavir and Cobicistat Inhibit 3 C-like protease (3CLpro). animals [116]
- Used for the treatment of HIV-1 patients
J. Clin. Med. 2020, 9, 1225 20 of 29

Table 5. Cont.

Drug/Treatment Mode of Action Antiviral Activity against COVID-19-Related Viruses References

- Anti-influenza drug
- Combination of nitazoxanide and oseltamivir is more
Oseltamivir Neuraminidase inhibitor [97,117]
effective in the treatment of ferrets infected with
influenza virus compared to oseltamivir monotherapy
- Commonly used for the treatment of SARS patients
suffering from severe pneumonia.
Steroid treatment
Anti-inflammatory - Because these drugs are immunosuppressive, they may [102,118]
(Methylprednisolon)
delay viral clearance if given before viral replication is
controlled
- Immunotherapy combined with antiviral drugs is
Convalescent plasma SARS-CoV-2-neutralizing antibodies [119,120]
efficient against COVID-19
Mesenchymal Stem Cells Anti-inflammatory and immunomodulatory - Enhances recovery in COVID-19 patients. [121]
- Inhibits the in vitro replication of SARS-CoV-2 on
Ivermectin Anti-parasitic and antiviral Vero-hSLAM cells with 5000-fold reduction in viral [122]
RNA in 48 hours
J. Clin. Med. 2020, 9, 1225 21 of 29

11. Vaccination
To date, there is no vaccine to prevent SARS-CoV-2 infection, and trials for vaccine development
are in the preliminary stages of research. Several vaccine candidates such as live attenuated,
adenovirus-vectored, recombinant protein, and nucleic acid (DNA and mRNA) vaccines are in
the pipeline [123].

12. Preventive Measures to Control the SARS-CoV-2 Spread

The epidemiology of SARS-CoV-2 is still unclear, and data availability is limited. Therefore, it is
imperative to follow preventive measures and safety precautions issued by health authorities to limit
exposure to the virus and to reduce further spread. General hygienic measures should be implemented,
such as (1) washing hands often with soap and water or an alcohol-based hand sanitizer, (2) cough or
sneeze etiquette, recommending covering of the mouth, (3) avoiding touching eyes, nose, and mouth
if the hands are not clean, (4) avoiding close contact with sick persons, (5) avoiding sharing dishes,
glasses, bedding, and other household items with sick people, (6) cleaning and disinfection of surfaces
that are often touched, and (7) staying home from work, school, and public areas when feeling sick.
The transmission route of SARS-CoV-2 is probably not only through cough, respiratory droplets,
and/or contaminated surfaces [13,124], but also through fecal–oral transmission [78]. Therefore, strict
hygienic measures should be followed, especially in dense cities or agricultural spaces [125].
Since the SARS-CoV-2 spread is primarily driven by travel, screening of travelers who arrive at
airports from pandemic areas for possible SARS-CoV-2 infection and entry-screening procedures are
necessary. Also, general hygienic precautions during travel are highly recommended. Travelers who
suffered from acute respiratory infection should be tested and reported to the respective public health
authorities [73]. In addition, people should be motivated to notify and report about travel history and
close contacts in case of SARS-CoV-2 infection.
Asymptomatic carriers (during the incubation period) and patients after recovery from the acute
form are also considered potential sources of the virus [12,13]. Strict hygienic measures should be
implemented to avoid virus transmission to healthcare workers and other contacts, i.e., placement of
SARS-CoV-2 suspected or confirmed patients in single-person rooms and wearing personal protection
equipment (PPE) such as masks, goggles, and protective gowns. Because early diagnosis and detection
of asymptomatic carriers of SARS-CoV-2 are successful factors for the treatment and prevention of
transmission, health authorities should designate laboratories to implement tests for a rapid and
accurate diagnosis [126]. The control of coronaviruses is based on biosecurity regarding animals as
well as on shifts in food habits, including discouraging the consumption of bushmeat and of animal
products without appropriate cooking [127]. Ban of wet marketplaces where live or dead animals are
handled should be implemented. Surveillance among people who have contact with wildlife and
improvement of biosecurity regarding wildlife trade are urgently needed to prevent the next pandemic
outbreak [128].

13. Challenges to Control SARS-CoV-2 and the Role of the One-Health Approach in Disease Control
The epidemiology of SARS-CoV-2 is still unclear. Many unresolved questions related to
SARS-CoV-2 epidemiology and pathogenicity pose great challenges for researchers. These unresolved
questions include: What is the origin of SARS-CoV-2? What is the intermediate host that transmitted
the virus from bats? Why does the virus cause severe disease and mortality in the elderly or those with
co-morbidities, while it is milder in children? Are aerosol, saliva, feces, urine, and foodborne the only
routes of transmission? What are the other unknown routes of transmission?
Control of the SARS-CoV-2 outbreak and future epidemics requires global efforts among
medical and veterinary clinicians, diagnosticians, epidemiologists, public health experts,
vaccinologists, pharmaceutical industries, economists, and governments to implement a One-Health
approach [128,129]. These measures must include: (1) writing policies and supporting funds required
J. Clin. Med. 2020, 9, 1225 22 of 29

for the implementation of One Health, prevention, and control measures, (2) hiring well-trained and
professional personnel, (3) performing rapid and accurate diagnosis and treatment of infected persons,
(4) developing and providing vaccines for virus control in humans, (5) conducting surveillance among
wildlife for the identification and characterization of possible reservoirs and surveillance among people
who are in contact with wildlife to identify risk factors in human behaviors and living environment,
(6) improving hygienic measures, (7) assessing the social and economic impacts of COVID-19 on the
population, (8) utilizing veterinary experience in the disinfection of premises and gatherings under the
supervision of health authorities to decrease outbreaks in humans, (9) providing antiviral drugs for the
treatment of the disease in humans, and (10) increasing public health awareness about the virus and
its transmission.

14. Conclusions and Future Perspective

The SARS-CoV-2 outbreak started in Wuhan City, China, in December 2019. It is now a global
pandemic, with 1,773,084 confirmed cases, 111,652 deaths, and 467,074 recoveries (as of 13 April 2020).
The virus has the potential for rapid and extensive spread between people and countries. There are a
lot of misleading information and knowledge gaps on the newly emerged SARS-CoV-2. Therefore,
we reviewed the latest updates about different aspects including epidemiology, source of infection,
transmission dynamics, zoonotic potential, virus characteristics, and discovery of novel strategies
for disease control to avoid spillover of infection in the future. Bats play an important role in the
transmission of the infection to humans. Coronaviruses are genetically diverse and have a high
tendency towards frequent genetic mutations and gene recombination, which increases the risk of
interspecies transmission. Information about the incubation period can help in establishing an effective
quarantine for asymptomatic carriers, thus preventing the virus spread. From our perspectives and
based on the currently available information about the virus and its epidemiology, the control of the
SARS-CoV-2 requires an effective and global disease coordination effort including multidisciplinary
research efforts (One-Health approach) through collaboration between governments, epidemiologists,
virologists, health authorities, veterinarians, and physicians. At this stage of the disease outbreak,
developing vaccines is crucial to limit the spread of the infection.

Author Contributions: Conceptualization, Y.A.H. and M.F.; methodology Y.A.H. and M.F.; software Y.A.H., M.F.,
A.E. and A.S.; validation, Y.A.H., M.F. and A.E.; formal analysis, Y.A.H., M.F. and A.E..; data curation, Y.A.H.,
M.F., and A.E.; writing—original draft preparation, Y.A.H, M.F., A.E., A.S., S.P.K. and A.A.S..; writing—review
and editing, Y.A.H., M.F., A.E., A.S., S.P.K., and A.A.S.; visualization, investigation, and supervision, Y.A.H. All
authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Acknowledgments: We gratefully acknowledge the authors, originating, and submitting laboratories of the
sequences from the GISAID’s EpiCoV™ Database, on which part of the phylogenetic tree construction is based.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Decaro, N.; Mari, V.; Elia, G.; Addie, D.D.; Camero, M.; Lucente, M.S.; Martella, V.; Buonavoglia, C.
Recombinant canine coronaviruses in dogs, Europe. Emerg. Infect. Dis. 2010, 16, 41–47. [CrossRef] [PubMed]
2. Wu, A.; Peng, Y.; Huang, B.; Ding, X.; Wang, X.; Niu, P.; Meng, J.; Zhu, Z.; Zhang, Z.; Wang, J. Genome
composition and divergence of the novel coronavirus (2019-nCoV) originating in China. Cell Host Microbe
2020, 27, 325–328. [CrossRef] [PubMed]
3. Guan, Y.; Zheng, B.; He, Y.; Liu, X.; Zhuang, Z.; Cheung, C.; Luo, S.; Li, P.; Zhang, L.; Guan, Y. Isolation and
characterization of viruses related to the SARS coronavirus from animals in southern China. Science 2003,
302, 276–278. [CrossRef] [PubMed]
4. Drosten, C.; Meyer, B.; Müller, M. Supplement to: Transmission of MERS-coronavirus in household contacts.
N. Engl. J. Med. 2014, 371, 1–10. [CrossRef]
J. Clin. Med. 2020, 9, 1225 23 of 29

5. Cui, J.; Li, F.; Shi, Z.-L. Origin and evolution of pathogenic coronaviruses. Nat. Rev. Microbiol. 2019, 17,
181–192. [CrossRef]
6. WHO. Summary of Probable SARS Cases with Onset of Illness from 1 November 2002 to 31 July 2003.
Available online: https://www.who.int/csr/sars/country/table2004_04_21/en/ (accessed on 10 March 2020).
7. WHO. MERS Situation Update, January 2020. Available online: http://www.emro.who.int/health-topics/
mers-cov/mers-outbreaks.html (accessed on 11 March 2020).
8. Huang, C.; Wang, Y.; Li, X.; Ren, L.; Zhao, J.; Hu, Y.; Zhang, L.; Fan, G.; Xu, J.; Gu, X.; et al. Clinical features
of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020, 395, 497–506. [CrossRef]
9. Zhou, P.; Yang, X.-L.; Wang, X.-G.; Hu, B.; Zhang, L.; Zhang, W.; Si, H.-R.; Zhu, Y.; Li, B.; Huang, C.-L. A
pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature 2020, 579, 270–273.
[CrossRef]
10. Chan, J.F.; Yuan, S.; Kok, K.H.; To, K.K.; Chu, H.; Yang, J.; Xing, F.; Liu, J.; Yip, C.C.; Poon, R.W.; et al.
A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person
transmission: A study of a family cluster. Lancet 2020, 395, 514–523. [CrossRef]
11. Paraskevis, D.; Kostaki, E.G.; Magiorkinis, G.; Panayiotakopoulos, G.; Sourvinos, G.; Tsiodras, S. Full-genome
evolutionary analysis of the novel corona virus (2019-nCoV) rejects the hypothesis of emergence as a result
of a recent recombination event. Infect. Genet. Evol. 2020, 79, 104212. [CrossRef]
12. Rothe, C.; Schunk, M.; Sothmann, P.; Bretzel, G.; Froeschl, G.; Wallrauch, C.; Zimmer, T.; Thiel, V.; Janke, C.;
Guggemos, W. Transmission of 2019-nCoV infection from an asymptomatic contact in Germany. N. Engl. J.
Med. 2020, 382, 970–971. [CrossRef]
13. Chan, J.F.; Kok, K.H.; Zhu, Z.; Chu, H.; To, K.K.; Yuan, S.; Yuen, K.Y. Genomic characterization of the 2019
novel human-pathogenic coronavirus isolated from a patient with atypical pneumonia after visiting Wuhan.
Emerg. Microbes Infect. 2020, 9, 221–236. [CrossRef] [PubMed]
14. Li, J.-Y.; You, Z.; Wang, Q.; Zhou, Z.-J.; Qiu, Y.; Luo, R.; Ge, X.-Y. The epidemic of 2019-novel-coronavirus
(2019-nCoV) pneumonia and insights for emerging infectious diseases in the future. Microb. Infect. 2020, 22,
80–85. [CrossRef] [PubMed]
15. WHO. Clinical Management of Severe Acute Respiratory Infection When Novel Coronavirus (nCoV) Infection
Is Suspected. Available online: https://www.who.int/publications-detail/clinical-management-of-severe-
acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected (accessed on 17 March
2020).
16. Cowling, B.J.; Leung, G.M. Epidemiological research priorities for public health control of the ongoing global
novel coronavirus (2019-nCoV) outbreak. Euro Surveill. 2020, 25, 2000110. [CrossRef] [PubMed]
17. Forni, D.; Cagliani, R.; Clerici, M.; Sironi, M. Molecular evolution of human coronavirus genomes. Trends
Microbiol. 2017, 25, 35–48. [CrossRef]
18. Beaudette, F.R.; Hudson, C.B. Cultivation of the virus of infectious bronchitis. J. Am. Vet. Med. A. 1937, 90,
51–56.
19. Cheever, F.S.; Daniels, J.B.; Pappenheimer, A.M.; Bailey, O.T. A murine virus (JHM) causing disseminated
encephalomyelitis with extensive destruction of myelin: I. Isolation and biological properties of the virus. J.
Exp. Med. 1949, 90, 181–194. [CrossRef]
20. Kahn, J.S.; McIntosh, K. History and recent advances in coronavirus discovery. Pediatr. Infect. Dis. J. 2005, 24,
S223–S227. [CrossRef]
21. Tyrrell, D.; Bynoe, M. Cultivation of viruses from a high proportion of patients with colds. Lancet 1966, 1,
76–77. [CrossRef]
22. Hamre, D.; Procknow, J.; Medicine. A new virus isolated from the human respiratory tract. Proc. Soc. Exp.
Biol. Med. 1966, 121, 190–193. [CrossRef]
23. Tyrrell, D.; Almeida, J.; Cunningham, C.; Dowdle, W.; Hofstad, M.; McIntosh, K.; Tajima, M.; Zakstelskaya, L.Y.;
Easterday, B.; Kapikian, A. Coronaviridae. Intervirology 1975, 5, 76–82. [CrossRef]
24. McIntosh, K.; Becker, W.B.; Chanock, R.M. Growth in suckling-mouse brain of “IBV-like” viruses from
patients with upper respiratory tract disease. Proc. Natl. Acad. Sci. USA 1967, 58, 2268–2273. [CrossRef]
[PubMed]
25. Lai, M.M.; Perlman, S.; Anderson, L. Coronaviridae. In Fields Virology; Knipe, D.M., Howley, P.M., Eds.;
Lippincott Williams & Wilkins: Philadelphia, PA, USA, 2007; Volume 1, pp. 1305–1318.
J. Clin. Med. 2020, 9, 1225 24 of 29

26. Hu, B.; Zeng, L.-P.; Yang, X.-L.; Ge, X.-Y.; Zhang, W.; Li, B.; Xie, J.-Z.; Shen, X.-R.; Zhang, Y.-Z.; Wang, N.
Discovery of a rich gene pool of bat SARS-related coronaviruses provides new insights into the origin of
SARS coronavirus. PLoS Pathog. 2017, 13, e1006698. [CrossRef] [PubMed]
27. Zaki, A.M.; Van Boheemen, S.; Bestebroer, T.M.; Osterhaus, A.D.; Fouchier, R.A. Isolation of a novel
coronavirus from a man with pneumonia in Saudi Arabia. N. Engl. J. Med. 2012, 367, 1814–1820. [CrossRef]
[PubMed]
28. Chu, D.K.; Hui, K.P.; Perera, R.A.; Miguel, E.; Niemeyer, D.; Zhao, J.; Channappanavar, R.; Dudas, G.;
Oladipo, J.O.; Traoré, A. MERS coronaviruses from camels in Africa exhibit region-dependent genetic
diversity. Proc. Natl. Acad. Sci. USA 2018, 115, 3144–3149. [CrossRef]
29. Lau, S.K.; Li, K.S.; Tsang, A.K.; Lam, C.S.; Ahmed, S.; Chen, H.; Chan, K.-H.; Woo, P.C.; Yuen, K.-Y. Genetic
characterization of Betacoronavirus lineage C viruses in bats reveals marked sequence divergence in the
spike protein of pipistrellus bat coronavirus HKU5 in Japanese pipistrelle: Implications for the origin of the
novel Middle East respiratory syndrome coronavirus. J. Virol. 2013, 87, 8638–8650.
30. Dudas, G.; Rambaut, A. MERS-CoV recombination: Implications about the reservoir and potential for
adaptation. Virus Evol. 2016, 2. [CrossRef]
31. Wang, Y.; Liu, D.; Shi, W.; Lu, R.; Wang, W.; Zhao, Y.; Deng, Y.; Zhou, W.; Ren, H.; Wu, J. Origin and possible
genetic recombination of the Middle East respiratory syndrome coronavirus from the first imported case in
China: Phylogenetics and coalescence analysis. mBio 2015, 6, e01280-15. [CrossRef]
32. Raj, V.S.; Mou, H.; Smits, S.L.; Dekkers, D.H.; Müller, M.A.; Dijkman, R.; Muth, D.; Demmers, J.A.; Zaki, A.;
Fouchier, R.A. Dipeptidyl peptidase 4 is a functional receptor for the emerging human coronavirus-EMC.
Nature 2013, 495, 251–254. [CrossRef]
33. Luo, C.-M.; Wang, N.; Yang, X.-L.; Liu, H.-Z.; Zhang, W.; Li, B.; Hu, B.; Peng, C.; Geng, Q.-B.; Zhu, G.-J.
Discovery of novel bat coronaviruses in south China that use the same receptor as Middle East respiratory
syndrome coronavirus. J. Virol. 2018, 92, e00116-18. [CrossRef]
34. Weiss, S.R.; Navas-Martin, S. Coronavirus pathogenesis and the emerging pathogen severe acute respiratory
syndrome coronavirus. Microbiol. Mol. Biol. Rev. 2005, 69, 635–664. [CrossRef]
35. Lai, M.M.; Cavanagh, D. The molecular biology of coronaviruses. In Advances in Virus Research; Elsevier:
Amsterdam, The Netherlands, 1997; Volume 48, pp. 1–100.
36. Tyrrell, D.; Bynoe, M. Cultivation of a novel type of common-cold virus in organ cultures. Br. Med. J. 1965, 1,
1467–1470. [CrossRef] [PubMed]
37. Drosten, C.; Günther, S.; Preiser, W.; Van Der Werf, S.; Brodt, H.-R.; Becker, S.; Rabenau, H.; Panning, M.;
Kolesnikova, L.; Fouchier, R.A. Identification of a novel coronavirus in patients with severe acute respiratory
syndrome. N. Engl. J. Med. 2003, 348, 1967–1976. [CrossRef] [PubMed]
38. Chen, N.; Zhou, M.; Dong, X.; Qu, J.; Gong, F.; Han, Y.; Qiu, Y.; Wang, J.; Liu, Y.; Wei, Y.; et al. Epidemiological
and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive
study. Lancet 2020, 395, 507–513. [CrossRef]
39. Fan, Y.; Zhao, K.; Shi, Z.-L.; Zhou, P. Bat Coronaviruses in China. Viruses 2019, 11, 210. [CrossRef]
40. Zhao, Y.; Zhang, H.; Zhao, J.; Zhong, Q.; Jin, J.-H.; Zhang, G.-Z. Evolution of infectious bronchitis virus in
China over the past two decades. J. Gen. Virol. 2016, 97, 1566–1574. [CrossRef]
41. Vlasova, A.N.; Halpin, R.; Wang, S.; Ghedin, E.; Spiro, D.J.; Saif, L.J. Molecular characterization of a new
species in the genus Alphacoronavirus associated with mink epizootic catarrhal gastroenteritis. J. Gen. Virol.
2011, 92, 1369–1379. [CrossRef]
42. Zhou, P.; Fan, H.; Lan, T.; Yang, X.L.; Shi, W.F.; Zhang, W.; Zhu, Y.; Zhang, Y.W.; Xie, Q.M.; Mani, S.; et al.
Fatal swine acute diarrhoea syndrome caused by an HKU2-related coronavirus of bat origin. Nature 2018,
556, 255–258. [CrossRef]
43. GISAID. Global Initiative on Sharing All Influenza Data. Available online: https://www.gisaid.org/ (accessed
on 14 April 2020).
44. Wu, F.; Zhao, S.; Yu, B.; Chen, Y.-M.; Wang, W.; Song, Z.-G.; Hu, Y.; Tao, Z.-W.; Tian, J.-H.; Pei, Y.-Y. A new
coronavirus associated with human respiratory disease in China. Nature 2020, 579, 265–269. [CrossRef]
45. Ceraolo, C.; Giorgi, F.M. Genomic variance of the 2019-nCoV coronavirus. J. Med. Virol. 2020, 92, 522–528.
[CrossRef]
J. Clin. Med. 2020, 9, 1225 25 of 29

46. Angeletti, S.; Benvenuto, D.; Bianchi, M.; Giovanetti, M.; Pascarella, S.; Ciccozzi, M. COVID-2019: The role of
the nsp2 and nsp3 in its pathogenesis. J. Med. Virol. 2020, in press. [CrossRef]
47. Krichel, B.; Falke, S.; Hilgenfeld, R.; Redecke, L.; Uetrecht, C. Processing of the SARS-CoV pp1a/ab nsp7-10
region. Biochem. J. 2019, 477, 1009–1019. [CrossRef] [PubMed]
48. Elena, S.F.; Sanjuán, R. Adaptive value of high mutation rates of RNA viruses: Separating causes from
consequences. J. Virol. 2005, 79, 11555–11558. [CrossRef] [PubMed]
49. Ferron, F.; Subissi, L.; De Morais, A.T.S.; Le, N.T.T.; Sevajol, M.; Gluais, L.; Decroly, E.; Vonrhein, C.;
Bricogne, G.; Canard, B. Structural and molecular basis of mismatch correction and ribavirin excision from
coronavirus RNA. Proc. Natl. Acad. Sci. USA 2018, 115, E162–E171. [CrossRef] [PubMed]
50. Lau, S.K.; Lee, P.; Tsang, A.K.; Yip, C.C.; Tse, H.; Lee, R.A.; So, L.-Y.; Lau, Y.-L.; Chan, K.-H.; Woo, P.C.
Molecular epidemiology of human coronavirus OC43 reveals evolution of different genotypes over time
and recent emergence of a novel genotype due to natural recombination. J. Virol. 2011, 85, 11325–11337.
[CrossRef]
51. Makino, S.; Keck, J.G.; Stohlman, S.A.; Lai, M. High-frequency RNA recombination of murine coronaviruses.
J. Virol. 1986, 57, 729–737. [CrossRef]
52. Zhang, X.; Yap, Y.; Danchin, A. Testing the hypothesis of a recombinant origin of the SARS-associated
coronavirus. Arch. Virol. 2005, 150, 1–20. [CrossRef]
53. Zhang, Z.; Shen, L.; Gu, X. Evolutionary dynamics of MERS-CoV: Potential recombination, positive selection
and transmission. Sci. Rep. 2016, 6, 25049. [CrossRef]
54. Lassmann, T. Kalign 3: Multiple sequence alignment of large datasets. Bioinformatics 2019, 36, 1928–1929.
[CrossRef]
55. Kalyaanamoorthy, S.; Minh, B.Q.; Wong, T.K.; von Haeseler, A.; Jermiin, L.S. ModelFinder: Fast model
selection for accurate phylogenetic estimates. Nat. Methods 2017, 14, 587–589. [CrossRef]
56. Nguyen, L.-T.; Schmidt, H.A.; Von Haeseler, A.; Minh, B.Q. IQ-TREE: A fast and effective stochastic algorithm
for estimating maximum-likelihood phylogenies. Mol. Biol. Evol. 2015, 32, 268–274. [CrossRef]
57. Kumar, S.; Stecher, G.; Li, M.; Knyaz, C.; Tamura, K. MEGA X: Molecular evolutionary genetics analysis
across computing platforms. Mol. Biol. Evol. 2018, 35, 1547–1549. [CrossRef] [PubMed]
58. Wan, Y.; Shang, J.; Graham, R.; Baric, R.S.; Li, F. Receptor recognition by novel coronavirus from Wuhan: An
analysis based on decade-long structural studies of SARS. J. Virol. 2020, 94, e00127-20. [CrossRef] [PubMed]
59. Park, Y.-J.; Walls, A.C.; Wang, Z.; Sauer, M.M.; Li, W.; Tortorici, M.A.; Bosch, B.-J.; DiMaio, F.; Veesler, D.
Structures of MERS-CoV spike glycoprotein in complex with sialoside attachment receptors. Nat. Struct.
Mol. Biol. 2019, 26, 1151–1157. [CrossRef] [PubMed]
60. Walls, A.C.; Park, Y.-J.; Tortorici, M.A.; Wall, A.; McGuire, A.T.; Veesler, D. Structure, function and antigenicity
of the SARS-CoV-2 spike glycoprotein. Cell 2020, in press. [CrossRef]
61. Andersen, K.; Rambaut, A.; Lipkin, W.; Holmes, E.C.; Garry, R. The proximal origin of SARS-CoV-2. Nat.
Med. 2020, 26, 450–452. [CrossRef]
62. Yount, B.; Roberts, R.S.; Sims, A.C.; Deming, D.; Frieman, M.B.; Sparks, J.; Denison, M.R.; Davis, N.; Baric, R.S.
Severe acute respiratory syndrome coronavirus group-specific open reading frames encode nonessential
functions for replication in cell cultures and mice. J. Virol. 2005, 79, 14909–14922. [CrossRef]
63. Khan, S.; Fielding, B.C.; Tan, T.H.; Chou, C.-F.; Shen, S.; Lim, S.G.; Hong, W.; Tan, Y.-J. Over-expression of
severe acute respiratory syndrome coronavirus 3b protein induces both apoptosis and necrosis in Vero E6
cells. Virus Res. 2006, 122, 20–27. [CrossRef]
64. Kopecky-Bromberg, S.A.; Martínez-Sobrido, L.; Frieman, M.; Baric, R.A.; Palese, P. Severe acute respiratory
syndrome coronavirus open reading frame (ORF) 3b, ORF 6, and nucleocapsid proteins function as interferon
antagonists. J. Virol. 2007, 81, 548–557. [CrossRef]
65. Phan, T. Genetic diversity and evolution of SARS-CoV-2. Infect. Genet. Evol. 2020, 81, 104260. [CrossRef]
66. CDC. Coronavirus Disease 2019 (COVID-19) Situation Summary. Available online: https://www.cdc.gov/
coronavirus/2019-nCoV/summary.html#risk-assessment (accessed on 3 April 2020).
67. WHO. Coronavirus Disease (COVID-2019) Situation Reports-48. Available online: https://www.who.int/docs/
default-source/coronaviruse/situation-reports/20200308-sitrep-48-covid-19.pdf?sfvrsn=16f7ccef_4 (accessed
on 10 March 2020).
J. Clin. Med. 2020, 9, 1225 26 of 29

68. WHO. Rolling Updates on Coronavirus Disease (COVID-19). Available online: https://www.who.int/
emergencies/diseases/novel-coronavirus-2019/events-as-they-happen (accessed on 14 April 2020).
69. WHO. Coronavirus Disease (COVID-2019) Situation Reports. Available online: https:
//www.who.int/docs/default-source/coronaviruse/situation-%E2%80%8Ereports/20200304-sitrep-44-
covid-19.pdf?sfvrsn=783b4c9d_2%E2%80%8E (accessed on 8 March 2020).
70. WHO. WHO Director-General’s Opening Remarks at the Media Briefing on COVID-19-11 March 2020.
Available online: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-
media-briefing-on-covid-19---11-march-2020 (accessed on 12 March 2020).
71. Helmy, Y.A.; El-Adawy, H.; Abdelwhab, E.M. A comprehensive review of common bacterial, parasitic and
viral zoonoses at the human-animal interface in Egypt. Pathogens 2017, 6, 33. [CrossRef]
72. Ji, W.; Wang, W.; Zhao, X.; Zai, J.; Li, X. Cross-species transmission of the newly identified coronavirus
2019-nCoV. J. Med. Virol. 2020, 92, 433–440. [CrossRef] [PubMed]
73. ECDC. Outbreak of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2): Increased Transmission
Beyond China—Fourth Update. Available online: https://www.ecdc.europa.eu/sites/default/files/documents/
SARS-CoV-2-risk-assessment-14-feb-2020.pdf (accessed on 26 February 2020).
74. Liu, S.L.; Saif, L.J.; Weiss, S.R.; Su, L. No credible evidence supporting claims of the laboratory engineering of
SARS-CoV-2. Emerg. Microbes Infect. 2020, 9, 505–507. [CrossRef] [PubMed]
75. Shi, J.; Wen, Z.; Zhong, G.; Yang, H.; Wang, C.; Huang, B.; Liu, R.; He, X.; Shuai, L.; Sun, Z. Susceptibility
of ferrets, cats, dogs, and other domesticated animals to SARS–coronavirus 2. Science 2020. [CrossRef]
[PubMed]
76. CDC. What You Need to Know about Coronavirus Disease 2019 (COVID-19). Available online: https:
//www.cdc.gov/coronavirus/2019-ncov/downloads/2019-ncov-factsheet.pdf (accessed on 6 April 2020).
77. Lai, C.C.; Shih, T.P.; Ko, W.C.; Tang, H.J.; Hsueh, P.R. Severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) and corona virus disease-2019 (COVID-19): The epidemic and the challenges. Int. J. Antimicrob.
Agents 2020, 55, 105924. [CrossRef]
78. Holshue, M.L.; DeBolt, C.; Lindquist, S.; Lofy, K.H.; Wiesman, J.; Bruce, H.; Spitters, C.; Ericson, K.;
Wilkerson, S.; Tural, A.; et al. First case of 2019 novel coronavirus in the United States. N. Engl. J. Med. 2020,
382, 929–936. [CrossRef]
79. Kampf, G.; Todt, D.; Pfaender, S.; Steinmann, E. Persistence of coronaviruses on inanimate surfaces and its
inactivation with biocidal agents. J. Hosp. Infect. 2020, 104, 246–251. [CrossRef]
80. Chen, Z.M.; Fu, J.F.; Shu, Q.; Chen, Y.H.; Hua, C.Z.; Li, F.B.; Lin, R.; Tang, L.F.; Wang, T.L.; Wang, W.; et al.
Diagnosis and treatment recommendations for pediatric respiratory infection caused by the 2019 novel
coronavirus. World J. Pediatr. 2020. [CrossRef]
81. Wang, D.; Hu, B.; Hu, C.; Zhu, F.; Liu, X.; Zhang, J.; Wang, B.; Xiang, H.; Cheng, Z.; Xiong, Y.; et al. Clinical
characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan,
China. JAMA 2020, 323, 1061–1069. [CrossRef]
82. WHO. Coronavirus Disease (COVID-19) Technical Guidance: Laboratory Testing for 2019-nCoV in Humans.
Available online: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/
laboratory-guidance (accessed on 12 March 2020).
83. Bai, Y.; Yao, L.; Wei, T.; Tian, F.; Jin, D.Y.; Chen, L.; Wang, M. Presumed asymptomatic carrier transmission of
COVID-19. JAMA 2020, 323, 1406–1407. [CrossRef]
84. WHO. Coronavirus. Available online: https://www.who.int/health-topics/coronavirus#tab=tab_3 (accessed
on 14 April 2020).
85. NCPERE. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19)
in China. Zhonghua Liu Xing Bing Xue Za Zhi 2020, 41, 145–151. [CrossRef]
86. Zhang, W.; Du, R.-H.; Li, B.; Zheng, X.-S.; Yang, X.-L.; Hu, B.; Wang, Y.-Y.; Xiao, G.-F.; Yan, B.; Shi, Z.-L.
Molecular and serological investigation of 2019-nCoV infected patients: Implication of multiple shedding
routes. Emerg. Microbes Infect. 2020, 9, 386–389. [CrossRef] [PubMed]
87. Perlman, S. Another decade, another coronavirus. N. Engl. J. Med. 2020, 382, 760–762. [CrossRef] [PubMed]
88. Shirato, K.; Nao, N.; Katano, H.; Takayama, I.; Saito, S.; Kato, F.; Katoh, H.; Sakata, M.; Nakatsu, Y.; Mori, Y.;
et al. Development of genetic diagnostic methods for novel coronavirus 2019 (nCoV-2019) in Japan. Jpn. J.
Infect. Dis. 2020, in press. [CrossRef] [PubMed]
J. Clin. Med. 2020, 9, 1225 27 of 29

89. Corman, V.M.; Landt, O.; Kaiser, M.; Molenkamp, R.; Meijer, A.; Chu, D.K.W.; Bleicker, T.; Brunink, S.;
Schneider, J.; Schmidt, M.L.; et al. Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR.
Euro. Surveill. 2020, 25, 2000045. [CrossRef] [PubMed]
90. Kim, H. Outbreak of novel coronavirus (COVID-19): What is the role of radiologists? Eur. Radiol. 2020, in
press. [CrossRef] [PubMed]
91. Pan, F.; Ye, T.; Sun, P.; Gui, S.; Liang, B.; Li, L.; Zheng, D.; Wang, J.; Hesketh, R.L.; Yang, L.; et al. Time
course of lung changes on chest CT during recovery from 2019 novel coronavirus (COVID-19) pneumonia.
Radiology 2020, in press. [CrossRef]
92. Ryu, S.; Chun, B. An interim review of the epidemiological characteristics of 2019 novel coronavirus.
Epidemiol. Health 2020, 42, e2020006. [CrossRef]
93. Chung, M.; Bernheim, A.; Mei, X.; Zhang, N.; Huang, M.; Zeng, X.; Cui, J.; Xu, W.; Yang, Y.; Fayad, Z.A. CT
imaging features of 2019 novel coronavirus (2019-nCoV). Radiology 2020, 295, 202–207. [CrossRef]
94. Song, F.; Shi, N.; Shan, F.; Zhang, Z.; Shen, J.; Lu, H.; Ling, Y.; Jiang, Y.; Shi, Y. Emerging 2019 novel coronavirus
(2019-nCoV) pneumonia. Radiology 2020, 295, 210–217. [CrossRef]
95. Li, H.; Wang, Y.; Xu, J.; Cao, B. Potential antiviral therapeutics for 2019 novel coronavirus. Zhonghua Jie He He
Hu Xi Za Zhi 2020, 43, E002.
96. Zylka-Menhorn, V.; Grunert, G. Coronavirus 2019-nCoV: Der Steckbrief des Virus ist im Fluss. Deutsches
Ärzteblatt Jg. 117, Heft 6. Dtsch. Arztebl. 2020, 117, A-250/B-219/C-215.
97. Han, W.; Quan, B.; Guo, Y.; Zhang, J.; Lu, Y.; Feng, G.; Wu, Q.; Fang, F.; Cheng, L.; Jiao, N.; et al. The course
of clinical diagnosis and treatment of a case infected with coronavirus disease 2019. J. Med. Virol. 2020, 92,
461–463. [CrossRef] [PubMed]
98. Lim, J.; Jeon, S.; Shin, H.Y.; Kim, M.J.; Seong, Y.M.; Lee, W.J.; Choe, K.W.; Kang, Y.M.; Lee, B.; Park, S.J. Case
of the index patient who caused tertiary transmission of COVID-19 infection in Korea: The application of
lopinavir/ritonavir for the treatment of COVID-19 infected pneumonia monitored by quantitative RT-PCR. J.
Korean Med. Sci. 2020, 35, e79. [CrossRef] [PubMed]
99. Huang, X.; Xu, Y.; Yang, Q.; Chen, J.; Zhang, T.; Li, Z.; Guo, C.; Chen, H.; Wu, H.; Li, N. Efficacy and biological
safety of lopinavir/ritonavir based anti-retroviral therapy in HIV-1-infected patients: A meta-analysis of
randomized controlled trials. Sci. Rep. 2015, 5, 8528. [CrossRef]
100. Al-Tawfiq, J.A.; Momattin, H.; Dib, J.; Memish, Z.A. Ribavirin and interferon therapy in patients infected
with the Middle East respiratory syndrome coronavirus: An observational study. Int. J. Infect. Dis. 2014, 20,
42–46. [CrossRef]
101. Arabi, Y.M.; Shalhoub, S.; Mandourah, Y.; Al-Hameed, F.; Al-Omari, A.; Al Qasim, E.; Jose, J.; Alraddadi, B.;
Almotairi, A.; Al Khatib, K.; et al. Ribavirin and interferon therapy for critically ill patients with Middle East
respiratory syndrome: A multicenter observational study. Clin. Infect. Dis. 2019, in press. [CrossRef]
102. Zhang, W.; Zhao, Y.; Zhang, F.; Wang, Q.; Li, T.; Liu, Z.; Wang, J.; Qin, Y.; Zhang, X.; Yan, X.; et al. The use of
anti-inflammatory drugs in the treatment of people with severe coronavirus disease 2019 (COVID-19): The
experience of clinical immunologists from China. Clin. Immunol. 2020, 214, 108393. [CrossRef]
103. Bradley, K.C.; Finsterbusch, K.; Schnepf, D.; Crotta, S.; Llorian, M.; Davidson, S.; Fuchs, S.Y.; Staeheli, P.;
Wack, A. Microbiota-driven tonic interferon signals in lung stromal cells protect from influenza virus infection.
Cell Rep. 2019, 28, 245–256.e244. [CrossRef]
104. Dai, M.; Liu, Y.; Chen, W.; Buch, H.; Shan, Y.; Chang, L.; Bai, Y.; Shen, C.; Zhang, X.; Huo, Y. Rescue fecal
microbiota transplantation for antibiotic-associated diarrhea in critically ill patients. Crit. Care 2019, 23, 324.
[CrossRef]
105. Ding, X.; Li, Q.; Li, P.; Zhang, T.; Cui, B.; Ji, G.; Lu, X.; Zhang, F. Long-Term safety and efficacy of fecal
microbiota transplant in active ulcerative colitis. Drug Saf. 2019, 42, 869–880. [CrossRef]
106. Domínguez-Díaz, C.; García-Orozco, A.; Riera-Leal, A.; Padilla-Arellano, J.R.; Fafutis-Morris, M. Microbiota
and its role on viral evasion: Is it with us or against us? Front. Cell. Infect. Microbiol. 2019, 9, 256. [CrossRef]
[PubMed]
107. Luo, H.; Tang, Q.-L.; Shang, Y.-X.; Liang, S.-B.; Yang, M.; Robinson, N.; Liu, J.-P. Can Chinese medicine
be used for prevention of corona virus disease 2019 (COVID-19)? A review of historical classics, research
evidence and current prevention programs. Chin. J. Integr. Med. 2020, 26, 243–250. [CrossRef] [PubMed]
J. Clin. Med. 2020, 9, 1225 28 of 29

108. Weng, J.-R.; Lin, C.-S.; Lai, H.-C.; Lin, Y.-P.; Wang, C.-Y.; Tsai, Y.-C.; Wu, K.-C.; Huang, S.-H.; Lin, C.-W.
Antiviral activity of Sambucus FormosanaNakai ethanol extract and related phenolic acid constituents
against human coronavirus NL63. Virus Res. 2019, 273, 197767. [CrossRef] [PubMed]
109. Chu, C.M.; Cheng, V.C.; Hung, I.F.; Wong, M.M.; Chan, K.H.; Chan, K.S.; Kao, R.Y.; Poon, L.L.; Wong, C.L.;
Guan, Y.; et al. Role of lopinavir/ritonavir in the treatment of SARS: Initial virological and clinical findings.
Thorax 2004, 59, 252–256. [CrossRef] [PubMed]
110. Wang, Y.; Ding, Y.; Yang, C.; Li, R.; Du, Q.; Hao, Y.; Li, Z.; Jiang, H.; Zhao, J.; Chen, Q.; et al. Inhibition of
the infectivity and inflammatory response of influenza virus by Arbidol hydrochloride in vitro and in vivo
(mice and ferret). Biomed. Pharmacother. 2017, 91, 393–401. [CrossRef]
111. Furuta, Y.; Gowen, B.B.; Takahashi, K.; Shiraki, K.; Smee, D.F.; Barnard, D.L. Favipiravir (T-705), a novel viral
RNA polymerase inhibitor. Antiviral Res. 2013, 100, 446–454. [CrossRef]
112. Furuta, Y.; Komeno, T.; Nakamura, T. Favipiravir (T-705), a broad spectrum inhibitor of viral RNA polymerase.
Proc. Jpn. Acad. Ser. B Phys. Biol. Sci. 2017, 93, 449–463. [CrossRef]
113. Janowski, A.B.; Dudley, H.; Wang, D. Antiviral activity of ribavirin and favipiravir against human astroviruses.
J. Clin. Virol. 2020, 123, 104247. [CrossRef]
114. Gao, J.; Li, J.; Shao, X.; Jin, Y.; Lü, X.W.; Ge, J.F.; Huang, Y.; Zhang, L.; Chen, L. Antiinflammatory and
immunoregulatory effects of total glucosides of Yupingfeng powder. Chin. Med. J. 2009, 122, 1636–1641.
115. Sheahan, T.P.; Sims, A.C.; Leist, S.R.; Schäfer, A.; Won, J.; Brown, A.J.; Montgomery, S.A.; Hogg, A.; Babusis, D.;
Clarke, M.O.; et al. Comparative therapeutic efficacy of remdesivir and combination lopinavir, ritonavir, and
interferon beta against MERS-CoV. Nat. Commun. 2020, 11, 222. [CrossRef]
116. Lathouwers, E.; Wong, E.Y.; Luo, D.; Seyedkazemi, S.; De Meyer, S.; Brown, K. HIV-1 resistance rarely
observed in patients using darunavir once-daily regimens across clinical studies. HIV Clin. Trials 2017, 18,
196–204. [CrossRef] [PubMed]
117. Mifsud, E.J.; Tilmanis, D.; Oh, D.Y.; Ming-Kay Tai, C.; Rossignol, J.F.; Hurt, A.C. Prophylaxis of ferrets with
nitazoxanide and oseltamivir combinations is more effective at reducing the impact of influenza a virus
infection compared to oseltamivir monotherapy. Antiviral Res. 2020, 176, 104751. [CrossRef] [PubMed]
118. Lee, N.; Allen Chan, K.C.; Hui, D.S.; Ng, E.K.; Wu, A.; Chiu, R.W.; Wong, V.W.; Chan, P.K.; Wong, K.T.;
Wong, E.; et al. Effects of early corticosteroid treatment on plasma SARS-associated Coronavirus RNA
concentrations in adult patients. J. Clin. Virol. 2004, 31, 304–309. [CrossRef] [PubMed]
119. Shen, C.; Wang, Z.; Zhao, F.; Yang, Y.; Li, J.; Yuan, J.; Wang, F.; Li, D.; Yang, M.; Xing, L.; et al. Treatment of 5
critically ill patients with COVID-19 with convalescent plasma. JAMA 2020, in press. [CrossRef]
120. Jawhara, S. Could Intravenous Immunoglobulin Collected from Recovered Coronavirus Patients Protect
against COVID-19 and Strengthen the Immune System of New Patients? Int. J. Mol. Sci. 2020, 21, 2272.
[CrossRef]
121. Atluri, S.; Manchikanti, L.; Hirsch, J. Expanded umbilical cord mesenchymal stem cells (UC-MSCs) as a
therapeutic strategy in managing critically ill COVID-19 patients: The case for compassionate use. Pain Phys.
2020, 23, E71–E83.
122. Clay, L.; Druce, J.; Catton, M.; Jans, D.; Wagstaff, K. The FDA-approved drug ivermectin inhibits the
replication of SARS-CoV-2 in vitro. Antiviral Res. 2020, in press. [CrossRef]
123. Chen, W.-H.; Strych, U.; Hotez, P.; Bottazzi, M.E. The SARS-CoV-2 vaccine pipeline: An overview. Curr. Trop.
Med. Rep. 2020, in press. [CrossRef]
124. Phan, L.T.; Nguyen, T.V.; Luong, Q.C.; Nguyen, T.V.; Nguyen, H.T.; Le, H.Q.; Nguyen, T.T.; Cao, T.M.;
Pham, Q.D. Importation and human-to-human transmission of a novel coronavirus in Vietnam. N. Engl. J.
Med. 2020, 382, 872–874. [CrossRef]
125. Neiderud, C.-J. How urbanization affects the epidemiology of emerging infectious diseases. Infect. Ecol.
Epidemiol. 2015, 5, 27060. [CrossRef]
126. WHO. Infection Prevention and Control during Health Care When Novel Coronavirus (nCoV) Infection
Is Suspected Interim Guidance. Available online: https://www.who.int/publications-detail/infection-
prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-
20200125 (accessed on 17 March 2020).
127. Kock, R.A.; Karesh, W.B.; Veas, F.; Velavan, T.P.; Simons, D.; Mboera, L.E.; Dar, O.; Arruda, L.B.; Zumla, A.
2019-nCoV in context: Lessons learned? Lancet Planet. Health 2020, 4, E87–E88. [CrossRef]
J. Clin. Med. 2020, 9, 1225 29 of 29

128. Daszak, P.; Olival, K.J.; Li, H. A strategy to prevent future pandemics similar to the 2019-nCoV outbreak.
Biosaf. Health 2020, 2, 6–8. [CrossRef]
129. Fawzy, M.; Helmy, Y.A. The one health approach is necessary for the control of Rift Valley fever infections in
Egypt: A comprehensive review. Viruses 2019, 11, 139. [CrossRef] [PubMed]

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