Abstract

         The disease COVID – 19 is caused by a novel Corona virus SARS-CoV-2 orginated from Wuhan, China. The disease became pandemic spreading in more than 213 countries. The first report on COVID – 19 in India was recorded on 30^th January 2020 from Kerala followed by other countries such as Russia, Spain, Brazil, UK, Italy, Turkey and Iran either on the same day or later. India being the most thickly populated country with 17.7% of total population of world, the number of cases recorded in India was 106,886 as of 20^th May 2020. However, in other countries infection exceeded the number than in India with their meager population. Therefore the researchers throughout the world developed an interest to know the methods of containment of the disease in India and this article highlights perspectives on the role of factors like air handling systems, mode of transport, nutritional facts and traditional medicine which are unique to India. The role of insects like cockroach and housefly in spreading the virus and other body fluids of infected person is also discussed and conducting joint studies representing different geographical zones at International level on these aspects is also suggested. Bringing policies in containment of SARS-CoV-2 virus as well as for other microbes in all countries is recommended.

Keywords: COVID-19, SARS-CoV-2, Pandemic, Containment, Airborne, IAQ, Transport, Traditional Medicine, India.

Introduction

         The disease COVID-19 is caused by a novel virus SARS-CoV-2¹, similar to the virus causing common cold, Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) belonging to family Coronaviridae². The virus was first reported from Wuhan the capital of Hubei Province in China³ during December 2019. The virus was first reported as an epidemic in Wuhan, China and later declared as Pandemic on 30^th of January 2020 by World Health Organization (WHO). The viral spread was recorded in 213 countries worldwide. Approximately 5 million persons around the world were infected by this virus, which is the highest record for any virus belonging to the family Coronoviridae. The symptoms of COVID-19 includes sore throat, dry cough, muscle and joint pain, fever, headache, formation of sputum, shortness in breath, fatigue, nausea and vomiting in few cases⁴. The disease symptom develops into multi organ failure resulting in fatality depending on the immune status of the patients. Fatality was mostly recorded among immunocompromised patients.

         The disease was first reported in India from the State of Kerala on 30^th of January, 2020. Three students from Wuhan, China travelled to Kerala were found to carry the infection of SARS-CoV-2. India even though being the most populated country with 17.7% of total population of the world, only 106886 confirmed cases were recorded as on 20 May, 2020. However, in other countries infection exceeded the number than in India with their meager population. When compared with top 11 countries infected with the virus, India was successful in containment of COVID-19. The success behind the containment of this disease in India developed an interest for researchers throughout the world. Apart from climatic factors like temperature, moisture and wind, other unique factors played major roles in containment of the virus in India. This includes uniqueness in air handling systems, mode of transport, nutritional facts and usage of traditional medicine. An insight on different non-pharmacological factors involved in the containment of the disease is provided in this article. All the data such as infected, fatality and recovery rates discussed in this article are based on values published by WHO, CDC and other organizations during May 2020.

Global Scenario

         As far as the prevalence of the Corona disease is concerned, United States (US) was found to be on top with more than 1.57 million cases recorded. 31.48% infection was in US, 6.05% in Russia, followed by Spain and Brazil with 5.58% and 5.44% respectively. India has recorded only around 2.14% of infection among the world population infected with SARS-CoV-2. Nearly 73% of infection was caused in 11 different countries and all other countries (202) shared the remaining 27% of infection (Fig. 1). The fatality recorded due to this disease was around 0.325 million. The fatality recorded worldwide was around 6.52% among the infected subjects. Maximum fatality was recorded in France (15.49%) followed by Italy and UK (14.2% each) and Spain (9.96%). The least fatality was recorded in Russia (0.94%). India recorded around 3.09% of fatality among the infected subjects⁵. The fatality recorded for top 11 infected countries is presented in Fig. 2.

Figure 1: Covid-19 infection (%) in different countries (as on 20 May 2020).

Figure 2: Fatality of Covid 19 (In %) in top 11 countries.

         Total number of cases recorded per million population was maximum in Spain (5963/million population) followed by US (4748/million) and Italy (3749/million). Nearly 640 people per million population was recorded for world on an average as of 20 May 2020. However, the cases recorded in India was only at 78/million population. The number of cases recorded per million of population for top countries infected with COVID-19 is presented in Fig. 3. The disease spreading rate (In days) from 100 cases to 100 thousand cases revealed that only 25 days were required in US, 31 days in Spain and 37 days in Germany. In Iran it took more than 75 days to reach 100 thousand cases from 100 cases and in India it took 64 days. Number of days required for different countries to reach 100 thousand cases from 100 cases is represented in Fig.4.

Figure 3: Covid – 19 infected persons per million in different countries.

Figure 2: Covid-19 Disease progression rate from 100 to 100 thousand subjects (In days) .

SARS-CoV-2 Transmission

         Aerosols of SARS-CoV-2 are generated through sneeze and cough of the infected subjects usually released as droplets particles at higher levels. These particles are also released from larynx, mouth, throat during exhalation while breathing and talking.. Millions of aerosol particles are generated while sneezing causing nasal secretions and mucus present in respiratory system thrown into the atmosphere at greater speed⁶. The morphological features of virus such as spherical or elliptical shape and their size 60-140nm in diameter⁷ functions as a Bio-nanomaterial and helps in their transmission through air. Due to their size and morphology they are buoyant in the atmosphere, sustain for longer time and easily transported to longer distance and this airborne nature of SARS-CoV-2 was highlighted by Morawska and Caw⁸. In India spitting is a common habit. It is found that India, China, and South Korea are significant spitting nations in the world⁹. The spitting in common place by infected subjects serve as an inoculum source of the virus. This moisture rich sputum along with mucus and saliva become dry and virus becomes airborne. The airborne viral particles are carried to longer distances depending upon the air temperature, wind, and humidity. It is noticed that airborne transmission is most potential when compared to transfer of virus through direct contact. This raises the doubt that insects like housefly, cockroach etc. sitting and feeding on the spitted phlegm, mucus and sputum may spread the disease. Thus, their role needs to be probed. The spread of virus through contact and isolation of virus from even sewages proves that they may be transmitted through bodily fluids.

Air Handling Systems

         The air circulation in other countries are maintained by centralized system using Air Handling Units (AHUs) and not with open windows. Theatres, malls, shopping complexes, corporate offices, and other residential buildings and apartments in other countries are maintained by centralized AHUs which are termed as Air Tight Buildings. The diseases associated with such buildings are widely reported as Building Related Illness (BRI) or Sick Building Syndrome (SBS). The air circulation maintained by AHUs are having a single point of source and air is continuously circulated within buildings¹⁰. Thus, if any subject occupying the building infected with SARS-CoV-2 sneeze or coughs within indoor, the inoculum is dispersed within and is circulated throughout the building which in turn affects the other occupants. Thus, exposure to the virus is manifold in such buildings. However, in India, majority of the buildings use open windows for air circulation. Few possess air condition systems as a single unit. In India, except malls, theatres and few corporate offices all other buildings rarely possess AHUs for air handing. Even in those buildings, attention was paid to clean the surfaces. These offices were closed by the Federal Government as Lockdown from the date of 24th March 2020. Thus, the spread of SARS-CoV-2 in India is contained.

Transport

         The countries which report more number of COVID-19 use Flight, Buses, and Trains provided with central air conditioned systems for their transport. Huge number of population use personal car switched on with Air condition system. These transport systems are considered as air tight as there is no external transaction of air as their doors are closed. This develops a microenvironment within the transport system and exposure risk associated with the nature of microbe present within¹¹. Thus, transmission of virus is easy and exposure to SARS-CoV-2 virus is more when co traveler is infected with the virus in such modes of transport. However, in India, the commuting system used by the general public is often of open type. Majority of population, i.e. nearly 70 % in India use two and three wheelers like scooters, mopeds, bikes, and autos as a mode of transport when compared to Japan (17%), Germany (10%), and USA (2-3%)¹². Remaining population use public transport system like Non A/c buses and Non A/c coaches in train which are of open types. This helps in air transaction between outdoor air along with the atmosphere within trains and buses. Even if any passenger positive for COVID either sneezes or coughs, the inoculum will be diluted and dispersed outward. Very few among the population use buses with Air conditioned system and A/c train coach. Usage of flight for transport is far less in India when compared with other countries due to economic status of general public. This favors the containment of virus in India.

Food Habits

         India is the most populated country with vegetarians due to religious belief and caste system followed. The number varies from 300 to 400 million people being vegetarian¹³. Other 40% consumes non vegetarian meats with less frequency which is attributed to economic status. However uncooked or raw meat are never consumed in India. The style of consuming meat in India is different from other countries as they are well cooked and added with more spices and condiments. The spices and condiments used in Indian culinary is widely found to possess antiviral properties and boosting immune system. To mention a few, 1) Star anise is found to possess antioxidants and rich in Vitamins A and C Effective as an antiviral and easing sore throats and cold, 2) Curcumin is a well-known antiviral compound present in Turmeric which is an effective antioxidant and anti-inflammatory in nature, 3) Fenugreek is used to treat sore throat as they are antiviral in nature, 4) Nutmeg used in Biriyani as a flavoring agent is found to boost immune system, 5) Cinnamon found to possess rich antioxidants and mixed with ginger to treat common cold, 6) Black pepper contains various anti-oxidants, 7) Cloves are found to possess anti-inflammatory, antiseptic, and pain relieving properties, 8) Mustard for common cold, 9) Cardamom rich in antioxidants, vitamins, and minerals, 10) Ginger is widely used which provides immunity against common cold, 11) Onion is rich in antioxidants and anti-inflammatory activities, and 12) Garlic is used as antiviral and against common cold. Thus, the immune system of the Indian population in general is strong when compared to other countries which recorded morenumber of SARS-CoV-2 viral infections. Further, the leaves of Murraya (Curry leaf) and Coriander are reported as antiviral culinary herbs. These herbs are used widely in Indian culinary. To name, Rasam (A boiled aqueous extract of different spices, condiments and culinary herbs) is unique culinary item of India which is not prepared in other countries. Thus, it is predicted that food habits of the Indian population provide innate or acquired immunity against SARS-CoV-2 when compared with other countries.

Traditional Medicine

         India is rich in its own traditional system of medicine in healing the patients. This is also popularly termed as an alternative system of medicine. The Indian system of medicine has three major divisions namely Ayurveda, Siddha, and Unani based on their origin. The Ayurveda system of medicine dates back to 1500 BC. It is a well-developed system of medicine with two major divisions as school of medicine and school of surgery. The other system is Siddha, which originates in southern part of India. This system has a specialty in usage of drugs of metals and minerals in origin along with that of vegetation (Herbs) dependent drugs as Ayurveda. Unani system of medicine came into existence in India by the time period of 1350 AD¹⁴. All the above system use plants in general.

         The following plant species are widely used throughout India for the treatment of cold, flu, and asthma related respiratory diseases. They include, Andrographis paniculata (Cold and Flu); Piper longum and P. nigrum (Cough, Asthma, and Fever); Clerodendrumserratum, Saussurialappa, and Solanum xanthocarpum (Asthma); Zingiber officinale (Asthma and Fever); Ocimum sanctum (Immunomodulator); Allium sativum, Boerhaviadiffusa, Calotropis gigantea, Curcuma longa, Eugenia jambolana, Ficus religiosa, Myristica fragrans, Rubia cordifolia and Vitex negundo (Anti-inflammatory). The plants like, Lycoris radiata, Artemisia annua, Ocimumbasilicum, Terminalia chebula, Polygonum cuspidatum, Curcuma longa, Melia azadirachandmany species of Phyllanthus, Calophyllum, Caesalpinia and Cajanus are found to possess antiviral properties¹⁵. Due to wide practice of traditional system of medicine in India and plenty of usage of antiviral plants provide protection to the population thus, preventing the infection of COVID-19.

Conclusion and Recommendations:

         The article provides the insight on non-pharmacological factors behind the successful containment of the infection of virus SARS-CoV-2 in India which is attributed to the following reasons, i.e. a) the uniqueness of buildings and maintenance of air circulation system as an individual units rather than centralized AHUs, b) Timely intervention and declaration of lock down by the Government of India which arrested the spread of virus through Indoor Air, c) Mode of Transport used by the general public in India, d) Food habits and the culinary system of India, and e) Massive usage of Traditional System of Medicine in India when compared with other countries. Policy on studying SARS-CoV-2 as airborne virus, their spread through other body fluids, role of insects in dispersion of disease causing virus is recommended. Expansion of such policy to other microbes will prevent future challenges. Based on the insight provided on the non-pharmacological factors in containment of COVID-19, few recommendations are made:

a) Government of India and Government of different states need to develop a policy to monitor indoor for the presence of SARS-CoV-2. This has to be expanded to other microbes too.

b) The spread of SARS-CoV-2 through perspiration or other body fluids of the subjects having COVID-19 need to be monitored as there is no solid evidence stating that the virus will not spread through sweat or other body fluids.

c) The role of insects like housefly and cockroaches on spreading the viral inoculum of COVID -19 from the sputum and phlegm spitted on common places by the infected people need to be established.

d) To combat the spread of COVID-19 it is strongly recommended that each individual building, malls, theatres, corporate offices of India need to be monitored for the presence of SARS-CoV-2 on surfaces, indoor air, air ducts, air vents, and AHU filters. People must be allowed to occupy such buildings only after getting clearance certificates from the Government bodies.

e) Specialized individuals or IAQ specialists must be appointed for regular monitoring of indoor environments.

Conclusion

         Financial support from R & D, Marina Labs, Chennai (Grant Number: ML-2020-RD001) is gratefully acknowledged.

References

World Health Organization. (2020). Naming the coronavirus disease (COVID-19) and the virus that causes it.

Pal, M., Berhanu, G., Desalegn, C., & Kandi, V. (2020). Severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2): An update. Cureus, 12 (3).

Hui, D. S., Azhar, E. E., Madani, T. A., Ntoumi, F., Kock, R., Dar, O., Ippolito, G., &Mchugh, T. D. (2020). The continuing epidemic threat of novel coronaviruses to global health–the latest novel coronavirus outbreak in Wuhan, China. International Journal of Infectious Diseases.

Centers for Disease Control and Prevention. (2020). Coronavirus disease 2019 (COVID‐19)—symptoms. Published April, 17.

https://www.worldometers.info/coronavirus/

Chen, S. C., Chio, C. P., Jou, L. J., & Liao, C. M. (2009). Viral kinetics and exhaled droplet size affect indoor transmission dynamics of influenza infection. Indoor Air, 19 (5), 401.

Cascella, M., Rajnik, M., Cuomo, A., Dulebohn, S. C., & Di Napoli, R. (2020). Features, evaluation and treatment coronavirus (COVID-19). In Statpearls [internet]. StatPearls Publishing.

Morawska, L., & Cao, J. (2020). Airborne transmission of SARS-CoV-2: The world should face the reality. Environment International, 105730.

Nayar, K. R., Bhat, L., Kumar, A., Babu, G. R., &Shaffi, M. (2016). The ‘Spittoon Syndrome’How Effective Will Be the Anti-Spitting Initiatives in India? Economic & Political Weekly, 26 & 27, 15 - 18.

Udaya Prakash, N. K. (2005). Indoor mold spectrum in the buildings of Singapore. Pollution Research, 24, S39 - S44.

Prakash, N. U., Bhuvaneswari, S., Kumar, M. R., Lankesh, S., & Rupesh, K. (2014). A study on the prevalence of indoor mycoflora in air conditioned buses. Microbiology Research Journal International, 282 - 292.

Solutions, I. T. (2009). Two-and-Three-Wheelers in India. Final report. International Council on Clean Transportation and Institute for Transportation and Development Policy, New Delhi, India.

Agrawal, S. (2017). Geographic Aspects of Vegetarianism: Vegetarians in India. In Vegetarian and Plant-Based Diets in Health and Disease Prevention (pp. 93-106). Academic Press.

Ravishankar, B., & Shukla, V. J. (2007). Indian systems of medicine: a brief profile. African Journal of Traditional, Complementary and Alternative Medicines, 4 (3), 319 - 337.

Lin, L. T., Hsu, W. C., & Lin, C. C. (2014). Antiviral natural products and herbal medicines. Journal of traditional and complementary medicine, 4 (1), 24 – 35.