CURRENT WORLDWIDE SCENARIO OF SARS-CoV-2
This novel virus, SARS-CoV-2, comes under the subgenus Sarbecovirus of the Orthocoronavirinae subfamily and is entirely different from the viruses responsible for MERS-CoV and SARS-CoV (3). The newly emerged SARS-CoV-2 is a group 2B coronavirus (2). The genome sequences of SARS-CoV-2 obtained from patients share 79.5% sequence similarity to the sequence of SARS-CoV (63).
As of 13 May 2020, a total of 4,170,424 confirmed cases of COVID-19 (with 287,399 deaths) have been reported in more than 210 affected countries worldwide (WHO Situation Report 114 [25]) (Fig. 3).
FIG 3  World map depicting the current scenario of COVID-19. Shown are countries, territories, or regions with reported confirmed cases of SARS-CoV-2 as of 13 May 2020. Different colors indicate different WHO designated geographical regions with the number of confirmed cases. The WHO region-wise total number of confirmed cases is depicted in different color strips. The leading information on the confirmed cases and deaths from all six WHO designated regions are depicted in circled balloons. The numbers of COVID-19 cases and fatalities on three major cruise ships are also depicted. (Based on data from the WHO at https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200513-covid-19-sitrep-114.pdf?sfvrsn=17ebbbe_4; updated numbers of cases, deaths, and patients recovered can be found at https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6.) Initially, the epicenter of the SARS-CoV-2 pandemic was China, which reported a significant number of deaths associated with COVID-19, with 84,458 laboratory-confirmed cases and 4,644 deaths as of 13 May 2020 (Fig. 4). As of 13 May 2020, SARS-CoV-2 confirmed cases have been reported in more than 210 countries apart from China (Fig. 3 and 4) (WHO Situation Report 114) (25, 64). COVID-19 has been reported on all continents except Antarctica. For many weeks, Italy was the focus of concerns regarding the large number of cases, with 221,216 cases and 30,911 deaths, but now, the United States is the country with the largest number of cases, 1,322,054, and 79,634 deaths. Now, the United Kingdom has even more cases (226,4671) and deaths (32,692) than Italy. A John Hopkins University web platform has provided daily updates on the basic epidemiology of the COVID-19 outbreak (https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6) (238).
FIG 4  Bar graph and pie chart for cases and deaths. Shown are laboratory-confirmed cases and deaths in China and the rest of the world due to SARS-CoV-2. (A) SARS-CoV-2 confirmed cases in the top five affected countries from each WHO designated region, where maximum casualties were reported to WHO until 13 May 2020. (B) Total numbers of deaths and cases in China only. (C) Total number of cases worldwide by region. COVID-19 has also been confirmed on a cruise ship, named Diamond Princess, quarantined in Japanese waters (Port of Yokohama), as well as on other cruise ships around the world (239) (Fig. 3). The significant events of the SARS-CoV-2/COVID-19 virus outbreak occurring since 8 December 2019 are presented as a timeline in Fig. 5.
FIG 5  Timeline depicting the significant events that occurred during the SARS-CoV-2/COVID-19 virus outbreak. The timeline describes the significant events during the current SARS-CoV-2 outbreak, from 8 December 2019 to 13 May 2020. At the beginning, China experienced the majority of the burden associated with COVID-19 in the form of disease morbidity and mortality (65), but over time the COVID-19 menace moved to Europe, particularly Italy and Spain, and now the United States has the highest number of confirmed cases and deaths. The COVID-19 outbreak has also been associated with severe economic impacts globally due to the sudden interruption of global trade and supply chains that forced multinational companies to make decisions that led to significant economic losses (66). The recent increase in the number of confirmed critically ill patients with COVID-19 has already surpassed the intensive care supplies, limiting intensive care services to only a small portion of critically ill patients (67). This might also have contributed to the increased case fatality rate observed in the COVID-19 outbreak.

Viewpoint on SARS-CoV-2 Transmission, Spread, and Emergence
The novel coronavirus was identified within 1 month (28 days) of the outbreak. This is impressively fast compared to the time taken to identify SARS-CoV reported in Foshan, Guangdong Province, China (125 days) (68). Immediately after the confirmation of viral etiology, the Chinese virologists rapidly released the genomic sequence of SARS-CoV-2, which played a crucial role in controlling the spread of this newly emerged novel coronavirus to other parts of the world (69). The possible origin of SARS-CoV-2 and the first mode of disease transmission are not yet identified (70). Analysis of the initial cluster of infections suggests that the infected individuals had a common exposure point, a seafood market in Wuhan, Hubei Province, China (Fig. 6). The restaurants of this market are well-known for providing different types of wild animals for human consumption (71). The Huanan South China Seafood Market also sells live animals, such as poultry, bats, snakes, and marmots (72). This might be the point where zoonotic (animal-to-human) transmission occurred (71). Although SARS-CoV-2 is alleged to have originated from an animal host (zoonotic origin) with further human-to-human transmission (Fig. 6), the likelihood of foodborne transmission should be ruled out with further investigations, since it is a latent possibility (1). Additionally, other potential and expected routes would be associated with transmission, as in other respiratory viruses, by direct contact, such as shaking contaminated hands, or by direct contact with contaminated surfaces (Fig. 6). Still, whether blood transfusion and organ transplantation (276), as well as transplacental and perinatal routes, are possible routes for SARS-CoV-2 transmission needs to be determined (Fig. 6).
FIG 6  Potential transmission routes for SARS-CoV-2. From experience with several outbreaks associated with known emerging viruses, higher pathogenicity of a virus is often associated with lower transmissibility. Compared to emerging viruses like Ebola virus, avian H7N9, SARS-CoV, and MERS-CoV, SARS-CoV-2 has relatively lower pathogenicity and moderate transmissibility (15). The risk of death among individuals infected with COVID-19 was calculated using the infection fatality risk (IFR). The IFR was found to be in the range of 0.3% to 0.6%, which is comparable to that of a previous Asian influenza pandemic (1957 to 1958) (73, 277).
Notably, the reanalysis of the COVID-19 pandemic curve from the initial cluster of cases pointed to considerable human-to-human transmission. It is opined that the exposure history of SARS-CoV-2 at the Wuhan seafood market originated from human-to-human transmission rather than animal-to-human transmission (74); however, in light of the zoonotic spillover in COVID-19, is too early to fully endorse this idea (1). Following the initial infection, human-to-human transmission has been observed with a preliminary reproduction number (R0) estimate of 1.4 to 2.5 (70, 75), and recently it is estimated to be 2.24 to 3.58 (76). In another study, the average reproductive number of COVID-19 was found to be 3.28, which is significantly higher than the initial WHO estimate of 1.4 to 2.5 (77). It is too early to obtain the exact R0 value, since there is a possibility of bias due to insufficient data. The higher R0 value is indicative of the more significant potential of SARS-CoV-2 transmission in a susceptible population. This is not the first time where the culinary practices of China have been blamed for the origin of novel coronavirus infection in humans. Previously, the animals present in the live-animal market were identified to be the intermediate hosts of the SARS outbreak in China (78). Several wildlife species were found to harbor potentially evolving coronavirus strains that can overcome the species barrier (79). One of the main principles of Chinese food culture is that live-slaughtered animals are considered more nutritious (5).
After 4 months of struggle that lasted from December 2019 to March 2020, the COVID-19 situation now seems under control in China. The wet animal markets have reopened, and people have started buying bats, dogs, cats, birds, scorpions, badgers, rabbits, pangolins (scaly anteaters), minks, soup from palm civet, ostriches, hamsters, snapping turtles, ducks, fish, Siamese crocodiles, and other animal meats without any fear of COVID-19. The Chinese government is encouraging people to feel they can return to normalcy. However, this could be a risk, as it has been mentioned in advisories that people should avoid contact with live-dead animals as much as possible, as SARS-CoV-2 has shown zoonotic spillover. Additionally, we cannot rule out the possibility of new mutations in the same virus being closely related to contact with both animals and humans at the market (284). In January 2020, China imposed a temporary ban on the sale of live-dead animals in wet markets. However, now hundreds of such wet markets have been reopened without optimizing standard food safety and sanitation practices (286).
With China being the most populated country in the world and due to its domestic and international food exportation policies, the whole world is now facing the menace of COVID-19, including China itself. Wet markets of live-dead animals do not maintain strict food hygienic practices. Fresh blood splashes are present everywhere, on the floor and tabletops, and such food customs could encourage many pathogens to adapt, mutate, and jump the species barrier. As a result, the whole world is suffering from novel SARS-CoV-2, with more than 4,170,424 cases and 287,399 deaths across the globe. There is an urgent need for a rational international campaign against the unhealthy food practices of China to encourage the sellers to increase hygienic food practices or close the crude live-dead animal wet markets. There is a need to modify food policies at national and international levels to avoid further life threats and economic consequences from any emerging or reemerging pandemic due to close animal-human interaction (285).
Even though individuals of all ages and sexes are susceptible to COVID-19, older people with an underlying chronic disease are more likely to become severely infected (80). Recently, individuals with asymptomatic infection were also found to act as a source of infection to susceptible individuals (81). Both the asymptomatic and symptomatic patients secrete similar viral loads, which indicates that the transmission capacity of asymptomatic or minimally symptomatic patients is very high. Thus, SARS-CoV-2 transmission can happen early in the course of infection (82). Atypical clinical manifestations have also been reported in COVID-19 in which the only reporting symptom was fatigue. Such patients may lack respiratory signs, such as fever, cough, and sputum (83). Hence, the clinicians must be on the look-out for the possible occurrence of atypical clinical manifestations to avoid the possibility of missed diagnosis. The early transmission ability of SARS-CoV-2 was found to be similar to or slightly higher than that of SARS-CoV, reflecting that it could be controlled despite moderate to high transmissibility (84).
Increasing reports of SARS-CoV-2 in sewage and wastewater warrants the need for further investigation due to the possibility of fecal-oral transmission. SARS-CoV-2 present in environmental compartments such as soil and water will finally end up in the wastewater and sewage sludge of treatment plants (328). Therefore, we have to reevaluate the current wastewater and sewage sludge treatment procedures and introduce advanced techniques that are specific and effective against SARS-CoV-2. Since there is active shedding of SARS-CoV-2 in the stool, the prevalence of infections in a large population can be studied using wastewater-based epidemiology. Recently, reverse transcription-quantitative PCR (RT-qPCR) was used to enumerate the copies of SARS-CoV-2 RNA concentrated from wastewater collected from a wastewater treatment plant (327). The calculated viral RNA copy numbers determine the number of infected individuals. The increasing reports of virus shedding via the fecal route warrants the introduction of negative fecal viral nucleic acid test results as one of the additional discharge criteria in laboratory-confirmed cases of COVID-19 (326).
The COVID-19 pandemic does not have any novel factors, other than the genetically unique pathogen and a further possible reservoir. The cause and the likely future outcome are just repetitions of our previous interactions with fatal coronaviruses. The only difference is the time of occurrence and the genetic distinctness of the pathogen involved. Mutations on the RBD of CoVs facilitated their capability of infecting newer hosts, thereby expanding their reach to all corners of the world (85). This is a potential threat to the health of both animals and humans. Advanced studies using Bayesian phylogeographic reconstruction identified the most probable origin of SARS-CoV-2 as the bat SARS-like coronavirus, circulating in the Rhinolophus bat family (86).
Phylogenetic analysis of 10 whole-genome sequences of SARS-CoV-2 showed that they are related to two CoVs of bat origin, namely, bat-SL-CoVZC45 and bat-SL-CoVZXC21, which were reported during 2018 in China (17). It was reported that SARS-CoV-2 had been confirmed to use ACE2 as an entry receptor while exhibiting an RBD similar to that of SARS-CoV (17, 87, 254, 255). Several countries have provided recommendations to their people traveling to China (88, 89). Compared to the previous coronavirus outbreaks caused by SARS-CoV and MERS-CoV, the efficiency of SARS-CoV-2 human-to-human transmission was thought to be less. This assumption was based on the finding that health workers were affected less than they were in previous outbreaks of fatal coronaviruses (2). Superspreading events are considered the main culprit for the extensive transmission of SARS and MERS (90, 91). Almost half of the MERS-CoV cases reported in Saudi Arabia are of secondary origin that occurred through contact with infected asymptomatic or symptomatic individuals through human-to-human transmission (92). The occurrence of superspreading events in the COVID-19 outbreak cannot be ruled out until its possibility is evaluated. Like SARS and MERS, COVID-19 can also infect the lower respiratory tract, with milder symptoms (27). The basic reproduction number of COVID-19 has been found to be in the range of 2.8 to 3.3 based on real-time reports and 3.2 to 3.9 based on predicted infected cases (84).

Coronaviruses in Humans—SARS, MERS, and COVID-19
Coronavirus infection in humans is commonly associated with mild to severe respiratory diseases, with high fever, severe inflammation, cough, and internal organ dysfunction that can even lead to death (92). Most of the identified coronaviruses cause the common cold in humans. However, this changed when SARS-CoV was identified, paving the way for severe forms of the disease in humans (22). Our previous experience with the outbreaks of other coronaviruses, like SARS and MERS, suggests that the mode of transmission in COVID-19 as mainly human-to-human transmission via direct contact, droplets, and fomites (25). Recent studies have demonstrated that the virus could remain viable for hours in aerosols and up to days on surfaces; thus, aerosol and fomite contamination could play potent roles in the transmission of SARS-CoV-2 (257).
The immune response against coronavirus is vital to control and get rid of the infection. However, maladjusted immune responses may contribute to the immunopathology of the disease, resulting in impairment of pulmonary gas exchange. Understanding the interaction between CoVs and host innate immune systems could enlighten our understanding of the lung inflammation associated with this infection (24).
SARS is a viral respiratory disease caused by a formerly unrecognized animal CoV that originated from the wet markets in southern China after adapting to the human host, thereby enabling transmission between humans (90). The SARS outbreak reported in 2002 to 2003 had 8,098 confirmed cases with 774 total deaths (9.6%) (93). The outbreak severely affected the Asia Pacific region, especially mainland China (94). Even though the case fatality rate (CFR) of SARS-CoV-2 (COVID-19) is lower than that of SARS-CoV, there exists a severe concern linked to this outbreak due to its epidemiological similarity to influenza viruses (95, 279). This can fail the public health system, resulting in a pandemic (96).
MERS is another respiratory disease that was first reported in Saudi Arabia during the year 2012. The disease was found to have a CFR of around 35% (97). The analysis of available data sets suggests that the incubation period of SARS-CoV-2, SARS-CoV, and MERS-CoV is in almost the same range. The longest predicted incubation time of SARS-CoV-2 is 14 days. Hence, suspected individuals are isolated for 14 days to avoid the risk of further spread (98). Even though a high similarity has been reported between the genome sequence of the new coronavirus (SARS-CoV-2) and SARS-like CoVs, the comparative analysis recognized a furin-like cleavage site in the SARS-CoV-2 S protein that is missing from other SARS-like CoVs (99). The furin-like cleavage site is expected to play a role in the life cycle of the virus and disease pathogenicity and might even act as a therapeutic target for furin inhibitors. The highly contagious nature of SARS-CoV-2 compared to that of its predecessors might be the result of a stabilizing mutation that occurred in the endosome-associated-protein-like domain of nsp2 protein.
Similarly, the destabilizing mutation near the phosphatase domain of nsp3 proteins in SARS-CoV-2 could indicate a potential mechanism that differentiates it from other CoVs (100). Even though the CFR reported for COVID-19 is meager compared to those of the previous SARS and MERS outbreaks, it has caused more deaths than SARS and MERS combined (101). Possibly related to the viral pathogenesis is the recent finding of an 832-nucleotide (nt) deletion in ORF8, which appears to reduce the replicative fitness of the virus and leads to attenuated phenotypes of SARS-CoV-2 (256).
Coronavirus is the most prominent example of a virus that has crossed the species barrier twice from wild animals to humans during SARS and MERS outbreaks (79, 102). The possibility of crossing the species barrier for the third time has also been suspected in the case of SARS-CoV-2 (COVID-19). Bats are recognized as a possible natural reservoir host of both SARS-CoV and MERS-CoV infection. In contrast, the possible intermediary host is the palm civet for SARS-CoV and the dromedary camel for MERS-CoV infection (102). Bats are considered the ancestral hosts for both SARS and MERS (103). Bats are also considered the reservoir host of human coronaviruses like HCoV-229E and HCoV-NL63 (104). In the case of COVID-19, there are two possibilities for primary transmission: it can be transmitted either through intermediate hosts, similar to that of SARS and MERS, or directly from bats (103). The emergence paradigm put forward in the SARS outbreak suggests that SARS-CoV originated from bats (reservoir host) and later jumped to civets (intermediate host) and incorporated changes within the receptor-binding domain (RBD) to improve binding to civet ACE2. This civet-adapted virus, during their subsequent exposure to humans at live markets, promoted further adaptations that resulted in the epidemic strain (104). Transmission can also occur directly from the reservoir host to humans without RBD adaptations. The bat coronavirus that is currently in circulation maintains specific “poised” spike proteins that facilitate human infection without the requirement of any mutations or adaptations (105). Altogether, different species of bats carry a massive number of coronaviruses around the world (106).
The high plasticity in receptor usage, along with the feasibility of adaptive mutation and recombination, may result in frequent interspecies transmission of coronavirus from bats to animals and humans (106). The pathogenesis of most bat coronaviruses is unknown, as most of these viruses are not isolated and studied (4). Hedgehog coronavirus HKU31, a Betacoronavirus, has been identified from amur hedgehogs in China. Studies show that hedgehogs are the reservoir of Betacoronavirus, and there is evidence of recombination (107).
The current scientific evidence available on MERS infection suggests that the significant reservoir host, as well as the animal source of MERS infection in humans, is the dromedary camels (97). The infected dromedary camels may not show any visible signs of infection, making it challenging to identify animals actively excreting MERS-CoV that has the potential to infect humans. However, they may shed MERS-CoV through milk, urine, feces, and nasal and eye discharge and can also be found in the raw organs (108). In a study conducted to evaluate the susceptibility of animal species to MERS-CoV infection, llamas and pigs were found to be susceptible, indicating the possibility of MERS-CoV circulation in animal species other than dromedary camels (109).
Following the outbreak of SARS in China, SARS-CoV-like viruses were isolated from Himalayan palm civets (Paguma larvata) and raccoon dogs (Nyctereutes procyonoides) found in a live-animal market in Guangdong, China. The animal isolates obtained from the live-animal market retained a 29-nucleotide sequence that was not present in most of the human isolates (78). These findings were critical in identifying the possibility of interspecies transmission in SARS-CoV. The higher diversity and prevalence of bat coronaviruses in this region compared to those in previous reports indicate a host/pathogen coevolution. SARS-like coronaviruses also have been found circulating in the Chinese horseshoe bat (Rhinolophus sinicus) populations. The in vitro and in vivo studies carried out on the isolated virus confirmed that there is a potential risk for the reemergence of SARS-CoV infection from the viruses that are currently circulating in the bat population (105).