The impact of new electronic communication mode in treatment of SARS-CoV-2 infection

Background: More than 230,000 cases of coronavirus disease (COVID-19) have been reported worldwide. We sought to discuss the impact of new electronic communication tools with patients in diagnosis and treatment of these cases. Methods: We recruited adult patients from Jan 20 to Feb 26, 2020, with laboratory-conrmed SARS-CoV-2 infection from The Fifth Aliated Hospital, Sun Yat-sen University, in Zhuhai, China. 47 eligible patients were enrolled and randomly classied into either a test or control group. All of them were treated with standard therapeutic regimen and routine ward-round. The test group was subdivided into three subgroups. The rst subgroup was arranged an extra 5min on-line ward-round by WeChat voice call once daily for basic disease communication. The second subgroup was given an extra 10min voice call once daily for further detail, similarly, the third subgroup was given an extra 10min than the second group every three days. The main end point was the duration of positive-to-negative conversion of SARS-CoV-2 RNA. Results: 47 patients were included in the nal analysis. The median time from disease diagnosed to the endpoint of test group was 7.0 days (interquartile range, 3.8 to 10.8), whereas the control group was 10.0 days (interquartile range, 6.5 to 14.5). It showed signicant reduced the duration time of virus from positive to negative by the NAT (nucleic acid testing) (P=0.032), especially compared the 10 minutes group (3.0 days, interquartile range, 3.0 to 7.5) to control group (P=0.0065). Conclusions: The patients with SARS-CoV-2 infection might benet from the use of the new electronic communication mode. It’s very valuable to reduce the shortage of medical protection resources and the risk of occupation.


Background
As of March 19, 2020, the coronavirus disease 2019 (COVID-19) has been reported to be responsible for more than 200,000 infections and 8700 deaths worldwide [1][2] . High-throughput sequencing has revealed that severe acute respiratory syndrome coronavirus 2 (SRAS-CoV-2) is similar to the coronavirus responsible for severe acute respiratory syndrome coronavirus (SARS-CoV), a member of the subgenus Sarbecovirus (Beta-CoV lineage B), with which it shares more than 79% of its sequence [3][4] . Evidence has revealed that the virus can spread by person-to-person respiratory transmission and contact transmission rapidly. The information regarding the epidemiology and clinical features of COVID-19 is scarce 5 . A few severe patients with COVID-19 have developed severe pneumonia, pulmonary edema, acute respiratory distress syndrome, or multiple organ failure even death 6 . Because of the worldwide shortage of medical resources, it is very important to nd a new medical mode to reduce protection resources consumption, what's more, avoid cross-infection among health-care workers and patients.
In our retrospective analysis, we designed a new model of physician-patient communication, aiming to prompt working e ciency in the diagnosis and treatment of COVID-19 and reduce occupational exposure risk.

Study design and participants
We enrolled patients from Jan 20 to Feb 26, 2020, at Department of Infectious Disease the Fifth A liated Hospital, Sun Yat-sen University, in Zhuhai, Guangdong Province, China. Patients diagnosed with SARS-CoV-2 infection were screened according to WHO interim guidance 3 . The inclusion criteria were as follows: (1) between 18 and 65 years old, (2) being SARS-CoV-2 RNA positive, (3) willing to provide respiratory swabs, and (4) using WeChat. The criteria for exclusion were as follows: (1) con rmed as severe COVID-19 pneumonia, (2) rapidly deteriorated into severe, (3) complicated with malignant tumors or compromised immune system, and (4) unable to make voice call daily by WeChat.
A con rmed case with SARS-CoV-2 infection was de ned as a positive result to high-throughput sequencing or real-time reverse-transcriptase polymerase-chain-reaction (RT-PCR) assay for nasal or pharyngeal swab specimens 1,7 . The incubation period was de ned as the duration from the contact of the transmission source to the onset of symptoms. Exposure history was de ned as exposure to people with con rmed SARS-CoV-2 infection or to the Wuhan area. Respiratory samples were collected every 1-2 days until two sequential negative results were obtained.
The study was approved by the Medical Ethical Committee of the Fifth A liated Hospital of Sun Yat-sen University (approval number L076-1) and informed consent was obtained from participants. Both of the test and the control groups were treated with standard therapy and routine ward-round, according to the guideline of diagnosis and treatment of SARS-CoV-2 infection (standard version) 8 . All changes in patients' conditions were monitored, recorded and responded timely.
Aiming to explore new electronic communication mode to treat the infectious disease, we grouped patients of the test group into three subgroups, providing additional high-quality on-line ward-round and psychological care using WeChat voice calls.
The rst group (5 minutes group) was given an extra on-line ward-round by WeChat voice call for 5 minutes once daily. In the 5 minutes patients could communicate with the doctor in charge about the disease progression. The second group (10 minutes group) was given an extra on-line ward-round by We-Chat for 10 minutes once daily. In the 10 minutes patients could communicate with the doctor in charge about the disease progression, and the extent and future outlook of the disease. The third group (10 minutes + minutes group) was given an extra 10 minutes' on-line talk every three days, which could gather more detailed information of the disease. The fourth group, also the blank controlled group, was just treated with standard therapy. Respecting patient consent, all patients were free to choose consent or opting-out.

Data collection
The epidemiological characteristics (including recent exposure history), clinical symptoms and signs and laboratory ndings were extracted from electronic medical records. Computed tomography was used as radiologic assessment. Laboratory assessments consisted of complete blood count, blood chemistry, coagulation test, liver and renal function, electrolytes, reactive protein, procalcitonin, lactate dehydrogenase and creatine kinase. All data were checked by two physicians (ZF and ZG) and a third researcher (JL) adjudicated any difference in interpretation between the two primary reviewers.

Primary Outcome
The primary endpoint was the duration of positive-to-negative conversion of SARS-CoV-2 RNA diagnosed by the NAT (nucleic acid testing). It was the time from laboratory conformed positive to negative of SARS-CoV-2 RNA result after two sequential negative respiratory tract sample results. The interval between the two negative results must be more than 24 hours.

Statistical analysis
We used SPSS (version 19.0) for all analyses. Continuous variables were presented as median (interquartile range) and compared with Mann-Whitney U test. Categorical variables were presented as number (%) and compared by Chi-square test or Fisher's exact test.

Results
A total of 47 patients with laboratory-con rmed SARS-CoV-2 infection met the eligibility criteria and completed the baseline assessment before being randomized into the trial. The demographics, clinical, and radiographic ndings were shown in Table 1 and they were similar between the test group and control group on admission. There were 21 male and 26 female enrolled, with the median age 36.0 years (interquartile range, 29.0 to 44.0). The incubation period was 6.0 days (interquartile range, 2.0 to 10.0).
The duration of positive-to-negative conversion of SARS-CoV-2 RNA of patients were tracked by viral NAT (Figure 1). The median time of the primary endpoint of test group was 7.0 days (interquartile range, 3.8 to 10.8), whereas of the control group was 10.0 days (interquartile range, 6.5 to 14.5), (P=0.032) ( Table 2). It showed signi cant reduced the duration of viral positive-to-negative conversion, compared with the 10 minutes group (3.0 days, interquartile range, 3.0 to 7.5 days) to control group (P=0.0065). However, the median time of the 5 minutes group was 7.0 days (interquartile range, 5.5 to 13.0), 10 minutes + 10 minutes group was 8.5 days (interquartile range, 4.8 to 16.0), and the two groups were no statistical difference to the control group (P=0.45 and 0.56, respectively).

Discussion
In previous studies, communication tool incorporated into the standard medical consultation was used to improve patients' self-Monitoring and understanding of disease [9][10] . The WeChat-based mobile health (mHealth) intervention via WeChat, which is the most popular social media app in china, was signi cantly reduced depressive symptoms among people living with HIV and depression 11 . In our study, WeChatbased on-line ward-round provided a contactless and effective communication channel in treatment of SARS-CoV-2 infection. Voice calls was chosen because it's more e cient than texting, besides, it keep a higher privacy protection than video calls.
In our study, the duration of respiratory viral RNA positive was ranging from 3.0 to 32.0 days of all the 47 patients. For SARS-CoV, viral RNA was detected in respiratory specimens from about a third of patients as long as 4 weeks after disease onset 10 . Similarly, the duration of MERS-CoV RNA detection in lower respiratory specimens persisted for at least 3 weeks [12][13] . We found that remote doctor-patient communication could help to reduce the duration of positive-to-negative conversion of SARS-CoV-2 RNA.
In particular, the 10 minutes group had an advantage over other groups. The duration of viral positive-tonegative conversion was signi cantly reduced, compared to the control group (P=0.032). High-quality communication and in-time feedback were presumed to be the mechanism of good prognosis.
Further more, the new electronic communication tool via WeChat additional to standard therapy cost less and easy to popularize. It reduced the risk of occupation and supplied a safer working condition for medical staff.
With the COVID-19 spreading worldwide rapidly, the medical resources could be making a run on a bank. It is urgent to nd a way to solve the shortage of medical protection resources and reduce the risks of occupational exposure of medicine 14     Data are presented as median (interquartile range) and n (%).