Coronaviruses are a group of related RNA viruses that cause diseases in mammals and birds. They are minute in size (about 65–125 nm) and contain a single-stranded RNA as nucleic material, size ranging from 26 to 32kbs in length, and categorized in five subgroups (alpha α, beta β, gamma γ and delta δ). Recently, at the end of 2019, Wuhan, an emerging business hub of China, experienced an outbreak of a novel coronavirus that killed more than 3000 and infected about 81000 individuals within the first fifty days of the epidemic (WHO Situation Report number 50).1 This new virus, responsible for a new severe respiratory syndrome, was reported to be a member of the β group of coronaviruses2 and it was defined as “Severe Acute Respiratory Syndrome Coronavirus 2” (SARS-CoV-2) by the International Committee on Taxonomy of Viruses.3
As remarked by Lippi et al., the novel coronavirus disease (COVID-19) “is the third coronavirus outbreak to have emerged in the past twenty years, after Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS)” 3.
Generally the human-to-human transmission occurs with close contact; in fact, the transmission primarily happen through the respiratory droplets production, just as influenza and other respiratory pathogens;2 however transmission may also occur through fomites in the immediate environment by touching an infected surface or object.4 Airborne transmission may be possible in specific circumstances and settings in which procedures or support treatments that generate aerosols are performed. Other routes of transmission, such as fecal-oral and blood borne transmission, may be possible too.
Usually, SARS-CoV-2, like other respiratory viruses, is considered to be more contagious when people are symptomatic. However, it was also reported some cases in literature, in which several people were infected from asymptomatic subjects during the “prodrome period”.4
The estimated incubation period between infection and onset of symptoms is approximately 5 days (range: 2-14 days) but with a high variability (Possible outliers: 0 - 27 days).
Columbus et al reported that approximately 25% of patients had required intensive care and reporting a clinical deterioration at roughly day 8 of illness; besides, 10% of them required intubation and mechanical ventilation and approximately 3% required extracorporeal membrane oxygenation.6
Clinically, the immune responses induced by SARS-CoV-2 infection are two phased:
- The first phase occurs during the incubation period and it represents a “non-severe stage”; in this phase, a specific adaptive immune response is required to eliminate the virus and preclude the disease progression toward more severe stages.7
- The second phase occurs later, when the protective immune response is almost impaired; in this phase, the virus will propagate in host’s cells resulting in a massive destruction of the affected tissues, especially in organs that have high ACE2 expression.7 A cytokine release syndrome seems to affect patients with severe conditions associated to a genetic susceptibility. 7
As reported by Yufang et al. in this phase, “the innate immune response to tissue damage caused by the virus could lead to acute respiratory distress syndrome (ARDS), in which respiratory failure is characterized by the rapid onset of widespread inflammation in the lungs and subsequent fatality”.7 Hence, the clinical features of COVID-19 are varied, ranging from asymptomatic state to acute respiratory distress syndrome and multi organ dysfunction.8
Due to the incontrovertible evidence demonstrating worldwide diffusion of SARS-CoV-2, COVID-19 has recently been declared a global pandemic disease by the World Health Organization (WHO);3 in that occasion, T.A. Ghebreyesus, the General Director of the Agency, warned the entire World on “the alarming levels of spread and severity, and by the alarming levels of inaction”.3
From then, The epidemiologic burden of COVID-19 is constantly evolving, with numbers of infected persons, hospital admissions and deaths growing near exponentially. 3
The last Situation Report of the WHO attests that COVID-19 has already infected as many as 4993470 people up to May 22, 2020, from 213 countries and territories, causing 327738 deaths (WHO Situation Report number 123).1 The current case fatality rate is calculated at approximately 6,5%.
The recent pandemic outbreak of COVID-19 worldwide caught the health care systems in every country around the world by storm and without a proper defense mechanism to cope and control such a pandemic.9
In fact, this outbreak is causing an overwhelming burden of illnesses that stresses health system capacity and adverse effects on healthcare workers including the risk of infection. The confinement of population and the outbreak impact on health care systems is disrupting routine care for non COVID-19 patients. 10 The health care has undergone a progressive significant worsening for these patients over the last pandemic weeks. In this context, telemedicine, particularly video consultations, has been promoted and scaled up to reduce the risk of transmission;10 in fact, it is a versatile tool with a wide range of applications.
The framework included tele-expertise, remote patient monitoring of contact cases, and teleconsultation for triage and isolated cases. 10 Telemedicine permits to non COVID-19 patients to get the necessary health care they need, while minimizing exposition to infection of themselves and medical staff. It is very important to remark that medical staff may become a potential and powerful vehicle for viral spread.11
In this paper the Authors reports their own experience with Telemedicine.