Coronavirus:unprecedented global war, from China to defeat covid-19

The first affiliated hospital of Zhejiang University School of Medicine released a useful ‘Handbook of COVID-19 prevention and treatment” compiled according to clinical experience. Prof. Tingbo Liang, Editor-in-Chief of the Handbook and Chairman of the First Affiliated Hospital of Zhejiang University, explains that Faced with an unknown virus, sharing and collaboration are the best remedy. As French president Emmanuel Macron said in a televised speech, “we are at war” and the invisible enemy for all is the novel Coronavirus. Many of the new cases in Italy, the second country after China, are doctors and medical workers engaged in first battlefield, the hospitals. Professor Liang affirms that to win this war, we must first make sure that our medical staff is guaranteed sufficient resources, including experience and technologies. Also, we need to make sure that the hospital is the battleground where we eliminate the virus, not where the virus defeats us. Therefore, the Jack Ma Foundation and Alibaba Foundation have convened a group of medical experts who have just returned from the frontlines of fighting the pandemic. With the support of the First Affiliated Hospital, Zhejiang University School of Medicine (FAHZU), they quickly published a guidebook on the clinical experience of how to treat this new coronavirus. The treatment guide offers advice and reference against the pandemic for medical staff around the world who are about to join the war.

Founded in 1947, The First Affiliated Hospital, Zhejiang University School of Medicine (FAHZU), is the earliest affiliated hospital of Zhejiang University. With six campuses, it has now evolved into a medical center integrating health care, medical education, scientific research and preventative care. In terms of overall strength, FAHZU is ranked 14th in China. As a large-size general hospital, it currently has over 6,500 employees, including academicians of the Chinese Academy of Engineering, National Distinguished Young Scholars and other outstanding talents. There is a total of 4,000 beds available to patients in FAHZU. Its main campus handled 5 million emergency and outpatient visits in 2019.

The handbook opens describing in details how to prevent the spread of COVID-19 in the hospitals, isolating the area management. Healthcare facilities shall set up a relatively independent fever clinic including an exclusive one-way passage at the entrance of the hospital with a visible sign; according to the clinical experience the doctors stress that the movement of people shall follow the principle of “three zones and two passages” : a contaminated zone, a potentially contaminated zone and a clean zone provided and clearly demarcated, and two buffer zones between the contaminated zone and the potentially contaminated zone. Then the handbook suggests to medical workers the screening Criteria for Suspected COVID-19 Cases. The manual also shows how to donning and removing personal protective equipment to manage COVID-19 patients and the disinfection procedures of isolating area and medical equipment.

FAHZU is a designated hospital for COVID-19 patients, especially severe and critically ill individuals whose condition changes rapidly, often with multiple organs infected and requiring the support from the multidisciplinary team (MDT). Since the outbreak, FAHZU established an expert team composed of doctors from the Departments of Infectious Diseases, Respiratory Medicine, ICU, Laboratory Medicine, Radiology, Ultrasound, Pharmacy, Traditional Chinese Medicine, Psychology, Respiratory Therapy, Rehabilitation, Nutrition, Nursing, etc. A comprehensive multidisciplinary diagnosis and treatment mechanism has been established in which doctors both inside and outside the isolation wards can discuss patients’ conditions every day via video conference. This allows for them to determine scientific, integrated and customized treatment strategies for every severe and critically ill patient. The doctors affirm that thoracic imaging is of great value in the diagnosis of C0VID-19, monitoring of therapeutic efficacy, and patient discharge assessment. A high-resolution CT is highly preferable. Portable chest X-rays are helpful for critically ill patients who are immobile. CT for baseline evaluation of patients with C0VID-19 is usually performed on the day of admission, or if ideal therapeutic efficacy is not reached, it can be re-performed after 2 to 3 days. If symptoms are stable or improved after treatment, the chest CT scan can be reviewed after 5 to 7 days. Daily routine portable chest X-rays are recommended for critically ill patients.

The expert team noted that C0VID-19 at the early stage often presents with multifocal patchy shadows or ground glass opacities located in the lung periphery, subpleural area, and both lower lobes on chest CT scans. The long axis of the lesion is mostly parallel to the pleura. Interlobular septa I thickening and intralobular interstitial thickening, displaying as subpleural reticulation namely a “crazy paving” pattern, is observed in some ground glass opacities. A small number of cases may show solitary, local lesions, or nodular/ patchy lesion distributed consistent with bronchus with peripheral ground glass opacities changes. Disease progression mostly occurs in the course of 7-10 days, with enlarged and increased density of the lesions compared with previous images, and consolidated lesions with air bronchogram sign. Critical cases may show further expanded consolidation, with the whole lung density showing increased opacity, sometimes known as a “white lung”.

Before the treatments the handbook classify the COVID-19 cases in 4 big groups: mild cases with mild clinical symptoms no pneumonia manifestations can be found in imaging; moderate cases with symptoms such as fever and respiratory tract symptoms; severe cases with one of the following critieria: the respiratory rate is 30 breaths/min, oxygen saturations 93% at a rest state; arterial partial pressure of oxygen (PaO,)/oxygen concentration (FiO,) s; 300 mm Hg, > 50% lesions progression within 24 to 48 hours in lung imaging and critical cases with occurrence of respiratory failure requiring mechanical ventilation; presence of shock; other organ failure that requires monitoring and treatment in the ICU. Critical cases are further divided into early, middle and late stages according to the oxygenation index and compliance of respiratory system. The doctors of Zhejiang recorded that early antiviral treatment can reduce the incidence of severe and critical cases, although there is no clinical evidence for effective antiviral drugs.

The clinical experience shows that COVID-19 is a disease of viral infection, therefore antibiotics are not recommended to prevent bacterial infection in mild or ordinary patients, but it should be used carefully in severe patients based on their conditions. The handbook affirms that antibiotics can be used with discretion in patients who have the extensive lung lesions, excess bronchial secretions, chronic airway diseases with a history of pathogen colonization in the lower respiratory tract, taking glucocorticoids with a dosage less to 20 mg for 7 days. The options of antibiotics include quinolones, the second or third generation cephalothins, as lactamase inhibitor compounds.

Due to the spread of the COVID-19 epidemic, the First Affiliated Hospital, Zhejiang University School of Medicine (FAHZU) and Alibaba jointly established the International Medical Expert Communication Platform of FAHZU with an aim to improve the quality of care and treatment and promote the sharing of global information resource. The platform allows medical experts all over the world to connect and share their invaluable experience in the fight against COVID-19.

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