Slide deck of Dr. Federico Lavorini from his expert webinar for Julphar Anti-Infectives on May 8, 2020.

1. Federico Lavorini
Dept. Experimental and Clinical Medicine
Careggi University Hospital Florence - Italy
The Deadly Virus and
the Italian Experience

2. Presenter Disclosures
F.L. has no conflict of interest related to the presentation

3. SARS Cov-2 in Italy (May 4th)
Ministry of Health, Italy
January 31, 2 tourists form China tested positive for SARS Cov-2 in Rome
February 21, first infection outbreak in Lombardia, North of Italy

4. Taxonomy of the Coronavirus
(SARS Cov-2)
Coronaviruses are classified as a family within the Nidovirales order. They are
zoonotic, meaning they are transmitted between animals and people.
The coronavirus subfamily is further classified into four genera: Alpha, Beta, Gamma,
and Delta coronaviruses
The human coronaviruses are in two of these genera:
- Alpha coronaviruses (HCoV-229 and HCoV-NL63)
- Beta coronaviruses (HCoV-2HKU1, HCov-OC43, MERS, SARS-CoV2)
SARS-CoV2 shares 79.5% sequence identify to SARS-CoV and 96.2% overall genome
sequnce identify to RaTG13, whichis a short RdRp region from a bat coronavirus.
Population genetic analses of 103 genomes of SARS-CoV2 indicates that there are 2
major tpes of viruses (L and S) currently circulating between humans

5. March 31, 2020.
March 31, 2020.
ACE2, an enzyme that physiologically counters Renin-Aldosteron-Angiotensin
activation, is the functional receptor to SARSCoV-2

6. SARS-Cov-2: Physical Characteristics
Electronic microscopic SARS-CoV-2
particle from a patient
直径约 0.12 μm
PM10
RED CELLS
BACTERI VIRUS
PM2.5
January 24, 2020, the National
Pathogenic Microbial Resources
Bank of China published the
picture of the novel

7. Why particle size important

8. Aerodynamic Characteristics and Trasmission
Aerosol particle size affects residence
timing in air and the propagation distance:
–The larger the particles, the shorter
the residence time in air and the shorter
the propagation distance;
–The smaller the particle, the longer the
residence timing in the air, the longer
the distance travelled, the easier the
penetration to the lower respiratory tract.
- Particles of 2,5 micron can settle in air
up to 2 hours.
- Particles of <1 micron can settle in air
up to 1 day.
2.5 micron
2 hours in
suspension

9. Orange head colour =
a source
White head colour=
a potential recipient
Potential routes of short and long-range airborne transmission, as well as the
downstream settling of droplets onto surfaces (fomites). From fomites, they may
be touched and transported by hands to be self-inoculated into mucosal
membranes (eyes, nose and mouth) to cause infection, depending on the survival
characteristics of individual pathogens on such surfaces, and the susceptibility of
the different exposed tissues to infection by these pathogens.

10. Transmission of the Coronavirus (SARS Cov-2)
• Person-to-person spread of SARS-CoV-2 occurs mainly via respiratory droplets;
virus is released when an infected person coughs, sneezes, or talks. Droplets tipically
do not travel more than 2 meters.
• Infection can also occur if a person touches an infected surface and then touches
his/her eyes, nose or mouth.
• Virus RNA levels appear to be higher soon after symptom onset compared to later
in the illness
Basic reproduction number
(R0) over time in Tuscany
R0

11. April 24 2020,
Public Health–Seattle and King County and CDC COVID-19 Investigation Team
More than half of residents with positive test
results were asymptomatic at the time of testing
and most likely contributed to transmission.

12. Airborne SARS-CoV-2 concentration
in different hospital areas
Yuan Liu et al. BioRxiv 2020
• No SARS-CoV-2 detected in ICU and CCU,
Minimization of airborne SARS-CoV-2 was likely
due to negative pressure ventilation rooms and
high air ex-change rate.
• High airborne SARS-CoV-2 level inside the
patient mobile toilet. This may come from
either the patient's breath or the aerosolization
of the virus-laden aerosol from patient’s faeces
or urine during use.
• High SARS-CoV-2 levels was detected in
protective apparel removal rooms.
• Re-suspension of virus-laden aerosol from the
surface of medical staff protective apparel
while they are being removed.
• Re-suspension of floor dust aerosol containing
virus

13. April 3, 2020.
Aerosol and fomite transmission of SARS-CoV-2 is plausible, since the virus can
remain viable and infectious in aerosols for hours and on surfaces up to days

14. Speaking generates thousands of droplets that are smaller than
those emitted when coughing or sneezing, and sufficiently large
to carry respiratory pathogens.
Speaking can be a major mode of SARS-CoV-2 transmission
April 19, 2020

15. Stages of Illness
Symptoms:
Lab.signs:
Mild constitutional symptoms,
fever, dry cough, diarrhea,
headache
Lymphopenia, prothrombin
time, D-dimer, LDH
Dyspnea, respiratory rate
CRP, ferritin, hypoxia,
P/F<300 mmHg
ARDS, shock, cardiac failure
IL6, troponin, CRP,
ferritin

16. COVID-19 in Italy (March 31)
Not specified
13%
Critical:35%
None
6,3%
Few:
14,3%
Severe:
20,95
Mild:42,5,3%
SYMPTOMS
Gianni Rezza et al. TASK FORCE COVID-19.
National Health Service, Italy

17. Clinical Presentation
Laboratory Findings:
• Blood count: normal WBC, leukopenia, lymphopenia (80%+),
thrombocytopenia
• Chemistries: elevated BUN/creatinine, elevated AST, ALT, and Total bilirubin
• Inflammatory markers: normal or low procalcitonin, high C-reactive protein
and ferritin;
• Miscellaneous: elevated D-dimer, IL 6, and lactate dehydrogenase
March 30, 2020
Also reported:
ageusia, anosmia,
dizziness, chills

18. Lancet 2020; 395: 1054–62
Clinical courses of major symptoms and outcomes and duration of viral
shedding from illness onset in 191 inpatients with COVID-19
54 inpatients
137 inpatients

19. Lancet 2020; 395: 1054–62
Temporal changes in laboratory markers from illness
onset in patients hospitalised with COVID-19

20. April 6, 2020.
Almost all patients (99%) required
respiratory support, (88% endotracheal
intubation, 11% noninvasive
ventilation) with high levels of PEEP;
ICU mortality was 26%.

21. Mortality in Italy (March 30)
Numberofdeaths
Age (yr)
Females Males Total
• Mean age of patients with COVID-19 was 62 yr (IQR 40-88);
• Mean age of deceased patients with COVID-19 was 78 yr (IQR 73-85).
• 50% of deceased patients had > 3 co-morbid diseases
10.026 patients (70% males) deceased with COVID-19 +

22. April 2020
A dedicated taskforce developed a response
plan which incuded:
1. Establishment of dedicated, cohorted
ICUs for COVID-19 patients;
2. Design of appropriate procedures for pre-
triage, diagnosis and isolation of
suspected and confirmed cases;
3. Training of all staff to work in the
dedicated ICU, in personal protective
equipment usage and patient
management.
Hospitals should be prepared to face
severe disruptions to their routine;
protocols and procedures might require re-
discussion and updating on a daily basi

23. Patient Management
Triage:
✓ Collection of clinical information including exposure to people positive to SARS-CoV-
2, recent symptoms; measurement of PaO2 or SatO2; short walking test
✓ If triage is positive: isolate the patient, naso-pharyngeal swab, chest X-ray/CT scan;
✓ 4 patient categories:
a) green= SaO2 >94%, RR<20 breaths/min;
b) yellow= SaO2 <94%, RR>20, good response to oxygen;
c) orange= SaO2<94%, RR>20, poor response to oxygen and needing
CPAP/NIV with high FiO2;
d) red= SaO2<94%, RR>20 poor response to high oxygen flow and/or CPAP/NIV,
respiratory distress, PaO2/FiO2<200 and needing endotracheal intubation.
After triage:
✓ Transfer suspected or confirmed cases to preselected COVID HUB facilities or to
infectious disease units;
✓ Transfer severely compromised patients, with worsened hemodynamic parameters,
low PaO2/FiO2 or patients not responding to CPAP/NIV, to the intensive care unit for
early intubation if beds are available and after prognostic evaluation.

24. Vitacca M et al ERJ 2020
“What to do“
management
pathway

25. Chest X-ray of a Covid-19 patient
Peripheral, bilateral opacities; no pleural effusions

26. Chest X-ray: effect of anti-IL6 R
Admission 2 days after treatment

27. Typical CT patterns of viral pneumonia
Varicella-zoster: multifocal well-defined
nodules with a surrounding patchy GGO
CMV: diffuse ill-defined patchy GGO
with septal thickening
HMPV: multiple ill-defined nodules or
GGO; tree-in-bud appearance
Influenza: multiple irregular areas of consolidation
and GGO with interlobular septal thickening

35. Xu Z et al.
• Diffuse Alveolar Damage (DAD) with cellular fibromixoid exudate
• Pulmonary edema with desquamation of pneumocytes
and hyaline membrane formation indicating ARDS
• Lymphocytes infiltration
«The pathological features of COVID-19 greatly rensemble those seen
in SARS and MERS coronavirus infections»

36. Incidence of thrombotic complication in critically ill ICU patients with COVID-19
Klok FA et al. Thromb Res 2020
31
%
• Pulmonary embolism 25
(segmental or subsegmental)
• Venous thrombosis 3
(leg veins or catheter tip)
• Arterial thrombosis 3
(ischemic stroke)
Zhou F et al. Lancet
2020

37. Xie Y. Radiology
2020

38. Perfusion abnormalities combined with the pulmonary vascular
dilation are suggestive of intrapulmonary shunting toward areas
where gas exchange is impaired, resulting in a worsening V/Q
mismatch and hypoxia.
Peripheral GGO and consolidation within the RUL, GGO
in the posterior left upper lobe (arrowheads), dilated
sub-segmental vessels proximal to, and within, the
opacities (arrows)
Wedge-shaped areas of decreased perfusion
within the upper lobes, with a peripheral halo
of higher perfusion.

39. Diagnosis: Swab vs CT
Ai T et al. Radiology 2020
57% 30% 2% 10%

40. CT findings
@ 3 days
Negative PCR in positive exposure and GGNs: 36 y-o woman with fever, sore throat, fatigue
Huang P et al. Radiology 2020;

41. Stages of Illness
Symptoms:
Lab.signs:
Mild constitutional symptoms,
fever, dry cough, diarrhea,
headache
Lymphopenia, prothrombin
time, D-dimer, LDH
Dyspnea, respiratory rate
CRP, ferritin, hypoxia,
P/F<300 mmHg
Treatments: Paracetamol, antivirals, Chloroquine, hydroxychloroquine,
Oxygen, ventilatory support, corticosteroids, IL-6
IL-1inhibitors, human immunoglobulin
ARDS, shock, cardiac failure
IL6, troponin, CRP,
ferritin

43. intubation rate:
high-flow oxygen 38%,
standard oxygen 47%
NIV 50%
Hazard ratio for death:
Standard oxygen vs the high-flow oxygen 2.01
(95% CI 1.01-3.99) P = 0.046
NIV vs the high-flow oxygen 2.50 (95% CI, 1.31 to
4.78) P= 0.006
In non hypercapnic patients with acute hypoxemic respiratory failure, intubation rates
were similar with high-flow oxygen, standard oxygen, or noninvasive ventilation.
There was a significant difference in favor of high-flow oxygen in 90-day mortality.

45. External PEEP prevents alveolar collapse

46. Eur Respir Rev 2020

47. Modified Venturi
system
PEEP valve
0-20 cmH2O
Manometer
PVC trasparent
Helmet latex-free
Dual flowmeter
Flow:60-120 L/min
FiO2:30-100% (a 60 L/min)
Apparatus with helmet

48. Well-fitting mask Filter Exhalation port
• Any patient on NIV should
be managed with a non-
vented mask and an
exhalation port in the circuit
• A filter should be placed in
the circuit between the
mask and the exhalation port
• Sequence of actions:
NIV mask on  ventilator on;
ventilator off NIV mask off
Apparatus with mask

49. Rapid rise time, PEEP> 8 cmH2O, P Support >10 cmH2O

51. - 47 patients with CAP and moderate ARF (PaO2/FiO2
210-285);
- Randomized to Helmet CPAP vs standard therapy;
- Primary endpoint: the time to reach a PaO2/FiO2 >315
Chest 2010;138: 114-20

52. CPAP: 1.5 hours to reach a PaO2/FiO2 >315
Standard therapy: 48 hours to reach a PaO2/FiO2 >315
CPAP: 95% of the patients reached primary endpoint;
Standard therapy: 30% of the patients reached primary endpoint;
Chest 2010;138: 114-20

53. - 81 patients with pneumonia and severe ARF (PaO2/FiO2
141±39);
- Randomized to Helmet CPAP vs standard oxygen therapy;
- Primary endpoint: percentage of patients meeting criteria
for ETI
Int. Care Med 2014;40:942-49

54. CPAP: ETI 15%
oxygen therapy: ETI 63%
Faster improvement in
PaO2/FiO2 with CPAP
Int. Care Med 2014;40:942-49

55. April 2020
COVID-19 pneumonia Type L COVID-19 pneumonia Type H
• Low elastance (high compliance),
• Low V/Q ratio,
• Low lung weight,
• Low lung recrutability.
• High elastance (decrease in gas volume)
• High right-to-left shunt,
• High lung weight,
• High lung recrutability.
A similar degree of hypoxemia is associated
with different patterns in lung imaging.

58. COVID-19 cosider cytokine storm
syndomes and immunosuppression
«Accumulating evidence suggests that a subgroup of
patients with severe COVID-19 might have a cytokine
storm syndrome. We recommend identification and
treatment of hyperinflammation using existing, approved
therapies with proven safety profiles to address the
immediate need to reduce the rising mortality.»

59. Survival curve in ARDS patients who did and
did not receive 6-MP therapy
6-MP therapy reduced the risk of death, the duration of MV
and increased the MV-free days

60. Time to clinical improvement
Patients treated with in L/R did NOT have a time to clinical
improvement different from that of patients treated with
standard care alone. However, they had a shorter stay in ICU.
GI adverse events were more common in the L/R group.

61. April 10, 2020,
53
Patients
Blue cells= improvement 36/53 (68%)
Beige cells= no change 9/53 (17%)
Gray cells= worsening 8/53 (15%)
Overall mortality was 13% over a median follow-up of 18 days

62. Hydroxychloroquine and Azithromycin as a
treatment of COVID-19: results of an open-
label, non-randomised clinical trial
• 6 asymptomatic patients, 22 with URTI, 8 with LRTI.
• 20 patients treated with H+A had a significant reduction of the
viral carriage 6 days after drug intake, and lower average
carrying duration.
• Azithromycin added to hydroxychloroquine was more effective
for virus elimation.

63. Hydroxychloroquine: conflicting results
U.S. study
medRxiv
April 21, 2020.
China study
medRxiv
April 14, 2020.