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WHO Declares COVID-19 a Pandemic
Domenico Cucinotta, Maurizio Vanelli
Editors of Acta Biomedica
Acta Biomed 2020; Vol. 91, N. 1: 157-160 DOI: 10.23750/abm.v91i1.9397 © Mattioli 1885
Debate
e World Health Organization (WHO) on
March 11, 2020, has declared the novel coronavirus
(COVID-19) outbreak a global pandemic (1).
At a news briefing , WHO Director-General, Dr.
Tedros Adhanom Ghebreyesus, noted that over the past
2 weeks, the number of cases outside China increased
13-fold and the number of countries with cases in-
creased threefold. Further increases are expected. He
said that the WHO is “deeply concerned both by the
alarming levels of spread and severity and by the alarm-
ing levels of inaction,” and he called on countries to take
action now to contain the virus. “We should double
down,” he said. “We should be more aggressive.”
Among the WHO’s current recommendations,
people with mild respiratory symptoms should be en-
couraged to isolate themselves, and social distancing is
emphasized and these recommendations apply even to
countries with no reported cases (2).
Separately, in JAMA, researchers report that
SARS-CoV-2, the virus that causes COVID-19, was
most often detected in respiratory samples from pa-
tients in China. However, live virus was also found in
feces. ey conclude: “Transmission of the virus by
respiratory and extrarespiratory routes may help ex-
plain the rapid spread of disease.”(3).
COVID-19 is a novel disease with an incompletely
described clinical course, especially for children. In a re-
cente report W. Liu et al described that the virus caus-
ing Covid-19 was detected early in the epidemic in 6
(1.6%) out of 366 children (≤16 years of age) hospital-
ized because of respiratory infections at Tongji Hospi-
tal, around Wuhan. All these six children had previously
been completely healthy and their clinical character-
istics at admission included high fever (>39°C) cough
and vomiting (only in four). Four of the six patients had
pneumonia, and only one required intensive care. All
patients were treated with antiviral agents, antibiotic
agents, and supportive therapies, and recovered after a
median 7.5 days of hospitalization. (4).
Risk factors for severe illness remain uncertain
(although older age and comorbidity have emerged as
likely important factors), the safety of supportive care
strategies such as oxygen by high-flow nasal cannula
and noninvasive ventilation are unclear, and the risk of
mortality, even among critically ill patients, is uncer-
tain. ere are no proven effective specific treatment
strategies, and the risk-benefit ratio for commonly
used treatments such as corticosteroids is unclear (3,5).
Septic shock and specific organ dysfunction such
as acute kidney injury appear to occur in a significant
proportion of patients with COVID-19–related criti-
cal illness and are associated with increasing mortality,
with management recommendations following avail-
able evidence-based guidelines (3).
Novel COVID-19 “can often present as a common
cold-like illness,” wrote Roman Wöelfel et al. (6). ey
report data from a study concerning nine young- to mid-
dle-aged adults in Germany who developed COVID-19
after close contact with a known case. All had generally
mild clinical courses; seven had upper respiratory tract
disease, and two had limited involvement of the lower
respiratory tract. Pharyngeal virus shedding was high
during the first week of symptoms, peaking on day 4.
Additionally, sputum viral shedding persisted after symp-
tom resolution. e German researchers say the current
case definition for COVID-19, which emphasizes lower
respiratory tract disease, may need to be adjusted(6). But
they considered only young and “normal” subjecta where-
D. Cucinotta, M. Vanelli
158
as the story is different in frail comorbid older patients, in
whom COVID 19 may precipitate an insterstitial pneu-
monia, with severe respiratory failure and death (3).
High level of attention should be paid to comor-
bidities in the treatment of COVID-19. In the litera-
ture, COVID-19 is characterised by the symptoms of
viral pneumonia such as fever, fatigue, dry cough, and
lymphopenia. Many of the older patients who become
severely ill have evidence of underlying illness such as
cardiovascular disease, liver disease, kidney disease, or
malignant tumours. ese patients often die of their
original comorbidities. ey die “with COVID”, but
were extremely frail and we therefore need to accu-
rately evaluate all original comorbidities.
In addition to the risk of group transmission of
an infectious disease, we should pay full attention to
the treatment of the original comorbidities of the in-
dividual while treating pneumonia, especially in older
patients with serious comorbid conditions and po-
lipharmacy. Not only capable of causing pneumonia,
COVID-19 may also cause damage to other organs
such as the heart, the liver, and the kidneys, as well as
to organ systems such as the blood and the immune
system. Patients die of multiple organ failure, shock,
acute respiratory distress syndrome, heart failure, ar-
rhythmias, and renal failure (5,6).
What we know about COVID 19?
In December 2019, a cluster of severe pneumonia
cases of unknown cause was reported in Wuhan, Hubei
province, China. e initial cluster was epidemiologi-
cally linked to a seafood wholesale market in Wuhan,
although many of the initial 41 cases were later reported
to have no known exposure to the market (7).
A novel strain of coronavirus belonging to the
same family of viruses that cause severe acute respira-
tory syndrome (SARS) and Middle East respiratory
syndrome (MERS), as well as the 4 human corona-
viruses associated with the common cold, was subse-
quently isolated from lower respiratory tract samples
of 4 cases on 7 January 2020 .
On 30 January 2020, the WHO declared that the
SARS-CoV-2 outbreak constituted a Public Health
Emergency of International Concern, and more than
80, 000 confirmed cases had been reported worldwide
as of 28 February 2020 (8). On 31 January 2020, the
U.S. Centers for Disease Control and Prevention an-
nounced that all citizens returning from Hubei prov-
ince, China, would be subject to mandatory quarantine
for up to 14 days . But from China COVID 19 arrived
to many other countries. Rothe C et al reported a case
of a 33-year-old otherwise healthy German business-
man :she became ill with a sore throat, chills, and myal-
gias on January 24, 2020 (9). e following day, a fever
of 39.1°C developed, along with a productive cough.
By the evening of the next day, he started feeling bet-
ter and went back to work on January 27.Before the
onset of symptoms, he had attended meetings with a
Chinese business partner at his company near Munich
on January 20 and 21. e business partner, a Shang-
hai resident, had visited Germany between January 19
and 22. During her stay, she had been well with no
signs or symptoms of infection but had become ill on
her flight back to China, where she tested positive for
2019-nCoV on January 26.
is case of 2019-nCoV infection was diagnosed
in Germany and transmitted outside Asia. However, it
is notable that the infection appears to have been trans-
mitted during the incubation period of the index pa-
tient, in whom the illness was brief and nonspecific.e
fact that asymptomatic persons are potential sources of
2019-nCoV infection may warrant a reassessment of
transmission dynamics of the current outbreak (9).
Our current understanding of the incubation pe-
riod for COVID-19 is limited. An early analysis based
on 88 confirmed cases in Chinese provinces outside
Wuhan, using data on known travel to and from Wu-
han to estimate the exposure interval, indicated a mean
incubation period of 6.4 days (95% CI, 5.6 to 7.7 days),
with a range of 2.1 to 11.1 days. Another analysis based
on 158 confirmed cases outside Wuhan estimated a me-
dian incubation period of 5.0 days (CI, 4.4 to 5.6 days),
with a range of 2 to 14 days . ese estimates are gener-
ally consistent with estimates from 10 confirmed cases
in China (mean incubation period, 5.2 days [CI, 4.1 to
7.0 days] and from clinical reports of a familial cluster
of COVID-19 in which symptom onset occurred 3 to 6
days after assumed exposure in Wuhan (10-12).
e incubation period can inform several im-
portant public health activities for infectious diseases,
WHO Declares COVID-19 a Pandemic 159
including active monitoring, surveillance, control, and
modeling. Active monitoring requires potentially ex-
posed persons to contact local health authorities to re-
port their health status every day. Understanding the
length of active monitoring needed to limit the risk for
missing infections is necessary for health departments
to effectively use resources. A recent paper provides ad-
ditional evidence for a median incubation period for
COVID-19 of approximately 5 days (13). Lauer et al
suggest that 101 out of every 10 000 cases will develop
symptoms after 14 days of active monitoring or quar-
antinen (13) . Whether this rate is acceptable depends
on the expected risk for infection in the population be-
ing monitored and considered judgment about the cost
of missing cases. Combining these judgments with the
estimates presented here can help public health officials
to set rational and evidence-based COVID-19 control
policies. Note that the proportion of mild cases de-
tected has increased as surveillance and monitoring sys-
tems have been strengthened. e incubation period for
these severe cases may differ from that of less severe or
subclinical infections and is not typically an applicable
measure for those with asymptomatic infections
In conclusion, in a very short period health care
systems and society have been severely challenged by
yet another emerging virus. Preventing transmission
and slowing the rate of new infections are the primary
goals; however, the concern of COVID-19 causing
critical illness and death is at the core of public anxi-
ety. e critical care community has enormous expe-
rience in treating severe acute respiratory infections
every year, often from uncertain causes. e care of
severely ill patients, in particular older persons with
COVID-19 must be grounded in this evidence base
and, in parallel, ensure that learning from each patient
could be of great importance to care all population,
Conflict of interest: e author declares that he has no commer-
cial associations (e.g. consultancies, stock ownership, equity inter-
est, patent/licensing arrangement etc.) that might pose a conflict of
interest in connection with the submitted article
References
1. WHO Director-General’s opening remarks at the media
briefing on COVID19 -March 2020
2. CIDRAP- Center for Infectious Disease Research and
Policy, 11 March 2020
3. Srinivas M, Gomersall CD, Fowler R. Critically Ill Patients
With COVID-19 JAMA. Published online March 11,
2020. doi:10.1001/JAMA.2020.3633
4. Zhang Q, Chen J, Xiang R, et al. Detection of Covid-19
in Children in Early January 2020 in Wuhan, China. N
Engl J Med, March 12, 2020 (letter) DOI: 10.1056/NE-
JMc2003717
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tients infected with 2019 novel coronavirus in Wuhan,
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doi:10.1016/S0140-6736(20)30183
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6736(20)30154-9
13. Lauer SA, Grantz KH, et al. e Incubation Period of
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doi: https://doi.org/10.7326/M20-0504
Received: 12 March 2020
Accepted: 13 March 2020
Correspondence:
Maurizio Vanelli
E-mail: maurizio.vanelli@unipr.it
D. Cucinotta, M. Vanelli
160
Appendix
Who is at Higher Risk?
Early information shows that some people are at higher risk of getting very sick from COVID 19. is includes:
• Olderadults,withcomorbidities
• Peoplewhohaveseriouschronicmedicalconditionslike:
- Heart disease
- Diabetes
- Lung disease
COVID-19 outbreak in Italy and it could last for a long time. (An outbreak is when a large number of people suddenly
get sick.) , Public health officials recommended community actions to reduce people’s risk of being exposed to COVID-19. ese
actions can slow the spread and reduce the impact of disease.If you are at higher risk for serious illness from COVID-19 because
of your age or because you have a serious long-term health problem, it is extra important for you to take actions to reduce your
risk of getting sick with the disease.
Everyday precautions
• Avoidclosecontactwithpeoplewhoaresick
• Takeeverydaypreventiveactions
• Cleanyourhandsoften
Wash your hands often with soap and water for at least 20 seconds, especially after blowing your nose, coughing, or
sneezing, or having been in a public place.
If soap and water are not available, use a hand sanitizer that contains at least 60% alcohol.
To the extent possible, avoid touching high-touch surfaces in public places – elevator buttons, door handles, handrails,
handshaking with people, etc. Use a tissue or your sleeve to cover your hand or finger if you must touch something.
Wash your hands after touching surfaces in public places.
Avoid touching your face, nose, eyes, etc.
Clean and disinfect your home to remove germs: practice routine cleaning of frequently touched surfaces (for example:
tables, doorknobs, light switches, handles, desks, toilets, faucets, sinks & cell phones)
Avoid crowds, especially in poorly ventilated spaces. Your risk of exposure to respiratory viruses like COVID-19 may
increase in crowded, closed-in settings with little air circulation if there are people in the crowd who are sick.
Avoid all non-essential travel
