Perfect storm: a viral disaster in the Italian region of Lombardy is a lesson for the world

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As Italy prepares to emerge from the first and largest blockage of coronaviruses in the West, it is becoming increasingly clear that something has gone terribly wrong in Lombardy, the hardest hit region in the most touched from Europe.

Italy was unlucky enough to be the first western country to be criticized for the epidemic, and its official total of 26,000 has fallen behind the United States in the global death toll. The first case of Italian origin was registered on February 21, at a time when the World Health Organization still insisted that the virus was “contagious” and not as contagious as the flu.

But there is also evidence that demographic and health deficiencies collided with political and commercial interests to expose the 10 million people of Lombardy to COVID-19 in an invisible way nowhere else, especially the most vulnerable in nursing homes.

Virologists and epidemiologists say that what has not worked will be studied for years, given that the epidemic has overtaken a medical system that has long been considered one of the best in Europe, while in neighboring Veneto , the effect was much more controlled.

Prosecutors, meanwhile, decide to bring criminal responsibility for the hundreds of deaths in nursing homes, many of which do not even count in the official toll of 13,269 deaths in Lombardy, half the Italian total.

On the other hand, frontline doctors and nurses in Lombardy are hailed as heroes for risking their lives to care for the sick in extraordinary conditions of stress, exhaustion, isolation and fear. A WHO official said it was a “miracle” to have saved as many people as they did.

Here’s a look at the perfect storm of what happened in Lombardy, from interviews with doctors, union representatives, mayors and virologists, as well as reports from the Higher Institute of Health, the national statistical agency ISTAT and the Organization for Economic Co-operation and Development, which advises developed economies on policy.

PREPARED NOT PREPARED

Italy was the first European country to cut all air traffic with China on January 31, and it even installed scanners at airports to check for fever. But by January 31, it was already too late. Epidemiologists now say that the virus has been circulating widely in Lombardy since early January, if not before.

Doctors treating pneumonia in January and February did not know it was the coronavirus because the symptoms were so similar and the virus was still largely confined to China. Even after Italy registered its first local case on February 21, doctors did not understand the unusual way COVID-19 could present itself, with some patients experiencing a rapid decline in their ability to breathe.

“After a stabilization phase, many deteriorated rapidly. It was clinical information that we did not have, “said Dr. Maurizio Marvisi, pulmonologist at a private clinic in Cremona, badly affected. “There was practically nothing in the medical literature. “

Because the intensive care units in Lombardy were already filling up a few days after the first cases in Italy, many primary care physicians tried to treat and monitor patients at home. Some put them on additional oxygen, commonly used for home cases in Italy.

This strategy proved to be fatal, and many died at home or shortly after hospitalization, after waiting too long to call an ambulance.

Home care “is likely to be the determining factor in why we have such a high death rate in Italy,” said Marivi.

Italy was forced to use home care in part due to its low capacity for intensive care: after years of budget cuts, Italy entered the crisis with 8.6 intensive care beds per 100 000 people, well below the average of 15.9 of the Organization for Economic Cooperation and Development and a fraction of 33.9 of Germany, said the group.

As a result, primary care physicians have become the front line filter for patients with the virus, an army of mainly independent practitioners who work outside the Italian regional hospital system.

Only those with strong symptoms were tested because the laboratories in Lombardy could not treat more. As a result, these family doctors did not know if they themselves were infected, let alone their patients.

With so little clinical information available, doctors also had no guidelines on when to admit patients or refer them to specialists. And being outside the hospital system, they did not have the same access to masks and protective equipment.

“The region was extremely late in providing protective equipment, and it was not enough because the first time they gave us 10 masks and surgical gloves,” said Dr Laura Turetta in the town of Varese. . “Obviously, for our close contact with patients, it was not the right way to protect ourselves. “

The association of doctors of Lombardy sent on April 7 a blistered letter to the regional authorities enumerating seven “errors” in their management of the crisis, among which the lack of tests for the medical personnel, the lack of protective equipment and the lack of data on contagion. .

The regional government and the civil defense agency defended its efforts, but acknowledged that Italy depended on imports and donations of protective equipment and that it simply did not have enough to get around.

LOST WEEKS

Two days after the registration of the first Italian case in the province of Lodi, triggering quarantine in 10 cities, another positive case was recorded more than an hour’s drive from Alzano, in the province of Bergamo. While the emergency room at the Lodi area hospital was closed, the Alzano emergency room reopened after a few hours of cleaning, becoming a primary source of contagion.

Internal documents cited by Italian newspapers indicate that a few serious cases of pneumonia that the Alzano hospital saw on February 12 were probably COVID-19. At the time, the Italian Ministry of Health recommended testing only for people who had gone to China or had been in contact with a suspected or confirmed positive case.

On March 2, the Higher Institute of Health recommended the closure of Alzano and Nembro, as did the towns of Lodi. But the political authorities never implemented the quarantine recommendation there, allowing the infection to spread for a second week until the entire Lombardy region was locked down on March 7.

“The army was there, ready to shut down completely, and if it had been done immediately, they might have been able to stop the contagion in the rest of Lombardy,” said Dr Guido Marinoni, chief of the association of doctors of Bergamo. “It was not done, and they took milder measures throughout Lombardy, and it allowed the spread. “

When asked why he had not sealed off Bergamo earlier, Prime Minister Giuseppe Conte argued that the regional government could have done it on its own. The governor of Lombardy, Atillio Fontana, replied that any mistake “” had been made by both. I don’t think there was any blame in this situation. “

Lombardy has one sixth of Italy’s 60 million inhabitants and is the most densely populated region, home to the commercial capital of Milan and the industrial heart of the country. Lombardy also has more people aged 65 and over than any other Italian region, as well as 20% of nursing homes in Italy, a demographic time bomb for COVID-19 infections.

“Obviously, looking back, we should have made a total stop in Lombardy, everyone at home and no one is moving,” said Andrea Crisanti, a microbiologist and virologist advising the regional government of Veneto. But he recognized how difficult this was, given the disproportionate role of Lombardy in the Italian economy, which, even before the pandemic, was headed for a recession.

“Probably for political reasons, this has not been done,” he told reporters.

INDUSTRIAL LOBBYING

Unions and mayors of some of Lombardia’s hardest-hit cities now say the country’s main industrial pressure group, Confindustria, has exerted enormous pressure to resist shutdowns and production stoppages because the economic cost would be too high in a region responsible for 21% of Italy’s gross domestic product.

On February 28, a week after the start of the epidemic and well after the registration of more than 100 cases in Bergamo, the provincial branch of Confindustria launched a social media campaign in English #Bergamoisrunning, to reassure customers. He insisted that the epidemic was no worse than elsewhere, that the “misleading feeling” of its high number of infections was the result of aggressive testing and that production in steel mills and other industries was not was not affected.

Cofindustria launched its own campaign in the greater Lombardy region, echoing this message, #Yeswework. The mayor of Milan proclaimed that “Milan does not stop”.

At the time, the head of Confindustria Lombardy, Marco Bonometti, recognized the “drastic measures” necessary for Lodi, but sought to reduce the feeling of alarm.

“We need to let people know that they can go back to their present lives while preserving their health,” he said.

Even after Rome locked all of Lombardy on March 7, it allowed factories to remain open, causing strikes by workers worried that their health would be sacrificed to run the Italian industrial engine.

“It was a huge mistake. They should have taken the example where the first cluster was found, “said Giambattista Morali, of the union of metallurgists of the city of Dalmine, in Bergamo. “Keeping the factories open did not help the situation; obviously it made it worse. “

Finally, production, except essential, was stopped on March 26. Confindustria National President Carlo Bonomi has called for the industry to be reopened, but in a safe manner.

“The paradigm has changed,” Bonomi said on RAI state television. “We cannot secure the Italians if we don’t reopen the factories. But how do you secure the factories to secure the Italians? “

It’s a tough sell, as Lombardy continues to add an average of 950 infections a day, while other regions add a few dozen to 500 each, with most of the new infections registered in nursing homes nurses. Italy is expected to begin a gradual reopening on May 4, with regions further south where the epidemic is more contained.

Lombardy will probably be the last to open completely, with its 72,000 confirmed cases, 70% of Italy’s total, and estimates that the real number could be 10 times higher.

A COST-BASED HOSPITAL

Perhaps no initiative better illustrates the confused response of the coronavirus in Italy than the 200-bed field hospital built in less than two weeks on the grounds of the Milan convention center.

The hospital was unveiled with great fanfare on March 31, the result of a fundraising campaign of 21 million euros ($ 23 million) led by the governor of Lombardy, a member of the right-wing party of the League, for attempt to reduce the pressure on regional intensive care units, which on this date were close to the capacity of 1324 patients.

The national civil defense agency objected to the plan, arguing that it could never equip it with fans or personnel in time. Instead, the agency, which comes under rival Rome’s 5-star Democratic government, preferred smaller field units installed outside hospitals and a program to move critically ill patients elsewhere.

In the end, the Milan field hospital was barely used, treating only a few dozen patients. Since its opening, Lombardy has seen pressure on its intensive care units drop dramatically, with just over 700 people requiring intensive care today.

Fontana, the governor, defended the decision and said he would do it again, saying to Radio 24, “We have to … prepare a roadblock in case the epidemic exceeds the embankment. “

MASSACRE TREATMENT HOUSE

As the regional government focused on the field hospital and sought to find intensive care beds, its testing capacity was lagging behind and nursing homes in Lombardy were in many ways left to fend for themselves.

Hundreds of elderly people have died in Lombardy and throughout Italy in what a WHO official has called a “massacre” of those most vulnerable to the virus. Prosecutors are investigating dozens of nursing homes, as well as measures taken by local health authorities and regional governments that may have made the problem worse.

Lombardy has more nursing homes than any other region, housing at least 24,000 elderly people, and has recorded more deaths in these facilities than in others. Of the 3,045 deaths that occurred between February 1 and April 15 in the region, 1,625 were positive for or had symptoms of the virus, according to preliminary results of a survey by the Higher Institute of Health.

Particular attention was paid to prosecutors in the March 8 decision by the regional government to authorize the placement of COVID-19 patients in convalescence to free up hospital beds. The region said it required homes to guarantee that patients would be isolated, but it was unclear who was responsible for guaranteeing this or whether someone had checked.

Even before that, staff at some homes said management had prevented them from wearing masks for fear of scaring residents.

A regional decree of March 30, again aimed at easing the pressure on intensive care units in Lombardy, told directors of nursing homes not to hospitalize sick residents aged 75 and over if they have any. other health problems. The decree declared that it was “appropriate to treat them in the same establishment to avoid other risks of decline in transport or while waiting in the emergency room”.

For the elderly in a nursing home in Nembro, one of the hardest hit cities in the province of Bergamo, the decree amounted to a death sentence. But he was not the first or the only one to give the impression that they were abandoned.

When management proactively banned visitors on February 24 to try to protect residents and staff from infection, local health officials responded by threatening sanctions and losing certification for interrupting family visits, said the new director of the establishment, Valerio Poloni.

In the end, 37 of the 87 inhabitants died in February and March. His doctor, as well as Poloni’s predecessor as director, also tested positive, were hospitalized and died. A resident of a nursing home could not be admitted to the hospital in late February because the emergency room was too busy.

Nursing home health director Barbara Codalli said she was told to use her existing resources. “The patient returned a few hours later, and a few days later, the patient died,” she told La7 television.

To date, none of the surviving residents have been tested. Poloni said tests should start in a few days. Two other residents have died so far in April, but the situation appears to be under control.

“We are quiet,” he said.

Associated Press editor Colleen Barry in Soave, Italy, contributed to this report.



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