At the height of the coronavirus outbreak in Italy, hospitals and crematoriums in the hardest-hit region of the country were overrun and obituaries filled 10 pages of a local newspaper. But about five months later, the nation has become somewhat of a success story in recovering from the devastating first wave of the epidemic.
In northern Italy, where the coronavirus ravaged cities from late February through April, doctors attribute the turnaround to the country’s strict national lockdown, widespread testing, robust contact tracing and a reopening process very gradual. But while Italy has seen a significant drop in the number of new infections – registering around 150 to 300 new cases every day in the country over the past week, from a record high of more than 6,500 on March 21 – experts are prepare for an inevitable second wave.
“We are concerned because the virus has not just disappeared,” said Dr Roberto Cosentini, head of the emergency medicine unit at Papa Giovanni XXIII hospital in Bergamo, in the Italian region of Lombardy.
Still, stay-at-home orders across the country were key to bringing the virus under control, said Francesco Longo, health economist and director of the Center for Research in Health and Social Care Management at Bocconi University of Milan. He added that the far-reaching mandate, promulgated by the federal government, had helped Italy avoid a situation similar to what is currently happening in the United States, where inconsistent lockdown and masking strategies between states have resulted in many different outbreaks at different times across the country.
“If you’re in Florida and you hear your governor say something and then the governor of New York says otherwise, it’s really hard,” he said. “In Italy, it was only one voice.”
Italy has recorded more than 247,000 confirmed cases and more than 35,000 deaths, the majority of which were concentrated in Lombardy. Cosentini said Italy was likely to see an upsurge in new COVID-19 infections in the fall – which, combined with the seasonal flu, could be difficult for local hospitals. Yet, it is also possible that a second wave will occur earlier than in October.
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Several European countries, including Spain, Germany and France, are already seeing an increase in new infections after months of relative stability. Cosentini said he fears a return to what the country went through at the end of February, but added that doctors and hospitals are also better equipped now to deal with the coronavirus – a result of difficult lessons learned during the initial outbreak.
“60 million people in the same boat”
Cosentini hospital treated its first coronavirus patient, an individual with severe pneumonia, on February 22. Even after following the situation as it unfolded in Asia, he said he and his colleagues were unprepared for how quickly the epidemic was going to worsen.
“We started with 10 to 20 patients, and by the beginning of March we had up to 80 new patients a day,” he said. “It was really difficult.”
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To cope with the influx of patients, doctors quickly learned that several procedures had to be reviewed. In addition to converting most other hospital wards to coronavirus wards, Cosentini has revamped the facility’s emergency rooms to accommodate the overflow of intensive care units.
He said hospitals in northern Italy were in high demand at the time, but if the government had not imposed a two-and-a-half-month national lockout on March 9, things could have become catastrophic.
“We were very close to the threshold of failure,” he said. “The toughest times were the first and second weeks of March, but then the social distancing and lockdowns started to work and gave us a chance to release recovering patients and have free beds for them. new people.
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Although some saw it as an extreme measure at the time, much of Italy’s success in reducing the infection rate was due to the fact that all Italians were under orders to stay at home, according to Longo.
“We had 60 million people in the same boat, and the national narrative was, ‘When infections are under control everywhere, we will reopen the whole country,’ he said. “It gave a strong sense of belonging to each other.”
Italian health officials have also understood the importance of being agile and adjusting their strategies as the epidemic evolves, said Dr Stefano Nava, head of respiratory and critical care at Sant ‘Orsola Hospital. from Bologna.
From the start, people were advised not to go to the hospital unless they were seriously ill, in order to avoid overloading the country’s health system. But that way of thinking has changed as doctors have learned more about the new virus.
“At first we waited too long to admit patients to the hospital, and when they were admitted we were probably too aggressive even with the treatment,” said Nava, who himself tested positive for COVID-19 and was ill for 31 days. . “We have learned that unless the patient is very sick, you have to be careful enough and treat non-aggressively to avoid further complications.”
This meant trying as much as possible to avoid intubating patients and only resorting to ventilators in the most extreme cases. It also meant expanding testing to find mild or moderate cases and, if necessary, intervening before patients experienced too much respiratory stress.
“The disease was new, not only to us but also to the patients, so patients would wait six to eight days after the fever started before entering,” Cosentini said. “It made some of the severe cases much more difficult to manage.”
Prepare a second wave
Even though the situation in Italy has stabilized, testing is expected to remain an important part of the country’s mitigation strategy, experts said, particularly as a way to track the spread of the virus among people who may be asymptomatic.
“The role of asymptomatic positive carriers remains a very big question, so it is very important to [test] lots of people, ”said Dr Eugenio Baraldi, director of neonatology and neonatal intensive care unit at the University Hospital of Padua. “It will be a big deal for everyone.”
The Italian government began lifting the lockdown measures on May 4, but reopening the country has been a slow and gradual process, according to Longo. Social distancing guidelines remain in place, particularly on beaches and other public places, but things have otherwise returned to a semblance of normalcy, he said.
Italians are encouraged to wear masks in restaurants and elsewhere in public where social distancing is difficult. Longo said mask compliance varies, with people living in the hardest-hit areas being more likely to closely adhere to the guidelines, while people living in areas less affected by the virus are more relaxed.
Reinforcing these behaviors will be essential as the country prepares for a second wave of the pandemic. Longo said the government has already launched a massive campaign to encourage people to get free flu shots to ease some of the burden on hospitals in the fall and winter.
The country is also investing in additional hospital beds and other resources to strengthen health facilities. And Longo said the federal government is working with state and local authorities to find the best way to contain future epidemics while supporting the country’s economic recovery.
“We’ve learned it’s not black and white – it doesn’t have to be lockdown or completely free,” he said. “We still have a lot of restrictions now, even though we’ve returned to our normal life.”
But perhaps the biggest lesson learned, Longo said, is that the message is important in building the cohesion that is essential within countries and between nations to fight the pandemic.
“The messages cannot be contradictory,” he said. “If 50% of the population obeys the rules and the remaining 50% don’t, it’s a mess. And then the virus wins. “