Italy emerging as the new epicenter for the Covid-19 pandemic

Prime Minister Giuseppe Conte of Italy extended the emergency measures against the coronavirus pandemic to the entire country on Monday in the hopes of limiting the spread of the infection to the South, and diverted resources to the heavily impacted Lombardy region.

In his TV address to the nation, he stated, “There is no more time.” The pandemic has found a new epicenter with more than 10,000 cases reported. In just 24 hours, 977 new cases were confirmed with 168 new fatalities, while 877 remain in critical condition. The total death toll in Italy from Covid-19 now stands at 631. The country’s health care infrastructure has become exhausted.

In a recent post that has gone viral by Dr. Daniele Macchini, an intensive care unit physician in Bergamo, a city near Milan, he gives an unsettling personal account of the devastation being wrought by the pandemic.

A man wearing a mask walks in St. Peter's Square at the Vatican, Friday, March 6, 2020. (AP Photo/Andrew Medichini)

“I will try … to convey to people far from our reality what we are living in Bergamo in these days of Covid-19 pandemic. I understand the need not to create panic, but when the message of the dangerousness of what is happening does not reach people, I shudder …

“The war has literally exploded, and battles are uninterrupted day, and night … cases are multiplying, we arrive at a rate of 15–20 admissions per day all for the same reason. The results of the swabs now come one after the other: positive, positive, positive. Suddenly the ER is collapsing.

“The staff is living at the hospital. Surgical cases are being canceled, and operating rooms are converted to treatment rooms where every available ventilator being used is considered ‘gold.’ Exhaustion has set in as endless shifts proceed without an end in sight. The staff is compelled to push beyond the limits of human endurance. They are unable to go home out of fear of infecting their families. Some are working while their families affected at home are struggling for their lives. They watch hopelessly, knowing that the fate of some of the patients they are caring for awaits them in just a few hours.”

Similar accounts were shared by Chinese physicians who labored for hours as they tried to make sense of the incomprehensible at the outbreak of the crisis. Many also became seriously ill and some succumbed to the bilateral interstitial pneumonia that took their last breath away.

Concluding, Dr. Macchini wrote, “I finish by saying that I really don’t understand this war on panic. The only reason I see is mask shortages, but there’s no mask on sale anymore. We don’t have a lot of studies, but is panic really worse than neglect and carelessness during an epidemic of this sort?”

The data being projected by various sources that are tracking the global statistics show that Germany, France, Spain, virtually the entire eurozone, as well as the United States, are only one to two weeks behind Italy. In the US as of Tuesday officially there were 985 cases reported with 29 fatalities, of which 25 occurred in Washington state at a nursing facility. There were 169 new cases in the US today, with Massachusetts announcing 51 new cases, a 124 percent increase.

New York State, with 173 cases, is just behind Washington with 179 cases. Most of these cases are in and around New York City. Because of the CDC’s utter failure in leading efforts in the detection and management of the epidemic, private labs are now being used to test people. Public officials are coming to an astounding realization that the magnitude of the problem has become critical.

Mayor Bill de Blasio told reporters yesterday, “They’re coming in so intensely now that being able to give you a detailed case breakdown, we’re not in that position to do that at this moment because there are so many coming forward.” There are nearly 2,000 people in the city on voluntary isolation, while 30 people have been placed in mandatory quarantine.

Governor Andrew M. Cuomo announced that he had declared a one-mile-radius containment zone in New Rochelle, New York, centered on a synagogue found to be the source of the state’s largest cluster of infections. All schools, religious and community centers will be closed for two weeks. According to the New York Times, the National Guard is also being deployed to “clean schools and to deliver food to quarantined residents, including hundreds of students now facing two weeks of being isolated at home.”

It is clear these measures are going into effect in preparation for the impending tsunami of sickened patients seeking treatment that is around the corner, bringing not only panic and chaos but social discontent and resentment over the state and government’s utter lack of preparedness or concern.

As the number of seriously ill continues to rise, local hospitals will find themselves overwhelmed by the sheer volume of patients seeking urgent medical attention. The intensive care unit (ICU) capacities will quickly dwindle as community after community is unable to deliver the necessary care. Makeshift rooms and beds will be improvised.

The triaging protocol might change from assisting the sickest immediately to attending to those who have a chance of surviving. There may develop a situation in which the elderly or those with severe comorbidities will not be admitted due to their very high risk of fatality, because the resources of a region are depleted. Hospitals may have to develop and employ scoring systems to make quick assessments as to who will be permitted admission.

In a recent study published on the Harvard Library web site, the authors report the lessons learned from Chinese cities on demand for inpatient and ICU beds for Covid-19. In Wuhan city, for the period from January 24 to February 29, Covid-19 accounted for 32,486 ICU-days and 176,136 serious-inpatient days. During the peak of the epidemic, lasting from mid- to late February, nearly 20,000 people were hospitalized, half of whom were considered in “serious” condition. Over 2,000 patients needed critical care.

The authors note that even if cities comparable to Wuhan, such as New York City, Los Angeles or Chicago, were to implement measures as severe as the lockdown imposed on Hubei province, “hospitalization and ICU needs from Covid-19 patients alone may exceed current capacity.” They also note that many US cities have a higher prevalence of vulnerable populations, which in turn would require even more resources to manage such a volume of patients.

A crucial lesson emphasized in the study’s discussion is that when health care resources became inundated in Wuhan, patients would travel to other facilities seeking aid. This only contributed to the ongoing community transmission the authorities were attempting to control. Additionally, as the health care system collapsed under the pressure of such large numbers of patients, medical staff were unable to deliver adequate care, which translated to worse outcomes.

The case fatality index for Wuhan city was highest, at 4.5 percent, while in Hubei province it was less, at 3.2 percent. For the rest of the regions that abided by the social distancing and contact quarantine measures instituted in the early phase of the epidemic, the study found that the fatality index was an exceptional low of 0.8 percent. These regions were able to keep their health care infrastructure operating at full capacity.

The US has about 2.8 hospital beds per 1,000 people. By comparison, Japan and South Korea have 12 hospital beds per 1,000, or four times the capacity. The measures instituted in Japan and South Korea have seen the number of new cases drastically curbed. In absolute terms, there are about 1 million beds in the US, of which about 70 percent are occupied at any given time. Even by the most conservative estimates, at the rate that the Covid-19 infection is growing in the US, it will reach capacity in less than two months.

Additionally, the US stockpile of N95 masks is around 12 million. With the outbreak permeating all health care facilities, health providers will have to don masks while they work in hospitals and urgent care centers. In approximately two to three days, this stock of perishables will become exhausted. It is unreasonable to assume that manufacturing will have the capacity to keep up with demand.

Dr. Macchini offered these important sobering sentiments to the global community, “We at the hospital simply try to make ourselves useful. You should do the same: we, doctors, influence the life and death of a few dozen people. You, with your actions and choices, decide the fates of many more.”