Feature

‘I stay at home’: Italy hardens emergency COVID-19 measures

TREVISO, Italy — Day after day, COVID-19 containment and mitigation measures become more stringent in Italy, while hospitals are under extraordinary pressure to meet the surge in cases.

On Wednesday, WHO Director-General Tedros Adhanom Ghebreyesus, PhD, MSc, declared COVID-19 a pandemic and stated that in only 2 weeks, the number of cases of outside China has increased 13-fold, and the number of affected countries has tripled.

The same day in Italy, the number of confirmed cases grew to 10,590 — over 2,000 more than the previous day. As of Thursday, there were 15,113 confirmed cases in the country.

With three consecutive decrees since Sunday, Italian authorities expanded pre-existing COVID-19-related restrictions, first to large areas of the northern part of the country and then nationwide, and have ordered the shutdown of all nonessential commercial activities.

“I am going to sign a decree that we can summarize in the words ‘I stay at home,’” Prime Minister Giuseppe Conte said while officially announcing the government’s decisions. He appealed to the sense of responsibility and spirit of collaboration of all citizens to achieve two goals: “contain transmission and avoid the overload of hospitals.”

I stay at home

According to the decree, “All citizens are advised to leave home only for work, health reasons and emergencies.” Written self-declarations must be exhibited, subject to verification by police, and false claims and violations are subject to criminal charges. All forms of gathering are prohibited, indoor as well as outdoor. Closure of schools and universities has been extended to April 3 and plans for online teaching have been implemented. Religious ceremonies, including funerals, are suspended.

From March 12, all commercial activities, including restaurants, cafes and shops, with the sole exceptions of grocery stores and pharmacies, must remain closed. Companies and factories that were previously encouraged to allow employees to work from home, have now been ordered to close all departments that are “not indispensable” for production.

“We are the first country in Europe to be hit hard by this coronavirus, but we are also the country that is reacting more strongly with the highest level of precaution, and we are becoming day after day a model for all others,” the prime minister said.

Health comes first, and the high toll taken on the Italian economy is a necessary sacrifice that will pay off in the long term, said Mario Conte, mayor of Treviso and president of a consortium of municipalities in the Veneto region.

“The more decisively we react now, the earlier we will be out of it. We are already making projects to relaunch our economy, which is suffering, but is strong enough to recover in due time,” Conte told Healio.

He noted that people are reacting well and responsibly to restrictions, although they impact habits that are important for the local population, such as having an aperitif with friends and family.

The regional health care system of Veneto, he said, is well equipped to deal with the emergency. “We have currently less than 1,000 positive cases and have a low mortality rate, with all victims being high-risk patients with severe concomitant pathologies,” he said.

Increasing ICU capacities

With 8,725 positive cases as of Thursday, Lombardy is the most affected region in Italy. The San Raffaele Hospital, a multispecialty university hospital in Milan, is being progressively reorganized and is increasing its ICU capacities to meet the demand.

“We now have 26 intensive care beds specifically for COVID-19 in which there are patients on mechanical ventilation for interstitial pneumonia, plus four on pressure support,” Alberto Zangrillo, MD, head of the hospital’s ICU, told Healio.

“We have maintained seven beds for postoperative intensive care and 15 for cardiovascular intensive care, since we are a reference center for electrophysiology and cardiovascular surgery,” Zangrillo said. “In order to do this, we have drastically reduced our surgical activities, while maintaining the capabilities for a small volume of emergency surgery.”

A specialized ED for patients with symptoms of COVID-19 has been created, in which patients are triaged to receive oxygen therapy, noninvasive respiratory assistance or intensive care.

Warning against misleading information, misinterpretation and fake news spreading on social media, Zangrillo said that no patient in his hospital, or any other hospital in the region, has been refused or discontinued therapy.

“There is no dramatic choice to make. We take care of every single patient, regardless of age,” Zangrillo said. “Every hospital in this country has increased, doubled and, in our case, tripled the number of intensive care beds. The problem is that this virus is extremely contagious and in 2 or 3 weeks has brought to our ICUs the number of patients we used to see in an entire year.”

He dissociated from the guideline criteria recently issued by the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) to help doctors make choices, under extraordinary circumstances, on the basis of age, prognosis and life expectancy.

“There may be patients, not only old but with severe pathologies, for whom [extracorporeal membrane oxygenation] therapy or invasive ventilation is not appropriate, and we must be aware that those patients, when undergoing invasive therapies, may have a negative prognosis,” Zangrillo said. “But elderly patients who have sufficient chances of surviving receive the highest standard of treatment. I do not know of any ICU in this region where the access criteria suggested by SIAARTI have been adopted.”

To his colleagues in the United States, Zangrillo suggested early adoption of containment measures that may help flatten the curve of the pandemic. Based on his experience to date, he also suggested an aggressive and proactive approach with invasive ventilation.

“When these patients develop pneumonia, they have a form of exudative alveolitis that in a very short time makes them very dependent on positive end-expiratory pressure. It is a form of pneumonia that tends to resolve but requires an ICU stay of more than 2 weeks,” he said. by Michela Cimberle

Disclosures: Mario Conte and Zangrillo report no relevant financial disclosures.

TREVISO, Italy — Day after day, COVID-19 containment and mitigation measures become more stringent in Italy, while hospitals are under extraordinary pressure to meet the surge in cases.

On Wednesday, WHO Director-General Tedros Adhanom Ghebreyesus, PhD, MSc, declared COVID-19 a pandemic and stated that in only 2 weeks, the number of cases of outside China has increased 13-fold, and the number of affected countries has tripled.

The same day in Italy, the number of confirmed cases grew to 10,590 — over 2,000 more than the previous day. As of Thursday, there were 15,113 confirmed cases in the country.

With three consecutive decrees since Sunday, Italian authorities expanded pre-existing COVID-19-related restrictions, first to large areas of the northern part of the country and then nationwide, and have ordered the shutdown of all nonessential commercial activities.

“I am going to sign a decree that we can summarize in the words ‘I stay at home,’” Prime Minister Giuseppe Conte said while officially announcing the government’s decisions. He appealed to the sense of responsibility and spirit of collaboration of all citizens to achieve two goals: “contain transmission and avoid the overload of hospitals.”

I stay at home

According to the decree, “All citizens are advised to leave home only for work, health reasons and emergencies.” Written self-declarations must be exhibited, subject to verification by police, and false claims and violations are subject to criminal charges. All forms of gathering are prohibited, indoor as well as outdoor. Closure of schools and universities has been extended to April 3 and plans for online teaching have been implemented. Religious ceremonies, including funerals, are suspended.

From March 12, all commercial activities, including restaurants, cafes and shops, with the sole exceptions of grocery stores and pharmacies, must remain closed. Companies and factories that were previously encouraged to allow employees to work from home, have now been ordered to close all departments that are “not indispensable” for production.

“We are the first country in Europe to be hit hard by this coronavirus, but we are also the country that is reacting more strongly with the highest level of precaution, and we are becoming day after day a model for all others,” the prime minister said.

Health comes first, and the high toll taken on the Italian economy is a necessary sacrifice that will pay off in the long term, said Mario Conte, mayor of Treviso and president of a consortium of municipalities in the Veneto region.

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“The more decisively we react now, the earlier we will be out of it. We are already making projects to relaunch our economy, which is suffering, but is strong enough to recover in due time,” Conte told Healio.

He noted that people are reacting well and responsibly to restrictions, although they impact habits that are important for the local population, such as having an aperitif with friends and family.

The regional health care system of Veneto, he said, is well equipped to deal with the emergency. “We have currently less than 1,000 positive cases and have a low mortality rate, with all victims being high-risk patients with severe concomitant pathologies,” he said.

Increasing ICU capacities

With 8,725 positive cases as of Thursday, Lombardy is the most affected region in Italy. The San Raffaele Hospital, a multispecialty university hospital in Milan, is being progressively reorganized and is increasing its ICU capacities to meet the demand.

“We now have 26 intensive care beds specifically for COVID-19 in which there are patients on mechanical ventilation for interstitial pneumonia, plus four on pressure support,” Alberto Zangrillo, MD, head of the hospital’s ICU, told Healio.

“We have maintained seven beds for postoperative intensive care and 15 for cardiovascular intensive care, since we are a reference center for electrophysiology and cardiovascular surgery,” Zangrillo said. “In order to do this, we have drastically reduced our surgical activities, while maintaining the capabilities for a small volume of emergency surgery.”

A specialized ED for patients with symptoms of COVID-19 has been created, in which patients are triaged to receive oxygen therapy, noninvasive respiratory assistance or intensive care.

Warning against misleading information, misinterpretation and fake news spreading on social media, Zangrillo said that no patient in his hospital, or any other hospital in the region, has been refused or discontinued therapy.

“There is no dramatic choice to make. We take care of every single patient, regardless of age,” Zangrillo said. “Every hospital in this country has increased, doubled and, in our case, tripled the number of intensive care beds. The problem is that this virus is extremely contagious and in 2 or 3 weeks has brought to our ICUs the number of patients we used to see in an entire year.”

He dissociated from the guideline criteria recently issued by the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) to help doctors make choices, under extraordinary circumstances, on the basis of age, prognosis and life expectancy.

PAGE BREAK

“There may be patients, not only old but with severe pathologies, for whom [extracorporeal membrane oxygenation] therapy or invasive ventilation is not appropriate, and we must be aware that those patients, when undergoing invasive therapies, may have a negative prognosis,” Zangrillo said. “But elderly patients who have sufficient chances of surviving receive the highest standard of treatment. I do not know of any ICU in this region where the access criteria suggested by SIAARTI have been adopted.”

To his colleagues in the United States, Zangrillo suggested early adoption of containment measures that may help flatten the curve of the pandemic. Based on his experience to date, he also suggested an aggressive and proactive approach with invasive ventilation.

“When these patients develop pneumonia, they have a form of exudative alveolitis that in a very short time makes them very dependent on positive end-expiratory pressure. It is a form of pneumonia that tends to resolve but requires an ICU stay of more than 2 weeks,” he said. by Michela Cimberle

Disclosures: Mario Conte and Zangrillo report no relevant financial disclosures.

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