Italian hospitals struggle with surge of COVID-19 as vaccination campaign gains speed
ASOLO, Italy — Italy, at the forefront of the COVID-19 pandemic a year ago, is still struggling, with hospitals under pressure despite encouraging signs of a decrease in the number of reported cases.
The number of patients with COVID-19 admitted to ICUs is growing, and ICU bed occupancy at a national level is 39% — over the critical threshold — according to the Ministry of Health. Floor bed occupancy is 43%.
Meanwhile, the vaccination campaign is picking up speed after a slow and uneven start. The aim is to vaccinate 500,000 people per day, and currently about 250,000 doses per day are being administered. The total number of people in the country who have received one dose is more than 10 million, of whom more than 3 million have received both shots.
ICUs under pressure
Roberto Fumagalli, MD, a professor at Milan Bicocca University and head of anesthesia and intensive care at the Niguarda Metropolitan Hospital, one of the largest hospitals in Milan, said just one of the hospital’s 35 COVID-19 ICU beds available.
“In the region overall, 830 ICU beds in a total of about 1,300 are occupied by COVID-19 patients,” he told Healio.
Lombardy, a highly populated region of Northern Italy, has been from the start the hardest hit region.
“During this second and third wave, we have never had less than 350 to 380 COVID-19 patients in intensive care. The average age has now dropped to 62 years, and [the] fatality rate is between 30% and 40%,” Fumagalli said.
The B.1.1.7 variant, first identified in the United Kingdom, is spreading rapidly and accounts for more than 50% of infections in the region.
“This virus has, at all times, been able to catch us unprepared. We did not expect variants to have such an impact, sparking a new surge of infections even more difficult to control,” Fumagalli said.
Since the start of the pandemic, the ICU has hosted more than 10,000 patients, he said, and the experience gained over 1 year has provided important insights into how to respond; nevertheless, the pressure is still high.
“One positive thing I perceive is there is less fear now that we have been vaccinated. During the first stage, besides the incredible situation we suddenly had to cope with, we were scared of getting infected and infecting our families. We took all precautions, but fear was with us all day long,” Fumagalli said.
The pandemic has exacted a high toll among health care workers, with 348 doctors and 48 nurses dying. Additionally, six took their life out of exhaustion and despair.
Resilience and cooperation
Since the first national lockdown last year, containment measures have been differentiated to take into account regional heterogeneity. Based on how widespread SARS-CoV-2 is locally and how local hospitals are able to respond, regions are divided into white, yellow, orange and red zones, indicating a progressively higher risk scenarios and increasingly severe restrictive measures.
Since March 15, because of the rise in cases, most regions have been classified as red zones, some as orange and none is currently yellow or white. Over the Easter weekend, the whole country will be placed under a national lockdown.
Friuli Venezia Giulia, another region in the north of the country, had a low number of infections during the first wave, but has recently been dealing with a significant increase.
“Thanks to the gigantic effort of our regional health care system and the high number of COVID tests performed, we were never classified as a red zone until 2 weeks ago,” Carlo Tascini, MD, head of the department of infectious diseases at Udine University Hospital, told Healio. “This created an erroneous perception in the population that the situation was under control, and many let their guard down. As a result, the province of Udine, capital of the region, [now ranks] fifth in Italy for number of cases. In addition, the B.1.1.7 variant has made numbers increase exponentially, and is now responsible for 70% of our cases.”
Tascini’s department had 13 beds before the pandemic on the second floor of a building that has now been entirely converted into a COVID-19 tower, including specialized units for COVID-19 pneumology, COVID-19 neurology and COVID-19 medicine, as well as intensive and subintensive care. Negative pressure provides high-flow oxygen ventilation that keeps the risk for transmission low among the hospital staff.
“This pandemic tragedy has highlighted the value, strength and resilience of our health care system throughout Italy,” Tascini said. “If every cloud has a silver lining, this has been for us, physicians and all health care personnel, the opportunity to work together across specialties. In our department, we have worked closely with anesthesiologists, surgeons, internists, and with laboratory staff. As a team, we have been able to efficiently organize our hospitals to respond to the pandemic crisis, working synergistically and cooperatively, in a way that we never thought we were capable of.”
Active surveillance and contact tracing
During the past year, Giampaolo Ciappa, MD, medical director of a large local health department in the metropolitan area of Naples, has been coordinating activities related to COVID-19 testing and contact tracing.
“We are seeing a slight improvement, probably the effect of the containment measures of the past 2 weeks, but also the effect of a more efficient system of contact tracing throughout the region,” he told Healio.
For every person who tests positive, they trace close contacts up to at least 2 weeks previously among family, friends and coworkers, and they are asked to self-quarantine for 14 days from their last exposure, or for 10 days if they test negative on day 10.
“We have had 3,000 people on active surveillance since March 2020, and the rate of hospitalization was very low, with only seven deaths,” Ciappa said.
Active surveillance involves home-based care from family doctors. If patients require oxygen therapy, this is also provided at home until the patients recover or until they need hospitalization.
“This model of home-based care has worked very well, and has shown to reduce hospitalization and costs,” Ciappa said. “Family doctors, the backbone of our health care system, should be praised for the crucial role they have played at every stage of the pandemic.”
Progress and hurdles of vaccination
The Gemelli University Hospital, the largest hospital in Rome, hosts a COVID-19 vaccine hub where more than 26,000 doses of vaccine have already been administered.
“We are working at a steady pace of 350 to 400 shots per day, up to 430 on peak days,” Patrizia Laurenti, MD, professor of hygiene and preventive medicine and now in charge of the COVID-19 vaccine hub, told Healio. “First, we vaccinated our health care personnel and gradually opened to other categories, starting with patients aged over 80 years and the medically vulnerable.”
The Italian government has issued guidance on prioritizing vaccines, starting with health care workers, people aged 80 years or older, vulnerable and severely disabled citizens, teachers and military personnel, followed by the other age groups in descending order. However, regions have developed independent plans, which have sparked controversies and caused delays in the vaccine rollout.
“Some regions have prioritized other categories, such as lawyers and judges, whereas other regions have proposed the vaccination of the working population first,” Laurenti said. “There has been heated discussion, but the government has firmly reasserted that priority should be given to the most vulnerable categories.”
Italy was among the countries that temporarily suspended the use of the AstraZeneca vaccine because of reports of thrombotic complications. After the European Medicines Agency (EMA) gave the green light, administration resumed, but many people cancelled their appointment over safety concerns. Refusal rates were up to 20% in some regions.
“Vaccine refusal is an issue of great concern that reflects poor understanding and misinformation, often fueled by the media and social media,” Laurenti said. “The EMA was clear and consistent in stating and then restating the safety of the AstraZeneca vaccine. Governments were perhaps right to seek further clarification, but putting vaccination on hold generated fear and confusion. Now people come and ask, ‘What vaccine am I getting?’ and we must use this as an opportunity to educate them and address misconceptions.”
Italy Ministry of Health. Phase 2 monitoring weekly report. http://www.salute.gov.it/imgs/C_17_monitoraggi_51_1_fileNazionale.pdf. Accessed April 1, 2021.