Italy races to contain COVID-19 outbreak
ASOLO, Italy — With 821 confirmed cases of COVID-19 as of Friday, Italy is the third-most affected country worldwide and has seen the most infections in Europe. The highest number of cases are in the northern regions of Lombardy and Veneto — both “engines” of the Italian economy. To date, the death toll has risen to 21, with most occurring in senior citizens over age 70 years with pre-existing conditions.
On Feb. 22, through a special government ordinance, 10 municipalities in Lombardy and one in Veneto, where clusters of the infection were identified, were put on lockdown. No one is permitted to enter or leave the areas in question, self-isolation is recommended and schools, museums, restaurants and shops are closed, except for grocery stores and pharmacies. Public and private events, including religious ceremonies, are suspended. All citizens have been submitted to COVID-19 testing.
From Feb. 23, the Ministry of Health extended several of these emergency measures to the entire regions of Lombardy and Veneto, and later to Piedmont, Liguria and Emilia Romagna, to contain the spread of the virus.
Impact on economy
A deluge of mutually contradicting information and conflicting opinions, fueled by television debates and social media, has been spreading anxiety and confusion among the Italian population. Fearing a quarantine, people have been stockpiling food, emptying grocery stores’ shelves. In usually crowded cities such as Venice and Milan, streets are empty and public transportation, shops, restaurants and cafes are deserted.
“The COVID-19 outbreak has been declared a Public Health Emergency of International Concern by WHO, and containment strategies have been recommended. However, there has been an overreaction in Italy that I have not seen elsewhere,” Giorgio Palù, MD, FESCMID, former president of the European Society of Virology, said in an interview.
He expressed concern for the social and economic consequences of containment measures.
“Government restrictions are driving our economy to a standstill. Italy is losing a great part of its GDP, 5 billion euros a day are lost on the stock market every day and tourism is on its knees,” he said. “For political reasons, and fear of acting in a politically incorrect way, containment measures were not applied when they should have been at the beginning of the outbreak, and now we are all running for cover, with the result that other countries are putting us in quarantine.”
The number of nations imposing travel restrictions to and from Italy is growing, and the situation has already caused hotels and travel agencies a loss of 200 million euros due to holiday booking cancellations.
Let the experts speak
According to Palù, there are three possible explanations for why Italy is the first, and so far only, European country in which an outbreak of such proportion has been registered.
“First, it might be because we are carrying out more specific virus tests on more people,” he said. “Second, because we have been less efficient than other nations in detecting the first carriers of the infection while they were crossing our borders. Third, it could be a stochastic phenomenon, in that it arrived here by chance.
“However, this third hypothesis seems improbable. Germany has a tenfold economic relationship than we have with China, and it seems unusual that they have only about 20 cases. Only using the sentinel system, many COVID-19 cases could be mistaken for influenza, since the range of possible symptoms goes from zero to interstitial pneumonia.”
Palù said media coverage has contributed to the spread of misinformation and fear in Italy.
“News is blown all out of proportion, with everybody feeling entitled to give ‘expert’ opinions,” he said. “When dealing with information that has an impact on public health, you cannot give the floor to sociologists, political scientists and the ‘man in the street.’
“Let the experts speak. And with experts I mean true scientists in the first place, and then specialized journalists and political decision-makers. I have heard opinions of too many so-called virologists, hygienists and epidemiologists who have never published a single scientific paper in a peer-reviewed virology journal.”
High transmissibility, low lethality
The lethality of COVID-19 appears to be lower than that of SARS or MERS, which also are caused by coronaviruses. Findings from a study published in The New England Journal of Medicine on Friday showed the case fatality rate was 1.4% among more than 1,000 Chinese patients with laboratory-confirmed COVID-19.
Palù said a precise percentage is difficult to calculate because high concentrations of the virus are found in asymptomatic subjects. Thus, the actual number of infected people may be much higher than is known.
“We know the numerator, which is the number of people who developed the symptoms, but not the exact denominator, because we do not know how many people have contracted the virus, have developed virus-specific antibodies and have remained asymptomatic,” he said. “If the denominator grows, and the mortality rate and the number of incident cases become consequently even lower, then we might eventually discover that our concerns were exaggerated.”
COVID-19 is caused by a new coronavirus, with a high affinity for the angiotensin converting enzyme 2 (ACE2), its main host cell receptor in humans.
“ACE2 is also the receptor for SARS, but the binding affinity of COVID-19 is thirty times higher, and this explains the higher transmissibility of the new virus,” Palù said.
There is some reassurance in the scientific evidence that the more a virus is diffusive, the less it is lethal. This is why the hunt for patient zero is an impossible task, while patient zero was quickly found for the more lethal SARS.
“A low-lethality virus is difficult to trace, and tends to survive with the host, gradually losing virulence. Possibly, COVID-19 might transform, like other coronaviruses, in an endogenous virus in humans,” Palù said.
‘Viruses know no boundaries’
Hospitals have adopted strict protocols for triage, admission and care of patients with COVID-19, and have intensified protection measures for the safety of personnel.
Giorgio Zanardo, MD, head of the ICU at a hospital in Castelfranco Veneto, said the situation is under control there.
“We had a few suspected cases that were not confirmed. Two of them are still in intensive care but tests are negative,” he said.
In the Veneto region, two people have died — “much fewer than the victims we see every year from influenza,” he added.
One of the victims, a 76-year old woman, was hospitalized in the nearby town of Treviso. Ten of the medical staff who cared for her have tested positive for the infection and are self-confined at home, so far with no symptoms.
“This was one of the first cases; the patient was taken care of like we normally do with pneumonia. Now our guard is up, and we have strict rules on how to protect ourselves,” Zanardo said.
The geriatric ward, where the patient stayed, is now closed due to lack of personnel and other hospitals are currently facing the challenges of an emergency that disrupts the normal routine.
However, the Veneto region has a well-organized health care system, which has maintained its efficiency in the emergency. People with influenza-like symptoms are encouraged to call an emergency number and are pre-triaged at home. Suspected cases are treated in separate areas and tests are performed in patients with specific signs and symptoms.
“At first there was an overuse of COVID-19 testing. We have tested the entire population of the towns that have been put in quarantine, and also tested many people suspected of having the disease,” Zanardo said. “Unfortunately, one result has been that our laboratories have been congested and unable to provide the results within reasonable times. Now we perform the test in specific cases, and two consecutive positive tests are necessary to confirm the diagnosis.”
“Containing the infection is a key priority. Other countries will experience outbreaks, because viruses know no boundaries. However, irrational fears should also be contained, and we should not forget that we are still very far from the death toll of influenza, which is on average 8,000 people per year in Italy,” Zanardo concluded. – by Michela Cimberle
Reference:
Guan W. N Engl J Med. 2020;doi:10.1056/NEJMoa2002032.
For more information:
Giorgio Palù, MD, FESCMID, professor of microbiology and virology and head of the molecular medicine department at Padova University and adjunct professor at Temple University in Philadelphia, can be reached at giorgio.palu@unipd.it.
Giorgio Zanardo, MD, head of the ICU at Castelfranco City Hospital, can be reached at giorgio.zanardo@iov.veneto.it.
Disclosures: Palù and Zanardo report no relevant financial disclosures.
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