Week 6 – Breaking the siege – Italy and the Coronavirus Epidemic

 

Coronavirus, Lockdown vs Knockdown - L'Eurispes

After weeks of lockdown Italians are impatient to see the numbers of infected and dead fall significantly so that they can start to resume their normal lives and activities. These feelings are shared by other badly hit countries like Spain and France. Meanwhile  UK government  officials contradict each other over Easter as the date for the  highest number of fatalities in the UK

Here are the  latest figures from Italy 

Day 35- Saturday, April 4th 2020

4,805 infected, 681 dead

29,010 /124,632 (23.3%)  hospitalised; 3,994/124,632 (3.2%)  in ICU

55,270/124,632  ( 44.3%) quarantined at home

NB: 124,632  = total number of infections

15,362 = total number of deaths

20,996 = total number of recovered

It is worth noting that 1 infected person was detected every 7.7  swabs which =  a 12.8% positive rate . At the height of the epidemic on March 7th  it was practically 1 to 1 with a  46.2% positive rate.

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This is a draft proposal of  conditions that will probably have to be met for breaking the siege. As you check through them, read about how close Italy comes to satisfying them today. Think about how long it might take to fulfil them (or something very similar) satisfactorily.

You can apply them to your own country and judge your own situation.

Remember: My comments may not refer to your present situation, given the Italian numbers and the time lag between the start of the epidemic in Italy and in  countries lying to its west and north. 

COVID-19 PHYSICAL DISTANCING MEASURES CAN BE LOOSENED WHEN ALL OF THE FOLLOWING CRITERIA ARE MET: Epidemiology Health Care Public Health

  1. Decreasing cases in the context of increasing testing (or stable testing
    with decreasing positivity) for at least 14 days

Comment: For the past 3-4 days, tests with tampons have greatly increased in number,thus accounting for the rise in the number of infections.  The trend will have to start reversing for at least  14 days.

     2. Decreasing numbers and proportions of cases not linked to a source case (goal less than 3 unlinked cases per 2-week period)

Comment:This is happening as the percentage of positive tampons continues to drop but, as with the other parameters, time will be needed to reach this threshold.

3. Steady decrease in influenza-like illnesses (ILI) in syndromic surveillance for at least 14 days

Query: What’s syndromic surveillance?

It means using non-traditional sources of data. Conventionally, disease surveillance is based on the patient describing symptoms, the doctor diagnosing the disease and then reporting it. In syndromic surveillance, data may be sourced from nurses helplines,  pharmacy sales of medications, school absenteeism, emergency hospital admissions and so forth.

Comment: AFAIK syndromic surveillance is in its infancy in Italy, if indeed it has been born!

Ambulanza coronavirus

   4. Decline in deaths for at least 14 days

Comment: The number of deaths has remained a steady 760+ for the last 3 days, dropping to 681 today. These are  significantly fewer than the 969 which occurred on March 27th, the worst day of the epidemic. There’s still a long way to go

  4. Decreasing health care worker infections such that infections are now rare

Comment: On the contrary, doctors and nurses are dying every day in Italy. Two doctors died in the last 24 hours, bringing the total to over 100. About 5,000 healthcare staff, mainly nurses, are ill with CoVid19. Many more have been infected and died or recovered since February 21st, the starting date of the epidemic when the 1st case was diagnosed.

5. Ability – including staffing – to double number of patients treated in intensive care units from current census

Comment: For the first day since the epidemic started, there are 74 free places in ICU wards today in Italy. It will take some time until half the places are free to accept new patients. Staff numbers have increased as  more doctors and nurses, including the newly graduated,  have been employed in the Health Service.

6. Ability – including staffing – to screen large numbers of symptomatic patients safely (e.g., outdoor tents, drive through)

Coronavirus, a Cremona oltre 100 contagi in più in un giorno: 665 ...

Comment: These services have been set up. It is not clear whether they are well enough equipped to screen “large numbers”. Italian university and hospital laboratories are working hard to set up a quick, reliable test  that will bypass issues like lack of a certain specific  reagent or type of swabstick.

7. Sufficient personal protective equipment (PPE) for all health care workers even if cases double

86 percent of health systems concerned about PPE shortages due to ...

Comment: The dramatic lack of PPE has played out all over infected countries, except perhaps in China and the Far East.In fact, the USA has even been accused of “piracy” as it was alleged to have “re-routed” supplies destined for other countries. However,  PPE is now finally arriving and being distributed throughout Italy but it is hardly sufficient for current needs. As whatever arrives is immediately pressed into use with demands for more, time will be needed to build up enough stocks to satisfy this condition. 79 Italian companies  applied to convert to producing PPE to the EU standard. Some applications were approved and conformity with specifications is now being tested. If the prototypes are approved, production is expected to start next week. The aim is for domestic production to cover all Italian needs

8. Sufficient face masks to provide to all patients seeking care even if cases double

Comment: See above

9. More discharges than admissions for COVID-19

Comment: With 29, 010 patients hospitalised and 20,996 considered as fully recovered, the balance has not yet shifted towards satisfying this parameter

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10. Ensure at least baseline capacity in general health services, including through expansion of telemedicine for Covid19 and usual care

Comment: The Faculty of Medicine at the University of Milan has developed a televideo programme for discharged/convalescent CoVid patients and their physicians which will start being rolled out next week.

11. Health care facilities enforce policies and redesign to minimize possibility of exposure at triage and all other locations

Comment: Separate hospital pathways and corridors for suspected CoVid cases were set up at the beginning of the outbreak. Family doctors are consulted by phone. Repeat prescriptions with a patient number  are e-mailed to pharmacies so patients no longer need to sit in waiting rooms to see the doctor.

13. All cases interviewed for contact elicitation

14. Contacts elicited for at least 90% of cases

15. 100% of symptomatic contacts and others with symptoms undergo testing within 12 hours of identification of symptoms

Comment: Steps towards satisfying all these criteria are being started. Italian doctors have abandoned the  (now obsolete) WHO criteria of testing only patients with symptoms and have started widespread testing. Identifying  symptom-free and symptom-lightly infected individuals is of paramount importance. As lockdown measures begin to dampen down the major outbreaks, they could be the source of  new outbreaks unless properly quarantined.

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16. Enough hand sanitizer to place at entry and strategically placed in buildings including workplaces

Comment: AFAIK this has been achieved in the few businesses  that are open to the public and in workplaces as Italian trades union managed to get a law passed to ensure workers’ safety. The quantity of sanitizer that is enough today with little footfall will need to be upped considerably when shops re-open and more people start to circulate again.

17. Designated facilities for non-hospitalized covidinfected people who can’t be safely cared for at home (e.g., because of space constraints, homelessness, medically vulnerable household members, or otherwise)

Comment: These “convalescence homes” are available in most regions.Indeed, the Civil Protection Agency in Umbria alone has assessed the suitability of  about 30 buildings in  various municipalities. As the balance shifts towards recovery rather than infection it remains to be seen whether places in them will be sufficient  

18. Demonstrated ability to convey physical distancing recommendations that change behavior in most residents

Comment: This ability has been demonstrated over the course of the epidemic. Italians have, on the whole, adhered to the lockdown and physical distancing instructions.


REFS & PICS

Home

https://www.ilmessaggero.it/video/cronaca/coronavirus_lombardia_casi_trend_calo-5148878.html

https://wwwnc.cdc.gov/eid/article/10/10/03-0789_article

https://www.piacenzasera.it/2020/04/e-sempre-un-bollettino-drammatico

https://www.ilfattoquotidiano.it/2020/04/04/coronavirus-in-italia-4805-nuovi-casi-la-curva-resta-stabile-ancora-681

https://www.theguardian.com/world/2020/apr/03/health-secretary-says-remarks-over-coronavirus-peak-over-interpreted

https://www.leurispes.it/coronavirus-lockdown

https://www.euractiv.com/section/coronavirus/news/italy

Click to access COV020_WhenHowLoosenFaucet_v4.pdf

 

Click to access COV020_WhenHowLoosenFaucet_v4.pdf

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