Nation adapts to “new normal” of masks and distancing; second wave now seen as unlikely.
Three weeks ago, the hospital Policlinico San Donato in Milan, Italy, slowly started to get back to a semblance of “normal.”
In the early days of the coronavirus pandemic, this 500-bed hospital was caring for 600 patients with COVID-19.
Now, the hospital’s chief cardiac surgeon, Lorenzo Menicanti, MD, says his unit is operating at 40% to 50% of its normal volume — which may sound underwhelming, but at one point his entire cardiac ICU was dedicated to the care of COVID-19 patients.
“We are almost out of the nightmare,” Menicanti told MedPage Today, noting that the hospital has seen no new positive cases in the last three weeks.
Once seen as the world’s worst hotspot, Italy has managed to bring the virus to heel, as has much of the rest of Europe. Italy has had more than 34,000 deaths, with nearly half of them in the Lombardy region, of which Milan is the capital.
At one time, experts in the U.S. were worried that it would become “the next Italy” — a prospect that now seems welcome as America has nearly 100,000 more deaths than the European country.
Menicanti attributes Italy’s success to surprisingly high levels of compliance with social distancing measures from the Italian people.
“In the beginning, all of us were shocked by the rules. To be locked in, not being able to travel or meet people, that’s very strange for us. Italians love crowded places,” Menicanti said. “But the population, incredibly, has followed the rules.”
Even today, Italians continue to be frightened into compliance and are “afraid to restart their lives normally,” he said.
“I think the feeling of the U.S. population is not the same,” he said.
Living the Nightmare
Italy’s first case of coronavirus was identified in Codogno, a town of 16,000 people about an hour’s drive from Milan.
Annalisa Malara, MD, an intensivist and anesthesiologist at Codogno Hospital, diagnosed the first patient there on Feb. 20.
Local officials responded swiftly: “I called the chief of the hospital who declared it a crisis situation,” Malara wrote in a narrative for the European Society of Cardiology.” The chief in Lombardy was contacted as were the politicians, and a national emergency was announced. Codogno hospital was put in lockdown and emergencies were sent to Lodi Hospital, which is 30 km away.”
The town locked down immediately and largely averted a major crisis, according to news reports. An Associated Press report from mid-March said most Codogno residents were wearing masks when they went outside, handshakes were forsaken and people kept a social distance as they waited in lines at pharmacies and food stores.
Other towns that didn’t implement such a strict lockdown right away, such as Bergamo and Cremona, were hit harder, and scenes of coffins piling up in churches were burned into the national psyche.
Mario Carminati, a priest in Bergamo, told the BBC that the “sound of ambulance sirens was constant. This was a reminder to be on the lookout, that if you didn’t do as they said, you could be next.”
“We don’t want to forget what happened,” Carminati said. “We want it to be a reminder of how to live in a certain way.”
That fear has produced compliance that made control of the virus possible, Menicanti said. The entire region of Lombardy now only has 41 COVID-19 patients in intensive care, down from a peak of 1,800. Only 277 people in the region are hospitalized with the disease.
“It’s another world, because in other times we had 12,000 patients hospitalized,” Menicanti told MedPage Today.
About 7% of staff at Policlinico San Donato became infected with the virus, a result Menicanti called lower than expected given that testing was limited at the beginning of the outbreak. “The PPE worked very well,” he said. “The incidence of infection in our hospital was low.”
However, more than 150 Italian doctors are said to have died from the virus.
Back to Business
Now in Lombardy, masks must be worn at all times while in public. Schools and universities remain closed. Bars and restaurants are open, but with social distancing rules in place. Some even place glass shields between tables. It’s the “new normal” that many Americans refuse to accept.
“It’s not nice to go to restaurants and see people inside cages, but it was a good way to start again, and people have accepted it,” Menicanti said.
While it was relatively easy to stop normal hospital operations and push all resources to COVID care, it’s “much more complicated to restart,” he said.
The layout of Policlinico San Donato has been changed so that there are new routes for COVID-free patients to enter and be transported through the hospital. All patients who enter the hospital must be screened for COVID and must have two negative swabs to be admitted to the surgical ward. An entire floor is devoted solely to screening.
Staff on the COVID wards are tested more frequently than those assigned to non-COVID areas. Menicanti said he’s tested about once a week.
A third of hospital beds must remain free in case there’s a new wave of infections, but “all the data we have in Italy are against this idea,” Menicanti said. “So probably in another couple of weeks, we will consider occupying all beds for normal operation.”
No Second Wave?
Like much of the rest of Europe, Italians have become so confident in their ability to control the virus that many experts believe there won’t be a massive “second wave” of infections and deaths.
Enrico Bucci, PhD, a molecular biologist and statistician who runs a company aimed at detecting research fraud, wrote in a widely shared Facebook commentary that the probability of having a second wave that produces as much mortality as the first is “pretty low.”
However, “the sooner we abandon spacing, masks, hand hygiene, tracking, isolation and containment measures in hospitals, the more we increase the likelihood of high-intensity epidemic waves,” Bucci noted.
Health officials have gotten better at identifying sources of infection and reacting quickly to contain them, Menicanti said. For instance, as soon as a hot spot at a company in Bologna was identified, it was shut down: “Now we know what to do” to prevent local outbreaks from growing into a large second wave, he said.
While he’s concerned about the winter and a double-whammy of flu and COVID cases, he noted that there’s a large campaign for flu vaccination that may help moderate that burden.
“Of course it’s not over, we know that,” he said. “But the population is very prudent and being very attentive to the rules.”
“Summer will be perfect, we hope,” Menicanti said. “We shall see what happens in October.”