At the peak of the coronavirus outbreak in Italy, hospitals and crematoriums in the country’s hardest-hit region were overrun and obituaries filled 10 pages of one local newspaper. But roughly five months later, the nation has become something of a success story in how to recover from the outbreak’s devastating first wave.
In northern Italy, where the coronavirus ravaged cities from late February through April, doctors credit the turnaround to the country’s strict nationwide lockdown, widespread testing, robust contact tracing and a very gradual process of reopening. But while Italy has seen a significant drop in the number of new infections — logging around 150 to 300 new cases nationwide each day for the past week, down from a record high of more than 6,500 on March 21 — experts are bracing for an inevitable second wave.
“We’re worried because the virus didn’t just disappear,” said Dr. Roberto Cosentini, head of the emergency medicine unit at the Papa Giovanni XXIII Hospital in Bergamo, in Italy’s Lombardy region.
Still, the countrywide stay-at-home orders were essential to getting the virus under control, said Francesco Longo, a health economist and director of the Centre for Research on Health and Social Care Management at Bocconi University in Milan. He added that the sweeping mandate, enacted by the federal government, helped Italy avoid a situation similar to what’s unfolding now in the United States, where inconsistent lockdown and masking strategies among states have resulted in many different surges happening on different timelines across the country.
“If you are in Florida and you hear your governor saying something, and then the governor in New York is saying the opposite, it’s really difficult,” he said. “In Italy, it was just one voice.”
Italy has recorded more than 247,000 confirmed cases and over 35,000 deaths, the majority of which was concentrated in Lombardy. Cosentini said it’s likely that Italy will see a surge of new COVID-19 infections in the fall — which, when combined with the seasonal flu, could be tough on local hospitals. Yet, it’s also possible that a second wave could come sooner than October.
Several European nations, including Spain, Germany and France, are already seeing upticks in new infections after months of relative stability. Cosentini said he fears a return to what the country experienced in late February, but he added that doctors and hospitals are also better equipped now to deal with the coronavirus — a result of tough lessons learned during the initial outbreak.
‘60 million people in the same boat’
Cosentini’s hospital treated its first coronavirus patient, an individual suffering from severe pneumonia, on Feb. 22. Even after following the situation as it unfolded in Asia, he said he and his colleagues were unprepared for how quickly the outbreak would escalate.
“We started with 10 to 20 patients, and by the beginning of March, we had up to 80 new patients a day,” he said. “That was really hard.”
To cope with the influx of patients, the doctors quickly learned that they needed to overhaul a number of procedures. In addition to converting most other hospital wards into coronavirus wards, Cosentini reorganized the facility’s emergency rooms to accommodate the overflow from the intensive care units.
He said hospitals across northern Italy were badly strained at the time, but had the government not imposed a 2½-month nationwide lockdown March 9, things may have become catastrophic.
“We were very close to the failure threshold,” he said. “The toughest times were the first and second weeks of March, but then social distancing and the lockdowns started to be effective and gave us a chance to discharge recovering patients and have free beds for new people.”
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Though some saw it as an extreme measure at the time, a big part of Italy’s success in driving down the rate of infection owes to the fact that all Italians were subject to the stay-at-home orders, according Longo.
“We had 60 million people in the same boat, and the national narrative was:' When infections are under control everywhere, we’ll reopen the entire country,'” he said. “This gave a strong sense of mutual belonging.”
Italian health officials also understood the importance of being nimble and adjusting their strategies as the outbreak evolved, Dr. Stefano Nava, chief of respiratory and critical care at Sant’ Orsola Hospital in Bologna, said.
Early on, people were advised to only go to the hospital if they were seriously ill, in a bid to avoid overwhelming the country’s health care system. But this thinking changed as doctors learned more about the novel virus.
“At the beginning, we waited too long to admit patients to the hospital, and when they were admitted, we were probably too aggressive even with the treatment,” said Nava, who himself tested positive for COVID-19 and was sick for 31 days. “We learned that unless the patient is very sick, you should be quite conservative and treat nonaggressively to avoid further complications.”
This meant trying as much as possible to avoid intubating patients and resorting to ventilators in only the most extreme cases. It also meant expanding the testing to find mild or moderate cases, and if necessary, intervening before patients were experiencing too much respiratory stress.
“The disease was new, not only to us but also to patients, so patients were waiting six to eight days after the onset of fever before coming in,” Cosentini said. “That made some of the severe cases much more difficult to manage.”
Bracing for a second wave
Even as the situation in Italy has stabilized, testing should remain an important part of the country’s mitigation strategy, experts said, particularly as a way to track the virus’ spread among people who may be asymptomatic.
“The role of positive asymptomatic carriers is still a very big question, so it’s very important to [test] a lot of people,” said Dr. Eugenio Baraldi, director of neonatology and the neonatal intensive care unit at University Hospital in Padua. “This will be a big problem for all of the world.”
The Italian government started lifting lockdown measures May 4, but the country’s reopening has been a slow and gradual process, according to Longo. Social distancing guidelines remain in place, particularly at beaches and other public venues, but things are otherwise back to some semblance of normalcy, he said.
Italians are encouraged to wear masks in restaurants and elsewhere in public where social distancing is challenging. Longo said mask compliance varies, with people in harder-hit areas more likely to adhere closely to the guidelines, while people in areas less impacted by the virus are more relaxed.
Reinforcing these behaviors will be critical as the country prepares for a second wave of the pandemic. Longo said the government has already started a widespread campaign encouraging people to get free flu shots in order to alleviate some of the burden on hospitals both in the fall and in winter.
The country is also investing in additional hospital beds and other resources to shore up health care facilities. And Longo said the federal government is working with state and local officials to figure out how best to contain future outbreaks while also supporting the nation’s economic recovery.
“We learned that it’s not black and white — it doesn’t have to be lockdown or completely free,” he said. “We still have a lot of restrictions now, even if we’re back to our normal lives.”
But perhaps the biggest lesson learned, Longo said, is that messaging matters in building the cohesion that is essential within countries, and among nations, to combat the pandemic.
“The messages can’t be contradictory,” he said. “If you have 50 percent of the population respecting the rules and the other 50 percent does not, it’s a mess. And then the virus wins.”