Coronavirus crisis in Italy possible in the United States

Three weeks ago, Italy barely had a coronavirus problem. Back then, when there was just three confirmed cases, shops and cafes were open, tourists came in and out of the country's great vacation destinations, and quarantines are relegated to history: 14th century Venice during the black plague.

Today, Italy has the second highest number of cases and deaths reported by Covid-19 outside of China: more than 10,100 and more than 630, respectively, to March 10. These figures are higher than those of two other coronavirus outbreaks, Iran and South Korea, and higher than those of any other country in Europe.

In an effort to slow the spread of infection, the government announced on Monday an extraordinary measure for a western democracy that has not been tried in modern times at the country level: the whole peninsula was quarantined until at least April 3. Even weddings and funerals are prohibited.

Emanuele Cremaschi / Getty Images

One big reason for the extreme response: the coronavirus has overwhelmed the country's health system, especially in the north. More than 80% of hospital beds in Lombardy, the most affected province, are occupied by patients with coronavirus, Bloomberg. Intensive care units are overloaded for elective surgeries were canceled in the bed release process. Stories abound social media on doctors rationing care, having to choose who among the needy patients presenting should receive treatment.

But behind the official Covid-19 figures hides a much broader health crisis, which is piling up across the country. The collateral damage caused by an over-stretched health system is even greater than the official toll of coronaviruses: pregnant women and babies, cancer and HIV patients, and children who need vaccines, who are now less likely to receive the health care they need.

Most health systems are fairly streamlined and … so an excessive increase (in the number of patients) quickly puts a strain on resources, said Richard Neher, a researcher at the University of Basel who was modeling how Covid-19 could stress hospital demand. If you react too late, you are in trouble.

Which is very clear, added Nerher: Without a drastic reduction in virus transmission, health systems will be overwhelmed.

In other words, the situation of Italy today could be that of any country tomorrow. Lombardy, one of the wealthiest regions in Europe, shows how an epidemic, almost overnight, can degenerate into a real crisis when civil servants do not prepare and react too slowly. And this push, according to many, is coming very soon to the United States.

It is not clear why Italys cases have grown so quickly

In early February, Italy had only a few identified cases of Covid-19. On February 23, Italian officials reported 76 confirmed cases at WHO. Two days later, the number increased to 229. The number of cases and deaths increased exponentially from there, while people with the virus from Italy have been identified in countries as far apart as Nigeria, Switzerland, Brazil and 39; Spain.

At that time, the rapid increase in cases identified both within the country and among travelers was so worrying, a Mission of WHO and the European Center for Disease Prevention and Control went to Italy to understand what was going on. Meanwhile, authorities have hastened to impose severe measures to try to stop the virus. In the north of the country, sporting, religious and cultural events have been canceled, as have university courses. Anyone who tried to enter or leave the areas of Lombardy where the epidemic was occurring was liable to fines. The severity of the response only rivaled that of China.

It is not known why the Italy Covid-19 epidemic has spread so rapidly compared to other European countries, but there are several competing theories. One is that an aggressive testing campaign focused on Lombardy, a wealthy northern region, has exacerbated the problem at a time when other countries have lagged behind in case detection.

Another is that the intense spread of the virus in the hospital system, before doctors realized that there was a problem, may have amplified the epidemic. Some 10 percent of medical workers in Lombardy have been infected, according to a March 3 statement Washington Post report, and health workers account for 5 percent of those infected in the country. (Reinforce this explanation: the Joint WHO-ECDC mission report suggests that Italy should work on its infection prevention and control measures in hospitals.)

There is also speculation about The burden of Italy is particularly severe due to the aging of the country's population. Covid-19 is known to particularly strike the elderly. This, along with the rapid increase in confirmed cases, has tested the limits of the health system.

We see a high percentage of positive cases admitted to our intensive care units (ICU), in the range of 10 percent of all positive patients, Italian doctors warned in a public letter. We want to send a strong message: get ready!

Covid-19 projections suggest disease is about to escalate in the United States

In many countries, possibly including Italy, once officials have started testing Covid-19 more widely, they find more cases. So far, testing in the U.S. has been painfully incompetent and slow, but as it progresses, experts expect an increase in the cases of Covid-19 in America.

For proof, look at the projections from the largest outbreak in the Americas, in Washington State, where there are 179 cases nowadays.

According to Fred Hutchinson Cancer Research Center computer biologist Trevor Bedford, Covid-19 has been able to spread to Seattle since at least mid-January, well before any spread is officially confirmed there, as Stats Helen Branswell first reported. Bedford worked with Nextstrain, an open source project that tracks the spread of pathogens around the world, including Covid-19. He also used data from collected samples to monitor influenza activity in Seattle, which were then reassigned to search for cases of coronavirus.

As of March 10, he and his colleagues felt, there have been up to 1,100 cases in Seattle alone.

Karen Ducey / Getty Images

Seattle data involves undetected community transmission, said Emma Hodcroft, colleague of Bedfords, co-developer of Nextstrain. He tells us (Covid-19) is circulating widely enough that random people who don't think they have a coronavirus have it.

It's only Washington, however. To date, the entire country is seriously behind in its testing capacity. As of March 8, only 1,700 Americans have been tested for the virus, a number that turns paler compared to the 50,000 who tested in Italy or the 23,000 tested in the United Kingdom, according to Internal of the business community.

A new scale-up preprint in the United States it is estimated that as of March 1, there were already 9,484 cases of Covid-19 in the United States. This is a much higher number than the 754 cases reported nationwide.

Looking at all the signs, and there are many, it would be shocking to me if we did not have a large number of undetected cases transmitting silently in the community, in several countries and regions, said Lawrence Gostin, world expert from Georgetown University.

If cases double every week as they appear to be doing now in Italy, the United States may soon face its own crisis.

I don't think (what happened in Italy) anything specific to what Italy did. It's just that if the virus has a chance of spreading undetected, it's hard to catch up to at that point, said Hodcroft. The Italian situation should be a great red flag for the rest of Europe and the United States.

What America and other countries need to do now

While Economy of Italy is already nose diving, we do not yet know the extent of the damage caused by the overwhelmed healthcare system of the country. We can however expect it to be significant, said Gostin. What we have learned from all past epidemics is that when your health system is stressed, many more people die from other diseases than from the real epidemic.

During the 2014-2016 Ebola epidemic, for example, people living in the countries at the center of the epidemic have failed to meet their basic medical needs. In the ongoing Ebola epidemic in the Democratic Republic of the Congo, interruptions in routine immunizations have contributed to massive measles epidemic. In the Chinas Covid-19 epidemic, many stories have already emerged cancer patients awaiting treatment who have been turned back, and HIV patients who ran out of drugs. Not to mention the economic and psychological epidemics.

So what should America do now to prevent this kind of collateral damage?

First, health officials must find ways to smooth the epidemic curve of the epidemic. And it starts with measures of social distancing, such as the cancellation of mass public gatherings, the encouragement of employees to work from home, and even the closure of schools and universities, if necessary.

Christina Animashaun / Vox

What is dangerous about an epidemic is when everyone gets it at the same time and a health system cannot respond, explained Steven Hoffman, director of the Global Health Strategy Lab at York University. The overall objective of social distancing measures is to reduce the peak of epidemics and reduce this pressure on the health system.

In Italy, these measures were only proactively implemented as a desperate countermeasure after health authorities began to see cases of coronavirus escalate.

Besides slowing the transmission of the virus, however, there are many other things that health officials should do now to prepare for a flare-up. And they go far beyond the basics, such as ensuring that hospital beds and intensive care units are freed up to meet patient demand, which healthcare professionals have access to personal protective equipment (including masks) and that there are enough ventilators to support the 10 percent of potential Covid-19 patients who will need help with breathing to stay in life.

In China, a huge effort to test and identify people infected with the virus, trace all their contacts and quarantine potentially exposed people has been essential to quell the epidemic there, according to Bruce Aylward, the director of a World Health Organization mission to China. Chinese authorities have also lowered barriers for those looking for Covid-19 tests by offering them free of charge and, in some cases, have sent health professionals to homes to skin people potentially infected with the virus.

Last but not least, China has improved its digital healthcare capacity to prevent people from showing up at pharmacies, clinics and hospitals, said Aylward:

Normally, a prescription in China cannot last more than a month. But they increased it to three months to make sure there was no shortage of people (when they had to close a lot of hospitals). Another thing: prescriptions can be filled online and via WeChat (instead of requiring a doctor's appointment). And they have set up a drug delivery system for the affected populations.

This type of approach is long overdue in America, even outside of a pandemic threat, said Tom Frieden, former director of the Centers for Disease Control and Prevention. There are more than 100 million Americans suffering from chronic diseases and people have to take their medications for diabetes, seizures and high blood pressure. This (care) should not be interrupted. And that means states and the federal government should think about how to deliver patient services online now, he added.

Another even more fundamental step is to make sure patients know when to go to clinics, when to get tested and when to stay at home, said Jennifer Nuzzo, infectious disease specialist and senior researcher at Johns Hopkins Center for Health Security.

Stringer / Getty Images

My first concern relates to people rushing to the ER because they are looking for information or tests, she said. This happened during the H1N1 pandemic in 2009. And that alone will severely strain health systems.

These measures could go further than the mass quarantine that Italy is currently trying and the one that China has implemented. This … resembles the methods used in medieval times, said Hoffman. Once you have instituted this, you not only put people in this (quarantine) at risk, but also encourage many others who may not have left the area to flee.

A preliminary modeling study focused on Wuhan, the city at the center of China's epidemic, showed that the foreclosure had only delayed the spread of the epidemics by three to five days. Yes, three days is better than nothing, but not when it comes at the expense we have seen (in China) and at the expense that will continue to be incurred for decades to come, added Hoffman . Think of the psychological trauma of these people who were locked up in their homes, who had to explain the situation to their children.

This will leave a lasting impression for a delay of three days.

When people are socially isolated, when they don't feel safe or dignified, they will react and take actions that are not useful for public health, said Hoffman. This feedback is something that Italy will soon have to face and other countries too, if they don't prepare now.