Post Publication Independent Review of

"COVID-19 and Italy: what next?"

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Post Publication Independent Review of "COVID-19 and Italy: what next?"

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Post Publication Independent Review of

COVID-19 and Italy: what next?

Prof Andrea Remuzzi, EngD

Prof Giuseppe Remuzzi, MD

Published: March 13, 2020 DOI:

Review Comments:

1. Quote "A global response to prepare health systems worldwide is imperative. Although containment measures in China have reduced new cases by more than 90%, this reduction is not the case elsewhere, and Italy has been particularly affected. There is now grave concern regarding the Italian national health system's capacity to effectively respond to the needs of patients who are infected and require intensive care for SARS-CoV-2 pneumonia." End of Quote. The authors seem to make an attempt to bring out new research insights which might be helpful for Italy and for all Nations due to the well accepted treatise that "Italy’s healthcare system is routinely ranked among the best in the world, based on its overall quality, equity of access, and the general health and life expectancy of the Italian population"

2. Quote "Our analysis might help political leaders and health authorities to allocate enough resources, including personnel, beds, and intensive care facilities, to manage the situation in the next few days and weeks. " End of Quote. Authors statement is sufficient. Doesnt need a further comment.

3. Quote "If the Italian outbreak follows a similar trend as in Hubei province, China, the number of newly infected patients could start to decrease within 3–4 days, departing from the exponential trend. However, this cannot currently be predicted because of differences between social distancing measures and the capacity to quickly build dedicated facilities in China." End of Quote. The authors are more pragmatic in their approach and not quick to jump in with supporting decisions only coz a unique trend was observed.

Further, read together with , it can be understood why a more pragmatic approach is required in research analysis and inferences, else research inferences may spin out of practicality into utopia and can even create an environment of psychosis in the society. Hence, as the authors of this research article have done, research inferences have to be more pragmatic in their approach.

4. Quote "Therefore, a coordinated global response is desperately needed to prepare health systems to meet this unprecedented challenge." End Quote. A multi-national tactical command and control center may be established in any Nation that is willing to offer this service to the World. Distributed Centers may be established in the Capital of ever Nation, connecting upto grassroots level.

5. Quote "Countries that have been unfortunate enough to have been exposed to this disease already have, paradoxically, very valuable lessons to pass on." End of Quote. The authors are right on this point. It is time to learn valuable lessons for the sake of our Nations and pass on the significant insights to other Nations

6. Quote "Although the containment measures implemented in China have—at least for the moment—reduced new cases by more than 90%, this reduction is not the case in other countries, including Italy and Iran.2" End of Quote.

The authors have cited as Reference number 2. The cited article gives more valuable insight as following:

Quote "

As covid-19 reaches countries unwilling or unable to monitor it, officials must use educated guesswork to track its evolution.

The number of cases each country reports depends both on the number of infections and on how many people get tested.

To derive fresh estimates, The Economist built a similar model. We tested the link within the oecd—a club of mostly rich countries, which should have strong detection capacity—between Chinese tourism in 2019 and confirmed covid-19 cases. As expected, oecd states that swapped lots of tourists with China, such as Switzerland, tend to report higher infection rates than do ones with small flows, like Belgium.

Applied worldwide, our model finds big outliers. The outbreaks in Iran, Italy and South Korea, where the virus is spreading internally, are bigger than tourist flows suggest. At the other extreme, countries like Singapore may have fewer diagnoses than expected because of strong containment efforts. But the Philippines, Russia, Myanmar and Indonesia have lots of people and tourism to and from China, and just eight confirmed cases in total. Thousands more have probably gone undetected.

Another pattern bolsters this finding. South Korea and China test regularly. In both places—excluding Hubei, where the virus began claiming lives before authorities formulated a response—0.5-1% of people who have tested positive have died. In other countries with at least one death, this rate is five times higher. Deaths are easier to count than infections are. The most likely explanation for this gap is that for every person diagnosed in these countries, four more do not know they are infected

" End of Quote.

These insights are crucial for Nations to prepare, evolve and continuously modify their COVID-19 National-Level containment and treatment protocols.

7. Quote "The mean age of those who died in Italy was 81 years and more than two-thirds of these patients had diabetes, cardiovascular diseases, or cancer, or were former smokers. It is therefore true that these patients had underlying health conditions, but it is also worth noting that they had acute respiratory distress syndrome (ARDS) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia, needed respiratory support, and would not have died otherwise. " End of Quote.

The Healthcare system in Italy is known to be one of the best in the world. Consequently, the mean age of those who died in Italy may have been 81 years, but we cannot derive any direct inference from it, for the simple reason that it is going to vary among ethnicities, populations and nations; also dependent on the quality of healthcare in that Nation.

Further, it can be seen that comorbities make things more difficult for a COVID-19 patient. The COVID-19 patient may progress into Acute Respiratory Distress Syndrome (ARDS), but when comorbities are present, it paints a more critical picture. This means that containment & treatment strategies for otherwise normal population and those with pre-existing comorbities may be unique and distinct and may need to be given more attention while devising plans & during adaptive implementation.

8. Quote "On March 8, 2020, the Italian Government implemented extraordinary measures to limit viral transmission—including restricting movement in the region of Lombardy—that intended to minimise the likelihood that people who are not infected come into contact with people who are infected. This decision is certainly courageous and important, but it is not enough. At present, our national health system's capacity to effectively respond to the needs of those who are already infected and require admission to an intensive care unit for ARDS, largely due to SARS-CoV-2 pneumonia, is a matter of grave concern." End of Quote.

Quote "In Italy, we have approximately 5200 beds in intensive care units. Of those, as of March 11, 1028 are already devoted to patients with SARS-CoV-2 infection, and in the near future this number will progressively increase to the point that thousands of beds will soon be occupied by patients with COVID-19. Given that the mortality of patients who are critically ill with SARS-CoV-2 pneumonia is high and that the survival time of non-survivors is 1–2 weeks, the number of people infected in Italy will probably impose a major strain on critical care facilities in our hospitals, some of which do not have adequate resources or staff to deal with this emergency."

This observation by the authors may raise alarm bells throughout all Nations, as patients with COVID-19 may have to be admitted into ICU, and with a survival time of non-survivors being 1-2 weeks, bed occupancy is going to be a major factor. The Nations will have to find new ways and means to improvise more ICU units into hospitals or new standalone ICU units.

At the time of writing this review, India is seen taking concrete steps in this direction, as evidenced by the following links.

9. Quote "We present the following predictions to prepare our political leaders—those who bear the greatest responsibility for national health systems and the government at the regional level, as well as local health authorities—for what is predicted to happen in the days and weeks to come. They can then implement measures regarding staff resources and hospital beds to meet the challenges of this difficult time. " End of Quote.

The authors are appreciated for this measure, wherein they have exhibited their foresight.

10. Some enlightening observations by the authors is summarised below.

Quote "On the basis of the exponential curve prediction, and the assumption that the duration of infection ranges from 15 to 20 days, it is possible to calculate that the basic reproduction number ranges from 2·76 to 3·25. This number is similar to that reported for the initial phase of the infection outbreak in the city of Wuhan, China3 and slightly higher than 2·2, as reported by Li and colleagues in a more recent report.4" End of Quote.

Quote "The number of patients admitted to intensive care units increased similarly in Italy, with an exponential trend up until March 8. " End of Quote.

Quote "The data available up until March 8 show that the trend in the number of patients who will need admission to intensive care units will increase substantially and relentlessly in the next few days. We can predict with quite a good degree of accuracy that this number will push the national health system to full capacity in a matter of days. " End of Quote.

Quote "At this point, the most important question is whether the increase in the number of patients who are infected and those requiring intensive care admittance will continue to rise exponentially and for how long. If the change in the slope of the curve does not take place soon, the clinical and social problems will take on unmanageable dimensions, which are expected to have catastrophic results. " End of Quote.

Quote " If the Italian outbreak follows a similar trend to that in China, we can suggest that the number of newly infected patients might start to decrease within 3–4 days from March 11. Similarly, we can foresee that the cumulative curve of patients who are infected will peak 30 days later, with the maximum load for clinical facilities for the treatment of these patients foreseen for that period." End of Quote.

In Summary, we can understand that initially there may be a high proportion of new infections which will start reducing over a given period, but the cumulative number of patients will be steadily increasing, and if the infection is assumed to range between 15 to 20 days, the cumulative demand on ICU beds with respiratory support is going to exponentially shoot over a period of time.

While this review is being written, India is taking drastic steps to boost its capacity for tougher challenges ahead.

11. Quote "Finally, our analysis tends to suggest that measures to reduce transmission should certainly be implemented, as our government did on March 9, by inhibiting people's movement and social activities, unless strictly required. Rather than revising the Schengen visa-free zone, the most effective way to contain this viral outbreak in European countries is probably to avoid close contact at the individual level and social meetings in each country." End of Quote.

At the time of writing this review, India is currently under a nationwide 21 day lockdown, severely restricting human movement (unless essential). To prevent transit of migrant labourers (who might be rendred jobless during this 21 day National lockdown), the Union Home Ministry has empowered the various States in India to use the State Disaster Relief Fund for relief measures for migrant laborers (rendered jobless) during this 21 day National lockdown.

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