Italy confirmed its two first cases of COVID-19 on 31 January 2020. The number of documented cases reached three on February 6, and it remained the same until February 20. However, the number ballooned to 150 cases by February 23 as more people sought medical attention due to some forms of respiratory distress. On March 24, the number of confirmed cases reached 69,176.
The country subsequently became the new epicenter of the global COVID-19 pandemic that started in Wuhan City in China after the Chinese government announced zero locally transmitted cases for the third straight day on March 21. However, the real issue with the localized epidemic in Italy does not rest alone with the number of confirmed cases. Deaths from the novel coronavirus disease have soared with fatality rates considerably higher than the global average.
Italy now has the highest number of cases and deaths outside mainland China. Outlook has remained grim. Policymakers and observers have been asking: What exactly happened to the country? Why are deaths from COVID-19 so high in Italy compared to other hard-hit countries? What are the factors contributing to the high fatality rate?
Coronavirus Pandemic in Italy: Examining and Explaining the Theorized Reasons or Factors Behind the High COVID-19 Deaths in Italy
Experts have theorized four possible reasons that could explain why Italy has high COVID-19 deaths. These are the failure of the Italian government to implement well-timed measures before the onset of the local outbreak and despite the looming threat from the emerging pandemic in China, insufficient data that underrepresent the extent of the epidemic in the country, its demographic composition with a special note on the sizeable elderly population, and the exponential growth in cases the overwhelmed the Italian healthcare system.
Failure of the Government to Provide Timely and Sufficient Response
An interview with Sandra Zampa, undersecretary of the Health Ministry of Italy, by The New York Times, noted that although the government did the best it could with the information it had, it initially looked China not as a practical warning but as a “science fiction movie” that had nothing to do with the interest of the Italians.
The New York Times report also added that officials from the right political spectrum were urging Prime Minister Giuseppe Conte in January to place returning schoolchildren from Chinese immigrant families in the northern regions under quarantine. However, officials from the left criticized the proposal as populist and fear-mongering
Conte subsequently implemented some measures on January 30 by banning all flights in and out of China. The government further declared a national emergency on January 31 after it confirmed two COVID-19 cases on the same day. However, when compared to the response of Taiwan or the measures undertaken by South Korea, these actions were too late.
An epidemiological analysis of Lombardy, the specific epicenter of the COVID-19 outbreak in Italy, revealed that the novel coronavirus SARS-CoV-2 was already in the country as early as January 1, thus concluding that disease went undetected for weeks. The study looked at nearly 6000 laboratory-confirmed cases to explore how the outbreak unfolded in the region.
One critical takeaway from the study is that by the time the government confirmed the first two cases on January 31, the virus was already spreading in Lombardy. It also suggests the necessity of aggressive containment strategies to control the outbreak.
Underrepresentation of the Extent of the Outbreak Due to Limited Testing
An interesting characteristic of COVID-19 is that it can affect individuals regardless of age and health status and not show any signs or symptoms. It is also important to note that it may take 5 to 14 days before a SARS-CoV-2 infection exhibits COVID-19 clinical presentation. Hence, these asymptomatic individuals do not only carry the virus but are also transmitting them through their encounters with other people.
Numerous experts and studies have explained that asymptomatic individuals and so-called silent transmission could be a contributing factor in the rapid spread of the disease not only in China or Italy but also in other countries that experienced an instant surge in new cases.
Italy focused its testing only in areas with large numbers of cases and in people with severe symptoms. The current numbers do not represent the entire number of the infected population. Factoring in the number of undocumented asymptomatic individuals would dramatically increase the number of COVID-19 cases in Italy and reduce the mortality rate.
More than the number of cases versus the rate of fatalities, however, it is also important to reiterate the fact that asymptomatic individuals were unknowingly spreading the disease. Experts noted that the absence of mass testing based on RT-PCR or molecular and rapid serological methods at the onset of the threat resulted in some level of complacency that blindsided the authorities.
The New York Times article also described how the 38-year-old Italian man from Lombardy labeled “Patient One” became a super spreader in a densely populated area. He had no direct contact with China, and experts believed he contracted the virus from another European.
In the hardly-hit city of Bergamo, Mayor Giorgio Gori considered the Champions League and a local hospital outbreak as a key factor in the rapid propagation of the disease. Speaking to The Guardian, he explained that about 40,000 football fans traveled from Bergamo to Milan on February 19 to watch the football match between Atalanta and Valencia. More than a third of their players and coaching staff had tested positive for the virus.
Elderly Population As Reason Why Italy Has High COVID-19 Deaths
Another widely accepted reason why deaths and mortality rates due to COVID-19 in Italy is so high is the sizeable number of the elderly population. Census reveals that the country has the oldest population in Europe thanks to an advanced and accessible healthcare system. Individuals aged 65 years and above comprised 23 percent of the total population. The median age is also at 47.3.
Most of COVID-19 deaths in Italy have been among people in their 70s. According to researchers, the mortality rate of the disease is dependent on the demographics of the population. The elderly are particularly susceptible to succumb to the virus because either they have a weakened immune system due to their advance age or they have comorbidities such as cardiovascular diseases, cancer, or diabetes, among others.
A study published on JAMA Network explained that stratifying the data by age group would reveal that the case-fatality rate in Italy and China would be similar for age groups 0 to 69. Moreover, in grouping individuals age 70 years and above, the elderlies represent 36.7 percent of cases in Italy compared with 11.9 percent in China.
The so-called social contact matrix is another possible reason why Italy has high COVID-19 deaths and why the elderly have become affected. Although elderly Italians mostly live by themselves, they are not isolated. Their lives are characterized by intense interaction with younger members of the population from their families or the community.
Asymptomatic individuals and those with milder symptoms may have unknowingly spread SARS-CoV-2 in the elderly population prior to the onset of a widespread outbreak. Hence, some observers believe that isolating the elderly from the rest of the community is critical in managing the threat from outbreaks and epidemics.
Overwhelmed Italian Healthcare System Worsening COVID-19 Outcomes
Factors such as unpreparedness, undetected carriers, and the elderly population could easily overwhelm hospitals and healthcare providers during an outbreak of an infectious disease. Of course, it is essential to note that Italy has one of the best healthcare systems in the world, with its high-end facilities, highly trained providers, and universal healthcare coverage.
However, the number of COVID-19 cases has been too much to handle. Note than in February alone, the new coronavirus had easily overloaded hospitals and health care providers all over northern Italy alone.
Health care workers who are in the frontlines of the outbreak are also at risk of contracting the virus. Soon after the situation worsened, doctors, nurses, caregivers, and other hospital workers either have become ill or needed to be placed on quarantined, thus crippling further the healthcare capability of the country.
Tough times also had called for extreme measures. The Italian College of Anesthesia, Analgesia, Resuscitation, and Intensive Care was forced to issue guidelines for the scenario. Specifically, the group urged that only those with the best chance of survival should have access to intensive care. The overall guidelines effectively promote the rationing of care.
Physicians Joseph J. Cavallo, Daniel A. Donoho, and Howard P. Forman wrote an article for the JAMA Health Forum explaining that healthcare systems are generally designed for average patient loads and not for epidemics. Thus, whenever containment fails, a significant growth in the number of cases can transform a public health emergency into an operational crisis. Photo credit: Facquis/Adapted/CC BY-SA 4.0
FURTHER READINGS AND REFERENCES
- Cavallo, J. J., Donoho, D. A., and Forman, H. P. 2020. “Hospital Capacity and Operations in the Coronavirus Disease 2019 (COVID-19) Pandemic—Planning for the Nth Patient.” JAMA Health Forum. Available online
- Cereda, D., Tirani, M., Rovida, F., Demicheli, V., Ajelli, M., Poletti, P., Trentini, F., Guzzetta, G., Marziano, V., Barone, A., Magoni, M., Deandrea, S., Diurno, G., Lombardo, M., Faccini, M., Pan, A., Bruno, R., Pariani, E., Grasselli, G., Piatti, A., Gramegna, M., Baldanti, F., Melegaro, A., and Merler, S. 2020. “The Early Phase of the COVID-19 Outbreak in Lombardy, Italy.” arXiv: 09320
- Giuffrida, A. 2020, March 24. “Bergamo Mayor Says Football Match Escalated Infections in Italian province.” The Guardian. Available online
- Horowitz, J., Bubola, E., and Povoledo, E. 2020, March 21. “Italy, Pandemic’s New Epicenter, Has Lessons for the World.” The New York Times. Available online
- Onder, G., Riezza, G., and Brusaferro, S. 2020. “Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy.” JAMA Network. DOI: 1001/jama.2020.4683
- Qiu, J. 2020. “Covert Coronavirus Infections Could Be Seeding New Outbreaks.” Nature. DOI: 1038/d41586-020-00822-x
