By Dr. Stefano Fagiuoli and Dr. Bianca Magro, Hospital of Bergamo
The first coronavirus (COVID-19) cases were identified in Wuhan, Chinain December 2019. Such a virus is a novel enveloped RNA beta-coronavirus, which lead to severe acute respiratory syndrome (SARS-CoV-2). The World Health Organization (WHO) declared COVID-19 a pandemic on 11 March 2020, after it infected over 100,000 people in the world.
The first documented case in Italy was a 38-year-old manager from the Lodi province, in the Lombardy region. The first case in Papa Giovanni XXIII Hospital in the Bergamo province – counting over 1,1 million inhabitants – was identified on 21 February 2020. Unlike the Codogno cluster, Bergamo was not immediately put under lockdown.
The rapid surge in cases led to a profound structural and logistical reorganization of Papa Giovanni XXIII Hospital. Many medical and surgical units were dismantled to create COVID-19-dedicated units quickly occupied by patients undergoing respiratory support, mainly continuous positive airway pressure (CPAP). As of 10 March 2020, five COVID19-dedicated units (amounting to 48 beds each) were progressively activated, with all non-COVID-19-infected patients being moved to other structures or discharged. Within one week, over 1,500 people were trained with peer education on COVID-19 management. On 30 March over 400 physicians, 900 nurses, and technicians were dedicated exclusively to COVID19 units.
First, Infectious Disease Unit was dedicated to treating only COVID-19 patients and separate COVID-19-units created in Internal Medicine Surgery Departments, Intensive Care Units (ICUs), the semi-intensive area, and the Emergency Room (ER). On 28 March, out of 779 beds, 498 were allocated to COVID-19 patients. At ER admission, positive or suspected cases were separated from other patients, and an early discharge protocol was soon activated to avoid overcrowding. In ER, an area was designated for immediate CPAP/Non-invasive Ventilation for a large number of patients while they awaited transfer to high-dependency units, and a Shock Room was established for intubated patients awaiting ICU beds. During the first week of March, the SARS-CoV-2-dedicated area covered 90% of ER.
All specialized doctors played a crucial role, in particular radiologists, pneumologists, and infectologists. Moreover, intensive care physicians monitored and constantly re-evaluated patients with mild to moderate respiratory failure in other COVID-19 units to individuate the best timing to transfer the patients to ICU for intensive care. By 9 March, 49 ICU patients needed mechanical ventilatory support. Elective surgeries were canceled, with outpatient services continuing for patients with priority access for dialysis, oncology visits and services, and non-deferrable obstetric assistance. A throat swab molecular testing (PCR) was performed within 72 hours for patients who needed hospital admission.
From 23 February, the number of visits due to COVID19 increased exponentially, with a peak of 90 on 16 March 1 while non-COVID-19 related visits declined. Overall, between 23 February and 31 May 1,944 COVID19 patients were admitted to the hospital, with a 30% mortality rate.
The clinical severity manifestations improved progressively until 23 May when no new COVID-19 patients were admitted. After the summer, a progressive increase in the new daily COVID-19 cases was reported, peaking at 35,073 daily cases on 16 November. This time, the Bergamo province accounted for only 2.8% of new regional daily cases, whereas the Milan province accounted for 36.9%. As for hospital admissions, Bergamo hospitals started taking in patients from other parts of Lombardy during the second wave.
There are different hypotheses to explain the difference in COVID-19 incidence in the Bergamo province between the first and the second wave. Firstly, the strict lockdown imposed in Lombardy after 8 March, and the viral infection containment measures, such as physical distancing and facemask use. The second hypothesis sees that the virus became milder over time, mainly causing a less severe upper respiratory tract infection. Lastly, the high infection rate during the first wave in Bergamo province might have conferred a measure of immunity. A recent study on 423 people in the Bergamo province, who returned to their workplace after the end of the first lockdown, showed that the seroprevalence of SARS-CoV-2 infection was at 38.5%, hence significantly higher than that reported in other badly hit areas in the world, including New York (19.8%) and London (17.5%). The longevity of the humoral response to SARS-CoV-2 is variable, ranging from 4 and to 6 months.
In conclusion, the lesson learned from Italy is that, despite not being fully prepared for this unprecedented event, the necessary actions to deal with SARS-CoV-2 were taken, albeit belatedly, with a peak reached a few weeks after the outbreak and then rapidly declining. The Bergamo experience taught us two things. Firstly, how major hospitals need to be reorganized for any potential future outbreak; secondly, it highlighted the need for better support and interaction with primary care physicians in the community, doctors, nurses, and other healthcare personnel. They need to be provided with simpler and clearer recommendations on how to handle and treat patients with initial COVID-19 symptoms.
About the Authors
Stefano Fagiuoli is currently the Chair of the Department of Medicine and the Director of the Gastroenterology and Transplant Hepatology Unit of the Papa Giovanni XXIII Hospital in Bergamo. He received both his Medical degree (1986) and the Specialization in Gastroenterology (1990) from the School of Medicine of the University of Padua. He earned a Fellowship in Transplant Medicine at the School of Medicine of the University Pittsburgh, where he has been visiting “Instructor” and visiting Professor. He has been Visiting Professor at the liver transplant centre of the Presbyterian University Hospital of Pittsburgh (USA) from January, 1991 until June 1993. From June 1992 until June 1994 he was employed as Attending physician at the Transplant Centre of the Baptist Medical Center di Oklahoma City (USA). He has been an attending in Gastroenterolgy and Hepatology at the University Hospital in Padua from 1994 until 2005. He earned both the European and the Italian Honorary Diploma in Transplant Hepatology. He has been Member and Coordinator of several educational medical programs in the field of Gastroenterology and Transplantation. He is currently appointed Professor of the School of Specialization in Gastroenterology and Coordinator of the Bergamo Executive council of the School of Medicine and Surgery of the University “Bicocca” of Milan. Dr. Fagiuoli has authored or co-authored over 250 peer review articles and over 40 books or books chapters.
Dr. Bianca Magro is specialized in hepatology and gastroenterology. She graduated cum laude from the University of Palermo in 2014 and has ever since worked treating digestive system and liver diseases such as cancer, hepatitis, and cirrhosis. She has been visiting transplant hepatologist at Pitiè Salpetirere Hospital in Paris, France. Currently, she is a medical director overlooking liver transplants at Bergamo Hospital Papa Giovanni XXIII. There, during the pandemic outbreak, Dr. Magro was directly involved in the treatment of Covid-19 cases in one of the most severely affected areas of whole Europe. Dr. Magro authored or coauthored various medical publications, principally on liver-related diseases. Her most recent publication addresses a way to predict in-hospital mortality from Covid-19.
