The Italian Connection

Guest Post by Willis Eschenbach [Note updates at the end]

Since the earliest days of the current pandemic, Italy has been the scary member of the family that you absolutely don’t want to emulate, the one cousin that gets into really bad trouble. The Italians have the highest rate of deaths from the COVID-19 coronavirus, and their numbers continue to climb. Here’s the situation today.

Figure 1. Deaths from the COVID-19 coronavirus expressed as deaths per ten million of the country population. Percentages of the total population are shown at the right in blue. All countries are aligned at the date of their first reported death. Most recent daily chart and charts of previous days are available by going here and scrolling down.

Italy, with over six thousand dead, is up well into the blue range. This is the range of annual deaths from the flu in the US. If the US coronavirus patients were dying at the same rate as in Italy, we’d have 38,000 coronavirus deaths by now in addition to the same number of flu deaths …

As a result, there has been much debate about why the Italian death rate is so high. People have suggested that it’s because they have one of the older populations in Europe. Others have noted that they often live in extended families. Some say it’s high numbers of smokers and polluted air. And some have pointed to their social habits that involve touching, kissing cheeks, personal contact during church rituals, and the like.

But we haven’t had good data to take a hard look at the question, or at least I hadn’t seen any.

In the comments to my post entitled END THE AMERICAN LOCKDOWN, wherein I passionately advocate just exactly that, I was given a link by a web friend, Mary Ballon, hat tip to her. It’s a report by a Swiss medical doctor about the COVID-19 deaths in Italy, well worth reading.

And in that document, there’s a further link to an Italian Government report. It’s in Italian of course, I have it on good authority that’s what they actually speak over there, who knew? They reported on the statistics of a large sample of the Italian deaths (355 out of 2003 total deaths at the time of the report). I got it, and the numbers are very revealing.

Let me start with the age distribution of the 2,003 Italians who had died at the time of the report. Figure 2 shows that it’s almost entirely old people. 

Figure 2. Age of 2,003 Italians who had COVID-19 at the time of death. 

Out of the 2,003 deaths, seventeen were people under fifty, and only 5 people under thirty died, while almost two hundred deaths were of people over 90. I’d read that the people dying in Italy were old, but I didn’t realize quite how old they actually are …

One thing I learned on this voyage was that the Italians distinguished between dying FROM the virus on the one hand, and dying WITH the virus on the other. Once I looked at the state of health of the Italian victims, however, I could see why they had to do that. Figure 3 shows the generous apportionment of serious diseases and conditions among the unfortunates.

Figure 3. Numbers of diseases in the sample of 355 Italians who had COVID-19 at the time of their death.

WOW! Yeah, they all had COVID-19. But three-quarters of them also had hypertension, a third had diabetes, a third had ischemic heart disease, a quarter of them had atrial fibrillation tossing clots into the bloodstream, and so on down the list.

As you can see from Figure 3, some people must have had more than one other disease besides COVID-19. Figure 4 shows the breakdown of the number of other diseases per patient.

Figure 4. Other diseases (comorbidities) of a sample of 355 of the 2,003 Italians who had COVID-19 at the time of their death.

For me, this was the most surprising finding of the entire study. Of all 355 people who died, only three did not have any of the diseases listed above. Three!

Looking at all of this as a whole picture, I had a curious thought about who they were representing. I thought … consider the characteristics of the people who died:

• More of the patients were over 90 than were under 60.
• The average age was 79 years.
• All but three of them had at least one other disease, so basically all of them were already sick.
• Three-quarters of them had two other diseases, and half of them had three or more other diseases. Half!

My thought was … that’s not a sample of the people in the street. That’s not a sample of an Italian family.

That’s a sample of a totally different population.

I was forced to a curious conclusion, both discouraging and encouraging. It is that most of these diseases were probably not community-acquired. Instead, I would hazard a guess that most of them go by the curious name of “nosocomial” infections, viz:

nos·o·co·mi·al

/ˌnōzōˈkōmēəl/

adjective MEDICINE

(of a disease) originating in a hospital.

Here’s what I suspect. I think that the COVID-19 disease got established in a couple of areas in Italy well before anyone even knew the disease was there, perhaps even before the Chinese recognized it as a novel disease.

And in some fashion, it got into the medical system. Doesn’t matter how. But once there, it was spread invisibly to other patients, in particular the oldest and weakest of the patients. It went from patient to patient, from patient to visitor and back again, and it was also spread by everyone in the hospital from administrators to doctors and nurses to janitors. In many, perhaps most cases, they didn’t even know they were sick, but they were indeed infectious.

And that’s why the pattern of the Italian deaths is so curious, and their number is so much larger than the rest of the world. It’s not a cross-section of the general population. It’s a cross-section of people who were already quite sick, sick enough that they were already visiting doctors and having procedures or being bedridden in hospitals. It was 85-year-olds with three diseases.

And it’s also why the death rate in Italy is so high—these people were already very ill. I can see why the Italians are distinguishing between dying FROM the virus and dying WITH the virus.

DISCUSSION AND CONCLUSIONS

As I said, this is both discouraging and encouraging. It’s discouraging because getting the virus out of a modern medical facility and a dispersed medical system isn’t easy. Italy has a big job ahead. And it’s discouraging because it means that the medical personnel who are so needed for the fight are getting the disease as well. Very likely they won’t die from it, but they will be hors de combat for three weeks or so. No bueno.

On the other hand, it is encouraging in a couple of aspects.

First, it lets us know what we need to do to prevent the Italian outcome. We have to, must, keep the virus out the medical system. 

• We need to seriously quarantine the sufferers away from other sick people.
• We need to set up testing facilities at all medical centers and test the medical personnel daily.
• In areas with a number of COVID-19 infections, we need to set up separate field hospitals. There are a number of commercial versions of these that are expandable by adding modules, and are pathogen-tight, with airlocks at the doors, HEPA exhaust filters and negative air pressure maintained throughout. We know how to do this stuff, we’ve just got to do it.
• We need to test in-hospital patients at the time of their arrival and continue to test them at intervals during their stay.
• We’ll have to be very careful with visitors to patients in the hospitals

It’s a big job, and we absolutely have to do it.

Second, it cautions us to not claim that everyone who tests positively for COVID-19 after death actually died FROM the disease. They may very well have died WITH the disease.

Finally, the other reason it’s encouraging that Italy’s infection is likely nosocomial is that it removes Italy as the mysterious bogeyman of the COVID-19 pandemic. In addition, it points to just what we have to do.

IF (and it’s a big if) we take the proper precautions to protect our vulnerable medical system and personnel, I don’t think that the US will get as high a death rate as Italy has today. 

Note that this makes me seriously question the idea of “flattening the curve” … if you let the virus into your hospitals and medical system you’re toast, no matter how flat the curve is.

So let’s end this crazy American lockdown, there’s a whole raft of work to be done shoring up our medical sector to withstand the coming wave, and it can’t be done at home with our heads in the sand, hundreds of thousands of people not working, jobs disappearing daily, and our economy in a shambles …

My very best regards to all, stay well in these parlous times,

w.

As Usual: I ask that when you comment, QUOTE THE EXACT WORDS YOU’RE DISCUSSING. Knowing who and what you’re referring to avoids endless misunderstandings and arguments.

[UPDATE]: Just after publishing this, I was reading about loss of the senses of smell and taste being symptoms of coronavirus infection. In the article, I found this:

Hopkins says an Italian doctor shared that “he and many of his colleagues had lost their sense of smell while working in northern Italy dealing with COVID-19 patients.”

… “many of his colleagues”. Kinda support my theory of nosocomial infection in Italy.

[UPDATE 2]: In the news today, the headline Coronavirus: 4,824 Italian Health Workers Are Infected … one in ten of their coronavirus cases are health workers …

[UPDATE 3]: Here’s a graph showing just how different Italy is from the other countries with numbers of cases …

PS—Let me take this opportunity to provide a wider readership to a comment that my obstropulous (yes, it’s a real word) good friend Steve Mosher posted on my blog yesterday. He’s living in Korea and has been a close observer of just how they are succeeding in controlling the virus. He spells out the level and the details of what we have to do. His comment is below, my thanks to him.The key is changing the criteria for testing. Here [in Korea] we test and track.

An employee of a call center in Seoul, was infected.
Office had 207 people.
March 8th. he tested positive.
EVERY person in that office was tested. today 152 have tested positive, they tested floors above and below his floor. Today 3 more from the 11th floor were found and 1 contact.

They are now tracing the contact, and the contact’s contacts. All will be tested. The business was in a residential building. 553 of the people in that building were tested. floors 13-18

This little beastie lives on surfaces for up to 3 days. See that elevator button? the hand rail on the stairs? the bathroom door handle? the coffee cup that pretty girl behind the counter handed you? it’s there. Now in my building we have hand sanitizer by the elevator buttons. you get in the habit of not touching public pretty quickly. Trust me I am not a germ phobe, but the changes have been simple when they are reinforced.

Let me give you a little taste of the highly detailed info we get.
Info that is shared daily in one spot, I will include some of the earlier call center case snippits

“In Daegu, every person at high-risk facilities is being tested. 87 percent completed testing and 192 (0.8 percent) out of 25,493 were confirmed positive. From Daesil Covalescent Hospital in Dalseong-gun, 54 additional cases were confirmed, which brings the current total to 64. In-patients on 6th and 7th floors are under cohort-quarantine.”

“From Guro-gu call center in Seoul, 7 additional cases (11th floor = 2; contacts = 5) were confirmed. The current total is 146 confirmed cases since 8 March. (11th floor = 89; 10th floor = 1; 9th floor = 1; contacts = 54)”

“From Bundang Jesaeng Hospital in Gyeonggi Province, 4 additional cases were confirmed. The current total of 35 confirmed cases since 5 March (20 staff, 5 patients in inpatient care, 2 discharged patients, 4 guardians of patients, 4 contacts outside the hospital). The 144 staff members who were found to have visited the hospital’s Wing no. 81 (where many confirmed cases emerged) were tested, 3 of whom tested positive.”

“Five additional confirmed cases have been reported from the call center located in Guro-gu, Seoul, amounting to a current total of 129 confirmed cases from the call center since 8 March. As of now, 14 confirmed cases in Gyeonggi Province has been traced to have come in contact with a confirmed patient who is a worker at the 11th floor call center at a religious gathering. Further investigation and tracing are underway.”

Test, Trace, Test more.

A random test in Iceland found 1% infected. 50% asymptomatic.

If the US persists in only testing the symptomatic you won’t squash this bug.

Our cases are going up in Seoul. So we will have 15 days of voluntary social distancing.

go to work
stay away from crowds
wash your hands
wear a mask
don’t touch your face