Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy

Original: JAMA. Published online March 13, 2020. doi:10.1001/jama.2020.4031

Author(s): Grasselli G, Pesenti A, Cecconi M.

Reviewer: Argyris Tzouvelekis, MD

Published: 20 Mar, 2020

The world has set its eyes on the pandemic crisis of COVID-19. In an elegant commentary recently published in JAMA, authors report the reaction of the government of Taiwan against the pandemic threat of the new coronavirus-COVID-19. These measures helped Taiwan to overcome the handicap of neighboring with China and disprove the pessimistic expectations predicting Taiwan to have the second highest number of cases of coronavirus disease 2019 (COVID-19) due to its proximity to and number of flights between China.

Currently Taiwan enumerates 59 cases with only one death. The government learned its lesson from the previous pandemic of SARS in 2003 and applied a number of measures for case identification, containment of the infection and resource allocation for public health protection. They used cutting-edge technologies and integrated bioanalytic data from the National Health Insurance database with its immigration and customs database. They implemented QR-code scanning to classify travellers’ infectious risk, facilitating immigration clearance, self-quarantine and tracking quarantined individuals through their mobile phone. While WHO declared COVID-19 a pandemia on the 13th of March and changed the criteria for suspicious cases by adding any case with severe acute respiratory infection that cannot be explained by another etiology, almost two months earlier, Taiwan health policies applied a proactive case-finding policy to identify potential community threats. Within one month Taiwan implemented a list of 124 measures including border control with China, reassurance and education of the public, policies focusing on schools and child-care, deconstruction of fake news and misinformation, relief to businesses and negotiations with other governments.

On the contrary the number of victims in Italy (as of 14th March) have raised up to 1441 with an overall 21,157 cases. Remarkably the vast majority of overall cases and deaths (n=744) have occurred in the region of Lombardia. In Milan resides the largest Chinese community of Italy accounting for more than 30,000 Chinese people. While the first reported case in Italy was a 30-year old patient, who developed bilateral interstitial pneumonia and intubated on the 20th of February 2020, he had no travel history or close contact with a confirmed or probable case and thus it was impossible to identify the source of transmission. By day 2, 36 new cases emerged with similar epidemiological characteristics indicating that the pandemic has entered the community phase. It is conceivable to speculate that the disease was transmitted by asymptomatic or mildly symptomatic travelers who visited China for Chinese New Year’s Eve on the 25th of January who were not identified and quarantined timely. Italy applied general quarantine on the 10th of March, almost 20 days following the first confirmed case. Same approach was followed by several other countries including France, UK, Germany, Spain and Switzerland, but not Singapore, Japan and Taiwan who were among the exceptions that developed a linear and not an exponential increase of confirmed COVID-19 cases.

The paradox of Taiwan highlights the amenable need for timely implementation of measures including proactive recognition of the crisis, application of case definition, contact tracing and enhancement of public awareness and education leading to suppression of the outbreak transmission. This Viewpoint describes the outbreak response infrastructure developed by the Taiwanese government following the SARS epidemic in 2003 and actions in response to COVID-19, including dedicated hotlines for symptom reporting, mobile phone messaging and case tracking, and the ramping up of facemask.

see also Wang, C.J., C.Y. Ng, and R.H. Brook, Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing. JAMA, 2020.

Respiratory critical care
Respiratory digests
Respiratory infections