key: cord-0892223-9vlgqi0d authors: Carbone, F; Montecucco, F title: SARS‐CoV‐2 outbreak and lockdown in a Northern Italy hospital. Comparison with Scandinavian no‐lockdown country date: 2020-06-07 journal: Eur J Clin Invest DOI: 10.1111/eci.13302 sha: 65092608869d81ba6079a765be03c9380e5314d1 doc_id: 892223 cord_uid: 9vlgqi0d The ongoing SARS‐CoV‐2 pandemic has evolved with cases of local transmission soon after the detection of imported cases in affected countries. However, the pandemic did not reach all countries at the same time and our country (Italy) had to act as forerunners. This article is protected by copyright. All rights reserved The ongoing SARS-CoV-2 pandemic has evolved with cases of local transmission soon after the detection of imported cases in affected countries 1 . However, the pandemic did not reach all countries at the same time and our country (Italy) had to act as forerunners. As first containment line, the heightened vigilance has become critical to prevent sustained transmission in new locations but many challenges have emerged -and others are still emerging -worldwide 2 . When applicable, lockdown was demonstrated to be effective in reducing transmission rates and need for hospitalization. However, those preventive measures cannot be applied everywhere, and many variables should be considered. In this regard, it can be useful to compare two opposite European countries, in which lockdown was imposed by authorities (i.e. Italy) or not (i.e. Sweden). Three weeks after the first containment measures in outbreak Italian regions, contagions dropped throughout national territory. Nationwide lockdown further contributed to contagion decline, but probably less than expected. Conversely, the contagion curve in Sweden seems to have not yet reached a decreasing trend. Being the number of tests carried out progressively risen over the weeks, such difference in contagion trend becomes even more evident. However, those are crude data that deserve further comments. Given the intimate nature of the infection, we should consider that Italy is 10fold more densely populated than Sweden, and Lombardy even 20-fold more (Table 1) . When compared with other -and more comparable -Scandinavian countries the impact of lockdown measures on contagion trend dramatically emerges 3 . Although this unorthodox policy based on the high levels of trust in Swedish society even got the interest of New York Times, it led to an amplification of the epidemic, which has now a number of death per million higher than other Scandinavian countries and even of U.S. (358 vs. 93 for Denmark, 53 for Finland, 44 for Norway and 267 for U.S.). Even considering the economic effect, a benefit from no-lockdown approach seems unlikely, as noticed by Financial Times. Concerning the different approaches in testing suspect cases any consideration about mortality would be too speculative. Sweden has tried to analyze burden and prevalence of prognostic factors for severe SARS-CoV-2 infection showing a relative low prevalence of chronic obstructive pulmonary disease (0.8%) and cardiovascular disease (7.4%) 4 . However, also considering the different median age, lethality, distribution across sex and comorbidities would be similar in Italy and Sweden. This article is protected by copyright. All rights reserved With regard to in-hospital control of outbreak, lesson from long-term care facilities clearly teaches us how aged populations living together in semi-confined spaces are most vulnerable to severe infections and rapid spread 5 In-hospital setting shows the same critically issues with exponentially worse consequences 7 . Appropriate triaging and cohorting/isolation upon arrival at emergency department (ED) was immediately recognized as critical to minimize nosocomial spread. Segregated "fever areas" -equipped for critical care -have been then created. However, as the weeks go by from the SARS-CoV-2 outbreak, case definition posed its own set of challenge, different from those characterizing previous SARS and MERS pandemics. Although common during disease, fever and respiratory symptoms may be not present at initial presentation 8, 9 . Similarly, isolating or cohorting patients with significant travel history have lost significance in the later phases, when the transmission of infection was already "local". It has therefore become increasingly evident how a great number of lateconfirmed cases did not fulfill definition criteria for SARS-CoV-2 infection. Such underestimation in early detecting infection at ED triage has represented a turning point as a single case managed without appropriate strategy may upset hospital organization determining rapid nosocomial spread among patients and healthcare professionals 10 . As the awareness of how case definition in clinical practice is widely dependent on the context grew, physicians have become more flexible and lowered the threshold of suspicion for determining who to test/isolate and how many times to do it. Further infrastructural modifications partitioning the ED into high-and low-risk "no fever areas"with different traffic flows -have also taken place. However, the widespread use of tests and isolation/cohorting measures strains resources of ED, especially in institutions with This article is protected by copyright. All rights reserved limited isolation beds. In addition, the flow of patients with non-SARS-CoV-2 diseases has risen again a few weeks after lockdown starting. Whether they were asymptomatic or contracted infection during stay at ED, a growing number of patients admitted to general ward was recognized as positive to SARS-CoV-2 infection. Therefore, several Hospitals in Italy had hospital-wide translated the concept of Our research group will retrospectively analyze the effectiveness of such measures in the next months, but some consideration may be already drawn. Pending randomized clinical trials validating therapeutic strategies and the development of a vaccine, this experience highlights the critical role of healthcare system organization 11, 12 . A common indication is to limit hospital access to life-threatening clinical conditions. Such call was widely received by population and has contributed to limit SARS-CoV-2 spread in the early phases of outbreak. This aspect is of paramount importance especially in countries where the healthcare system is universally guaranteed, a concept often misinterpreted and reduced to that of "free service". Noteworthy, this indication is coming at a time when the reorganization of hospital services toward the outpatient care was already felt as an urgent need in many Italian regional healthcare systems. Such reorganization is certainly appealing from an economic point of view but potential clinical advantages are less clear 13 . Highly efficient "out-patient hospital" may potentially contain muti-drug resistant bacterial infections but they are incompatible with epidemic occurrence. Indeed, outpatient care is largely closed in our institution and it is likely that some patient has needed to care at ED. A pneumonia outbreak associated with a new coronavirus of probable bat origin Novel Coronavirus Outbreak in Wuhan, China, 2020: Intense Surveillance Is Vital for Preventing Sustained Transmission in New Locations ECDC) ECfDPaC. TOTAL CONFIRMED DEATHS DUE TO COVID-19 Burden and prevalence of prognostic factors for severe COVID-19 in Sweden COVID-19 in long-term care facilities: An upcoming threat that cannot be ignored Asymptomatic carrier state, acute respiratory disease, and pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): Facts and myths Containing COVID-19 in the emergency room: the role of improved case detection and segregation of suspect cases. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Clinical, laboratory and imaging features of COVID-19: A systematic review and meta-analysis. Travel medicine and infectious disease COVID-19 diagnosis does not rule out other concomitant diseases Inpatient Care of Patients with COVID-19: A Guide for Hospitalists. The American journal of medicine Improving Communication About COVID-19 and Other Emerging Infectious Diseases Coronavirus disease 2019: the harms of exaggerated information and non-evidencebased measures Hospitals as health factories and the coronavirus epidemic Clinician Education and Adoption of Preventive Measures for COVID-19: A Survey of a Convenience Sample of General Practitioners in Lombardy, Italy. Annals of internal medicine This study was supported by a grant from the Rete Cardiologica of Italian Ministry of Health (#2754291) to Prof. F. Montecucco. This study was supported by a grant from Fondazione Carige to Prof. F. Montecucco. This article is protected by copyright. All rights reserved This article is protected by copyright. All rights reserved Accepted Article