The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has already taken on pandemic proportions, affecting over 100 countries in a matter of weeks. A global response to prepare health systems worldwide is imperative. Although containment measures in China have reduced new cases by more than 90%, this reduction is not the case elsewhere, and Italy has been particularly affected. There is now grave concern regarding the Italian national health system's capacity to effectively respond to the needs of patients who are infected and require intensive care for SARS-CoV-2 pneumonia. The percentage of patients in intensive care reported daily in Italy between March 1 and March 11, 2020, has consistently been between 9% and 11% of patients who are actively infected. The number of patients infected since Feb 21 in Italy closely follows an exponential trend. If this trend continues for 1 more week, there will be 30 000 infected patients. Intensive care units will then be at maximum capacity; up to 4000 hospital beds will be needed by mid-April, 2020. Our analysis might help political leaders and health authorities to allocate enough resources, including personnel, beds, and intensive care facilities, to manage the situation in the next few days and weeks. If the Italian outbreak follows a similar trend as in Hubei province, China, the number of newly infected patients could start to decrease within 3–4 days, departing from the exponential trend. However, this cannot currently be predicted because of differences between social distancing measures and the capacity to quickly build dedicated facilities in China.

Introduction

1 Callaway E Time to use the p-word? Coronavirus enter dangerous new phase. 2 The Economist

Tourism flows and death rates suggest covid-19 is being under-reported. According to Nature, the spread of coronavirus disease 2019 (COVID-19) is becoming unstoppable and has already reached the necessary epidemiological criteria for it to be declared a pandemic, having infected more than 100 000 people in 100 countries.Therefore, a coordinated global response is desperately needed to prepare health systems to meet this unprecedented challenge. Countries that have been unfortunate enough to have been exposed to this disease already have, paradoxically, very valuable lessons to pass on. Although the containment measures implemented in China have—at least for the moment—reduced new cases by more than 90%, this reduction is not the case in other countries, including Italy and Iran.

Italy has had 12 462 confirmed cases according to the Istituto Superiore di Sanità as of March 11, and 827 deaths. Only China has recorded more deaths due to this COVID-19 outbreak. The mean age of those who died in Italy was 81 years and more than two-thirds of these patients had diabetes, cardiovascular diseases, or cancer, or were former smokers. It is therefore true that these patients had underlying health conditions, but it is also worth noting that they had acute respiratory distress syndrome (ARDS) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia, needed respiratory support, and would not have died otherwise. Of the patients who died, 42·2% were aged 80–89 years, 32·4% were aged 70–79 years, 8·4% were aged 60–69 years, and 2·8% were aged 50–59 years (those aged >90 years made up 14·1%). The male to female ratio is 80% to 20% with an older median age for women (83·4 years for women vs 79·9 years for men).

On March 8, 2020, the Italian Government implemented extraordinary measures to limit viral transmission—including restricting movement in the region of Lombardy—that intended to minimise the likelihood that people who are not infected come into contact with people who are infected. This decision is certainly courageous and important, but it is not enough. At present, our national health system's capacity to effectively respond to the needs of those who are already infected and require admission to an intensive care unit for ARDS, largely due to SARS-CoV-2 pneumonia, is a matter of grave concern. Specifically, the percentage of patients admitted to intensive care units reported daily in Italy, from March 1, up until March 11, was consistently between 9% and 11% of patients who were actively infected.

In Italy, we have approximately 5200 beds in intensive care units. Of those, as of March 11, 1028 are already devoted to patients with SARS-CoV-2 infection, and in the near future this number will progressively increase to the point that thousands of beds will soon be occupied by patients with COVID-19. Given that the mortality of patients who are critically ill with SARS-CoV-2 pneumonia is high and that the survival time of non-survivors is 1–2 weeks, the number of people infected in Italy will probably impose a major strain on critical care facilities in our hospitals, some of which do not have adequate resources or staff to deal with this emergency. In the Lombardy region, despite extraordinary efforts to restrict the movement of people at the expense of the Italian economy, we are dealing with an even greater fear—that the number of patients who present to the emergency room will become much greater than the system can cope with. The number of intensive care beds necessary to give the maximum number of patients the chance to be treated will reach several thousand, but the exact number is still a matter of discussion among experts. Health-care professionals have been working day and night since Feb 20, and in doing so around 20% (n=350) of them have become infected, and some have died. Lombardy is responding to the lack of beds for patients with COVID-19 by sending patients who need intensive care but are not infected with COVID-19 to hospitals outside of the region to contain the virus.