Are the hospitals the real super-spreaders?

The paradox

Italy has been in strict lockdown for approx. three weeks. With lockdowns, we should see a sharp bend in the curve of total numbers of people infected within just one viral generation time. After two viral generations, the new case rate should have collapsed completely.

Consider the R0: the number of new people infected by each already-infected person. If community transmission (e.g. via bars, restaurants and general social interaction) accounts for, say, two-third of total spread, then a lockdown should see the effective R0 fall to less than 1.0, and in this case the spread would quickly collapse once lockdown measures are taken. Even if community transmission was only, say, half of total spread, then lockdown R0 would be around 1.5 and we'd have transmission approximately equal to a bad seasonal flu.

So far, however, we have not seen a material bend in the curve in Italy. Why not, when enough time has passed?

One reason could be the ever-changing levels of testing. This is the general problem: We a) do not have enough data about current positive cases, b) we have barely any data about negative cases c) the framework for measuring and interpreting the data we do have is inconsistent and changing daily.

But, let’s just take at face value what I keep being told: that Italy is NOT getting better. Well then, we need an explanation for why.

I believe the reason is this: the mass spread of Covid-19 is happening in hospitals.

Why hospitals are super-spreaders - especially in southern Europe

Firstly, the healthcare system is particularly underfunded and especially badly managed in Italy. My Italian friends all say the same thing: medics, particularly General Practitioners (GPs; we call them “family doctors” in Germany), are underpaid and hence often underqualified. For this reason, Italians, driven by panic and fear – fear which has been grotesquely inflated by our hysterical media – Italians are flocking directly to the hospitals, rather than to their GP. They are skipping out the usual primary care process, such that nobody is making an educated decision about whether or not hospital was really the best place for them.

In comparison, in Germany during the flu season of 2017/18, approx. nine million people (9m!) consulted their family doctor for flu symptoms (official RKI data). Imagine if even a fraction of that number went to hospital directly. Even German hospitals would collapse under that pressure. Thanks to the well-trained General Practitioners in Germany the wave into the hospitals was reduced to “only” 45.000 admissions - a large number compared to the current Covid-19 numbers.

Secondly, even in a normal year, Italy is the worst EU country for antibiotic-resistance deaths. Despite Italy having only 11% of the EU’s population, they have over 30% of all EU deaths caused by bacteria resistant to antibiotics annually (ISS Higher Health Institute data).

Hospitals are everywhere risky places for infections at the best of times, but Italian hospitals are riskier than most. Italy has a huge hygiene problem in hospitals! Anytime, not just now.

My guess: many people in Italy (and, by the same token, Switzerland, Spain, etc.), who simply have a regular cold or flu, are going to the hospitals directly, which are already overwhelmed capacity-wise, and there, in the corridors and the waiting rooms, are contracting Covid-19. They might get it from the patient next to them, the doctor examining them, or simply from the chair they are sitting in, as a Covid-19 bearing patient might have touched the chair before.

So, hospitals are the super-spreaders. Worse: it’s not just Covid-19 they are spreading. After all, it’s not as though every other virus and bacterium has politely gone into hibernation, simply because Covid-19 is getting all the attention!

A vicious cycle

The media frenzy has characterized Covid-19 as some hyper-lethal assassin, which is frankly taking it way too far. The health advisor to the Italian Prime Minister has already stated: “The way in which we code deaths in our country is very generous, in the sense that all the people who die in hospitals with the coronavirus are deemed to be dying of the coronavirus. On re-evaluation by the National Institute of Health, only 12% of death certificates have shown a direct causality from coronavirus, while 88% of patients who have died have at least one pre-morbidity, many had two or three”. This, coupled with a very old population (EVERY YEAR Northern Italy has a significantly higher death rate than the rest of Italy and Europe), explains a lot.

The problem now is that EVERY other Western country is looking at Italy as a typical case and drawing exactly the WRONG conclusions. And it’s a vicious circle. Hospitals fill up, so guess what – they call in more doctors, nurses, orderlies and others. In hard-hit places they're getting volunteers. Every one of those new workers is also a new vector to the rest of the community. The media shows us pictures of hospitals collapsing, which frightens people who might just have the cold or the normal flu, and so they go …. to the hospital.

By the way, as said before, thanks to excellent GPs, most German hospitals are quite empty. And I am confident the German system will continue to avoid being overwhelmed, NOT because of the partial lockdown, but because of a far better primary care process compared to most other countries.

The solutions

• Call for calm and urge people with non-life-threatening symptoms to consult their GP first (ideally remotely), and only in urgent cases to go to hospital. Make people aware that hospitals can be very dangerous, especially if you don’t have a good reason to be there.
• As I have already been quite vocal about: we need to make use of approved drugs which have compelling (if early) evidence of efficacy on Covid-19. I understand that some hospitals are already using these drugs off-label for Covid-19 (e.g. Hydroxychloroquine + Azithromycin, Kaletra, soluble ACE2), but as with any viral drug, they most likely are best administered EARLY in the disease. Give those tools to GPs, not just the hospitals. Once more: the goal must be to keep people away from hospitals.
• And finally, as if it needed saying for the millionth time: fix the basics in hospitals: (i) adequate PPE (personal protective equipment like masks), and (ii) obsessive hand-washing protocols for all, including the patients!

Stay healthy!