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MARCH 30, 2020 -- UPDATED March 31, 2020 — Editor's note: This article has been updated with data on the high case-fatality rate in Italy.
Sixty-one doctors and other healthcare professionals have died of COVID-19 in Italy, which has been the country worst hit by the coronavirus pandemic so far, with 11,591 deaths as of March 30, according to the Johns Hopkins coronavirus resource center.
A list of clinicians who have died during the COVID-19 epidemic has been compiled by the country's National Federation of Orders of Surgeons and Dentists (FNOMCeO) and is being updated daily.
"Our doctors have been sent to war unarmed," Filippo Anelli, president of the federation, told the Financial Times. He added: "The dead do not make a noise. Yet, the names of our dead friends, our colleagues, put here in black and white, make a deafening noise."
Anelli also highlighted the lack of personal protective equipment in a March 25 statement: "It is reasonable to assume that these events would have been largely avoidable if health workers had been correctly informed and equipped with sufficient adequate personal protective equipment: masks, gloves, disposable gowns, protective visors, which instead continue to be in short supply."
Nearly all of the doctors who have died were in northern Italy, where the epidemic began. Four were general practitioners (GPs) in Bergamo, the epicenter of the pandemic, in the Lombardy region, and another four GPs were in Lodi, a nearby town also in the Lombardy region.
Overall, 23 (38%) of the 61 doctors who have died were GPs, the family doctors who would be the first line of defense for anyone who is feeling unwell.
Then there are specialists, who presumably would have been seeing the more severely affected patients treated in hospitals. The list includes several pulmonologists, an anesthesiologist, an epidemiologist, and a medical examiner, as well as two doctors who were working in nursing homes.
Other healthcare professionals have also died from COVID-19. The list includes several dentists as well as an ophthalmologist.
Two of the dentists were 49 and 55 years old, notable because most of the other clinicians who died were in their 60s and 70s (and one was 90).
The FNOMCeO list does not specify whether these doctors were still working as physicians or whether they had retired. In Italy, the state pension starts at age 68, but doctors can choose when to retire, so many doctors are often still working at age 70 or older.
In addition, the majority of the deceased doctors are male, which reflects what has been reported for the overall COVID-19-related deaths in Italy (one analysis found that 70% of COVID-19 deaths were male, and mean age was 80).
Initially, the epidemic hit the north of the country, with Bergamo at the epicenter. To stop the virus from spreading across the country, the Italian government introduced strict measures on social distancing — a nationwide prohibition of large gatherings was issued on March 9 and then tighter restrictions on March 11; the whole country is currently in lockdown.
However, the list of clinician deaths shows that the virus had already spread down to the south of Italy, as several of the deaths listed are in Naples.
Describing how the virus spread in Italy in a commentary published March 23 in the Journal of the American Medical Association, Italian experts note that all regions of the country have now reported COVID-19 cases.
The first three cases of COVID-19 in Italy were identified in early February and involved people who had traveled to China. Then a severe case was seen on February 20 in Lombardy in a man in his 30s with no history of travel abroad (described as a super-spreader and dubbed "Patient 0," he was more likely to have been Patient 200, said an Italian epidemiologist).
Many more cases then appeared, including a substantial number of critically ill patients. "On the basis of the number of cases and of the advanced stage of the disease it was hypothesized that the virus had been circulating within the population since January," the authors write.
High Case-Fatality Rate in Italy
The case fatality rate from COVID-19 seen in Italy has also been higher than reported in other countries, note the authors of this JAMA commentary. They are led by Graziano Onder, MD, PhD, of the Italian National Institute of Health (Istituto Superiore di Sanità, based in Rome), which has launched a surveillance system to collect information on all people with COVID-19 throughout the country.
The overall fatality rate of persons with confirmed COVID-19 in the Italian population, based on data through March 17, was 7.2% (1625 deaths/22,512 cases).
This rate is higher than that observed in other countries (eg, rate of 2.3% reported in China), they comment, and they add that this may be a result of several factors.
One of these is related to definitions, specifically how the fatality rate is counted.
Onder and colleagues explain that in Italy, the case-fatality statistics are based on defining COVID-19-related deaths as those occurring in patients who test positive for SARS-CoV-2 via RT-PCR, independent from preexisting diseases that may have caused death. But this may have led to an overestimation of the case-fatality rate, they warn.
An analysis of a subgroup of 355 patients who died from COVID-19 shows that they were elderly and had many comorbidities. The mean age was 79.5 years and half of the patients (48.5%) had three or more underlying diseases, while the remainder had either one or two underlying conditions (25% in each group). The underlying conditions included ischemic heart disease (30%), diabetes (35.5%), active cancer (20%), and atrial fibrillation (24.5%). Only 3 patients (0.8%) had no underlying disease.
This analysis of 355 patients also found that 70% were male.