Adaptation to measures
The first confirmed COVID-19 case in Switzerland was reported in the Canton of Tessin by the the Italian border. At that time, Italy had 322 cases [17] although assumingly many cases were unreported yet due to restrictive COVID-testing in the early phase of the pandemic. Close economical and working relationships, including cross-border commuters traveling back and forth all contributed to an early and rapid dissemination of COVID-19 in Switzerland. For the first five days, all positive results in Switzerland could be retraced to a physical contact with people from the northern part of Italy. In a week, the numbers in Switzerland increased rapidly. Most of the new infections thereafter were gathered within the own national borders.
Long before WHO declared the pandemic, the Swiss Federal Office of Public Health (Bundesamt für Gesundheit – BAG/FOPH) took measures to protect its citizens and prevent a collapse of the national healthcare system. Surely, the federalist political system and trust of the Swiss people in the national healthcare system has proven to be helpful in that matter. By keeping the transmission paths for official instructions short, running national campaigns in TV and on billboards, a continuous flow of information was ensured to all socioeconomic classes.
The first official measures included a close control of people travelling from COVID-hotspots and filling storages for protective medical gear to the best possible extent. Plans and strategies for an imminent lockdown were discussed early on. The border to the southern neighboring country was closed by March 11, 2020 when 1,168 people were reported to be tested positive for COVID-19 in Switzerland and 12,462 in Italy[17, 18]. By decree of the Federal Council from March 17, 2020 on most retailers, public buildings and recreational parks remained closed and mandatory physical distancing was implemented putting local law enforcement in charge to transpose that law. Employees were asked to stay at home whenever possible and recommendations on working from home were given. Controversially discussed, as still unknown to what extent kids and younger people contribute to a rapid spread of the virus, schools and Universities, kindergartens and most daycare facilities for children also closed their doors during the peak incidence of COVID-19. Elective surgery was banned from March 17 on. Only operations where a delay might lead to a shortening of life expectancy, permanent damage, worsening of the clinical status or if postponement was associated with severe impact in life-quality were allowed. In Switzerland there are 38,000, hospital beds with around 1,000 beds in 82 Intensive Care Units (ICU) [19]. Under pressure of the expected COVID-19 crisis, the healthcare providers in Switzerland succeeded to increase the number of ICU beds up to 1,500 by closing operating theatres, reopening ICU wards, buying and reactivating outsourced ventilators.
By the end of April, Switzerland had 30,000 patients tested positive for COVID-19, one of the highest incidences worldwide (up to 1,500 new infections per day, i.e. 17/100,000 inhabitants) surpassed only by Hubei province in China, Italy and later on the pandemic spread in Spain and the US. Despite all fears, the healthcare system in Switzerland did not collapse under the first flood of patients. Since SARS-CoV-2-tests were not widely available at that time, the initial strategy intended testing of vulnerable patients (>65y of age) and patients requiring hospitalization only [11]. This testing strategy limited the assessment of the overall COVID-burden, allowing no statement on prevalence or asymptomatic infections, but surely led to a proper identification of patients in need for hospitalization or immediate medical care. Switzerland has a reasonably high physician density of 4.4 doctors per 1,000 inhabitants but not higher than the surrounding countries (Germany: 4.2, Austria 5.1, Italy 4.0, France 3.2) [20]. What may be different is the role of the primary care physician (PCP) in the national healthcare system. Most PCPs in Switzerland are organized in a network, have a close accountability for their patients and are capable to do a first-line screening for patients with potential COVID-19 infection. The highly structured PCP-network prevented an overload of patients in the secondary and tertiary hospitals allowing them to focus on sick patients. The main involvement of cardiac surgery was in treatment of COVID-19 patients when they needed ECMO support. The following section will focus on that. No patient underwent cardiac surgery on an urgency or emergency setting with an ongoing COVID-19 infection at our Department during the first wave.
The healthcare system in Switzerland never collapsed. The first couple of weeks, hospitals faced shortness of protective medical gear, especially in the southern part of Switzerland, one of the first hotspots. The government supported the healthcare facilities with medical supplies and required equipment was flown in before partial lockdown. Shortness on staff was overcome with short-term employment of medical students, supportive care for supply-chains etc. came from 8,000 armed forced.
By April 27, 2020 the federal council started to stepwise ease down on the lockdown measures allowing retailers to reopen again and people to meet in smaller groups. For two months, the number of new infections remained low until the incidence started to increase again at the end of June. Immediate countermeasures were taken, now obliging commuters to wear facemasks in the public transport. Since the numbers did not grow far beyond 100 new infections per day and backtracking mechanisms were implemented for public gatherings, there is hope, that a second wave can be averted without going into a second lockdown and another economic crisis.
By July 19, 2020 out of 726,806 tests performed in Switzerland, 33,431 were reported to be positive for COVID-19 (4.6%), leading to 1,687 deaths so far. None of our fellow co-workers in the clinic for cardiac surgery was infected with COVID-19. Fifty-three out of 8,480 hospital employees were tested positive. Most of those employees reportedly had no contact to COVID-19 patients. Not a single infection could be traced back to an in-hospital contact with an infected patient, proving protective measures to have worked effectively. Overall, 143 patients with COVID-19-infections had to be hospitalized in the USZ, 130 had a successful recovery, 12 (8.4%) deaths were reported.