pay for up to five days. employees and employers that violate this requirement will face a fine between €400 and €1500. the unemployed and those living on pension are exempted from showing their health vaccine certificate. on 5 january 2022, italy mandated vaccines for people over the age of 50. the decision was made to ease pressure on its health service and reduce fatalities. the option to be tested instead of vaccinated has been removed. potential sanctions for non-compliance have yet to be announced. endemic phase on 15 november 2022, the italian minister of health orazio schillaci appeared on a broadcast of porta a porta where he discussed the reduction of quarantine guidelines and said italy is in an "endemic phase of covid, we must take the same precautions we had before for the flu". lockdown areas main article: covid-19 pandemic lockdown in italy on 22 february 2020, the government established a lockdown for eleven municipalities in lombardy and veneto. map of the ten lombard municipalities under lockdown since 22 february municipalities under quarantine, 22 february comune province region population bertonico lodi lombardy 1,118 casalpusterlengo lodi lombardy 15,293 castelgerundo lodi lombardy 1,498 castiglione d'adda lodi lombardy 4,646 codogno lodi lombardy 15,907 fombio lodi lombardy 2,317 maleo lodi lombardy 3,098 san fiorano lodi lombardy 1,839 somaglia lodi lombardy 3,837 terranova lodi lombardy 927 vò padua veneto 3,305 quarantine total 53,785 on 7 march, the government prepared to extend until 3 april the restricted zone to all of lombardy, plus fourteen other provinces in veneto (3), emilia-romagna (5), marche (1) and piedmont (5). the lockdown affects over 16 million people, roughly a quarter of italy's total population, and prevents people from entering or leaving the zone, except "for proven occupational needs or situations of need or for health reasons", under threat of fines. the enclave nation of san marino, which is nestled between two of the provinces, has been effectively locked down as well. provinces under quarantine since 8 march provinces under quarantine, 8 march province region population alessandria piedmont 420,017 asti piedmont 214,342 bergamo lombardy 1,115,536 brescia lombardy 1,265,954 como lombardy 599,204 cremona lombardy 358,955 lecco lombardy 337,380 lodi lombardy 230,198 mantua lombardy 411,958 milan lombardy 3,263,206 modena emilia-romagna 705,422 monza and brianza lombardy 875,769 novara piedmont 368,607 padua veneto 938,957 parma emilia-romagna 452,022 pavia lombardy 545,888 pesaro and urbino marche 358,886 piacenza emilia-romagna 287,152 reggio emilia emilia-romagna 531,891 rimini emilia-romagna 339,437 sondrio lombardy 180,811 treviso veneto 888,293 varese lombardy 890,768 venice veneto 857,841 verbano-cusio-ossola piedmont 157,844 vercelli piedmont 170,298 quarantine total 16,466,636 on 9 march, prime minister conte announced that the lockdown would be extended to the entire country. impact healthcare the pandemic outbreak heightened the pressure on the italian healthcare system. on 9 march, alessia bonari, a nurse from grosseto who worked at a hospital in milan, posted on instagram stating that she was physically strained from being overworked and was scared to work after treating over 10,000 patients who have tested positive. bonari and her co-workers had been extremely exhausted due to the pressures of work, and according to her, health caretakers had been working in uncomfortable conditions. the post, which reached global notoriety, contained a photo of her bruised face from wearing unfit masks and hazmat goggles, and stated that "the protective devices are bad." she concluded her post persuading others "to be selfless, to stay at home and thus protect those who are most fragile." an intensive care nurse, showing her bruised face during the peak of the pandemic, in pesaro on 17 march, undersecretary at the ministry of health sandra zampa announced the purchase of many new ventilators as well as the importing of one and a half million masks from south africa. to deal with the numbers of covid-19 patients, intensive care units were expanded, and new hospitals were created, especially in lombardy. in emilia-romagna, professor marco ranieri developed a method to double the efficiency of ventilators in icus. the lack of a single protocol for hospitals was considered to be a problem. due to hospitals overcrowding with coronavirus patients, thousands of cancer patients experienced difficulties in getting access to treatment and transplants, with their lives put at even higher risk. dozens of cancer hospital sections were indeed either dedicated to host coronavirus wards, or closed after personnel got infected. according to a study, cancer patients represented 17% of coronavirus fatalities in italy. in march 2020, oncologist luigi cavanna of the hospital of piacenza was one of the first physicians in italy to focus on house calls, realising that too many critically ill covid-19 patients were arriving at his hospitals and that some of them could have been treated earlier at home before a possible escalation of the symptoms. a letter published on the nejm catalyst innovations in care delivery claimed that one of the reasons for the high death count in the area of bergamo was hospital contamination. progressively, different hospitals became dedicated to covid-19 patients only, and more rigid separations were set up between hospital sections and triage structures. in some regions, hotels were used to host healthcare workers or patients, and in liguria a ship was adapted to host people in quarantine. on 1 april, the first italian drive-through testing facilities opened in alessandria and in north-western tuscany. at least ten different clinical trials were ongoing in italian hospitals at the beginning of april. the supercomputer of enea in portici was used to run advanced simulations related to other possible drugs. some of the treatments employed for covid-19 patients involved the administration of antiviral drugs. remdesivir was tested with promising initial results in naples. despite doubts from the scientific community, avigan (favipiravir) was also included in testing protocols by italian medicines agency (aifa) even though it was not authorised in europe. similarly to france, hydroxychloroquine (the less toxic version of the malaria drug chloroquine) was also tested: in lazio, its use was reported by the second week of april on a significant fraction of the roughly a thousand covid-19 patients confined at home. later prohibited by aifa, the use of hydroxychloroquine was approved again in december by the council of state upon request of some general practitioners. plasma treatment already tried in china (transfer of antibodies from recovered covid-19 patients to sick people) was tested at the hospital of pavia (and later in mantua) under the supervision of professor cesare perotti; the first two donors involved in the research programme were a married couple, both doctors and among the first covid-19 patients reported in the province. the final results published in may showed a reduction in mortality. in the beginning of april, based on the results of autopsies showing the presence of micro-thrombosis in the lungs of covid-19 patients, doctors in tuscany and other areas of northern italy started to use heparin to reduce the risk of blood clotting; the news was originally circulating on social media from internal chats of healthcare workers and considered a hoax by virologist roberto burioni, but protocols including low-molecular-weight heparin were formally submitted as a treatment proposal to aifa. a programme involving 14 research centres was approved on 13 april. nurses of the coronavirus task force to support health structures in northern italy the workforce of the healthcare system underwent massive reorganisation. pediatricians were assigned to adult patients and as a result, their insurance coverage had to be adapted. retired professionals were asked to go back to work to fill the vacancies, despite the high risk for their age group. at the peak of the pandemics volunteers from the rest of the country were sent to hospitals in critical areas of northern and central italy. healthcare workers were also affected by coronavirus infections, with a higher percentage of the infected healthcare workers being women because of their predominance among nurses. this resulted in death in a considerable number of cases, especially amongst general practitioners. by the end of march, more than 60 doctors in italy had died with covid-19, and the figure increased to 80 by 4 april and later 145 by 22 april. healthcare personnel were also subject to high levels of stress, and the risk of professional burn-out was considered high, particularly across nurses and in more affected areas. two suicides, one of a nurse in jesolo and one of a nurse in monza, were assumed to be related to psychological pressure. the emergency was an occasion to test or develop new protocols based on digital technologies. with the aim of reducing consumption of protective equipment, robots were introduced in hospitals in varese, and remote diagnostics were introduced to monitor home care patients in lodi. to facilitate home calls from patients, istituto italiano di tecnologia in genoa (iit) and istituto di robotica e macchine intelligenti (i-rim) designed a robot for video calls that could be assembled by hospital personnel and that was tested at the end of april in pisa, massa-carrara and induno olona. economy sets of personal protective equipment in a civil protection hub, ready to be distributed to the regions the pandemic provoked large economic damage to the italian economy. the sectors of tourism, accommodation and food services were among the hardest hit by foreign countries' limitations to travel to italy, and by the nationwide lockdown imposed by the government on 8 march. by april, finance minister roberto gualtieri predicted a 6% gdp decline for 2020. on 12 march, the italian stock market was among the worst hit during black thursday, when the ftse mib index lost 17% of its value in one day. multiple factories, like fiat chrysler, halted production in some of their plants. on 21 march, the government issued the shutdown of all non-essential businesses, industries, and economic activities. the economist predicts a 7% gdp decline for italy in 2020. economist alberto bisin forecast that italy's debt-to-gdp ratio would rise from 130% to 180% by the end of the year, due to borrowing and losses. multiple economists believe that italy will struggle to pay back its debt. although the virus has hit northern italy hardest, economically deprived areas of southern italy are suffering the most from the lockdown. many residents of those areas work in the grey economy and are therefore not eligible for unemployment benefits. in some places the italian mafia was reported to be delivering groceries to needy residents. prosecutors warned that the mafia was not acting out of altruism and was instead seeking control over residents. conversion of production to medical supplies