Italy’s Response to the Coronavirus Pandemic – Now updated

From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

Italy’s Response to the Coronavirus Pandemic – the August update

Iris Bosa, Adriana Castelli, Michele Castelli, Oriana Ciani, Amelia Compagni, Matteo M. Galizzi, Matteo Garofalo, Simone Ghislandi, Margherita Giannoni, Giorgia Marini, and Milena Vainieri

Overview of the last 2 months (June – July 2020)

From the beginning of June (end of “Phase 2”), all businesses have restarted their normal activity, subject to sector-specific COVID-19 safety protocols and social distancing rules. Restrictions on travelling abroad to/from non-EU and non-Schengen countries are still in place, along with airport controls on every passenger entering the country through rapid swabs. It is still mandatory to wear face-masks (for ≥6yo) indoors, on public transport, in shops/businesses, and to keep at least 1m distance. Guidelines on schools/universities are being issued at the time of writing.

The app Immuni was finally released and available to download on 1st June. Two months after its launch, only 4 million Italians (6% of total population) have downloaded it, against the 12 millions (20% of total population) threshold estimated for the effectiveness of the app.

After a long debate, on 17th July the Parliament issued the Law 17 July 2020, n. 77, which converts the Decree Law 19 May 2020, n. 34, also known as Decreto Rilancio (‘kick-start decree’). The decree introduces financial resources to support labour and the economy and the resilience of the health system (e.g. reinforce primary care with community and family nurses, increase number of scholarships for GPs and palliative care specialists, issue guidelines for nursing homes, 70% increase in ICU beds, hiring of healthcare workforce). A €2,000 bonus is awarded to healthcare professionals who worked during the Phase 1.

An extension of the 6-month state of national emergency declared on 31st January to 15th October was approved on 30th July (Decree Law 30 July 2020, n. 83).

On 3rd August the Italian National Institute for Statistics (ISTAT) released the first data of its national serological survey. Based on 64,660 people tested between 25th May and 15th July, ISTAT estimates that a total of 1,482,000 people contracted the virus (i.e. 2.5% of the Italian population, six times higher than observed based on swab tests). There is, however, a huge regional variation in cases: in Lombardy, the prevalence is around 7.5%, and even higher in Bergamo and Cremona (24% and 19%, respectively).

On 6th August the total number of COVID-19 cases in Italy was 249,204 (detected with almost 118,000 tests performed per million inhabitants), of which 804 are currently in hospitals (5% in ICU beds). The total number of deaths was 35,187, 14% of the total number of COVID-19 cases. Due to imported cases, asymptomatic cases and (isolated) epidemic outbreaks, the Rt index was > 1 in 12 out of 21 Regions (Report 12, 27th July-2nd August).

Indirect consequences of the COVID-19 pandemic

Given that the number of COVID-19 infections is relatively under control, attention has shifted to address the indirect consequences of the first wave of the COVID-19 emergency. These can be identified in three categories of healthcare-related services: i) suppression or delay in access for urgent services due to the restrictions imposed during the early phase of the pandemic, which will likely determine an increase, in the short term, in the demand for related hospitalizations; ii) discontinuation of care for chronic conditions and prevention programmes, which will become evident in the short- to medium-term through an escalation in new diagnoses and rapid deterioration in health states; iii) long-term effects associated to the lockdown, especially in children, and to the economic recession linked to the health emergency.

Whilst for the latter it is currently difficult to suggest plausible figures, estimates related to the other two indirect sets of consequences are slowly emerging. One of the Italian Research Centers on healthcare management in Rome reported almost 900,000 “lost” hospitalizations compared to the same period in 2018, mainly in oncology and cardiovascular disease areas. The sharp decline in E&R access also affected non-urgent cases, although what is worrying is the significant drop in acute coronary syndrome admissions. On top of the devastating COVID-19 effects on mortality and life expectancy, this phenomenon accounts for additional indirect mortality associated to the pandemic as explained in official reports by ISTAT and ISS (i.e. 11,600 deaths vs 13,700 directly attributable to the virus in the first quarter of 2020 due to missed COVID-19 diagnoses, pressure on the healthcare system and “fear” of showing up at the hospital).

As for chronic diseases, an oncology scientific society estimated between 24,000 and 30,000 missed diagnoses of malignant tumours; between 200,000 and 300,000 periodic checks averted; and about 600,000 postponed surgical interventions. In terms of primary prevention, a 15%-19% decline in vaccine jabs administered during the lockdown has been reported. This backlog needs to be tackled quickly given the upcoming reopening of schools, and the approaching flu season.

National and regional responses to the backlog in healthcare procedure and treatments

From the central level some directives have been issued in relation to ICU activities, provisions of separate COVID-19 and non-COVID-19 paths for patients, ultimately leading to a reduction in production capacity, particularly across the hospital sector. Waiting times are also set to increase, with dermatology, gastroenterology and imaging being the most affected specialties. Finally, healthcare providers have resorted to digital health applications to grant access to virtual consultations and remote visits and monitoring. However, in a strongly decentralized system, some regional healthcare systems (e.g. Autonomous Province of Trento) were better prepared than others to scale up ongoing digital health projects and quickly convert them to the needs posed by the COVID-19 pandemic. Other regions had to cope with substantial lack of digital capacity, and inadequate engagement of healthcare professionals, resulting in delays in the uptake of telehealth solutions.

Italy’s response to the coronavirus pandemic: Update (May 2020)

Iris Bosa, Adriana Castelli, Michele Castelli, Oriana Ciani, Amelia Compagni, Matteo Garofano, Margherita Giannoni, Giorgia Marini, and Milena Vainieri

Overview of the last 30 days

The latest figures show that Italy has reached the peak and the number of new positive cases, including those in ICUs, has been decreasing since April 20th. The number of deaths is still 369 as of May 6th.

In mid-April, the scale and seriousness of the infection in nursing homes (Residenza Assistenziale, RSA) made the headlines. A survey of nursing homes conducted by the National Health Institute (Istituto Superiore di Sanità) showed that Lombardy – the region with the highest number of RSA beds – has also been the worst-hit with half of its deaths reporting COVID-like symptoms. Very fragile elderly, lack of testing, limited isolation of potentially positive residents and scarcity of PPE might explain the mortality rate in some facilities. Other nursing homes/regions limited the spread/deaths by enforcing early “lockdown” measures or by promptly monitoring nursing homes since the start of the epidemic (e.g. Umbria).

Italy’s Phase 2 response to COVID-19

On April 26th, the Italian PM announced the rules for the “Phase 2” of COVID-19 response, launched on May 4th. Supported by a new dedicated task-force, the government had to confront the uphill task of restarting the country’s economy while safeguarding population health.

As of May 4th, most primary and secondary productive sectors, professionals and private healthcare clinics and most retail shops, businesses and customer services resumed their normal activity. Reopening is subject to enforcement of sector-specific COVID-19 safety protocols, and use of thermo-scanners to monitor workforce and customers.

Free movement of citizens is no longer restricted to essential needs (work, health, and supplies), with the following activities now allowed within the region of residence: visiting close relatives in small groups; accessing public gardens/parks except for playgrounds; practicing individual training; attending funerals and accessing cemeteries; buying takeaway food. Travel to holiday homes is still banned. As in most European countries, public transport guidelines have been introduced to avoid crowding and facilitate social distancing. However, consumer associations raised concerns in terms of their applicability in densely populated cities. The Government is also asking for standardized guidance on international travel and tourism at the European level to aid the recovery of this sector.

It is mandatory to wear face-masks indoors, on public transport, in shops/businesses, and to keep at least 1m distance. Schools are expected to reopen in a staggered way in September, with guidance still to be issued.

Finally, the Italian government has selected “Immuni” as the app to be used for contact tracing during Phase 2. The application is based on Bluetooth Low Energy (BLE) technology, and not on GPS, and follows a decentralized privacy-preserving approach to proximity tracing, thanks to collaboration with Google and Apple. The application is currently being tested and is expected to be released by the end of May. Immuni will be free to download but non-mandatory, which increases uncertainty about its real effectiveness given that a minimum threshold of 60% of actual users is needed. A clinical diary functionality (monitoring of symptoms and health status), without interaction with physicians, is also embedded in the app.

An overview of the healthcare sector

During the COVID-19 emergency, many healthcare organisations, incl. hospitals, reduced the number of elective surgeries and cancelled almost all outpatient visits, while increasing phone consultations/telemedicine provision were possible. For example, 80% of Italian breast cancer units postponed surgeries. Hospitals need now to deal with cancelled surgeries, through a re-conversion of their beds and re-organization of operating rooms schedules.

As 81% of COVID-19 positive individuals, with either mild or no symptoms, are in isolation at home or in dedicated facilities; and with increasingly fewer people being hospitalized, efforts have shifted to the primary care sector by increasing (1) early detection of cases through strengthening of viral testing and laboratory capacity (e.g. drive-through facilities); (2) serological testing, mainly for healthcare professionals; (3) early treatment at home for patients with low/mild symptoms through GPs/hospital specialist monitoring with the aim of preventing access to ER and hospitalization.

Reflections

One of Italy’s key challenges is the recurring tensions between central and regional governments on the measures put in place to lift the lockdown and kick-start the economy. At the time of writing a few regions have already expressed disagreement with these measures, and the central government has replied by stating that they may be allowed to diverge from central measures in the second half of May, given their different stages in the epidemiological evolution of the disease. According to the IMF, Italy’s GDP is forecast to fall by 9.1% in 2020, the biggest downturn in the Eurozone since the Greek crisis. The grim economic outlook demands a vigorous and brave recovery plan with virtually no room for further hesitation. The next two months will reveal whether the preventive measures are working and the health system is able to cope with a potential second wave of infections.

Italy’s response to the coronavirus pandemic – Original post (April 2020)

Iris Bosa, Lecturer, Business School, University of Edinburgh
Adriana Castelli, Senior Research Fellow, Centre for Health Economics, University of York
Michele Castelli, Lecturer in Health Policy, Population Health Science Institute, Newcastle University
Oriani Ciani, Associate Professor of Practice, SDA Bocconi School of Management, Bocconi University
Amelia Compagni, Associate Professor, Department of Social and Political Sciences, Bocconi University
Matteo Garofano, HR and Training Department officer, Local Health Authority of Parma
Margherita Giannoni, Associate Professor, Department of Economics, University of Perugia
Giorgia Marini, Assistant Professor of Public Economics, Department of Juridical and Economic Studies (DSGE), La Sapienza University of Rome
Milena Vainieri, Associate Professor, Management and Health Lab, Institute of Management, Department of Embeds, Sant’Anna Advanced School of Pisa

Timeline and nationwide response

On January 31st, after the detection in Rome of two COVID-19 positive Chinese tourists travelling from Wuhan, the Italian Cabinet declared a 6-month national emergency and formally entrusted the SARS-CoV-2 outbreak emergency plan to the head of the Civil Protection Department.

On February 22nd, the first Italian COVID-19 positive patient was reported by the health authorities in Lombardy, followed by a number of additional cases in the neighbouring areas of Emilia Romagna and Veneto. On February 23rd, the first “red zones” were created near the hotspots. The clusters emerging in the Northern part of the country revealed a wide community spread of the virus; hence, additional restrictive measures were raised in the entire Lombardy and Veneto, Emilia Romagna, Friuli Venezia Giulia, Liguria, and Piedmont regions in subsequent days. Schools and universities were officially closed nationwide on March 4th. A partial lockdown was introduced in the whole country on March 9th, followed by a complete lockdown on March 22nd when all non-essential activities were shut down. Further restrictions of movements were introduced on March 25th. On April 9th the cumulative COVID-19 cases were 143,626, with 18,279 deaths.

The National government’s response to the outbreak of the coronavirus was forceful and proactive, converting military hospitals into COVID-19 facilities; introducing financial hardship measures for individuals, families and businesses; and supporting the conversion of some factories to produce PPE and other medical devices (e.g. Armani and Mares). Further, it launched periodical calls for hiring additional healthcare workers to cope with the emergency and address personnel shortages: for example, more than 9,400 nurses applied to the March 28th call for 500 vacancies.

Finally, the shortage of PPE led to the appointment of a “Super Commissioner” in early March, with extra powers over managing the procurement of PPE and respirators for the entire country by the national government, highlighting the need for a country-wide response.

The Regional response

The Italian National Health System is, however, a devolved system where regional administrations have extensive powers to organize and allocate resources across providers and care settings within national guidelines and in the respect of national rules. During the crisis, regional governments and municipalities have often called for and implemented tighter containment measures to redress national measures. These ‘local’ interventions, often supported by evidence-based assessments, were aimed at addressing local health and healthcare needs (e.g. the saturation of ICU capacity).

The epicentre of the COVID-19 outbreak was located in Lombardy and several other Northern Italian regions, and in most Central and Southern regions, such as Umbria and Apulia, SARS-CoV-2 transmission has been mainly due to imported cases from the affected areas in the North.

Many regions established task-forces/units to manage the emergency, with the involvement of the scientific community and the not-for-profit sector. The healthcare workforce was increased through fast-track hiring of both medical and nursing students, and by allowing retired healthcare professionals to go back to practice. Most regions increased lab testing and hospital capacity by creating or converting hospital beds to intensive, acute or post-acute care dedicated to COVID-19 patients. Temporary filter/triage areas were often established outside hospitals. The response designed at the regional level often reflects pre-COVID-19 organization of the regional healthcare system. In this respect, Lombardy is known to have a strong hospital-centred system, different from other regions. This may have turned out to be a drawback given the increased risk of hospital transmission observed in the region and the fact that the majority of COVID-19 patients do not require hospitalisation. While the North was under pressure, Central and Southern regions had relatively more time to plan the response, set up a new configuration of healthcare services, and plan for stricter monitoring and managing of the disease in a primary care setting.

Screening strategies varied: while in some regions they targeted only symptomatic or even hospitalised patients and the healthcare workforce, Veneto tested more widely and this may have contributed to limiting the further spread of the virus.

Issues of great concern throughout the outbreak have been the extremely high proportion of cases (13,522) and casualties (133) among healthcare workers, and that several hotspots emerged in nursing homes across the country.

Good practices emerged: supporting fragile population groups with home delivery of medical devices and drugs (Apulia/Veneto/Umbria); sending facemasks to all families (Lombardy/Tuscany); monitoring nursing homes (Umbria); delivery of smartphones to hospitals to encourage communication between patient and family members (Emilia-Romagna).

Reflections on COVID-19 response in Italy

Italy was the first European country hit by COVID-19, with the highest number of deaths in the world, so far. It has also been the first country, outside of China, to impose strict lockdown measures. The Italian national and regional governments had to deal with an unprecedented trade-off between enforcing measures that impinge on individual liberties in a democratic system, and the need to contain, or at least mitigate, the spread of the virus. Some delays in lockdown enforcement, especially in closing non-essential production activities, resulted because of the need to acquire the consensus of both industry and union representatives.

Both the multi-level government structure and the decentralised healthcare system have enabled local governments (both regional and municipalities) to tailor their responses to local needs and to react proactively by adopting additional measures. However, this pluralism might have impeded faster and more integrated responses, and may have fuelled inter-governmental tensions.

In the early phase of the emergency slow compliance with public health measures and a flux of people travelling out of the most hard-hit regions towards the South (after the ministerial decree was prematurely leaked to the press), may potentially have had a negative impact on the spread of the outbreak in previously unaffected areas. Although, these regions took actions that may have allowed them to “flatten the[ir] curve” earlier and more effectively compared to the Northern ones.

This pandemic has hit the country after years of strict spending reviews and severe cost containment measures (see 2008 economic crisis) that have cut down resources to the healthcare system and hospital capacity. In the urgency of addressing COVID-19 patients in a hospital setting (with the doubling of ICU beds in the span of 15 days), Italy might have been slow in organizing an equally effective response at the primary/community level. The high level of infected GPs (as compared to all healthcare professionals) testifies the lower level of attention that this part of the healthcare workforce has received in the overall COVID-19 emergency response strategy.

In terms of use of the evidence, the Istituto Superiore di Sanità has played a role during the emergency by providing scientific advice (e.g. issuing of guidance on how to use PPE) and coordinating national data collection together with the Civil Protection Department. Alongside the national scientific and technical committee that supports the government, both institutions are in charge of delivering daily updates on the progression of the COVID-19 epidemic.

According to the April 9th update, the curve of COVID-19 inpatients (especially those requiring ICU) is decreasing, and the growth rate of total cases is slowing down. Yet, this is not the time to celebrate – the risk of relapse has been announced by the Prime Minister. A key challenge ahead is finding the best possible balance between keeping the virus under control while gradually lifting lockdown measures that are having tough economic and financial consequences.

Health Economics, Policy and Law serves as a forum for scholarship on health and social care policy issues from these perspectives, and is of use to academics, policy makers and practitioners. HEPL is international in scope and publishes both theoretical and applied work.

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