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April 7, 2020

What Other Countries Can Learn From Italy During the COVID-19 Pandemic

Author Affiliations
  • 1Section of Hygiene, University Department of Health Sciences and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
  • 2Department of Woman and Child Health and Public Health, Public Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
  • 3Stanford Prevention Research Center, Department of Medicine, School of Medicine, Stanford University, Stanford, California
  • 4Meta-Research Innovation Center at Stanford (METRICS), Stanford, California
JAMA Intern Med. 2020;180(7):927-928. doi:10.1001/jamainternmed.2020.1447

In the coronavirus disease 2019 (COVID-19) pandemic, Italy has been hit very hard,1 with 110 574 documented cases and 13 155 documented deaths related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as of April 1, 2020. The number of cases and deaths cannot be explained simply because of the epidemic starting in Italy earlier compared with other countries besides China. It is important to understand why death rates were so high in Italy to learn how to best prepare and how to plan for optimal actions in other countries. Some contributing factors may be immutable (eg, age structure of the population), but even these need to be laid out carefully in preparedness assessments. Some other contributing factors are potentially modifiable.

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    6 Comments for this article
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    collateral damage
    Carol Vassar, MD | retired community faculty UVM
    We could learn from the experience in Italy a possible effect that such a disruption has on other patients. What was the effect on mortality for patients (and the population) that did not have COVID 19. How did that compare to other years. Knowing how this effected the rest of the population could influence the cooperation of the public. It would also be important for planning.
    CONFLICT OF INTEREST: None Reported
    Mortality comparison
    Lovel Giunio |
    Decisions have to be made on insufficient data. It is vital to question and reevaluate decisions as soon as new data and new ideas arrive. Contrarians are as important as data gatherers, and should be treated with civility, and arguments exchanged in honest discussion until a level of knowledge is reached that is necessary to make the next set of decisions. In many instances, it should be appreciated that there are not enough data, and many different explanations are valid, even if some less likely to be true. 

    On the other hand, contrarians should be ready to return the
    favor and clearly acknowledge when events, data, or arguments/logic prove some of the contra concepts wrong, enabling search for truth to move on without losing energy on dead avenues/zombie ideas.
    It would be nice to know if there are data on the number of deaths in affected Italian regions and cities in 2019 as compared to 2020. It would probably add to our understanding of the burden of disease from COVID-19 and enable us to better predict the needs and allocate necessary resources.
    CONFLICT OF INTEREST: None Reported
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    Italy's regional data comparisons will allow for a better understanding of the epidemic dynamics
    Caterina Zanetti, MD, PhD | University Hospital of Padua
    Authors state that it is difficult to predict the effects of specific major public health decisions, such as lockdowns, on the course of the COVID-19 pandemic.
    Italy is a decentralized country. The national lockdown occurred at a time (March 10, 2020) when cases were unevenly distributed across the country: many thousands of cases and many hundreds of fatalities were already registered in Lombardy, Emilia, and Veneto, as opposed to few cases and fatalities registered among other regions.
    So, comparing Italy's regional data, we will be able to analyze the effect of an early lockdown, as opposed to a late lockdown,
    not only on the number of cases and fatalities but also on the surge capacity, the flattening of the contagion curve, and other health care outcomes.
    CONFLICT OF INTEREST: None Reported
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    Air Pollution and COVID19.
    Enrique Barros, M.D. | Universidade de Caxias do Sul
    Ioannidis et al, help clarify the state of scientific uncertainties arising from the COVID19 related high death toll in Italy. One other puzzle piece to investigate is the role of ambient air pollution, as some cutting edge research findings point to ambient PM2.5 levels as a significant contributor to COVID19 death toll in New York City. (https://www.medrxiv.org/content/10.1101/2020.04.05.20054502v1.article-metrics).
    CONFLICT OF INTEREST: Received a refund from the WONCA Air Health Train-the-Trainer Program
    Use of convalescent plasma during the epidemic
    Anthony Smithyman, BSc, PhD | Research Laboratory
    As an immunologist I would be interested to learn from the Italian experience whether convalescent plasma/serum ( from the 34,000 recoverees) has either already been used, or is projected to be used to treat COVID-19 patients during this crisis. If so this information would be extremely valuable for other regions/countries just entering the exponential infectivity phase.

    If not, what were the reasons for not using this form of treatment? Scarcity of plasma, regulatory issues, lack of data, insufficient proof, or blood bank system simply overwhelmed? Italy has a highly sophisticated medical structure and it would be surprising if this
    century old method had not been attempted in at least some centres.

    In the absence of a vaccine we are not exactly overwhelmed with effective treatments at the moment so any information on the use of passive immunity in Italy I'm sure would be much appreciated by the global community.
    CONFLICT OF INTEREST: None Reported
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    Italy’s experience underscores the need for effective chronic disease management in the global response to COVID-19
    TONY KUO, MD, MSHS | University of California, Los Angeles (UCLA)
    We read with great interest Boccia et al.’s recent article on what other countries can learn from Italy’s experience during the COVID-19 pandemic [1]. With 110,574 documented cases and 13,155 documented deaths as of April 1, 2020, the authors rightfully cautioned against rushed interpretation of death rates and immutable (e.g., age structure) as well as modifiable factors that may have contributed to this health crisis. The authors made an important distinction between deaths with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection versus deaths caused by the virus, pointing out that 98.8% of patients who had died had at least 1 comorbidity and 48.6% had 3 or more, most of which were chronic in nature. Collectively, the data and the lessons presented suggest the importance of chronic disease (especially if uncontrolled) in fueling this pandemic, posing as a modifiable risk factor for complications and death due to SARS-CoV-2.

    With 694,296 confirmed cases and 31,456 deaths as of April 18, 2020, the United States has surpassed much of the world in SARS-CoV-2 infection [2]. Much like Italy’s experience, the disease burden has fallen disproportionally on the older adult population with multiple underlying conditions – most of them chronic – including those attributed to adverse health behaviors (e.g., smoking). Preliminary estimates from the CDC COVID-19 Response Team found that among infected patients who were admitted to the intensive care unit, 78% had one or more chronic conditions, including diabetes (32%); cardiovascular disease (29%); chronic lung disease defined as asthma, chronic obstructive pulmonary disease, or emphysema (21%); chronic renal failure (12%); and tobacco use (8% were either current or former smokers) [3]. Not surprisingly, as the pandemic sweeps through the United States, long-term care facilities, which houses many of these individuals, are being hit the hardest.

    Italy’s experience has reverberated around the globe. As the United States and other countries begin to consider exit strategies from lockdown, government leaders and public health authorities may do well to strengthen the infrastructure for chronic disease management. Proven initiatives such as leveraging health information technology (e.g., clinical decision support, health information exchanges, disease registries, expansion of telehealth), team-based care with all members practicing at top of license, and quality-based performance incentives should be rapidly deployed. To date, optimal control of chronic comorbidities represents an overlooked but critical component of the COVID-19 response and of the forthcoming effort that will be needed to recover from this pandemic [4,5].


    Tony Kuo, MD, MSHS
    UCLA Departments of Family Medicine and Epidemiology

    Steven Chen, PharmD, FASHP, FCSHP, FNAP
    USC School of Pharmacy

    Michael Hochman, MD, MPH
    USC Gehr Family Center for Health Systems Science and Innovation


    References
    1. Boccia S et al. JAMA Intern Med. 2020 Apr 7. DOI: 10.1001/jamainternmed.2020.1447
    2. Johns Hopkins University & Medicine Coronavirus Resource Center: https://coronavirus.jhu.edu/us-map.
    3. CDC COVID-19 Response Team. MMWR Morb Mortal Wkly Rep. 2020 Apr 3;69(13):382-386. DOI: 10.15585/mmwr.mm6913e2
    4. Fineberg HV. Editorial. N Engl J Med. 2020 Apr 1. DOI: 10.1056/NEJMe2007263
    5. Di Domenico L et al. Report #9: https://www.epicx-lab.com/uploads/9/6/9/4/9694133/inserm-covid-19_report_lockdown_idf-20200412.pdf
    CONFLICT OF INTEREST: None Reported
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