Dealing with COVID-19: Lessons Learned from the Italian Experience

The outbreak of COVID-19 has been challenging in Italy according to the latest data reported by the Higher Institute of Health [1]. As of June 25, 2020, there are 239,821 total cases of which 33,592 deaths nationwide related to severe coronavirus 2 infection (SARS-CoV-2) of acute respiratory syndrome (Fig. 1). The vast majority of cases were concentrated in four northern regions, Lombardy, Emilia-Romagna, Piedmont and Veneto, but all 20 Italian regions have reported cases of COVID-19. Of these, Lombardy was the epicenter of the Italian outbreak [2].

Three lessons emerged from the Italian epidemic of COVID-19 that can serve as a blueprint to improve future plans for the outbreak of viruses.

First, early reports on the spread of COVID-19 can help inform public health officials and medical practitioners in effort to combat its progression; second, inadequate risk assessment related to the urgency of the situation and limited reporting to the virus has led the rapid spread of COVID-19; third, an effective response to the virus had to be undertaken with coherent system of actions simultaneously.

We retrieved information on COVID-19 total cases and related deaths from various sources, including Istituto Superiore di Sanità, Presidency of the Council of Ministers, Department of Civil Protection. We also retrieved data from current literature and official documentation data on the development of COVID-19 outbreak and on the mitigation and containment measures undertaken by the Italian government.

Knowing the epidemiological pattern to trace the first cases, is very important because only in this way it can be understood how the outbreak of the virus began and how it spread. Furthermore, by tracing their contacts it is possible to immediately contain the spread of the virus, isolate it and avoid the pandemic. In Italy, the first case of secondary transmission occurred in Codogno, Lombardy, on February 20, 2020 [3]. He was a thirty-seven-year old man hospitalized in intensive care for pneumonia and tested positive for COVID-19 disease. In a more recent study [4], it has been shown that another patient 1 exists in Italy, is a man who lives and works in Milan, the capital of Lombardy, who was hospitalized for a case of pneumonia and was identified as positive for COVID-19, the same day as the man from Codogno. The analysis of the virus's genetic sequence concluded that the two patients were not infected by the same cluster. In early March, the phylogenetic analysis of the first 3 genomes obtained from the Italian SARS-CoV-2 isolated circulating in Lombardy and sequenced at the Luigi Sacco Hospital [5], demonstrated both the Chinese origin of the epidemic and their derivation from a cluster of genomes isolated in other European countries (particularly in Germany and Finland) and in Central-South America. The patient's index was not clear. The identification of the first case and the availability of genetic sequences could have provided Italy with a huge advantage to face the emerging global pandemic.

Unfortunately, several pulmonologists and infectious disease specialists continued to argue that the pathogen involved in the epidemic was a common Human Parainfluenza Virus (HPIV), a misinterpretation that prompted leaders, healthcare professionals and ordinary people to underestimate the danger, the contagiousness and virulence of COVID-19 disease and to waste precious time to combat its spread. The rapid evolution of the epidemiological situation made it necessary to strengthen the strategy to contain the outbreak of the disease.

The public health measures implemented in Italy (March 8, 2020) to reduce the spread of the COVID-19 epidemic included a surveillance system and activation of isolation, community containment with social distancing, communication to the population for the adoption of responsible lifestyles [6]. On March 8, the government declared a lockdown (movement prohibited, except for proven work needs or emergency situations) [7] in Lombardy, several provinces of Emilia-Romagna, of Veneto and of Piedmont. The initial decision of the government to impose the lockdown only to the regions of northern Italy, detonated a massive exodus in southern Italy and caused the spread of the virus in the regions where it was not present. After this unpleasant event, with the decree entitled “I stay at home”, the Prime Minister decided to apply drastic measures for public health, and extended the lockdown in entire country from 10 March [8]. Unfortunately, the government's response to the epidemic was not enough. No account was taken of the fact that pandemics develop in a non-linear way (they start slowly but intensify following an exponential trend) and are therefore particularly difficult to deal with.

Italian leaders did not understand that the best time to take effective measures was the initial one when there were few infections. Therefore, the Italian government responded to the epidemic by issuing a series of decrees which entailed gradual restrictions rather than immediate systematic interventions. In this way, Italy followed the spread of the virus rather than preventing it. An effective response to the virus had to be undertaken with a coherent system of actions and simultaneously.

The public health tools available to control person-to-person transmittable diseases, in the absence of vaccines and specific treatment [9, 10] should include: epidemiological pattern to trace the first cases; the availability of genetic sequences for the rapid identification of the new virus; epidemiological management on the territory through swabs for the detection of infections; active surveillance and local monitoring; community containment with social distancing; information for citizens to make them responsible; use of the mask; fast local lockdowns based on the number COVID-19 cases, considering the amount of people hospitalized and percentage of positive swabs.

In addition, it is necessary to understand that containment measures can serve to slow down the spread of a pandemic, but must be integrated with a rapid and effective reorganization of the entire health system, strengthening the hospital wards necessary for the treatment of serious cases; creating alternative structures for the diagnosis and isolation of infectious patients and their contacts; and greater training and protection of health workers.

In the above mentioned ways, it is possible to prepare a response system to face future disease outbreaks. Therefore, the lessons that emerged from the Italian epidemic COVID-19 can serve as a blueprint for improving future plans for the outbreak of viruses.

Lessons from all countries are needed to prepare a complete framework of actions to manage future health emergencies. If it is true that we live in a global village, we must think about these problems globally.