Protecting our health care workers while protecting our communities during the COVID-19 pandemic: a comparison of approaches and early outcomes in two Italian regions, 2020

  1. Nancy Binkin
  2. Federica Michieletto
  3. Stefania Salmaso
  4. Francesca Russo

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Abstract

Introduction

Italy, which has been hard-hit by the COVID-19 pandemic, has an overriding national strategy, but its 21 regions have adapted their response based on the organization of their curative and public health services. In this paper, we compare short-term outcomes for two northern Italian regions which had almost simultaneous initial outbreaks: Lombardy, which had a patient-centered approach that relied on primary care physicians and hospital care, and Veneto, which focused on community-based diagnosis and care.

Methods

We used numerator and denominator data from public Italian government sources to calculate reported rates of COVID-19 testing/1000, COVID-19 cases/100,000 overall and for health care workers (HCWs) and non-HCWs, deaths per 100,000, and the percent of cases admitted to hospitals and ICUs for February 24-April 1, 2020.

Results

As of April 1, 2020, Lombardy experienced 44,733 cases and 7,539 deaths; for Veneto, the corresponding values were 9,625 and 499. The cumulative case rate was 445/100,000 for Lombardy and 196/100,000 for Veneto, a 2.3-fold difference. Mortality rates were 7.5 times higher in Lombardy than in Veneto (75/100,000 and 10/100,000, respectively). Cumulative rates of testing were nearly twice as high in Veneto and were 2.7 times higher in the first week of the epidemic. In Lombardy, 51.5% of patients were admitted, including, 5.2% to intensive care units; for Veneto, the corresponding figures were 25.1% and 4.3%, respectively. HCWs account for 14.3% of all cases in Lombardy compared with 4.4% in Veneto. In Lombardy, the rate among HCWs was 19.1 times higher than in the general population (6,924/100,000 versus 362/100,000), while in Veneto it was 3.9 times higher (676/100,000 versus 172/100,000).

Discussion

The community-based approach in Veneto appears to be associated with substantially reduced rates of cases, hospitalizations, deaths, and infection in HCWs compared with the patient-centered approach in Lombardy. Our findings suggest that the impact of COVID-19 can be reduced through strong and aggressive public health efforts to confirm and isolate initial cases and contacts in a timely way and to minimize unnecessary contact between HCWs and cases through home-based testing and pro-active home follow-up.

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  1. ScreenIT

    SciScore for 10.1101/2020.04.10.20060707: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    This study has several limitations. It is an observational study based on the experience of only two regions, and because of its observational nature, it is difficult to draw indisputable causal relationships. Lombardy experienced a more rapid initial explosion of cases, and had the onset been slower, there might have been time to organize and implement more public health measures to reduce transmission in the community. Additionally, this study represents a point in time, with Italy now only beginning to experience a decline in new cases. As cases continue to occur, the presumptive impact of the Veneto approach may lessen as the public health system and hospitals become increasingly strained. In terms of methodological limitations, case and death reporting may have differed between the two regions. Veneto, with its real-time integrated information system, may have had more complete and accurate case reporting. However, if cases and deaths were more likely to be notified than in Veneto than in Lombardy the effect would be to underestimate rates for Lombardy and increase, rather than decrease observed differences in the case and death rates between the two regions. Differences in HCW testing could have also affected our results. HCWs in Veneto who have been in close contact with cases but do not have symptoms are tested three times over fourteen days as part of the policy to keep them on the job. This testing policy in Veneto would likely lead to the detection of more HCW case...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

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  2. Version published to 10.1101/2020.04.10.20060707v2 on medRxiv
  3. Version published to 10.1101/2020.04.10.20060707v1 on medRxiv