Learning from variation in Northern Italy in response to COVID-19

One of the major issues when discussing pretty much anything is the tendency to aggregate nations into a single unit and then compare to other nations that are not comparable. For example, the United States is a federal republic of 330 million people. New York state is not Washington state. And neither is Texas.

The same applies to Italy, which is a diverse nation of 60 million. The normal way to understanding Italian variation is from north to south. But, during the recent COVID-19 outbreak one aspect that is important to note is that Lombardy and Veneto in the Po river valley have taken very different tracks. Lombardy is about twice as populous as Veneto but has five times as many confirmed cases of Covid-19. And 15 times the death toll (8905 vs. 631 dead as of April 5th).

A Italian-speaking friend, who has been tracking the Italian press notes that the big difference seems to be that Veneto is attempting to implement the test-and-trace philosophy that South Korea rolled out. And, in Veneto, they aggressively test people who are not symptomatic to catch silent spreaders who don’t exhibit Covid-19 (in contrast to Lombardy where they tend to test once symptoms present and not even always then).

Below is a recent interview with professor Andrea Crisanti, quickly translated from Italian, where he outlines his philosophy and the path he sees forward for getting COVID-19 under control.

[begin translation]

The virologist behind widespread swab testing in the Veneto signs off on a study with Neil Ferguson, the English statistician who changed Boris Johnson’s mind: “The data show the efficacy of restrictions. Those infected should be in hotels in order to not spread the virus within their immediate family”.

“It would be best to wear masks and gloves even at home. And above all to limit to the absolute essential any use of shared spaces at home. I realize the sacrifice but the results of our study on the probability of infection clearly demonstrate the absolute efficacy of these restrictions.”

Even at the cost of his popularity, Professor Andrea Crisanti is pushing forward on a new front in the fight against the virus. After the idea of widespread testing, which in the Veneto seems to have worked, he is back with a proposal that will make families sigh: masks even inside the walls of the family home.

Cristanti makes this recommendation after deep analysis of the epidemiological data with 40-some collaborators including researchers and technicians divided into two working groups, an Italian one associated with the hospital and University of Padua where he is director of the department of molecular medicine, and a British one coordinated by Neil Ferguson from Imperial College London, the mathematician who changed Boris Johnson’s mind and converted him to adopting a more aggressive strategy.

The study, born from the research on Vo’ Euganeo, will soon be available to the international scientific community. These, in a nutshell, are the conclusions: if there’s a positive case in the family, the risk of being infected is 84 times higher than the norm; so by identifying and isolating all the infected cases, the reproductive capacity of the virus (R₀) falls immediately from 2 to 0.2. With isolation, you eliminate transmission, even without imposing drastic containment measures on the rest of the population. After having reconstructed and traced all the chains of transmission, from which children are excluded, it is estimated that the first cases of infection in Vo’, the outbreak with the first death in Italy, date back to the second week of January.

Professor Crisanti, after weeks of shutdown, masks at home could seem useless. You begin to feel that if you haven’t already caught it the danger has passed.

No, that’s not the case. The cases are piling up. People don’t all get sick at the same moment. We see a progression.  They arrive at hospital in bunches, entire nuclear families. This means that if we don’t watch out, our family homes can be transformed into so many little outbreaks of infection. Let’s say that at this moment, those most protected are the singles. It would be worth accompanying any such strictures with a serious public information campaign. It’s really not that easy to defend yourself from infection.

Besides gloves and masks, how do we find our way out of this again?

You need decisive action. It would be useful to go into private homes and do testing at least of all those who have recorded mild symptoms. And then all the family members and everyone else who was in contact with the infected subjects. And not just that. It would be very useful to transfer everyone who tests positive into ad hoc structures. Naturally I’m speaking of those with symptoms mild enough not to require hospital admission.

And which structures do you have in mind?

I’m thinking, for example, of hotels left empty. There are tons of hotels and they’re comfortable too. Those who had tested positive would naturally be able to keep in touch with their families. A decision like this ends up being political because it would require investment. We are nevertheless discussing it. We could move ahead with a couple, three pilot studies in areas with the greatest lodging density like Venice, Padua and spa towns.

Is there not a risk of creating a sort of leper colony?

Absolutely not, certainly not in any negative sense. They would be entirely dignified accommodations just for as long as those infected need to recover. This is a health emergency and it has to be faced with the weapons of science, of epidemiology. The leper colony, the ghetto and walls all represent the furthest thing from my ideal world. But here, walls serve to save. Here, to get back to our freedom and unity we must as a matter of course resort to separation.  The source of contagion within families is important, even more than the other two: the unruly minority who go out in public (defying stay-at-home orders), and those who are obligated to work through the shutdown.

When can we hope to first see the much awaited results?

Indicators tell us that finally something good is happening, even if the deaths are still so many. I’m confident.

We are expecting more weeks of complete shutdown. What will a return to work look like?

We have to define an acceptable level of risk because zero does not exist. Naturally, the timing will be dictated by politics. I can only say what would be worth doing from a public health standpoint.

And what would be worth doing?

Swab testing and serological testing on a large scale in order to avoid introduction into a workplace setting by infected workers. In the case of a new outbreak, you’d have to immediately shut down that hotspot. It would be wise to open gradually region by region.

As in?

I would first reopen areas where the risk of transmission is lowest, like Sardegna, provinces like Cagliari, Oristano.  And I would keep for last Lombardy, Bergamo in particular. But you have to be fast and timely. Because I have to say that the worst evil in the fight against coronavirus has been this: bureaucracy. We could have done so much and done it immediately.