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To establish the new restrictive measures defined by the new DPCM and try to contain the infection in the individual regions, “old” data, collected last Friday and referring to the week between October 19 and 25, will be used. The decision was made from the control room of the coronavirus emergency. In the meeting held yesterday morning it was revealed that the data collected in the last seven days is not enough to develop a new monitoring and, among other things, a serious deterioration in communications by the regions, which send numbers incomplete.
Having reliable and up-to-date data on the progress of the epidemic is essential above all to adopt “differentiated and well-targeted” measures, in the selective logic proposed yesterday by Prime Minister Giuseppe Conte. However, it is not easy to understand what this data is, where it is collected and who analyzes it, and what are the alert thresholds that trigger restrictive measures at the national level or in individual regions. The figures that the government considers are not only those that Civil Protection publishes daily: they are also others, and they must be contextualized with care.
In summary, all parameters and data are contained in four documents. The first is the “roadmap” for monitoring health risk, that is, a protocol of actions that mark the phases of the epidemic. Then there are the 21 indicators for risk control, which are the numbers used to understand if the situation is serious or not. The third document, entitled “Prevention and response to Covid-19”, was prepared in mid-October by the Higher Institute of Health and defines the four alert scenarios and the possible evolution of the emergency. And finally, the individual DPCMs -like the last one- that translate the scenarios obtained from the data into operational decisions, such as the closure of regions or sectors of work. We will examine everything in detail below.
The premise is that an epidemic, especially this epidemic, is a difficult phenomenon to decipher. Not only for politics, as we have seen around the world, but also for the most experienced epidemiologists. A single number cannot explain what is happening, what the problems are, and how to intervene. That is why the implemented solutions are so complex.
The roadmap
The first scheme that defines the phases of health risk monitoring was attached to the Decree of the Prime Minister signed on April 26 and at that time it was important to know what the conditions were to leave the confinement. At first glance, and not just at first glance, it is very complex.
There is a beginning – “assess whether there are minimum standards of epidemiological surveillance quality” – and an end, simply called “end of the pandemic”, followed by a phase called “preparation” for possible new epidemics.
The roadmap contained in the Decree of the Prime Minister of April 26
Phase 1, or blockade, is activated if the minimum standards of epidemiological surveillance are not respected, therefore, when the infection is so severe that swab screening is ineffective. A condition that occurred seven months ago, in March, when the national shutdown was decided.
Phase 2A is an assembly phase of trend evolution. To start the emergency exit, there must be an improvement of at least 60% of a series of parameters: number of symptomatic cases reported per month in which the date of onset of symptoms is indicated; number of cases reported in the month with a history of hospitalization, ward or intensive care; number of notified cases in which the municipality of domicile is reported. In short, a significant decrease in new infections and new hospitalizations.
The analysis of these data leads to assess whether “the transmission of Covid-19 in the region is stable.” Stability is verified in a period of 14 days through the number of cases reported by civil protection, the number of new outbreaks and the R indext calculated by the Higher Institute of Health, that is, the index used to measure how much the virus is transmitted and which “represents – to use the definition of the Ministry of Health – the average number of infections produced by each infected individual after the application of the virus. measures to contain the epidemic itself “. Therefore, it is a very useful tool to evaluate the effectiveness of restrictive measures.
– Read also: Explanation of the positivity rate of swabs
At this point on the roadmap there is also the opportunity, if the data shows a decided increase in some areas, to “establish a subregional red zone.”
In phase 2A, other important criteria are introduced to verify a possible deterioration, such as the verification of any overload of the health systems, the ability to promptly test all suspected cases, the possibility of guaranteeing adequate resources for the location of contacts, isolation and quarantine. These are all the problems Italy is facing at the moment.
In summary, at the end of April it was already clear which were the main critical problems that the regions would face without adequate prevention.
The last two phases of the roadmap are number 3, which can only be reached with the arrival of the vaccine or “generalized access to treatments”, therefore with a containment of the infection without putting pressure on hospitals. . The fourth phase, as already mentioned, is called “preparation” and it means that the epidemic is behind us.
The 21 indicators
The 21 indicators studied to verify the severity of the epidemic contain the values of the alert thresholds that must be monitored through data collection at the local and national levels.
The indicators are grouped into three areas. The first measures the data collection capacity of individual regions.
The first area of indicators designed to monitor the epidemic (Quotidiano Sanità)
The second area refers to the ability to test all suspected cases and the ability to ensure adequate resources for contact tracing, isolation and quarantine. One of the most important thresholds refers to the median time between the onset of symptoms and the date of isolation: it should not exceed three days. On contact tracing, one of the biggest issues this fall, the regions are being asked for a periodic report to understand whether the right forces have been deployed to track the cases. At the moment, almost all regions do not seem to meet this parameter. In fact, it is now clear that contact tracing has been omitted in many areas. Already in this decree of six months ago, however, it was recommended to guarantee this task “no less than 1 person for every 10,000 inhabitants, including epidemiological investigation activities, contact tracing, quarantine monitoring, swab execution”. “.
The third area of parameters used to monitor the epidemic (Quotidiano Sanità)
The third area of indicators, on the other hand, considers above all the stability of the health services, that is, the pressure on the hospitals, and the monitoring of the transmission of the infection as observed every day through the Civil Protection data .
– Read also: How to read data on intensive care
The list of 21 indicators provides for the monitoring of nine parameters, including nonumber of new outbreaks, number of accesses to the emergency room due to coronavirus, occupancy rate for beds in intensive care.
(Photo Cecilia Fabiano / LaPresse)
All the data collected are analyzed by two evaluation algorithms that in turn generate a risk matrix, “defined as the combination of the probability and the impact of a health threat.” For simplicity, all these parameters are used to determine the probability that the health situation will worsen. With a high impact and a high probability of getting worse there is a risk defined as “very high”.
It must be said that regions cannot always collect this data, which limits the understanding of the situation. Several times in recent months, the Scientific Technical Committee has called for greater investment from the regions to collect data with greater precision. In the latest weekly ministry report it was explicitly written: “There is increasing difficulty in finding complete data due to the severe overload of local services, this could lead to underestimating the transmission speed in particular in some regions ”. It is a major problem.
– Read also: Is a confinement only possible for older people?
The four scenarios
In mid-October another document was approved that contemplates four possible scenarios for the evolution of the epidemic. It is called “Prevention and response to Covid-19: evolution of the strategy and planning in the transition phase for the autumn-winter period” and has been studied by the Higher Institute of Health, Ministry and Regions in collaboration with Civil Protection, Aifa , Inail, Instituto Spallanzani, Universidad Católica, Areu 118 Lombardia and Fundación Bruno Kessler.
All four scenarios are based on the data we have reported so far and are clearer than the decrees.
Scenario number 1 is the “localized transmission situation (outbreaks) substantially unchanged compared to the period July-August 2020.” So it has already been overtaken by the growth of infections in recent weeks.
The second scenario identifies a “situation of sustained transmissibility” with an index Rt always between 1 and 1.25. Again, in some regions the Rt, which allows monitoring the effectiveness of interventions during an epidemic, is already above 1.5.
– Read also: Immuni is not working, but it could
Scenario number 3 identifies a “situation of sustained and generalized transmissibility with risks to the health system in the medium term”, with regional Rt values always between 1.25 and 1.5. With this scenario, “the growth in the number of cases could cause an overload of healthcare services in 2-3 months”.
The fourth scenario, the worst, shows the consequences of a “situation of uncontrolled transmissibility, with regional Rt values higher than 1.5”. The study explains that such a scenario could lead to a high number of cases and an overload of healthcare services, without the possibility of tracking the origin of new cases.
– Read also: Contact tracing no longer works
Policy translates scenarios into operational decisions. In the last DPCM, for example, in the regions that fall under scenario 4, it will be prohibited to leave the house except for proven work needs or situations of need, that is, almost only for health reasons.
All the measures decided in the DPCM may change over time, with the green light of other DPCMs, depending on the evolution of the epidemic, as has happened in the last three weeks with the approval of three measures to limit the transmission of the infection .
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