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The Italian government, with the Decree of the Presidency of the Council of Ministers of November 4, 2020, established that the Regions can be included in different risk zones, defined by some colors: the red zone, the orange zone, the yellow zone.
The entry of the regions into the different bands has been linked by the Ministry of Health to 21 parameters, which are listed below. The parameters – decided on April 30 by the Ministry of Health, and fed by the data transferred to the government by the Regions themselves – then lead to a synthetic decision, that is, to move to a range, with more or less standards restrictive derived from it.
The Regions, however, have asked the government with a letter to modify the parameters used to decide the movements in the different bands.
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The Regions write that the indicators are no longer suitable for current monitoring, because they are designed for a different epidemiological situation, and propose other indicators, namely these:
1. The percentage of positive swabs, excluding, as far as possible, all detection and re-evaluation activities of the same subjects, in general and by macro context (territorial, HCP / hospital, other) per month. Also enter rapid antigen tests, otherwise the denominator is wrong.
What does that mean? Depending on the region, retesting people who tested positive should not be counted, and may do more intermediate swabs before turning negative. The simple reason: if I am positive, I take a swab to see if I have turned negative, but I am still positive, the current system counts one more positive swab; the regions ask instead not to count it, because the number of positive people does not increase.
Regions are also calling for rapid antigen tests, which are currently not counted, to be included in the count. By including these tests, which are also used in bulk, the denominator increases: and therefore the percentage of positivity (number of positives divided by the total number of swabs or tests) could drop dramatically.
2. Rt calculated on the basis of the integrated ISS surveillance
The Rt index is calculated in this way.
3. Occupancy rate of total ICU beds (code 49) for patients with COVID-19.
4. Occupancy rate of the total beds in the medical area for COVID-19 patients.
5. Ability to ensure adequate resources for contact tracing, isolation and quarantine:number, type of professional figures and time / person dedicated to locating contacts in each territorial service
In summary, as explained by the president of the Autonomous Province of Trento, Maurizio Fugatti, we ask to evaluate the percentage of buffers (and tests, ed) positive on those carried out, the Rt index, the occupancy rate of beds in intensive care, the occupancy rate of hospitalized positions and the ability to carry out contact tracing. It is not known, explained Fugatti, if the Government will accept to modify the parameters n, if so, when the provision will finally come into force.
The Minister of Health, Roberto Speranza, said that the dialogue with the regions is always open, but that it is the 21 parameters that indicate the risk index, together with the RT, and determine what measures to implement in the territories: in short, for now, no changes are expected in the adopted criteria.
And also the president of the Higher Institute of Health, Silvio Brusaferro, defended the use of multiple indicators, saying that it is very important to understand that when managing an epidemic, one works in a real world with all the variables of the case and there must be a reading capacity in a highly articulated reality. Precisely because it requires more indicators, it is an important element that leads to an estimation of risks. Risk estimation is a tool that, when assembling risk unifiers, is a system that accompanies us in identifying the risk of the epidemic getting out of control.
The 21 parameters of government
The 21 parameters that the government still uses, indicated in a provision of the Ministry of Health of April 30, must meet three requirements:
1. tracking ability
2. ability to diagnose, investigate and manage contacts
3. results related to the stability of transmission and the resilience of health services
Monitoring capabilities
1. Number of symptomatic cases reported per month in which the date of symptomatic onset is indicated / total symptomatic cases reported to the surveillance system in the same period.
2. Number of cases reported per month with a history of hospital admission (in rooms other than the ICU), indicating the date of admission / total cases with a history of hospital admission (in rooms other than IT) notified to the surveillance system in the same period .
3.Number of cases reported per month with a history of transfer / admission to the ICU with an indication of the date of transfer or admission to the ICU / total cases with a history of transfer / admission to the ICU notified to the surveillance system during the same period.
4. Number of cases notified per month in which the municipality of domicile or residence is notified / total of cases notified to the surveillance system in the same period.
5. Number of weekly checklists administered to residential and healthcare facilities (optional).
6. Number of residential social and health structures that respond weekly to the checklist with at least one criticality found (optional).
Ability to diagnose and manage contacts.
1. Percentage of positive swabs excluding, as far as possible, all detection and “reevaluation” activities of the same subjects, in general and by macro context (territorial, HCP / hospital, others) per month.
2. Time between the date of appearance of symptoms and the date of diagnosis.
3. Time between the date of onset of symptoms and the date of isolation (optional).
4. Number, type of professionals and time / person dedicated in each territorial service to locating contacts.
5. Number, type of professionals and time / person dedicated in each territorial service to sampling / sending activities to reference laboratories and monitoring of close contacts and cases placed respectively in quarantine and isolation.
6. Number of confirmed cases of infection in the region for which a periodic epidemiological survey has been carried out with a search for close contacts / total of new confirmed cases of infection.
Stability of transmission and stability of health services.
1. Number of cases reported to Civil Protection in the last 14 days.
2. Rt calculated on the basis of integrated ISS surveillance (two indicators will be used, based on the date of onset of symptoms and the date of hospitalization).
3. Number of cases reported to COVID-net sentinel surveillance per week (optional).
4. Number of cases by date of diagnosis and date of onset of symptoms reported to the integrated surveillance of COVID-19 per day.
5. Number of new transmission outbreaks (2 or more epidemiologically linked cases or an unexpected increase in the number of cases at a defined time and place).
6. Number of new cases of confirmed SARS-CoV-2 infection per region not associated with known transmission chains.
7. Number of accesses to the PD with ICD-9 classification compatible with syndromic frameworks attributable to COVID-19 (optional).
8. Occupancy rate of the total ICU beds (code 49) for patients with COVID-19.
9. Occupancy rate of the total beds in the medical area for COVID-19 patients.
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