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Gerardo Astorino

Professore a contratto a titolo gratuito

Dipartimento di Scienze Mediche e Chirurgiche


  1. COVID-19 cases before and after the “I stay at home”
    decree, Bologna Local Health Authority, Italy

    Elisa Stivanello, Vincenza Perlangeli, Davide Resi, Paolo Marzaroli, Lorenzo Pizzi,Paolo Pandolfi on behalf of the Bologna Public Health Department COVID-19 group*
    Department of Public Health, Azienda USL di Bologna, Bologna, Italy
    *The members of the Bologna Public Health Department COVID-19 group are listed at the end of the article
    Summary. Background and aim of the work: Various measures have been taken by the Italian Government to contain and mitigate the COVID-19 outbreak and on March 11th a decree called “I stay at home” put the whole nation under lockdown. Our aim is to describe sociodemographic and transmission profile of COVID-19 cases that were transmitted before and after the introduction of the decree in the Bologna Local Health Authority. Methods: Cases were classified as transmitted before or after the decree according to the date of last contact with a COVID-19 case or, if this date was unavailable, we used the date of onset of symptoms considering the incubation period. Sociodemographic, clinical and epidemiological information was
    collected by using the infectious disease monitoring database, hospital discharge, deprivation index and long term care facility databases. Results: In the period after the publication of the decree, there were more elderly, females, strangers, retired, residents in nursing homes and deprived people than in the first period. There were
    also more health care personnel and less professionals/managers, sales or office workers. In both phases, family is mentioned as the first community attended although less frequently in the second group. Conclusions: The profile of the new COVID-19 cases changed during the outbreak suggesting a differential effect of lockdown
    measures on the population. An equity lens should be used when analyzing the impact of pandemia and the measures taken to curb it. ( Key words: COVID-19, mitigation measures, containment measures, prevention, equity Acta Biomed 2020; Vol. 91, N. 3: IN PRESS DOI: 10.23750/abm.v91i3.9750 © Mattioli 1885
    COV I D - 1 9 u p d at e
    At the end of December 2019, China reported a cluster of pneumonia cases of unknown origin that would later be identified as severe acute respiratory syndrome coronavirus 2 (1). Since then, the disease,
    designed as Coronavirus Disease (COVID-19), spread to various countries and was declared a pandemia on March 2020 by WHO (2,3).
    Measures to contain and mitigate the epidemics have been taken by different countries. Containing measures including case isolation, contact tracing, quarantine and mitigation measures including general
    lockdown and social distance, seem to have worked (4) during the COVID-19 outbreak in China. Systematic review suggested that social distancing measures can be effective interventions to reduce transmission and mitigate the impact of an influenza pandemic (5). Nevertheless, given the many uncertainties regarding pathogen
    transmissibility and virulence, the effectiveness and generalizability of these efforts are still unknown (5,6).
    Timing, duration and compliance of the implementation of these measures increase the variability and the delay of their effect. It is also unknown whether they impact differently on different populations and whether in some population subgroups their effect is more rapid.
    2 E. Stivanello, V. Perlangeli, D. Resi, et al.
    In Italy the first local case of COVID-19 was diagnosed on 20 February and since then the epidemic spread in many regions disproportionately, hitting some northern areas with an exponential rise (7,8).
    The Italian Government took several restrictive measures during the following weeks, at the beginning at a local scale and with a containment goal and later at a national scale and with a mitigation goal: mandatory quarantine, active surveillance, suspension of all public events, banning of mass gatherings, closure of all educational
    institutes, and finally on 11 March a decree labeled “I Stay at home” was issued. This decree put the entire country under lockdown. All commercial and administrative activities that were considered not
    essential were suspended, all movement of people was forbidden unless for proven necessity (health, work or food supply) and self isolation when sick was highly recommended. The number of new cases kept on increasing till March 20 and then slightly decreased and
    as on April 14th they were 2972 new daily cases (9,10).
    Our aim is to describe the sociodemographic and transmission profile of COVID-19 cases that were transmitted after the introduction of the “Stay at home” decree in the Bologna Local Health Authority
    (LHA), Northern Italy as of April 14thand compare them with the cases transmitted before the introduction of the decree.
    Methods Bologna LHA is in the Emilia Romagna Region, the Italian region that as of April 14th has the highest number of COVID-19 cases after Lombardy. Bologna LHA covers an area of about 880.000 inhabitants.
    The new cases were classified into two groups: “before decree” group if the date of contact with a COVID-19 case was before 12 March (first day of the implementation of the decree) and as “after decree”
    group if the date of contact was 12 March or afterwards.
    If the date of the last contact with a confirmed
    case was unavailable we used the date of onset of
    symptoms. If the onset of symptoms occurred before
    14 March we classified the case as transmitted before
    the lockdown, if the onset of symptoms occurred after
    March 25 (date of implementation of the decree + 14
    days for the incubation period) we classified the case
    as transmitted after the decree. In order to avoid any
    misclassification, all other cases were excluded.
    Confirmed cases and contacts are defined according
    to ECDC (11). Diagnostic testing is done in accordance
    with the Ministry of Health Guidelines (12).
    During the study period the test was performed only
    to subjects with an epidemiological link with another
    case and symptoms such as fever and/or cough and/or
    dyspnoea or to subjects with an interstitial pneumonia.
    In Bologna, since the beginning of the outbreak, all
    confirmed cases of COVID-19 occurring in the area
    are notified at the Public Health Department who carries
    out contact tracing and surveillance according to
    national protocols. People with confirmed COVID-19
    are interviewed by telephone to collect information
    on profession, clinical and transmission characteristics
    (symptoms, date of onset, travel history, and close
    contacts with known COVID-19, attendance for any
    reason of community and dates of last contact with
    positive cases). All the information is registered in a
    regional electronic database (SMI: Infectious Disease
    Surveillance) that already contains the main demographic
    information (age, gender, residency, citizenship)
    of all residents. When cases are unable to be interviewed
    because of physical or cognitive problems,
    medical personnel or cares are involved.
    The SMI database was the main tool we used to
    identify the new cases and to retrieve most of the sociodemographic
    and transmission characteristics. We
    grouped profession as: managers/professionals, sales
    workers/office staff, semiskilled and unskilled workers,
    all health personnel (physicians, nurses, assistants,
    chemists, laboratory and radiology personnel, cleaners,
    ambulance drivers and all other personal service), service
    workers (excluding health personnel), retired and
    other non working categories. Urban residency was attributed
    to cases with a residency in Bologna town. We
    grouped the community that the cases mentioned as attended,
    into five categories: family, hospital, work (excluding
    hospital environment), long term care facilities
    (LTCF) and others. As LTCFs include a broad spectrum
    of homes for elderly, to identify the residents in
    nursing home, we used the nursing home database. In
    addition to each case we attributed the Charlson Comorbidity
    Index to clinically characterize the populaCOVID-
    19 cases before and after the “I stay at home” decree, Bologna Local Health Authority, Italy 3
    tion. This index considers 19 categories of comorbidity
    that are defined by using the hospitalization discharge
    database of the two previous years (13). In this paper
    this index is expressed in 3 categories: no comorbidity,
    one comorbidity and two or more comorbidities.
    To describe the socioeconomic feature we used
    the Deprivation Index. The Deprivation index is developed
    using variables from the 2011 General Census
    of Population and Housing (14). Five traits that represented
    the multidimensionality of the social and material
    deprivation concept were considered: low level of
    education, unemployment, non-home ownership, oneparent
    family and household overcrowding. The index
    is calculated by summing standardized indicators. The
    index is classified in 5 groups very rich, rich, average,
    deprived and very deprived.
    Variables are presented as absolute and relative
    frequency. Person’s chi-square test was used to compare
    The present is a retrospective study and no additional
    diagnostic tool or information was collected. As
    only routine and anonymized data were used, no informed
    consent was needed. Because the analysis was
    conducted as part of the surveillance activities of a public
    health institute, there was no need for approval by
    an institutional review board. Nevertheless, the study
    was conducted in accordance to the GDPR (General
    Data Protection Regulation) n° 679 07/04/2016, and
    Italian Law about personal data treatment (D. Lgs 30
    giugno 2003).
    From 28 February to 14 April the Public Health
    Department of the Bologna LHA registered 2882
    COVID-19 cases, corresponding to the 0.33% of the
    Figure 1 shows the rapid increase in the number
    of cases by date of onset of symptom and date of diagnosis
    and the reduction of the number of new cases.
    1034 cases were classified as transmitted before
    the decree and 1418 after the publication of the “I Stay
    at home” decree. 430 were excluded because the date
    of last contact with a positive case was missing and the
    onset of symptoms occurred between 14 and 25 March
    e.g. a period that does not allow to allocate the cases to
    one group or another.
    Table 1 shows the profile of the two groups, before
    and after decree. In the first group there were
    more males than females and the most common agegroup
    was 45 to 64 years. In the second period there
    Figure 1.
    4 E. Stivanello, V. Perlangeli, D. Resi, et al.
    Table 1. Sociodemographic, clinical characteristics and community attended before and after the decree, Bologna LHA, 28 February
    – 14 April
    Before decree After decree P
    n % n %
    Total cases 1034 100 1418 100
    F 463 46,49 829 59,34
    M 533 53,51 568 40,66 <0.0001
    Agegroup, years
    <15 14 1,35 25 1,76 0.4242
    15-24 23 2,22 52 3,67 0,0405
    25-44 218 21,08 313 22,07 0,5566
    45-64 425 41,10 388 27,36 <0.0001
    65-75 151 14,60 135 9,52 0.0001
    >75 203 19,63 505 35,61 <0.0001
    Italian 963 93,13 1272 89,70
    Non italian 71 6,87 146 10,30 0,003
    Urban residency 515 49,81 655 46,19 0,077
    Residency in nursing homes 15 1,45 190 13,40 <0,0001
    Professionals/mangers 87 8,41 30 2,12 <0.001
    Sales workers/office staff 197 19,05 112 7,90 <0.001
    Unskilled and semiskilled workers 65 6,29 54 3,81 0.005
    Health Personnel 222 21,47 433 30,54 <0,001
    Service workers (excl health personnel)
    19 1,84 18 1,27 0,245
    Retired 355 34,33 668 47,11 <0,001
    Other (non working categories) 82 7,93 100 7,05 0,413
    Work 207 20,02 112 7,90 <0,001
    Long term care facility 43 4,16 469 33,07 <0,001
    Family 507 49,03 599 42,24 0,001
    Hospital 196 18,96 343 24,19 0,002
    Other 64 6,19 82 5,78 0,674
    None 189 18,28 80 5,64 <0,001
    Charlson Index*
    0 895 94,81 1189 90,83 0.004
    1 19 2,01 68 5,19 <0,0001
    2 30 3,18 52 3,97 0.3204
    (continued on next page)
    COVID-19 cases before and after the “I stay at home” decree, Bologna Local Health Authority, Italy 5
    were more women than men and the most common
    agegroup was the 75 years and over.
    Italians were by far the majority of cases in both
    groups though non Italian citizenship was higher in
    the “after decree” group (P=0,003).
    In the first period about 50% of the persons were
    rich or very rich according to the Deprivation Index, in
    the second period 36,9% were rich and very rich, while
    deprived and very deprived increased from 34% to the
    47%. This distribution is maintained also after excluding
    residents in nursing homes (data not shown).
    In the second period there is a lower proportion
    of professionals/managers, sales or office workers
    (P<0,0001) and a higher proportion of health personnel
    and retired people (P<0,0001). In both groups
    family is mentioned as the first community attended
    even if the frequency is lower in the “after decree”
    group (P=0,001).
    In the second period work was mentioned less
    frequently as community attended (P<0,0001) whereas
    hospital was mentioned more often (P=0,002). Residents
    in nursing homes were more frequent in the second
    period and this was confirmed by the attendance
    to all types of LTCFs (P<0,0001).
    In the second period there were less cases without
    morbidities (P=0,004).
    In this work we describe retrospectively all new
    cases of COVID-19 that were likely transmitted before
    or after the “I Stay at home” decree in Bologna
    LHA area from the beginning of the outbreak to April
    We identified 1418 cases transmitted after the introduction
    of the decree and show that these cases differ
    in terms of various features when compared to the
    initial cases of the outbreak. During the second period
    there are more women, vulnerable people because of
    age or comorbidities and more health personnel but
    less professionals, managers and sales workers/office
    staff than in the first period. In addition we observed
    also a change in the distribution of socioeconomic categories
    over time.
    The higher prevalence of males that is observed
    during the first period is in line with other studies
    on COVID-19 (15). The change in gender distribution
    over time suggests that the measures to control
    transmission had a differential effect according to gender.
    Women provide most of the informal care within
    family and given their predominant role as front line
    health care workers (16) are more exposed to the disease
    similarly to what happened in previous outbreaks
    After the decree, there were more elderly and residents
    in LTCFs. The decree did not address the problem
    of LTCFs directly, visits to these facilities were already
    banned since the beginning of March. Though,
    as Mc Michael has recently reported, once COVID-19
    has been introduced into a LTCFs has the potential
    to spread rapidly and widely (18). Residents of LTCF
    are at higher risk of infections and exposure (19) the
    nursing home provides a milieu that is conductive to
    Before decree After decree P
    n % n %
    Deprivation index*
    Very rich 257 28.34 237 18.87 <0,0001
    Rich 194 21.39 227 18.07 0,0546
    Average 144 15.88 202 16,08 0,8972
    Deprived 157 17,31 319 25.40 <0.001
    Very deprived 155 17.09 271 21.58 0.0096
    Table 1. Sociodemographic, clinical characteristics and community attended before and after the decree, Bologna LHA, 28 February
    – 14 April
    *only on residents; §the sum is different from total because some gave multiple answers
    6 E. Stivanello, V. Perlangeli, D. Resi, et al.
    outbreaks of infectious diseases due to the close proximity
    of susceptible patients in the institutional setting
    and subsequent cross transmission of organisms
    among patients through contact with staff members or
    environmental contamination (20). Very recent studies
    show that a large proportion of COVID-19 infections
    are undocumented and that the total force of infection
    is mediated through these undocumented infections.
    Identification and isolation of currently undocumented
    infections has in fact been recommended by some
    authors to fully control the epidemics (6,21).
    The changes in professions during the two phases
    directly stems from the decree, most commercial
    and administrative activities were suspended and teleworking
    was enhanced for professionals or office staff
    whereas health personnel had to continue working
    maintaining the risk of being exposed.
    Rich and very rich were more frequent among
    cases of the first period than among cases of the second
    period whereas deprived or very deprived were
    more frequent among cases of the second period. This
    change could arise from different factors and not only
    from the lockdown. For example, rich people likely
    own larger and bigger houses where transmission
    within household during lockdown is more difficult,
    and besides the lockdown, they also have more tools
    to adopt behavioral changes to protect themselves and
    their relatives as the epidemic spread. Research on
    risk of transmission across population of different socioeconomic
    level is needed. Authors underscores that
    COVID-19 exacerbates inequalities in some countries
    and that part of the disproportionate impact of the
    COVID-19 pandemic on some community is due to
    structural factors that prevent those communities from
    practicing social distancing. In addition, front line
    workers are disproportionately the poorer belonging
    to segregated communities (22).
    This is a descriptive study of two groups of COVID-
    19 cases with a transmission before and after the
    “I stay at home” decree. Given this type of study we
    cannot infer that changes between the two groups are
    attributable to the decree. Modification in the groups
    profile depends also on other decrees, measures and on
    behavioral changes that might have been adopted at
    different speed across the population. Nevertheless it
    is clear that the profile of the new cases changed over
    time and in some population subgroups COVID-19
    transmission has slowed down more rapidly than in
    others. Further, the accuracy of respondents in reporting
    information is questionable, and in particular, the
    degree to which cases were able to accurately recall the
    date of last contact and date of onset of symptom is
    As Sjödin et al. underline transmission continues
    to occur during lockdown especially when the reduction
    of activities is not complete and the household
    size is large (23). Specific stringent protective measures
    and public health strategies should be implemented
    for all categories that remain on the front line
    or for person such as residents of LTCF that cannot
    enjoy the benefits of general lockdown measures. Last
    but not least, efforts should be made to address gender
    and health inequity aspects and identify solutions
    to practice measures such as social distance or proper
    quarantine with an equity approach. To ensure that
    COVID-19 work is grounded in health justice, we
    must generate and publicly report data on how it affects
    different populations and social groups and use a
    health equity lens to examine if and how the pandemic
    (and the measures taken to control it) is exacerbating
    Bologna Public Health Department COVID-19 group:
    Astorino Gerardo, Morena Baldini, Nicola Bossio, Elena Bovolenta,
    Veronica Canal, Chiara D’Eusebio, Mauro Di Bitetto,
    Filippo Ferretti, Giulia Gherardi, Maurizio Liberti, Angelo Lo
    Russo, Patrizia Maurizi, Francesca Mezzetti, Muriel Assunta
    Musti, Marisa Padovan, Maria Cristina Pirazzini, Luciana
    Prete, Flavia Rallo, Filippo Sandorfi, Tiziana Sanna, Michela
    Stillo, Andrea Ubiali.
    Conflict of interest: Each author declares that he or she has no
    commercial associations (e.g. consultancies, stock ownership, equity
    interest, patent/licensing arrangement etc.) that might pose a conflict
    of interest in connection with the submitted article
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    Received: 8 May 2020
    Accepted: 14 May 2020
    Elisa Stivanello
    Department of Public Health, Azienda USL di Bologna,
    Bologna, Italy
    Tel. +39 051 2869398
    Fax +39 051 2869394

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