The three facets of the SARS-CoV-2 pandemic during the first two waves in the northern, central, and southern Italy

Background: There is a scarcity of information in literature regarding the clinical differences and co-morbidities of patients affected by Coronavirus disease 2019 (COVID-19), which could clarify the different prevalence of the outcomes (composite and only death) between several Italian regions.Objective: This study aimed to assess the heterogeneity of clinical features of patients with COVID-19 upon hospital admission and disease outcomes in the northern, central, and southern Italian regions.Methods: An observational cohort multicenter retrospective study including 1210 patients who were admitted for COVID-19 in Infectious diseases, Pulmonology, Endocrinology, Geriatrics and Internal Medicine Units in Italian cities stratified between north (263 patients);center (320 patients);and south (627 patients), during the first and second pandemic waves of SARS-CoV-2 (from February 1, 2020 to January 31, 2021). The data, obtained from clinical charts and collected in a single database, comprehended demographic characteristics, co-morbidities, hospital and home pharmacological therapies, oxygen therapy, laboratory values, discharge, death and Intensive care Unit (ICU) transfer. Death or ICU transfer were defined as composite outcomes.Results: Male patients were more frequent in the northern Italian region than in the central and southern regions. Diabetes mellitus, arterial hypertension, chronic pulmonary and chronic kidney diseases were the comorbidities more frequent in the southern region;cancer, heart failure, stroke and atrial fibrillation were more frequent in the central region. The prevalence of the composite outcome was recorded more fre-quently in the southern region. Multivariable analysis showed a direct association between the combined event and age, ischemic cardiac disease, and chronic kidney disease, in addition to the geographical area.Conclusions: Statistically significant heterogeneity was observed in patients with COVID-19 characteristics at admission and outcomes from northern to southern Italy. The higher frequency of ICU transfer and death in the southern region may depend on the wider hospital admission of frail patients for the availability of more beds since the burden of COVID-19 on the healthcare system was less intense in southern region. In any case, predictive analysis of clinical outcomes should consider that the geographical differences that may reflect clinical differences in patient characteristics, are also related to access to health-care facilities and care modalities. Overall, the present results caution against generalizability of prognostic scores in COVID-19 patients derived from hospital cohorts in different settings.(c) 2023 The Author(s). Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/li-censes/by-nc-nd/4.0/).

COVID-19 pandemic impact on mental health in a large representative sample of older adults from the Lombardy region, Italy.

BACKGROUND: We aimed to assess the prevalence of depressive and anxiety symptoms, hopelessness and insomnia in the older adults before and during the COVID-19 pandemic identifying subgroups at higher risk of mental distress. METHODS: Within the Lost in Lombardy project, a web-based cross-sectional study was conducted on a representative sample of 4400 older adults aged 65 years or more from the Lombardy region recruited between November 17th and 30th 2020. RESULTS: The prevalence of depressive symptoms increased by +112 % during the pandemic, anxiety symptoms by +136 %, insufficient sleep by +12 %, unsatisfactory sleep by +15 %. Feelings of hopelessness were more frequent among women compared to men and increased with increasing age. A worsening in each of the four specific mental health outcomes was more frequently observed in women (OR = 1.50, depression; OR = 1.31, anxiety; OR = 1.57, sleep quality; OR = 1.38, sleep quantity), in subjects who decreased their physical activity during the pandemic (OR = 1.64, depression; OR = 1.48, anxiety; OR = 2.05, sleep quality; OR = 1.28, sleep quantity), and with increasing number of pre-existing chronic diseases. The use of at least one psychotropic drug - mostly antidepressants/anxiolytics - increased by +26 % compared to pre-pandemic. LIMITATIONS: Pre-pandemic symptoms were retrospectively reported during the Covid pandemic. Potential information and recall bias should not be ruled out. CONCLUSIONS: If confirmed by future longitudinal studies, our findings could support evidence-based health and welfare policies on responding to this pandemic and on how to promote mental health and wellbeing, should future waves of infection emerge.

The Impact of COVID-19 on Lombardy Region ST-Elevation Myocardial Infarction Emergency Medical System Network-A Three-Year Study.

Objectives: The COVID-19 pandemic had a significant impact on emergency medical systems (EMS). Regarding the ST-elevation myocardial infarction (STEMI) dependent time network, however, there is little evidence linked to the post-pandemic phase regarding this issue. Such information could prove to be of pivotal importance regarding STEMI clinical management, especially pre-hospital clinical protocols such as fibrinolysis. Methods: A retrospective observational cohort study of all STEMI rescues recorded in the Lombardy EMS registry from the 1st of January 2019 to the 30th of December 2021. Results: Regarding the number of STEMI diagnoses, March 2020 (first pandemic wave in Italy) saw a reduction compared to March 2019 (OR 0.76 [0.60-0.93], p = 0.011). The average time of the entire mission increased to 63.1 min in 2021, reaching 64.7 min in 2020, compared with 57.7 min in 2019. The number of HUBs for STEMI patients saw a reduction, falling from 52 HUBs in the pre-pandemic phase to 13 HUBs during the first wave. Conclusions: During the pandemic phase, there was an increase in the transportation times of STEMI patients from home to the hospital. Such changes did not alter the clinical approach in the out-of-hospital phase. Indeed, the implementation of fibrinolysis was not required.

Coronavirus and birth in Italy: results of a national population-based cohort study

Introduction: The study was implemented to provide guidance to decision-makers and clinicians by describing hospital care offered to women who gave birth with confirmed SARS-CoV-2 infection. Materials and methods: National population-based prospective cohort study involving all women with confirmed SARS-CoV-2 infection who gave birth between February 25 and April 22, 2020 in any Italian hospital.

The First 110,593 COVID-19 Patients Hospitalised in Lombardy: A Regionwide Analysis of Case Characteristics, Risk Factors and Clinical Outcomes.

Objectives: To describe the monthly distribution of COVID-19 hospitalisations, deaths and case-fatality rates (CFR) in Lombardy (Italy) throughout 2020. Methods: We analysed de-identified hospitalisation data comprising all COVID-19-related admissions from 1 February 2020 to 31 December 2020. The overall survival (OS) from time of first hospitalisation was estimated using the Kaplan-Meier method. We estimated monthly CFRs and performed Cox regression models to measure the effects of potential predictors on OS. Results: Hospitalisation and death peaks occurred in March and November 2020. Patients aged ≥70 years had an up to 180 times higher risk of dying compared to younger patients [70-80: HR 58.10 (39.14-86.22); 80-90: 106.68 (71.01-160.27); ≥90: 180.96 (118.80-275.64)]. Risk of death was higher in patients with one or more comorbidities [1: HR 1.27 (95% CI 1.20-1.35); 2: 1.44 (1.33-1.55); ≥3: 1.73 (1.58-1.90)] and in those with specific conditions (hypertension, diabetes). Conclusion: Our data sheds light on the Italian pandemic scenario, uncovering mechanisms and gaps at regional health system level and, on a larger scale, adding to the body of knowledge needed to inform effective health service planning, delivery, and preparedness in times of crisis.

Designing social distancing policies for the COVID-19 pandemic: A probabilistic model predictive control approach.

The effective control of the COVID-19 pandemic is one the most challenging issues of recent years. The design of optimal control policies is challenging due to a variety of social, political, economical and epidemiological factors. Here, based on epidemiological data reported in recent studies for the Italian region of Lombardy, which experienced one of the largest and most devastating outbreaks in Europe during the first wave of the pandemic, we present a probabilistic model predictive control (PMPC) approach for the systematic study of what if scenarios of social distancing in a retrospective analysis for the first wave of the pandemic in Lombardy. The performance of the proposed PMPC was assessed based on simulations of a compartmental model that was developed to quantify the uncertainty in the level of the asymptomatic cases in the population, and the synergistic effect of social distancing during various activities, and public awareness campaign prompting people to adopt cautious behaviors to reduce the risk of disease transmission. The PMPC takes into account the social mixing effect, i.e. the effect of the various activities in the potential transmission of the disease. The proposed approach demonstrates the utility of a PMPC approach in addressing COVID-19 transmission and implementing public relaxation policies.

THE IMPACT OF COVID-19 PANDEMIC ON THE HEALTHCARE SYSTEM IN LOMBARDY

This chapter aims to provide suggestive evidence on how the Lombardy region dealt with the COVID-19 pandemic in 2020 and discuss future challenges for the Lombardy healthcare system. After an introduction to the wide spread of the virus inside the region, we describe the Lombardy health system so the reader may understand the context in which the virus has taken hold so quickly. The pandemic has heavily stressed the system, mainly because Lombardy experienced an excess of hospital admissions. We have considered the increased mortality rate as a proxy of the proper managing of the COVID-19 pandemic. In addition, we describe the process of treating non-COVID patients, such as those affected by acute myocardial infarction (AMI), stroke and oncological diseases. Despite the pandemic, hospitals have been able to guarantee a high level of performance. A discussion of the future evolution of the healthcare system concludes this chapter. © 2022 by Emerald Publishing Limited.

Boosters and time since last anti-COVID-19 vaccine dose: lead public health choices by real-time epidemiological assessment

BACKGROUND: the levels of anti-SARS-CoV-2 antibodies after the second vaccine dose decline in the following months;an additional vaccine dose (booster) is able to swiftly restore the immune system, significantly reducing the risk of severe disease. In the winter of 2021, a new, particularly infectious variant made the need to increase booster coverage in the population even more urgent. OBJECTIVES: to present, using real data, an evaluation of the effectiveness of the booster dose in reducing severe disease caused by SARS-CoV-2 infection in terms of COVID-19 hospitalization and intensive care admission, and all-cause mortality. DESIGN: descriptive study of vaccination uptake;associative study of the factors linked with uptake of vaccination and COVID-19 symptoms;associative study of vaccine effectiveness against hospital admission and mortality. SETTING AND PARTICIPANTS: population residing in the Milan and Lodi provinces (Lombardy Region, Northern Italy), eligible for anti-SARS-COV-2 vaccination, with subjects aged >= 19 years alive as at 01.10.2021, not residing in nursing homes, followed-up until 31.12.2021. MAIN OUTCOME MEASURES: COVID-19 symptoms, hospitalization, intensive care hospitalization, and all-cause mortality in the period 01.10.2021-31.12.2021. RESULTS: the cohort included 2,936,193 patients as of 01.10.2021;at the end of the observation period (31.12.2021), 378,616 (12.9%) were unvaccinated, 60,102 (2.0%) had received only 1 dose and had not had the disease, 68,777 (2.3%) had received only 1 dose and had had the disease, 412,227 (14.0%) were fully vaccinated with 2 doses less than 4 months earlier, 198,459 (6.8%) had received 2 doses [4,5) months earlier, 439,363 (15.0%) had received 2 doses [5,6) months earlier, 87,984 (3.0%) had received 2 doses [6,7) months earlier, 74,152 (2.5%) had received 2 doses more than 7 months earlier, 62,614 (2.1%) had received 2 doses and had had the disease, and, finally, 1,153,899 (39.3%) had received a booster shot. In the study period (01.10.2021-31.12.2021), characterized by a very high prevalence of the omicron variant, 121,620 cases (positive antigen/molecular test), 3,661 hospitalizations for COVID-19, 162 intensive care admissions for COVID-19, and 7,508 deaths from all causes were identified. Compared to unvaccinated subjects, subjects who received a booster had half the risk of being symptomatic, and had half the risk of experiencing fatigue, muscle aches, and dyspnoea. In comparison with boosted subjects, unvaccinated subjects had a 10-fold risk of hospitalization, a 9-fold risk of intensive care, and a 3-fold risk of dying. CONCLUSIONS: this work highlights the effectiveness of vaccination in reducing serious adverse events in boosted subjects and the need to implement specific policies of engagement to bring subjects who received their second dose earliest to get a booster.

Impact of the post-COVID-19 condition on health care after the first disease wave in Lombardy.

BACKGROUND: Lombardy was affected in the early months of 2020 by the SARS-CoV-2 pandemic with very high morbidity and mortality. The post-COVID-19 condition and related public health burden are scarcely known. SETTING AND DESIGN: Using the regional population administrative database including all the 48,932 individuals who survived COVID-19 and became polymerase-chain-reaction negative for SARS-CoV-2 by 31 May 2020, incident mortality, rehospitalizations, attendances to hospital emergency room, and outpatient medical visits were evaluated over a mid-term period of 6 months in 20,521 individuals managed at home, 26,016 hospitalized in medical wards, and 1611 in intensive care units (ICUs). These data were also evaluated in the corresponding period of 2019, when the region was not yet affected by the pandemic. Other indicators and proxies of the health-care burden related to the post-COVID condition were also evaluated. MAIN RESULTS: In individuals previously admitted to the ICU and medical wards, rehospitalizations, attendances to hospital emergency rooms, and out-patient medical visits were much more frequent in the 6-month period after SARS-CoV-2 negativization than in the same prepandemic period. Performances of spirometry increased more than 50-fold, chest CT scans 32-fold in ICU-admitted cases and 5.5-fold in non-ICU cases, and electrocardiography 5.6-fold in ICU cases and twofold in non-ICU cases. Use of drugs and biochemical tests increased in all cases. CONCLUSIONS: These results provide a real-life picture of the post-COVID condition and of its effects on the increased consumption of health-care resources, considered proxies of comorbidities.

What relevance of regional regulatory models? The Lombardy issue in the COVID-19 health crisis

The article investigates the impact of the Covid-19 crisis in the Lombardy region. This region has been strongly hit by the health crisis: More than 30% of the Covid-19 deaths in Italy occurred here. Against this background, the aim is understanding the reason why the impact of the pandemic has been so problematic in this regional case. In particular, the role played by the regulatory model characterizing the Lombardy's health care system will be considered. The central hypothesis is that the traditional weakness affecting territorial health care services in Lombardy as well as the lack of coordination of such services with the hospital system have played a crucial role (path-dependence) in undermine the contrast to the Covid-19 crisis in this region. © 2021 Franco Angeli Edizioni. All rights reserved.

Hospital risk management at the time of Covid-19: An analysis of the Lombardy Region

Covid-19 has imposed a rethinking of risk management systems in the healthcare sector. The aim of this paper is to investigate how the risk has been and is managed by the healthcare organizations, on the basis of regional directives. The analysis focuses on the health system of the Lombardy Region. In particular, the authors focused on the resolutions adopted by the Lombardy Region in the acute phase of the pandemic (2 March 2020-12 May 2020) with the aim of rebuilding the system put in place by the Region for risk prevention and management. Thanks to the resolutions, the Lombardy Region has established a risk management system, consisting of a surveillance system and an emergency management system that seems to have led to positive consequences. Copyright © FrancoAngeli

The early phase of the COVID-19 epidemic in Lombardy, Italy.

BACKGROUND: In the night of February 20, 2020, the first epidemic of the novel coronavirus disease (COVID-19) outside Asia was uncovered by the identification of its first patient in Lombardy region, Italy. In the following weeks, Lombardy experienced a sudden increase in the number of ascertained infections and strict measures were imposed to contain the epidemic spread. METHODS: We analyzed official records of cases occurred in Lombardy to characterize the epidemiology of SARS-CoV-2 during the early phase of the outbreak. A line list of laboratory-confirmed cases was set up and later retrospectively consolidated, using standardized interviews to ascertained cases and their close contacts. We provide estimates of the serial interval, of the basic reproduction number, and of the temporal variation of the net reproduction number of SARS-CoV-2. RESULTS: Epidemiological investigations detected over 500 cases (median age: 69, IQR: 57-78) before the first COVID-19 diagnosed patient (February 20, 2020), and suggested that SARS-CoV-2 was already circulating in at least 222 out of 1506 (14.7%) municipalities with sustained transmission across all the Lombardy provinces. We estimated the mean serial interval to be 6.6 days (95% CrI, 0.7-19). Our estimates of the basic reproduction number range from 2.6 in Pavia (95% CI, 2.1-3.2) to 3.3 in Milan (95% CI, 2.9-3.8). A decreasing trend in the net reproduction number was observed following the detection of the first case. CONCLUSIONS: At the time of first case notification, COVID-19 was already widespread in the entire Lombardy region. This may explain the large number of critical cases experienced by this region in a very short timeframe. The slight decrease of the reproduction number observed in the early days after February 20, 2020 might be due to increased population awareness and early interventions implemented before the regional lockdown imposed on March 8, 2020.

Is administered competition suitable for dealing with a public health emergency? Lessons from the local healthcare system at the centre of early COVID-19 outbreak in Italy.

OBJECTIVES: The Lombardy Region, Italy, was the most severely affected by the COVID-19 outbreak. In absence of effective treatments and with basic hygiene measures made mandatory, Lombardy response to COVID-19 relied on its healthcare system characteristics, the administered competition or "quasi-market" model. The aim of the study was to review the strengths and weaknesses of Lombardy's response during the first wave of the COVID-19 epidemic, to explore whether the healthcare model influenced crisis management and describe which policies could help to contain future outbreaks. The results are expected to provide similar healthcare systems with lessons to avoid mistakes and learn from best practice. METHODS: Data for quantitative analyses on the performance of the Lombardy and Veneto Regions healthcare systems were derived from existing government sources including the Italian Civil Protection Agency and the Ministry of Health. RESULTS: Lombardian quasi-market model, traditionally characterized by a strong hospital network, was held responsible for many suboptimal outcomes. According to critics, years of disinvestments in community care resulted in a hospital overload. However, the same model was responsible for other positive outcomes which have been substantially neglected, such as the opportunity to test for effective containment treatments in a safe environment and rapidly extend the number of beds. CONCLUSIONS: The performance of a quasi-market model against public health emergencies largely depends on integration between policy-makers and balance between healthcare providers, which require clear regulation. Reducing institutional fragmentation between levels of governance, improving the coordination of healthcare facilities and adopting telemedicine technologies are means by which healthcare networks could strengthen their resilience against future outbreaks.

How Did COVID-19 Affect Suicidality? Data from a Multicentric Study in Lombardy.

The aim of the study was to describe the characteristics of subjects accessing the emergency rooms for suicidal behavior during the first epidemic wave of COVID-19 in three Emergency Departments (EDs) in Lombardy (Italy). A retrospective chart review was conducted for the period 8 March-3 June 2020, and during the same time frame in 2019. For all subjects accessing for suicidality, socio-demographic and clinical data were collected and compared between the two years. The proportion of subjects accessing for suicidality was significantly higher in 2020 than in 2019 (13.0 vs. 17.2%, p = 0.03). No differences between the two years were found for sex, triage priority level, history of substance abuse, factor triggering suicidality and discharge diagnosis. During 2020 a greater proportion of subjects did not show any mental disorders and were psychotropic drug-free. Women were more likely than men to receive inpatient psychiatric treatment, while men were more likely to be discharged with a diagnosis of acute alcohol/drug intoxication. Our study provides hints for managing suicidal behaviors during the still ongoing emergency and may be primary ground for further studies on suicidality in the course of or after massive infectious outbreaks.

Comparison of ammonia air concentration before and during the spread of COVID-19 in Lombardy (Italy) using ground-based and satellite data.

Several anthropogenic activities have undergone major changes following the spread of the COVID-19 pandemic, which in turn has had consequences on the environment. The effect on air pollution has been studied in detail in the literature, although some pollutants, such as ammonia (NH3), have received comparatively less attention to date. Focusing on the case of Lombardy in Northern Italy, this study aimed to evaluate changes in NH3 atmospheric concentration on a temporal scale (the years from 2013 to 2019 compared to 2020) and on a spatial scale (countryside, city, and mountain areas). For this purpose, ground-based (from public air quality control units scattered throughout the region) and satellite observations (from IASI sensors on board MetOp-A and MetOp-B) were collected and analyzed. For ground-based measurements, a marked spatial variability is observed between the different areas while, as regards the comparison between periods, statistically significant differences were observed only for the countryside areas (+31% in 2020 compared to previous years). The satellite data show similar patterns but do not present statistically significant differences neither between different areas, nor between the two periods. In general, there have been no reduction effects of atmospheric NH3 as a consequence of COVID-19. This calls into question the role of the agricultural sector, which is known to be the largest responsible for NH3 emissions. Even if the direct comparison between the two datasets shows little correlation, their contextual consideration allows making more robust considerations regarding air pollutants.

Development of a Critical Care Response - Experiences from Italy During the Coronavirus Disease 2019 Pandemic.

Italy was the first western country facing an outbreak of coronavirus disease 2019 (COVID-19). The first Italian patient diagnosed with COVID-19 was admitted, on Feb. 20, 2020, to the intensive care unit (ICU) in Codogno (Lodi, Lombardy, Italy), and the number of reported positive cases increased to 36 in the next 24 hours, and then exponentially for 18 days. This triggered a response that resulted in a massive surge in ICU bed capacity. The COVID19 Lombardy Network organized a structured logistic response and provided scientific evidence to highlight information on COVID-19 associated respiratory failure.

Almost one year of COVID-19 pandemic: how radiotherapy centers have counteracted its impact on cancer treatment in Lombardy, Italy. CODRAL/AIRO-L study.

Lombardy has represented the Italian and European epicenter of the coronavirus disease 2019 (COVID-19) pandemic. Although most clinical efforts within hospitals were diverted towards the care of virally infected patients, therapies for patients with cancer, including radiotherapy (RT), have continued. During both the first and second pandemic waves, several national and regional organizations provided Italian and Lombardian RT departments with detailed guidelines aimed at ensuring safe treatments during the pandemic. The spread of infection among patients and personnel was limited by adopting strict measures, including triage procedures, interpersonal distance, and adequate implementation of personal protective equipment (PPE). Screening procedures addressed to both the healthcare workforce and patients, such as periodic nasopharyngeal swabs, have allowed the early identification of asymptomatic or pauci-symptomatic COVID-19 cases, thus reducing the spread of the infection. Prevention of infection was deemed of paramount importance to protect both patients and personnel and to ensure the availability of a minimum number of staff members to maintain clinical activity. The choice of treating COVID-19-positive patients has represented a matter of debate, and the risk of oncologic progression has been weighted against the risk of infection of personnel and other patients. Such risk was minimized by creating dedicated paths, reserving time slots, applying intensified cleaning procedures, and supplying personnel and staff with appropriate PPE. Remote working of research staff, medical physicists, and, in some cases, radiation oncologists has prevented overcrowding of shared spaces, reducing infection spread.

Dangerous liaisons: an online experiment on the role of scientific experts and politicians in ensuring public support for anti-COVID measures.

The effectiveness of public health measures to prevent COVID-19 contagion has required less vulnerable citizens to pay an individual cost in terms of personal liberty infringement to protect more vulnerable groups. However, the close relationship between scientific experts and politicians in providing information on COVID-19 measures makes it difficult to understand which communication source was more effective in increasing pro-social behaviour. Here, we present an online experiment performed in May 2020, during the first wave of the pandemic on 1131 adult residents in Lombardy, Italy, one of the world's hardest hit regions. Results showed that when scientific experts recommended anti-contagion measures, participants were more sensitive to pro-social motivations, unlike whenever these measures were recommended by politicians and scientific experts together. Our findings suggest the importance of trusted sources in public communication during a pandemic.

Can reasoned mass testing impact covid-19 outcomes in wide community contexts? An evidence-based opinion.

We describe the early phases of a COVID-19 epidemic in two contiguous Italian regions, Lombardy and Veneto, which were heavily and simultaneously hit by SARS-CoV-2 in Italy but showed markedly different disease outcome in terms of case fatality rate, SARS-CoV-2-attributable mortality and hospitalization. We discuss data limitations together with similarities and differences of the regional context possibly affecting COVID-19 control in the two regions. We conclude that the better COVID-19 outcome in Veneto was due, at least in part, to the adoption of a strategy of active search of asymptomatic SARS-CoV-2 infections (Reasoned Mass Testing), instead of a strategy strictly based on the detection of symptomatic cases.