Covid-19 caught us- and also Italian epidemiology- unprepared. How could this happen?
Thanks to John Snow’s historic work on the origin of the cholera epidemic that hit London in 1854, epidemiology has proven to be a powerful public healthcare tool, able to emphasise the associations between elements or conditions of the environment and specific infectious diseases, and to identify the necessary measures to contain their spread. There has been a progressive epidemiological transition since then, with cardiovascular diseases taking over communicable diseases as the leading cause of death in the world. We mistakenly assumed that infectious diseases could be kept under control with the use of antibiotics and vaccines and that epidemiology and public healthcare should focus their efforts elsewhere. It seemed as though communicable diseases only concerned low-income countries, where the limited access to antibiotics and vaccines has required- and still does require- public healthcare to put great efforts into interventions. I really don’t think it is a coincidence that one of the most informative studies on the transmission modalities of Covid-19 was conducted in India . In Italy the focus of epidemiology is typically on occupational aetiology, the impact of exposure in workspaces and the effect of environmental factors, the exposure to polluted sites, air pollution, electromagnetic fields and climate change. The epidemiology of infectious diseases gave way to clinical research, where there is a lot of pressure from the market around developing vaccines, diagnostics and treatments, with less and less interest for public healthcare interventions. The HIV epidemic should have taught us that epidemiology is a cross-sector methodology, a process and a way of thinking and assessing analytically the knowledge and the data that apply to all areas related to health.
The HIV epidemic should have taught us that epidemiology is a cross-sector methodology, a process and a way of reasoning and assessing analytically the knowledge and the data that apply to all areas related to health.
Do you not believe, then, that the activities put in place by Italian epidemiology, amid the Covid-19 emergency, were a point of reference anyway?
Of course they were. Both the Italian Association of Epidemiology (AIE) and the scientific focus of the Epidemiologia & Prevenzione (Epidemiology & Prevention) journal did significant work to facilitate the activities put in place by the Italian regions, particularly those that were impacted the most: Lombardy, Piedmont and Emilia-Romagna. After rapidly creating an archive of preprints of the studies conducted during the emergency, the journal dedicated a special issue to the pandemic where it made a call for scientific papers that were yet to be peer reviewed prior to publication. They organised different webinars with roughly 400 participants. The drafts of position papers were also very useful. I am referring specifically to the report produced by the AIE on the “Use of immunological tests and assessment of seroprevalence” that discussed the limitations of diagnostic tests and also emphasised the relevance of public healthcare activities, and the great group work, coordinated by Giovannino Ciccone from the Molinette Hospital, that identified the priorities of epidemiological clinical research . Overall, despite the initial shock, the Italian epidemiology community worked well.
What is the difference between the Italian epidemiological response and the past response to the HIV infection when this was just emerging?
They were similar responses under certain aspects. Back then- similarly to today- information was utilised to promote a series of spread containment measures, such as the disinfection of reusable medical equipment and the introduction of single-use equipment, that were not initially planned. Now the same thing is happening around hands sanitation, a measure that should always be in place to prevent nosocomial and- even more so- community acquired infections, and around the implementation of personal protective equipment. All healthcare activities should only ever take place under safe conditions. Furthermore, in the case of HIV as well, there was a push to immediately introduce treatments before any evidence of efficacy was produced- zidovudine (AZT) is an example of this; it was initially introduced as an antitumor drug but then different clinical trials demonstrated that there were no benefits when it was prescribed in early monotherapy compared to when it was given later on. Nevertheless, I believe that Italian epidemiology played an important role in the management of HIV and we only partially see that now. For example, at the time they managed to limit the improper use of diagnostic and screening tests for HIV, while today there does not seem to be much consideration around the predictive value of the tests in terms of prevalence of infection. Another fundamental achievement was the creation of the first national register of AIDS cases and the register of HIV infections. The Lazio region played a very important function in this regard. The implementation of epidemiological surveillance systems, such as the HIV and AIDS registers, was definitively a determining factor for the development of epidemiological knowledge. However, some people paid the price for creating a tool that is now part of our national regulations. I would like to mention, in this regard, the Director of the Lazio Regional Public Healthcare Agency, Carlo Perucci, who was sued for allegedly cataloguing AIDS patients and subsequently cleared of all. I believe that today we find ourselves in a very similar situation in terms of the difficulties we face when trying to create systems that collect the essential data we need to identify, develop, plan and finally assess the interventions necessary to fight the epidemic.
We urgently need to invest the few resources we have in evaluating the best methodological tools to face an epidemic, to better understand its direct and indirect effects on health and to reduce its impact.
What “lessons” should we draw for Italian epidemiology to have a different level of preparedness in the future?
One lesson we should draw, not to be caught unprepared in the future, is to be equipped with effective and efficient data collection tools that are fast and standardised, and to promote the implementation of assessments to evaluate the efficacy of the different containment measures. It is puzzling how today there is so much talk of personalised medicine, artificial intelligence and open data and yet there is no platform, shared nationally and regionally, with basic features allowing the prompt collection of the data we need to monitor the course of the epidemic (now there is a Covid-19 outbreak but who knows what the future brings), to identify the most adequate measures and to assess their efficacy. Based on this I think we urgently need to invest the few resources we have in evaluating the best methodological tools to face an epidemic, to better understand its direct and indirect effects on health and to reduce this impact. The abovementioned work by Ciccone and colleagues2 on the research priorities in the clinical and epidemiological field is useful and worth sharing in this respect; it should be read as a sort of appeal to promote the epidemiological research done in this area.
Written by Laura Tonon
 Laxminarayan R, Wahl B, Dudala SR, et al. Epidemiology and transmission dynamics of covid-19 in two Indian states. Science 30 Sep 2020: eabd7672.
 Ciccone G, Deandrea S, Clavenna A, et al. Covid-19 and clinical-epidemiological research in Italy: proposed research agenda on priority topics, produced by the Italian Association of Epidemiology. Epidemiol Prev 2020, in press. Preliminary draft: https://repo.epiprev.it/1938
Research priorities in the time of Covid-19
The Covid-19 pandemic has provoked a huge of clinical and epidemiological research initiatives, especially in the most involved countries. However, this very large effort was characterized by several methodological weaknesses, both in the field of discovering effective treatments (with too many small and uncontrolled trials) and in the field of identifying preventable risks and prognostic factors (with too few large, representative and well-designed cohorts or case-control studies). In response to the fragmented and uncoordinated research production on Covid-19, the Italian Association of Epidemiology (AIE) stimulated the formation of a working group (WG) with the aims of identifying the most important gaps in knowledge and to propose a structured research agenda of clinical and epidemiological studies considered at high priority on Covid-19, including recommendations on the preferable methodology.
“This research agenda represents an initial contribution to direct clinical and epidemiological research efforts on high priority topics with a focus on methodological aspects. Further development and refinements of this agenda by Public Health Authorities are encouraged”. This is what the working group coordinated by Gianni Ciccone writes, presenting the 12 general research questions identified as priorities on which to orient public health resources on Epidemiology and Prevention.
Source: Ciccone G, Deandrea S, Clavenna A, et al. Covid-19 and clinical-epidemiological research in Italy: proposal of a research agenda on priority topics by the Italian association of epidemiology. Epidemiol Prev 2020; 44 (5-6) Suppl 2:51-59. doi: 10.19191/EP20.5-6.S2.103