Pasquariello, Paolo

Stranges, Saverio

English

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Western University Scholarship@Western Epidemiology and Biostatistics Publications Epidemiology and Biostatistics Department 6-1-2020 Excess mortality from COVID-19: a commentary on the Italian experience Paolo Pasquariello Stephen M. Ross School of Business Saverio Stranges Schulich School of Medicine & Dentistry, saverio.stranges@uwo.ca Follow this and additional works at: https://ir.lib.uwo.ca/epidempub  Part of the Biostatistics Commons, and the Epidemiology Commons Citation of this paper: Pasquariello, P., Stranges, S. Excess mortality from COVID-19: a commentary on the Italian experience. Int J Public Health 65, 529–531 (2020). https://doi.org/10.1007/s00038-020-01399-y COMMENTARYExcess mortality from COVID-19: a commentary on the ItalianexperiencePaolo Pasquariello1 • Saverio Stranges2,3,4Received: 7 May 2020 / Revised: 16 May 2020 / Accepted: 23 May 2020 / Published online: 28 May 2020 Swiss School of Public Health (SSPH+) 2020Keywords COVID-19  Case fatality rate  Italy  Testing  Health care system  Demographics  Comorbidites Epidemiological trendsThere has been much discussion about why case fatalityrate from COVID-19 in Italy (at 13.3% as of April 20,2020, versus a global case fatality rate of 6.9%; Worl-dometer 2020) is considerably larger than in other coun-tries. In this commentary, we propose several potentialexplanations underlying these differences.Demographics and chronic comorbiditiesAs widely reported, the novel Severe Acute RespiratorySyndrome CoronaVirus-2 (SARS-CoV-2) appears to bemost harmful to male elderly (Onder et al. 2020) and Italyhas one of the oldest populations globally. In addition,Italy’s elderly are well-integrated within society. Forinstance, Italian elderly usually live with their extended,multi-generation families, and actively participate in thelife of their communities (Mazzola et al. 2016). Whilesocially beneficial, this integration may have facilitated theexposure of this vulnerable population subgroup to infec-tion more than in other high-income countries. Accord-ingly, the distribution of the demographic profile ofCOVID-19 deceased individuals in Italy is skewed, withmedian age of around 81 years (Istituto Superiore di San-ita’ 2020).COVID-19 appears to be especially harmful to indi-viduals with preexisting chronic conditions or high-riskbehaviors (smoking), some of which are highly prevalent inthe Italian population, especially among the elderly (Onderet al. 2020). Accordingly, hypertension, type 2 diabetes,ischemic heart disease, atrial fibrillation, cancer, chronickidney disease, stroke and COPD are among the mostcommon comorbidities consistently associated withCOVID-19-related Italian fatalities (Onder et al. 2020;Istituto Superiore di Sanita’ 2020).Definition of COVID-19 related deathsIn the absence of consistent international guidelines, theremay be considerable discrepancies among countries indistinguishing deaths from other causes while beinginfected with COVID-19. To our understanding, Italycurrently labels COVID-19-related deaths as those wherepatients tested positive to the virus, independent of theprimary underlying cause of morbidity. Other countriesmay be using a less expansive definition of COVID-19-related deaths, as those induced directly by the virus, thusreporting lower case fatality rates.Effect of COVID-19 on the Italian NationalHealth SystemThe coronavirus pandemic severely stressed the localprovision of health care. In particular, intensive care units(ICUs) of local and regional hospitals in Italy in general,and especially in the Lombardy region, had to deal with& Saverio Strangessaverio.stranges@uwo.ca1 Ross School of Business, University of Michigan, Ann Arbor,MI 48109, USA2 Department of Epidemiology and Biostatistics, SchulichSchool of Medicine and Dentistry, Western University,Kresge Building, Room K201B, London, ON N6A 5C1,Canada3 Department of Population Health, Luxembourg Institute ofHealth, Strassen, Luxembourg4 Humanitas University Medical School, Milan, Italy123International Journal of Public Health (2020) 65:529–531https://doi.org/10.1007/s00038-020-01399-y(0123456789().,-volV)(0123456789().,-volV)thousands of patients with severe acute respiratory syn-dromes induced by COVID-19. This nearly exhausted theavailable provision not only of ICU beds, but also of res-pirators and ventilators (Rosenbaum 2020). In addition, theepidemic progressed at a speed that made adding capacitychallenging while the global supply chain is stretched andat times broken. This suggests that some patients may havenot received the best possible care, leading to worse healthoutcomes. These events are remarkable, since Lombardy isone of the wealthiest regions in Europe, while the ItalianHealth System is widely considered among the best in theworld in terms of access, quantity and quality of careprovided (World Population Review 2020).It is equally important to emphasize that COVID-relatedcase fatality rates within Italy display significant hetero-geneity, e.g., as high as 18.5% in Lombardy, also the mostpopulous region of Italy, and as low as 4.3% in Umbria,among the least populated, as of April 20, 2020 (Diparti-mento della Protezione Civile 2020). Yet, the regional casefatality rate is also highly positively correlated (up to 68%)with the regional-level number of hospitalized symp-tomatic and/or ICU-admitted COVID-19 patients, onceagain suggesting that fatalities spiked as hospitals’ capacitydiminished, especially in the most affected northernregions where the vast majority of deaths occurred.Extent of testing for COVID-19 and the tipof the icebergItaly and South Korea are among the countries where themost tests per thousand people for COVID-19 were per-formed as of April 20, 2020 (Our World In Data 2020). Ofcourse, running more tests implies in principle that a largerportion of the coronavirus iceberg would be observed,including infected but asymptomatic individuals, relativeto other countries where COVID-19 is stealthily spreadingand killing. However, Italy has so far mostly testedsymptomatic people, while it was widely reported thatSouth Korea adopted extensive contact tracing by testingseveral asymptomatic people for each symptomatic one onthe basis of immediate proximity. Nevertheless, thisapproach (adopted by other Asian countries as well) alsoraises concerns for the potential violation of privacy andhuman rights; hence, its applicability to Western countriesis uncertain.In light of these observations, we developed a simplemodel to estimate the Italian coronavirus under-testing andiceberg as a function of recent estimates of the asymp-tomatic proportion of infected individuals (Nishiura et al.2020). Intuitively, our model is based on expressing basicepidemiological aggregates as explicit functions ofobservable and unobservable parameters from the currentItalian and South Korean testing experiences as well as onassuming that Italy would have experienced similarobservable epidemiological outcomes as South Korea if ithad adopted the same testing approach. See Pasquarielloand Stranges (2020) for further details and analysis.We estimate from this model that if Italy had followedthe more proactive South Korean testing approach, itshould have tested between ten and more than twentyasymptomatic people for each symptomatic one it did test.Such more widespread testing would have yielded acoronavirus iceberg from one-tenth to more than two timeslarger than its observed tip. These estimates translate innon-trivial over-reporting of the current COVID-19 casefatality rate in Italy, as compared to countries (like SouthKorea) adopting proactive and extensive contact tracing. Inparticular, our model implies an estimated case fatality rateof slightly less than 9%, i.e., about one-third lower than thecurrent one.Lessons learned from the Italian experienceWe conclude that Italy’s COVID-19 case fatality rate islikely to be inflated by such factors as the iceberg effect ofunder-testing. However, we also acknowledge that deathsin Italy are likely higher than in other equally affectedcountries because of its unique demographic and socioe-conomic profile. In addition, we emphasize the central roleplayed by the stress imposed by the pandemic on the healthcare system of the most affected areas and its likely con-tribution to their high death tolls.Therefore, we caution from ignoring the lessons that theItalian circumstances may offer to other impacted Westerncountries. The COVID-19 pandemic has exposed severalintrinsic structural limitations of the Italian national publichealth care system, especially a lack of coordinated andtimely response mechanisms for enabling rapid actions,like those deployed by several Asian countries, and a lackof adequate community response, which is critical forepidemic containment.In a context of limited evidence and significant uncer-tainty, Italy is running a massive public health interventionthat is unique in the history of Western democracies. Weall have to hope that it succeeds.Funding This article was not funded by any grant.Compliance with Ethical StandardsConflict of interest The authors declare that they have no conflict ofinterest.530 P. Pasquariello, S. Stranges123Human and animal rights This article does not contain any studieswith human participants or animals.ReferencesDipartimento della Protezione Civile (2020) Emergenza coronavirus,dati regionali. https://github.com/pcm-dpc/COVID-19/blob/master/dati-regioni/dpc-covid19-ita-regioni.csv. Accessed 21 Apr2020Istituto Superiore di Sanita’ (2020) Characteristics of COVID-19patients dying in Italy—report based on available data on April23, 2020. https://www.epicentro.iss.it/en/coronavirus/bollettino/Report-COVID-2019_23_april_2020.pdfMazzola P, Rimoldi S, Rossi P et al (2016) Aging in Italy: the needfor new welfare strategies in an old country. The Gerontologist.https://doi.org/10.1093/geront/gnv152Nishiura H, Kobayashi T, Miyama T et al (2020) Estimation of theasymptomatic ratio of novel coronavirus infections (COVID-19).Int J Infect Dis. https://doi.org/10.1016/j.ijid.2020.03.020Onder G, Rezza G, Brusaferro S (2020) Case-fatality rate andcharacteristics of patients dying in relation to COVID-19 in Italy.JAMA. https://doi.org/10.1001/jama.2020.4683Our World In Data (2020) COVID-19 testing. https://ourworldindata.org/covid-testing. Accessed 21 Apr 2020Pasquariello P, Stranges S (2020) Excess mortality from COVID-19:lessons learned from the Italian experience. Preprints. https://doi.org/10.20944/preprints202004.0065.v2Rosenbaum L (2020) Facing Covid-19 in Italy—ethics, logistics, andtherapeutics on the epidemic’s front line. NEJM. https://doi.org/10.1056/NEJMp2005492World Population Review (2020) Best healthcare in the world 2020.https://worldpopulationreview.com/countries/best-healthcare-in-the-world/. Accessed 21 Apr 2020Worldometer (2020) COVID-19 coronavirus pandemic. https://www.worldometers.info/coronavirus/. Accessed 21 Apr 2020Publisher’s Note Springer Nature remains neutral with regard tojurisdictional claims in published maps and institutional affiliations.Excess mortality from COVID-19: a commentary on the Italian experience 531123

Excess mortality from COVID-19: a commentary on the Italian experience

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Excess mortality from COVID-19: a commentary on the Italian experience

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