Managing the Pandemic: Lessons From Italy’s Veneto Region
Last updated: March 29, 2020
What often gets lost in the reporting of Italy’s dire COVID-19 statistics is that the suffering has been disproportionately borne by the northern region of Lombardy, one of Europe’s wealthiest and most productive areas. As of March 29, Lombardy held the grim record of over 41,000 novel coronavirus cases and 6,300 deaths (42% and 59% of Italy’s total, respectively).
To Lombardy’s east lies Veneto, a region which is faring remarkably better despite experiencing sustained community spread early on.
Figure 1. Cumulative number of fatalities in select regions, by number of days since 10th fatality
The trajectories of these two regions are being shaped by a myriad of factors, including Lombardy’s greater population density and higher number of cases when the crisis erupted. But some notable differences have to do with policy choices local authorities made early in the cycle, as well as crisis management approaches developed over the last several weeks. (Italy’s health care system is decentralized, giving regions considerable autonomy in these matters).
While Lombardy and Veneto applied similar approaches to social distancing and retail closures, Veneto took a more aggressive tack on active surveillance, including testing, tracing, and isolation (at home and in medical facilities).
Before we go any further, one caveat: Veneto’s experience shouldn’t be taken as a paragon. There were plenty of operational screw-ups and shifts in tactics as policy makers and health experts searched for the best solutions. The region has also been constantly wresting with scarcity in equipment and personnel. That said, there are six key elements of Veneto’s strategy that are worth unpacking:
1. Relentlessly scale testing capacity
As of March 28, Veneto performed close to 95,000 tests across 5 million people, compared to Lombardy’s 107,000 over 10 million (see Figure 2 for a population-adjusted comparison over time). When Veneto’s ambitious diagnostic strategy was announced in late February, it was met with skepticism from central authorities. Italy’s representative to the World Health Organization dismissed it as “unscientific” and likely to overestimate the actual cases — and therefore spark unwarranted panic. The region had to bootstrap the program, funding the acquisition of the requisite equipment and reagents to make it work.
Figure 2. Tests performed per 100,000 people by region
Some of the early diagnostics efforts concentrated on Vò, a town of three thousand and home to Italy’s first confirmed COVID-19 fatality. On March 6, a team led by Professor Andrea Crisanti at the University of Padova tested all residents and found that three percent were infected, most of whom were asymptomatic. Those who tested positive were quarantined and within two weeks the incidence of COVID-19 in Vò dropped to virtually zero. While regional authorities understood that universal testing wouldn’t be practical with a population in the millions, the Vò experience confirmed their hypothesis that thorough and disciplined searches for asymptomatic cases, coupled with isolation and tracking, were going to be critical levers for rolling back the pandemic (for more on the Vò experiment, read this piece from the University of Chicago’s Luigi Zingales).
2. Target mildly symptomatic cases
In late February Lombardy decided to limit testing to clearly symptomatic cases, such as patients with multiple issues like respiratory difficulties and sustained high fevers (in fairness to Lombardy’s officials, this decision was in line with official guidance from health authorities in Rome). Veneto kept the testing threshold low so that even mildly symptomatic cases can be detected. In practice, this means that anyone walking into an ER or calling their doctor with flu-like symptoms is swabbed. Some hospitals recently received testing equipment that generates results in an hour: patients are screened outside the medical facilities and follow different admission protocols depending on test results.
3. Focus on home diagnosis and care
A relatively reliable supply of kits across the region makes it possible to collect samples directly from a patient’s home, which are then processed in regional and university labs. At-home testing is handled by a dedicated group of over 720 disease prevention specialists, divided into fifteen teams across the region (these specialists also perform regular check-ins with patients). The focus on home diagnosis and care has reduced the burden on hospitals and minimized the risk of COVID-19 spread in medical facilities. Currently 27% of Veneto’s active cases are hospitalized, while in Lombardy the proportion is 51%.
4. Trace contacts as much as possible
If someone tests positive, everyone in that patient’s home and apartment building is tested (for those living in a single-family home, screening extends to neighbors in a radius of a few hundred meters). Close friends and co-workers are also identified and tested by the local disease prevention teams. If tests kits are not immediately available, those who were in contact with the patient are asked to self-quarantine. Currently more than 13,000 suspected cases in Veneto are being asked to remain at home at all times.
Contact tracing is likely to unearth asymptomatic cases and this, combined with the the focus on mildly symptomatic cases (see item #2), can explain part of the large differences between Lombardy and Veneto in terms of case age distribution (asymptomatics are likely younger),hospitalizations, and reported case fatality rates (younger cases are less likely to develop severe complications).
Figure 3. Age distribution of cases, Lombardy vs. Veneto
Figure 4. Reported case fatality rates, Lombardy vs. Veneto
5. Establish a hub and spoke system of dedicated hospitals for COVID-19 patients
Veneto created a network of COVID hospitals that includes provincial “spokes,” where entire buildings or wings were carved out (and sealed off) for coronavirus patients requiring non-acute care. Larger hospitals function as regional “hubs” with dedicated ICU areas for acute cases (to make room for other patients, the region re-opened old hospitals). Dedicating medical facilities to handle coronavirus cases streamlines the process for intake and treatment, and reduces the risk of COVID-19 infections among medical staff and patients.
6. Emphasize health care and other essential workers
Veneto has allocated a large portion of its testing capacity to regularly screen medical professionals and those in contact with at-risk populations, such as caregivers in nursing homes. This step, as well as #5 above, might help explain the stark differences in medical staff infections between Lombardy’s and Veneto (figure 5). Testing also targeted other workers exposed to the public despite the lockdown, such as supermarket cashiers, pharmacists and protective services staff.
Figure 5. COVID-19 Cases among medical staff in Lombardy, Veneto, and other regions
Over the last several weeks Veneto has worked to further boost testing capacity, with the goal of performing over 10,000 tests by the end of March and 20,000 by mid-April (on a population-adjusted basis, that is the equivalent of 1.3 million tests a day in the United States). With a more robust and distributed diagnostic footprint, the region will be able to increase the breadth and frequency of testing for essential workers and at-risk groups such as the elderly. Veneto’s medical and public health leaders understand that greatly expanding screening capabilities is a pre-requisite for easing the current lockdown regime as quickly as possible.
While Veneto’s s approach may not yet be as digitally savvy as South Korea and Singapore, it still requires a considerable amount of investment and coordination among a number of officials and medical professionals distributed across the territory (for more detail on the their approach click here for more — in Italian). Regional authorities are cautiously optimistic their efforts are bearing fruit.
Veneto’s results have been noticed by other regions like Campania, Emilia Romagna and Tuscany. In the third week of March they decided to follow Veneto’s lead and committed to increasing diagnostic capacity. On March 27, Lombardy decided to lower its testing threshold to include mildly symptomatic cases. The experience of all these local experiments bears watching in the coming weeks.
Generalizing beyond Veneto’s experience, a few lessons stand out for me (beyond the relatively obvious conclusion that overinvestment in the diagnostic effort early on is key):
- Active surveillance efforts can work locally if one can stitch together a rich collaborative fabric connecting hospitals, labs, and medical professionals deployed across the territory. While testing machines and reagents make the headlines, the human and relational capital required for such a distributed effort is just as important.
- Testing and tracing can pay dividends even if it’s not as high tech as it was in Singapore and South Korea (for another relatively low-tech example, see James Perason’s highly informative Twitter thread)
- Decentralization can be a real advantage — provided the benefits it generates propagate swiftly. Coordinated response and shared support at the national level are surely important when battling a virus that doesn’t respect local borders. But the rapid pace of the crisis and sheer amount of uncertainty makes it exceedingly difficult for central authorities to (i) spot the issues quickly, (ii) devise the “one best way” to address these, and (iii) deploy solutions quickly and with sufficient nuance to fit varying local conditons. Veneto has played the role of positive deviant. The challenge for Italy and other countries is to learn from this experience and other forms of distributed innovation more quickly than the virus spreads.
Note to readers: I’m an outside observer with a public policy background and a personal stake in understanding what’s unfolding in Italy and how that might inform responses to mitigate the impact of COVID-19. I’ve prepared this synthesis from public sources like press briefing, interviews, and official documents providing operational details on Veneto’s pandemic response.
I’m also grateful to Raffaella Sadun and Gary Pisano, professors at Harvard Business School, for the dialogue on these topics over the last few days, which culminated in a Harvard Business Review article. (Of course, the responsibility for any shortcomings and inaccuracies reported here rests with me).
If you’re interested in diving into the regional dynamics of Italy’s pandemic, I maintain a public dashboard, updated daily: https://public.tableau.com/profile/michele.zanini#!/vizhome/ITALYCovid-19TrendsbyRegion/Summary
And if you want to dig deeper, I highly recommend a recent conversation between Professor Michele Boldrin and Professor Stefano Merigliato (dean of the Medical School at the University of Padova. It’s in Italian, but Youtube’s auto-translate works wonders.
