Can Italy finally start the dance to control Coronavirus?
In short, probably yes: the containment measures adopted in Italy managed to greatly slow down the COVID spread, more than it looks like. Therefore, it is time to gradually release the lockdown and start the dance to control COVID. What does it mean? Let’s go into the details.
If you are following the evolution of the epidemic curve in Italy, you know that the number of new cases is still increasing. Why is that? Well, by now you should have realized this: those numbers mean nothing, they are very far from the real number of COVID cases. To understand this, just look at the case fatality rate (CFR) in Italy vs other countries: if we were able to find all COVID cases, we would have a CFR of 12%: absolutely unrealistic, even considering important factors such as the high fraction of elderly. The estimates for COVID CFR are around 1%, ten times smaller. Not only the fraction of reported cases over real cases is much smaller than one, but it is reasonable to think that this fraction is increasing in time. The efficiency of the Italian health system at looking for new cases is indeed expected to increase, as it is the capacity for testing. Therefore, you should not be excessively worried about the number of cases still increasing.
Which indicator should we use then? The reported number of deaths is definitely a more reliable indicator. Let’s look at this plot: three-days average number of COVID deaths in time, where vertical lines correspond to three main containment measures: school closure (green), lockdown (red), stop to all non-essential activities (black). Note anything weird? Yes, containment measures are shifted forward by 14 days. This is indeed the average time elapsed from contagion to death, equal to the sum of the incubation period (estimated to 1–14 days, average 5 days) and time elapsed from the onset of symptoms to death (estimated in Italy to be 8–9 days on average). Note that other studies estimate longer time windows. This plot tells you a simple fact: containment measures are not just working now, they also worked in the past curbing the spreading. We are just seeing the effects 2 weeks later. School closure did not manage to slow down COVID spread, while it did the national lockdown, dated 12/03. Note that the effects of the non-essential activity closure, dated 22/03, are not yet visible in death counts: they “started acting“ only yesterday. The red area corresponds to days in which the effect of the lockdown is effective: it will last until 14 days from today, at least. During this period, the number of deaths is expected to go down further.
What if neither the number of COVID deaths is reliable? If you think so, you are right: also this number has been dramatically underreported. In the news, you probably read about elderly people dying in retirement homes by the dozen, without even getting tested for COVID. Data can show it clearly: in this preprint, the authors compare reported COVID deaths with the excess of mortality in March 2020 with respect to March 2019. They found that real COVID deaths in Lombardy might be three times higher than reported. A similar situation is probable in other countries. Does this mean that the peak has not been reached yet? Actually, it looks like the opposite could be true: this analysis (in Italian) includes the excess of mortality among COVID deaths, and it estimates that we could have reached the peak even earlier.
If containment measures worked in Italy, why should we gradually release them? Well, this is the last fact to know: we cannot beat the coronavirus. It’s already among us, and it will remain so for months, probably years. All we are doing during the lockdown is not “beating” the COVID, just buying us some time. This time was desperately needed for several reasons: avoid the collapse of health systems, build up capacity in testing and tracking cases, find therapies, etc. But unfortunately, we cannot extirpate COVID from the earth. The truth is that many more will be infected and die unless we keep the lockdown until we find a vaccine, and it could be years. This is unreasonable. So, since Italy managed to stop the COVID spread and flatten the epidemic curve, it’s time to move to the next phase: the dance against COVID, so well explained at the end of this article.
Let me be very clear: starting the dance phase does not mean we go back to normality. If so, the contagion will sneaky start over and in a few weeks, we will be overwhelmed again by deaths. But the time earned with the lockdown allowed us to prepare for this new phase. What we need to do is quite simple and very difficult at the same time: a huge behavioral change by everyone, for a very long period of time. It’s possible to go back to almost-normal life only if we understand we must enforce social distancing, that has been shown to work in China. From now on, think you live in an invisible plastic ball of 2 meters radius, nobody should enter your ball. In all public places, measures should be taken to enforce social distancing.
Apart from individual behavioral change, strategic decisions need to be taken. Without entering in details, measures should include leveling up safety in hospitals (which have been the main transmission chain of contagion), massive serology testing, tracking through apps (respecting privacy), etc. Again, data can help to design such strategies. According to this preprint, in Lombardy between 6% and 12% of the population could have been infected. In the Province of Bergamo, it could be up to 40%. Data refer to March, these ratios will go up. By no means, these numbers suggest herd immunity, also because we still do not know if the coronavirus gives immunity. But they suggest that a large fraction of the population in some areas could go back to work, if serology tests confirm the presence of antibodies.
The COVID lockdown has been so long and harsh that thinking about the “after” completely filled our days. Now, in Italy, it could finally be the moment to act. A lot has to be done, but it is finally time to start thinking about what the “new normal” looks like.
