Policy responses for Italy - HSRM

Italy


Policy responses for Italy

1.5 Testing

The ‘Relaunch Decree’ of 19th May (n° 34) and its latest amendments of 28th June have established that regions and autonomous provinces are responsible for setting up networks between microbiology laboratories that perform Sars-CoV-2 tests. Regions ought to identify them following directions given nationally by the Ministry of Health, which has defined benchmark criteria regarding structural requirements and staff technical skills. Moreover, regions must identify a regional laboratory of reference that maintains direct contact with the National Health Institute (ISS) and that, in turn, identifies public and private laboratories in possession of such requirements. It is responsibility of the regions and autonomous provinces to pass on lab data on positive cases to the ISS.
Data recorded on 8th May showed that, on average, 2,51% of the Italian population were given a nasopharyngeal test, though this rate was above 4% in Friuli Venezia Giulia, Trentino-Alto-Adige, Valle d'Aosta and Veneto. Campania, in the South, had the lowest rate (0,84%). During the first week of May, as the country was transitioning from Phase 1 to Phase 2, the country carried out an average of 6.62 swabs every 1,000 inhabitants, however with differences among regions once again. In fact, the highest weekly rates were recorded in the northern regions of Trentino-Alto-Adige, Valle d'Aosta, Veneto and Friuli-Venezia-Giulia whereas the lowest was registered in Puglia.
On April 3rd, the Ministry of Health underlined the importance of serological testing for research purposes and for epidemiological evaluations concerning viral circulation. Nonetheless, further evidence is needed with regards to their performance and usefulness in the diagnosis of SARS-CoV-2 infection.
On April 17th, the Extraordinary Commissioner launched a simplified and urgent call for proposals for a rapid supply of CLIA and/or ELISA serological test kits, with the purpose of carrying out 150 000 serological tests within a national investigation (“serosurvey”) to assess the actual extent of the spread of the SARS - CoV-2 infection. The Technical Scientific Committee, together with INAIL and the Italian National Institute of Statistics (ISTAT) has organized the sampling of the 150 000 individuals differing by sex, lifestyle and age groups and distributed among 2000 municipalities. In the event of a positive diagnosis, nasopharyngeal swabs were performed to identify any contagious state.
 
The investigation was conducted between 25th May and 15th July 2020. A total of 64,660 tests were conducted by ISTAT and the Red Cross. By 3rd August the first results were presented, leading to estimate that 1 482 000 people in Italy had contracted the virus, corresponding to 2.5% of the entire population. As expected, there were heterogenous results among regions as Lombardy, the first region in terms of number of positive individuals, showed a prevalence of 7.5% while all the Southern Regions were below 1%. Healthcare professionals are the most affected category and intra-family transmission appears high; however, the infection does not seem to spread if  precautionary measures are followed. Moreover, 27.3% of those infected were asymptomatic, underlining the importance of recommended preventive measures.

By the end of April, the MOH declared that serological tests, in particular rapid diagnostic tests (RDT), are not sufficiently valid for health surveillance according to Law 81/2008 thus, at present, there are no indications of their use for both diagnostic and prognostic purposes in the workplace, nor to determine the contagion potential of individual workers.
However, in the meantime, private initiatives have been launched to promote serological diagnosis at individual and occupational level through private laboratories. Some citizens have been attracted by adverts of private labs and have decided to pay out-of-pocket to be tested; furthermore, several employers have offered free serological screening to their workers. Some of these initiatives have been guided by a public health approach but, in several cases, there have not been clear strategies for follow-up. Patients are usually sent to their GP or the Local Health Authority for further investigations. The costs and the quality of private testing is showing a wide range of variability, arising relevant concerns on their transparency and reliability and on different regional approach to serological testing. In light of these approaches and while we await the results of the national seroprevalence survey, it should be highlighted that the use of serological tests for operational purposes - CLIA / ELISA being the most accurate - has been working well to identify new positive cases, especially in regions where the virus circulated pervasively in the population. More specifically, many citizens who tested positive in the SARS-CoV2 molecular swab tests had first been alerted by the presence of IgG found thanks to serological tests and now have low viral loads. It seems, in fact, that positivity to swabs is more a consequence of viral shedding (elimination of residues of the virus from the cells of the nasopharynx) than a matter of actual contagion in progress.

As of 23rd September, the Health Ministry is working on updating its testing strategy. On 30th September, it authorised rapid testing in schools.

According to the ECDC testing data file (please refer to https://www.ecdc.europa.eu/en/publications-data/covid-19-testing), by 23rd September 2020, Italy had performed a total of 10,094,002 RT-PCR tests of which 296,717 resulted positive. This leads to a testing rate of 1018.4 for every 100,000 inhabitants and to a weekly test positivity of 1.7% (intended as the percentage of new confirmed cases over number of tests performed weekly).

In the meantime, all Italian regions have equipped themselves differently for serological testing methods, target population and accessibility for private citizens. Overall, numerous private diagnostic labs have made available the test to private citizens, starting from May 2020. In some regions such as Lombardy, Liguria, Sicily, Campania, Puglia and Lazio, it is also possible to request a nasopharyngeal swab on the basis of specific agreements with the Regional Health System.

Lombardy

Since 23rd April, Lombardy has started performing serological tests for the detection of antibodies against the new Coronavirus by conducting pilots in the most affected areas (Brescia, Bergamo, Cremona, Lodi). Such tests, based on chemiluminescence technology (CLIA), use an immunological assay for the quantitative determination of specific anti-S1 and anti-S2 IgG antibodies directed against SARS-CoV-2 present in serum or in human plasma samples.

The aim is to facilitate the diagnosis of COVID-19 and allow Local Health Authorities to analyze the immune status of infected patients by indicating the presence of IgG antibodies against SARS-CoV-2. According to regional guidelines, the results of these tests are not suitable for diagnostic purposes, to be certain on the negativity of SARS-CoV-2 infection nor to obtain information on the status of the infection.

Initially, tests were addressed to specific categories of citizens:
a) health care professionals
b) people who had had contact with positive cases in voluntary isolation, without symptoms for at least 14 day or who had not received a nasopharyngeal swab test, identified by Local Health Authorities thanks to epidemiological investigations
c) symptomatic people reported to the Local Health Authorities by General Practitioners and Pediatricians, who had not received a nasopharyngeal swab test.

Starting from 29th April, serological testing was then extended to the entire region. On 21st May, it was decided to pay specific attention also to all essential-service workers (prefectures, firefighters, courthouse employees and of the labour inspectorate, INAIL, INPS, etc.); parallel to those organized by the Region, other initiatives are being promoted directly by some municipalities (e.g. 50,000 tests promoted by the Municipality of Bergamo for individuals aged between 18 and 64).
As of June 12th, Lombardy had carried out 264,024 CLIA serological tests, of which 161,695 on general citizens (suspected cases and their contacts, reported by GPs) and 102,329 physicians and healthcare professionals. Of these, 41,250 citizens (equal to 25.6%) and 13,402 healthcare operators (equal to 12.6%) tested positive for IgG.


Emilia-Romagna
The Emilia-Romagna Region was among the first (3rd March) to resort to RDT for screening health workers even several times on a voluntary basis. From mid-April, the screening protocol was integrated with CLIA / ELISA analysis in the event of a positive IgM / IgG outcome.
The Emilia-Romagna Region has scheduled 250,000 tests to be carried out and, on 11th May (latest data release on the Region's website), 87,216 rapid tests had been carried out of which 52,249 on social or healthcare personnel (5.5% were positive to IgG, 3.2% to IgM and 2.2% to both antibodies) and 34,675 on law enforcement workers and other categories at risk (4.7% tested positive for IgG, 2.6% tested for IgM and 1.8% to both antibodies). In addition, about 100,000 voluntary CLIA/ELISA tests are in progress on parts of the population that had the greatest chance of contacting Covid-19 in the provinces of Piacenza and Rimini as well as in the municipality of Medicina (still ongoing and results are not yet available as of June 22). Moreover, from 12th May, private citizens can be tested only with a prescription and through out-of-pocket payment; subsequent tests in case of positivity, on the other hand, remain at the expense of the region. Employers who voluntarily decide to carry out serological screening on their employees are simply required to communicate to the Region their wish to adhere to the program and indicate a chosen laboratory among those authorized.


Lazio
On 24th April 2020, the Lazio Regional Council gave the go-ahead to perform 300.000 serological tests on law enforcement personnel and healthcare professionals, to understand how the virus has been circulating in given contexts and guide targeted control interventions in more risk-exposed areas.

This investigation, the largest in the country do far, will be conducted by the National Institute for Infectious Diseases (INMI) Lazzaro Spallanzani hospital and will be monitored by the Regional Service for Epidemiology, Surveillance and Control of Infectious Diseases (SeReSMI), with costs borne by the Regional Health Service. According to the Regional Tariff Nomenclature, the cost of venous blood sampling is EUR 2.58, or EUR 14 if done at home; ELISA and CLIA serological tests are valued at EUR 12.65, while capillary sample analysis at EUR 15.07.
Tests will be performed on staff working in public health facilities (including outpatient specialists, doctors responsible for continuity of care, general practitioners, pediatricians and community pharmacists) in private hospitals and nursing homes accredited by the NHS and, also, on law enforcement personnel. Adherence to the investigation is individual and voluntary for all subjects and participation to the initiative is confirmed by signing an informed consent.

All samples will be computerized and stored in the INMI Spallanzani Bio-bank and the gathered information will be centralized in the regional surveillance platform.

Local Health Units are responsible for the organization and delivery of tests for health workers through specifically designated healthcare facilities which, other than collecting and storing informed consents, managing bookings, and registering patient data, will also have to send samples to their laboratory of reference and contact subject that have tested positive, to guide them towards the nasopharyngeal testing.
In the case of testing on law enforcement personnel, each agency is required to identify one delegate to coordinate communication with the INMI Spallanzani hospital, the Local Health Unit and the Laboratory of reference. The type of serological test for each agency has been chosen by law enforcement officers on the base of organizational requisites. In fact, the Police Force, the Fire Brigade, the Coast Guard and the Armed Forces have adhered to intravenous sampling, while the Carabinieri, the Finance Police and the Department of Corrections will use POCTs. The INMI Spallanzani hospital will collect and store informed consents, manage bookings, provide reports, send the samples to the reference laboratory, direct the positive subjects to nasopharyngeal swabs and make sure that waste is disposed in special containers provided by Local Health Units.
As of June 15th, the Lazio Region has carried out 108,404 serological tests and, on average, in 2.4% of cases IgG were found (2% among health workers, 4% in the cohort of citizens who took the paid test); it has also been announced that an ulterior screening program will be carried on 100,000 individuals among school workers, such as teachers, administrative or technical staff for the safe reopening of schools.

Tuscany
Over 20 000 tests have been carried out in public health facilities from 14th to 29th April, during a screening campaign directed to employees and operators engaged in social and health services, carried out by the North-West Tuscany Local Health Unit. Out of the 20,036 rapid serological tests performed, less than 2 percent resulted positive. Employees were given the chance to book the date of the test via a specially created timetable with slots available from 14th to 28th April 2020. The initiative was entirely managed remotely through an app called 'serotest': 15,056 tests were performed in the outpatient departments of hospitals whereas the remaining 4,980 were done in itinerant structures.
The Local Health Unit staff also provided rapid serological tests and nasopharyngeal swabs in its 119 homes for the elderly and for people with disabilities. Guests living in such structures had 3,900 rapid tests with 135 positive results (3.46%); 4,122 tests were performed on the staff with 81 positive tests (1.96%).

Marche
On April 3rd, the Marche Region decided to use the serological tests on healthcare professionals within a regional epidemiological surveillance program. Occupational health physicians are  responsible for the surveillance and those who test positive to IgM (with or without positive IgG) should undergo molecular swab testing.

On April, 29th, the Region decided to include law enforcement personnel within the regional program too and provided precise instructions on the use of serological tests in the workplace. Employers must declare their willingness to participate to the regional survey and their occupational health physician is responsible for carrying out the procedure. The participation of workers is voluntary as it should not be considered within the mandatory health surveillance and the employer should cover the costs of both serological and molecular tests. Serological tests will be performed in labs accredited with the NHS and the overall results will be communicated to the Region for epidemiological purposes. Only workers testing positive to molecular testing should be reported to their Local Health Authority for isolation and surveillance.

Veneto
From 30th April, asymptomatic workers in Veneto can be screened under the supervision of their attending physician, by means of nasopharyngeal swabs or serological tests, with costs charged to the employer.
As of June 15th, the Veneto Region carried out approximately 750,000 rapid serological tests (immunochromatographic test on capillary venous blood) on health workers and essential services personnel. However, the results could not be found in the documentation published on the institutional website.


Piedmont
From April 29th, employers are allowed to test employees under the supervision of the attending phyisician, in which case serological tests can be performed in both private and regionally authorized labs. On May 4th, the Region activated a Healthcare Screening Program from the beginning of May based on CLIA / ELISA technology.


For many other regions, the published data is either poorly detailed or out of date, making any attempt to analyze and use it for diagnostic or research purposes quite complex. Supported by a circular of the Ministry of Health of 9th May three regions - Calabria, Friuli-Venezia Giulia and Sardinia – have decided to not conduct serological tests at all.



Sources:

- http://www.salute.gov.it/portale/ministro/p4_10_1_1_atti_1_1.jsp?lingua=italiano&id=219 
- https://www.regione.lombardia.it/wps/portal/istituzionale/HP/DettaglioRedazionale/servizi-e-informazioni/cittadini/salute-e-prevenzione/coronavirus/test-sierologici-anticorpi-anti-covid19
- http://www.regione.lazio.it/rl/coronavirus/indagine-epidemiologica-forze-dellordine-coinvolte-oltre-60mila-unita/ 
- https://www.ilmessaggero.it/roma/news/coronavirus_lazio_via_300mila_test_sierologici_forze_ordine_sanitari-5190212.html
- https://www.pisatoday.it/cronaca/test-sierologici-asl-toscana-nord-ovest-coronavirus.html
- https://www.osservatoriomalattierare.it/news/attualita/16017-coronavirus-caotica-la-situazione-dei-test-sierologici-in-italia
- Ministry of Health Circular n° 14925 of 29th April 2020 “Operative instructions regarding the activities competent clinicians in the context of measures to contrast and contain the spread of virus SARS-CoV-2 in the workplace and in the community”.
- Ministry of Health Circular of 3rd April 2020 “Covid-19 Pandemic – Update on instructions regarding diagnostic tests and on criteria to follow for the determination of priorities. Updates regarding laboratory diagnosis”
- http://www.regione.lazio.it/rl/coronavirus/approvata-delibera-di-giunta-per-test-sierologici-operatori-sanitari-e-forze-dellordine/
- ALTEMS Covid-19 working group - Instant REPORT#6: 8 Maggio 2020  - Analisi dei modelli organizzativi di risposta al Covid-19, available at https://altems.unicatt.it/altems-6REPORT%20ALTEMS.pdf
- ALTEMS Covid-19 working group - Instant REPORT#9: 28 Maggio 2020  - Analisi dei modelli organizzativi di risposta al Covid-19, available at
- http://www.cerismas.com/web/images/COVID-19/InstantReport/INSTANT_REPORT_NUMERO_9.pdf
- Ministry of Health Circular n° 0016106 of 9th May 2020 “COVID-19: screening and diagnostic tests”.
- Law Decree 19th May 2020, n. 34  - Urgent measures in the field of health, support for work and the economy, as well as social policies connected to the epidemiological emergency caused by COVID-19. [Available at [https://www.gazzettaufficiale.it/eli/id/2020/05/19/20G00052/sg]
- Amendments to Law Decree 19th May 2020, n. 34 of 28th June – [Available at http://www.quotidianosanita.it/allegati/allegato8651425.pdf]
- http://www.salute.gov.it/portale/news/p3_2_1_1_1.jsp?lingua=italiano&menu=notizie&p=dalministero&id=4998&fbclid=IwAR3BhaUUtypVY4pG_n3HCcERgVPg_7vnfWrJfqERWMjKPx-iX9GEits-hs4 
- ECDC. Covid-19 Country overviews. Last update 24th September [Available at: https://covid19-country-overviews.ecdc.europa.eu/#19_italy]
- https://www.ecdc.europa.eu/en/publications-data/covid-19-testing
- I-COM. Riportare la sanità al centro. Dall’emergenza sanitaria all’auspicata rivoluzione della governance del SSN -  Rapporto Area Innovazione, Settembre 2020.

NATIONAL GUIDELINES ON TESTING
The first two confirmed cases of Covid-19 were represented by two Chinese tourists travelling to Rome on January 31st, and the first cases among Italian residents were registered on February 21st in Lombardy and Veneto Regions. 
Since the beginning of the mitigation phase (26 February), Italian national guidelines on testing followed WHO and ECDC guidelines stating that patients with symptoms could be tested if (i) they had contacts with a confirmed case; (ii) they came from areas where local transmission was ongoing; (iii) they were hospitalized.

However, it has been challenging to ensure full consistency with this policy throughout the Italian territory. This was due by the fact that the regions, which are responsible for health services’ delivery, organized the tracing and testing in different manners (see regional examples below) and, particularly at the beginning, experienced a severe lack of testing material and capacity. Additionally, information on testing policies has often been unclear and contradictory.

From the first phases of the outbreak, the Department of Civil Protection has set up over 700 triage tents outside Hospital Emergency Departments to avoid mass gatherings of potentially positive cases in waiting rooms and to rapidly identify those who are infected. In other cases, the test is executed either at home or in 152 laboratories (Updated to 6th April. There were 77 on 20th March and 46 on 9th March) authorized by the National Health Service and active nationally.

Those who present symptoms must not enter a hospital or a doctor’s surgery. They must, in fact, contact their General Practitioner who is equipped with a triage checklist of questions to assess the eligibility of the person for the test and, if necessary, will approve it. Testing modalities follow the WHO protocols (Reverse Real-Time PCR (rRT-PCR)) and positive cases are then confirmed only by the ISS National Laboratory. At present, safety protocols recommend executing two tests, the results of which take about 4-6 hours. An Ordinance released by the Ministry of Health on 3rd April establishes a set of eleven diagnostic tests that have been formally recognized and could be used in Italian laboratories. In line with WHO recommendations, the Scientific and Technical Committee advises using serological tests for the assessment of antibody levels solely for research and epidemiological evaluation. At present, they do not, in fact, provide sufficient information to determine the severity of the infection and could also potentially lead to false negatives, since they do not detect active infections in early or asymptomatic stages.

Accreditation of labs for testing
For labs to be enrolled in the list of authorized centres to make the diagnosis, the first five positive and first ten negative samples must coincide with the results of the regional reference centres. They must send a representative number of samples to the ISS’s National Laboratory in order to monitor the molecular epidemiology of the virus. All positive samples of deceased patients must be preserved in the facility that has performed the test and subsequently sent off to the National Laboratory if requested.
In some cities, mobile labs or so-called drive-through clinics are also present, and allow personnel to take samples without individuals having to get out of their car.

Recovered patients
Patients who become asymptomatic after showing symptoms such as fever, rhinitis, cough, sore throat, dyspnoea or even pneumonia with respiratory difficulties associated to SARS-CoV-2, may still test positive to SARS-CoV-2 and are to be classified as clinically recovered. A patient is recovered when, after eliminating symptoms, s/he has resulted negative for two consecutive tests executed at a distance of at least 24 hours.

Since SARS-CoV-2 tests could result positive for long periods of time, the National Health Council and Regional Experts for COVID emergencies have provided suggestions on the appropriate timing for testing. Positive patients should be re-tested after being considered clinically cured.  If the patient is still symptomatic tests must occur, no earlier than 7 days after the first positive test whereas, if asymptomatic, the second test should be performed no earlier than 14 days from the first positive result. Due to limited testing capacity and with the intent of reducing the number of patients still positive to the second test, several local health authorities usually space out the tests even further; hospitals, in contrast, tend to perform tests closer to one another to facilitate the discharge of their COVID-19 patients.

REGIONAL APPROACHES
As testing capacity greatly varies by region, national guidelines outline the basic criteria for testing and regions are authorized to broaden their eligibility criteria. Generally, samples belonging to health care professionals have absolute priority over others.

Delivering and analysing results has been a challenge in many regions, particularly those with a rapidly increasing number of cases. Many have therefore been working to expand laboratory capacity with the aim of increasing the number of tests and reduce waiting times for results.

Piedmont
On 26th March, Piedmont, a region with 5 million inhabitants, announced a successful increase in regional testing capacity that will give priority to 55,000 health workers and to all front-line health workers, even if asymptomatic. Initially, the region was in fact equipped with 2 reference labs whereas, today, it can resort to 20 accredited laboratories processing 3,500 tests per day.

Lombardy
Lombardy, with about 10 million inhabitants, has 31 laboratories and a maximum capacity of 11,000 tests per day. At the beginning of the COVID-19 epidemic, swab tests were broadly used to identify cases as part of the contact tracing strategy. During the first days of March, as recommended by the CSS, Lombardy tested only symptomatic patients. From the second week of March, it reduced the testing spectrum to only severe patients presenting multiple symptoms in pre-hospitalization. On 26th March, however, the strategy was changed again, as the region announced a change in policy to extend testing also to people presenting only one symptom, and to all healthcare professionals; on 7th April molecular testing was extended also to residential and nursing homes, both for guests and health and social professionals, and to patients with flu like symptoms authorised by their GP. Since then, it has performed a total of 351 423 tests. (For further information, see “Transition measures: testing)

Veneto
Going beyond national guidelines aligned with WHO and ECDC recommendations, Veneto (a region with about 5 million inhabitants) adopted a different approach to testing aiming towards mass population screening. The regional government approved on 16th March a plan for large-scale population testing. Capacity was scaled-up by involving all microbiology laboratories in regional hospitals to increase the number of tests processed per day from 3,210 to over 11,000. Testing priority is being given to 54,000 healthcare professionals, GPs, pharmacists and vulnerable people such as elderly patients in long-term care nursing homes. In addition, a regional pilot research project is conducting 10,000 tests on essential-services workers, such as supermarket workers, public transportation personnel and police officers. By March 31st, the region declared to have performed 105,000 tests, out of which 8,724 citizens were found to be positive. In addition, it purchased 700,000 rapid testing kits and is planning a trial project to test population immunity by identifying COVID-19 antibodies through blood tests. These approaches were triggered by a pilot experience at the very beginning of the outbreak, in the village of Vo Euganeo, with 3,000 inhabitants. The entire population was tested, and this is believed to have been key in containing the outbreak as 50 to 75% positive cases were found to be totally asymptomatic or with mild symptoms only. Isolation measures were therefore imposed to all positive cases (including those without symptoms) to contain local transmission. As a result, the total numbers of cases went down from 88 to 7 in about 10 days.

Emilia-Romagna
Similarly, Emilia-Romagna, which has performed over 50,000 tests (latest data available on 31st March), has announced its intent to extend tests also to asymptomatic cases and has currently been testing by means of the so-called “drive-through” modality to increase its capacity, which allows people to be tested without getting out of their car, by appointment. 

Campania
In the south of the country, the region of Campania (5.8 million inhabitants) has also identified, with the support of the regional reference lab, 9 additional testing sites to drastically shorten processing times and has now set the goal of performing 2,000 tests per day. It has also purchased 1 million “Antibody Determination Kits” which is a rapid testing technique that will be used first on health professionals and then on other risk-exposed categories of workers. At present, it has performed 14,403 tests (latest data available on 31st March).

Marche
With about 1.5 million inhabitants, Marche has 8 laboratories and a maximum capacity of around 1,000 tests per day.  Citizens are tested according the WHO priorities. Tests are used also to transfer patients in different health care settings and people presenting symptom authorised by their GP. At present (20/04/2020), it has performed a total of 42,782 tests. (For further information, see “Transition measures: testing)

Sources
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- WHO, Protocol: Real-time RT-PCR assays for the detection of SARS-CoV-2 Institut Pasteur, Paris. https://www.who.int/docs/default-source/coronaviruse/real-time-rt-pcr-assays-for-the-detection-of-sars-cov-2-institut-pasteur-paris.pdf?sfvrsn=3662fcb6_2 
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