Reflections on COVID19: strategies, management and programming

During the emergency period caused by COVID-19 which affected global public health and, given the health situation that Italy is facing in these difficult months, the need to reflect on preventive strategies for strengthening management and health planning has been highlighted. In this regard, we report the reflections of the Coordinator for vaccinations of the Cagliari ASL, Dr. Gabriele Mereu.

"Nobody could have imagined, when in China in late 2019 the deaths from coronavirus were still being classified as "deaths from pneumonia of unknown origin", or when there was talk of only the spread of the infection from animals to humans (as with bird flu), that just 5 months later the New York Times, on reaching 100,000 official deaths in the USA, would run the headline "Incalculable deaths from Coronavirus in the USA"

In the meantime, while strictly the sanitary and social-distancing rules, which we will necessarily have to abide to for time to come, expectations turn towards the discovery of a vaccine or of effective drugs to tackle the new coronavirus. In particular, several studies focus on vaccines, with forecasts regarding the timing of its approval and availability, which are in constant fluctuation according to the different phases of the ongoing trials.

Those experienced in the field of clinical studies are well aware of the many steps and timescales necessary for the vaccine to be proven immunogenic, i.e. capable of producing the necessary quantity of useful antibodies; effective, i.e. capable of preventing the disease it needs to protect against and safe for humans, i.e. harmless to the human organism.

Once approved by regulatory bodies (the EMA in Europe and the FDA in America), the vaccine will then be produced, also taking into account that the production capacities of the pharmaceutical companies are not unlimited. It should also be remembered that on several occasions, such as during the flu vaccination campaign, the companies supplying the vaccine have been unable to keep up with demand. Finally, it must be established which categories should be prioritised when vaccination is made available - certainly the elderly, people with multiple pathologies, health workers and those in the public emergency services, and potentially those who have been in contact with individuals who tested positive for the virus etc.

According to the most recent discoveries, another means of tackling coronavirus, alongside a vaccine, could be the use of monoclonal antibodies. In detail, the antibodies of patients cured of coronavirus would be isolated, characterised and produced in the laboratory in large quantities. In practice, these would constitute natural drugs intended for administration to those who swab-tested positive in order to stop the progress of the disease or for people who, given their profession, were at immediate risk of contagion (health personnel, public security forces, volunteers, etc.) It would therefore be the best option in cases in which the time needed for the vaccine to produce sufficient antibody titers proves excessive.

The advantage over hyperimmune plasma, which is currently the only weapon available, stems from the fact that the latter always requires an individual donor patient. Moreover, inoculation is not always feasible given the possible incompatibility between donor and recipient and the potential risk of infection should also be taken into consideration.

Pending the new vaccine and new drugs, with the obvious hope that they are not necessary for the natural attenuation of the virus, it is essential to implement the coverage of other vaccinations which indirectly can reduce the burden of lethality and pathogenicity of the coronavirus, such as the flu vaccine, both due to the many cases of coinfection registered, and given the late diagnoses when initially mistaken for influenza in unvaccinated patients.

Pneumococcal pathologies can also misdirect from a correct etiological diagnosis of coronavirus, as well as causing our national health system an unresolved burden every year in terms of hospitalisations, deaths and social costs. Both of these vaccinations are aimed at the same target population that suffered the most during the SARS-CoV-2 pandemic.

Pending the Italian Ministry of Health's data, the coverage in Region of Sardinia during the 2019-2020 campaign, from an estimate of the doses consumed are expected to exceed those of past seasons. As early as the month of April, ATS Sardinia and the Health Department promptly started all the necessary procedures aimed at completing the tender which will be completed when the offers are evaluated in early June.

The doses requested are almost double those of the previous year, this in order to guarantee coverage for the target population, as well as satisfying the need to vaccinate additional cohorts that are expected to be included in the new ministerial circular.

These cohorts are expected to include, after many years of waiting, children under 6 years of age. If it is true that given children's natural immunity they can respond better to new infections, confirmed by childhood cases of coronavirus, during flu epidemics, although the same severity of cases has not been recorded compared to the elderly, children have a far higher propensity to become infected (in peak periods 40 per thousand of average incidence compared with 6 per thousand for the elderly), also given the fact that half of all elderly people are vaccinated.

Therefore, since minors are a frequent vehicle of contagion for adults (parents, grandparents, teachers), limiting the spread of the virus in these cohorts could finally interrupt this inauspicious chain of transmission enabling, in addition to saving lives, a reduction of social costs as is already happening in those countries where this health policy has been implemented for some time.

This year more than ever a greater involvement of all operators involved in the vaccination campaign will be needed; hygienists, general practitioners, paediatricians, doctors from teaching hospitals, nursing homes, care homes, company physicians etc. each with their own skill-sets, must guarantee high levels of coverage in outpatient clinics all the while ensuring less crowding and facilitating social-distancing in order to better guarantee all those useful prophylaxis measures not only for the prevention of coronavirus infections, but also for all other airborne infections."

Dr. Gabriele Mereu

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