Letter to the Editor
COVID-19 and primary care: A perspective from Italy
COVID-19 y la atención primaria: una perspectiva desde Italia
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Fernández-Prada, F.A. Moraga-Llop, J.J. Pérez-Martín, G. Mirada-Masip" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Fernández-Prada" ] 1 => array:2 [ "nombre" => "F.A." "apellidos" => "Moraga-Llop" ] 2 => array:2 [ "nombre" => "J.J." "apellidos" => "Pérez-Martín" ] 3 => array:2 [ "nombre" => "G." 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Ghidinelli, F. Martire" "autores" => array:2 [ 0 => array:4 [ "nombre" => "F." "apellidos" => "Ghidinelli" "email" => array:1 [ 0 => "federicoghidinelli@hotmail.it" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "F." "apellidos" => "Martire" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Division of primary care, ATS Brescia, Via Duca Degli Abruzzi 15, 25124 Brescia BS, Italy" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Division of Primary Care, ATS Brescia, Italy" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "COVID-19 y la atención primaria: una perspectiva desde Italia" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3012 "Ancho" => 2508 "Tamanyo" => 260073 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Institution flowchart for suspect COVID-19 cases.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The advent of the coronavirus disease 2019 (COVID-19) has widely reshaped our daily life.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Not only has it affected Asian people, but also it spread rapidly to Europe, America and to the rest of the world.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Italy was the first Western country with a fast increase of people with COVID-19 infection.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">As confirmed from the “Istituto Superiore di Sanità”, Italy had more than 12,000 confirmed cases and more than 800 deaths in the first phase of this pandemic, making it one of the most affected countries in the world after China.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The first response to the COVID-19 pandemic was to institute aggressive containment measures and to promote public knowledge on this devastating disease.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Clearly, general practitioners (GPs) and other primary healthcare workers have constituted a fundamental role in the fight against the spread of SARS-CoV-2 virus.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The initial clinical presentation of the SARS-CoV-2 infection is non-specific and patients generally present to their GPs with mild upper respiratory tract symptoms and other flu-like clinical manifestations.</p><p id="par0040" class="elsevierStylePara elsevierViewall">One of the main problems during this pandemic has been the great pressure on hospitals, given by the high number of patients hospitalized due to rapid worsening of their clinical condition.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> An early and rapid recognition of the COVID-19 disease might significantly reduce the hospitalization rate of patients and, thus, a well-represented coordination between primary healthcare workers and health care system is essential.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In this manuscript we describe the response of Italian primary health care to the COVID-19 pandemic and the management of community outpatients.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The first point of consultation toward which people turn to in Italy have been their GPs.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Thus, it has been fundamental to be able to recognize people with suspected upper and lower respiratory tract infections compatible with COVID-19 and to isolate them from the rest of patients to avoid the spread of SARS-CoV-2 virus.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The high volume of patient flow with non-specific clinical manifestations forced Italian GPs to identify, isolate and manage patients in a remote way.</p><p id="par0065" class="elsevierStylePara elsevierViewall">After the development of international recommendations for community patients by the World Health Organization (WHO), several guidelines have been published in Italy on how to manage people with suspected COVID- 19 disease. These guidelines are available by the Italian Ministry of Health reported on the official national website.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The standard procedure relies on the isolation of the cases for their clinical assessment.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The main recognized assessment method is the laboratory confirmation through molecular assessment of the presence of SARS-CoV2 in nasal, oro-pharyngeal and saliva swab samples. The molecular methods are preferred to the rapid antigen-test because of their higher sensitivity and specificity.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">According to the new guidelines published by the Lombardy region of Italy and available at <a href="https://www.ats-brescia.it/disposizioni-ufficiali">https://www.ats-brescia.it/disposizioni-ufficiali</a>, a possible case is defined as a case with at least one of these criteria: cough, dyspnea, fever or ageusia, anosmia or dysgeusia.</p><p id="par0085" class="elsevierStylePara elsevierViewall">A probable case is a case that fulfills the possible case criteria and is a close contact of a confirmed SARS CoV2 case or is a health care worker.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Finally, a contact becomes a case when positive or symptomatic.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Otherwise, a contact is defined as an individual that has been traced through contact tracing, having had a close contact with a positive SARS CoV2 case up to 48<span class="elsevierStyleHsp" style=""></span>h before the beginning of the clinical symptoms or a positive swab in the case of an asymptomatic positive patient.</p><p id="par0100" class="elsevierStylePara elsevierViewall">All primary health care identification, isolation and diagnostic pathways are summarized in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">COVID-19 pandemic has clearly subverted the entire health care system.</p><p id="par0110" class="elsevierStylePara elsevierViewall">All these measures adopted by the Italian health care system for community out-patients have had the primary role to reduce the pressure on hospitals and to increase protection level for other non-COVID-19 infected patients.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Not only have they impacted positively on community outpatients, but they have also been helpful to hospitals during this period.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Clearly, it should be required to develop higher degree of collaboration among GPs and hospital clinicians because of the great need to accelerate treatment of patients with COVID-19.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Furthermore, there is not enough internationally shared data available in scientific literature on how to manage community outpatients affected by this infection.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Thus, more international guidelines on the management of community patients during this pandemic are needed to improve the performance of health care systems in all countries worldwide.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Only a well-organized cooperation among all health care workers can improve all patients’ quality life.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3012 "Ancho" => 2508 "Tamanyo" => 260073 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Institution flowchart for suspect COVID-19 cases.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3013 "Ancho" => 2508 "Tamanyo" => 267672 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Institution flowchart for close contact COVID-19 cases.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "COVID-19 and Italy: what next?" 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Published online 2020:1–8. <a target="_blank" href="https://www.simit.org/">https://www.simit.org/</a>." ] ] ] 5 => array:3 [ "identificador" => "bib0060" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis of SARS-CoV-2 infection" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Cunningham" 1 => "S. Beese" 2 => "J. 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