La piramide epidemiologica del COVID-19 (e non solo)

Ora che è venuto il momento di darsi delle strategie per il controllo di eventuali future (re)insorgenze epidemiche diventa fondamentale darsi un criterio di lettura dell’andamento epidemiologico del COVID-19 in modo da identificare tutti i possibili livelli e tutte le possibili modalità di intervento e da dare loro un peso e una priorità.

 

A questo scopo può risultare utile immaginare una sezione di piramide in cui stratificare la popolazione target. In modo molto semplice fino alla banalità si può rappresentare la diffusione e la progressione della infezione causa del COVID-19 in 5 livelli:

 

  1. la popolazione generale, quella esposta alla circolazione del virus, destinataria di tutti gli interventi di prevenzione primaria che sono finalizzati alla riduzione del numero di persone contagiate e quindi suscettibili sia di trasmettere ad altri che di ammalarsi;
  2. i soggetti contagiati asintomatici la cui identificazione con le conseguenti misure di isolamento contribuisce alla riduzione della circolazione dell’agente;
  3. i soggetti colpiti in forma (ancora) lieve dalla malattia la cui pronta identificazione e gestione può consentire un miglior decorso clinico e una riduzione del rischio di ospedalizzazione e di evoluzione verso le manifestazioni cliniche più gravi che possono arrivare a determinare il decesso della persona colpita;
  4. i soggetti ospedalizzati che richiedono misure sia sul versante terapeutico che su quello preventivo in quanto l’ospedale è sia sede di cura che, purtroppo, sede di ulteriori casi di contagio;
  5. i soggetti ricoverati in terapia intensiva che costituiscono sia i casi più gravi che quelli che determinano un maggior assorbimento di risorse.

 

Il modo in cui il COVID-19 colpisce e si diffonde in una popolazione dipende dalla efficacia sul campo delle misure adottate ai vari livelli. Perché ad ogni livello è possibile far corrispondere una serie di interventi in grado di influenzare il passaggio al livello successivo che è clinicamente più grave e organizzativamente più oneroso in termini di costi di erogazione. Alcune prime considerazioni emergono da questa semplice rappresentazione della epidemiologia del COVID-19.

 

Per quanto riguarda il primo livello, quello della popolazione sana, va ricordato che:

  1. gli interventi di prevenzione primaria generalizzati sulla popolazione (in primis il distanziamento sociale) hanno sicuramente il maggior impatto sanitario, ma hanno costi sociali molto alti e vanno quindi  “bilanciati”;
  2. vi è una grande variabilità nella diffusione della infezione e quindi della malattia nelle varie realtà geografiche e sociali e quindi la sorveglianza epidemiologica diventa essenziale per avere l’approccio più razionale rispetto alla specifica situazione destinataria delle diverse possibili misure;
  3. nella popolazione generale ci sono sottogruppi a maggior rischio sia di contrarre l’infezione sia di sviluppare forme cliniche più gravi e quindi una particolare attenzione andrà rivolta a questi gruppi rappresentati in particolare dai soggetti fragili e/o con condizioni croniche specie se ricoverati in strutture socio-assistenziali;
  4. la occasione è buona per rilanciare le politiche per la presa in carico della cronicità ad esempio attraverso l’infermiere di comunità e il ricorso a forme di teleassistenza.

 

Per quanto riguarda gli interventi sui soggetti contagiati la loro pronta identificazione e la successiva gestione della possibile catena di contagio che essi potrebbero innescare richiede, tra l’altro, di:

  1. definire eventuali politiche di screening mirato e avere una rete di laboratori affidabile e monitorato;
  2. potenziare i servizi dei Dipartimenti di Prevenzione per la pronta gestione dei casi documentati di contagio;
  3. disporre di strutture da destinare alle persone da tenere in isolamento.

 

Per quanto riguarda la gestione dei casi “lievi” questa richiede di avere equipe che intercettino all’esordio i casi sospetti e li trattino con le misure ritenuti al momento più efficaci. Dovrebbero essere le stesse equipe che si occupano di assistenza domiciliare e di gestione proattiva (e quindi “di iniziativa”) della cronicità. Così come si dovrebbe far uso degli strumenti della teleassistenza previsti per il monitoraggio dei pazienti cronici.

 

Quanto agli interventi in regime di ricovero ci limitiamo a dire che la loro buona gestione consente di ridurre l’accesso alle terapie intensive che sono il livello che garantisce il peggior rapporto tra costi ed efficacia degli interventi erogati.

 

Qualche considerazione finale di sintesi:

  1. stanno per arrivare notevoli risorse alla sanità per costruire un Servizio Sanitario in grado di fare tesoro della tragica esperienza di questa pandemia da COVID-19. E’ fondamentale che il loro uso avvenga con la guida di una strategia di sanità pubblica che la “nostra” piramide può aiutare a costruire;
  2. le azioni da mettere in campo sono tante a tanti livelli, ma vanno privilegiate quelle che hanno un impatto su tutta l’area della sezione della piramide;
  3. alcune azioni hanno un impatto solo se ci fosse una grave riemergenza epidemica (il potenziamento delle terapie intensive) che altre azioni potrebbero impedire o contenere;
  4. alcune azioni hanno un impatto “a prescindere” dalla emergenza epidemica perché sono comunque utili su un piano di sanità pubblica. Questo è il caso del potenziamento dei servizi territoriali sia distrettuali che di prevenzione;
  5. molte misure sono “semplici” e a bassa tecnologia, ma richiedono una grande capacità di erogarle capillarmente in modo adeguato, il che richiede la formazione del personale e il monitoraggio delle loro attività (si pensi alla gestione dei casi sospetti o a quelli positivi al tampone);
  6. la gestione coordinata di tutte queste azioni è una grande sfida sia per la politica che per i tecnici. Per riuscirci il sistema si deve mettere “i pantaloni lunghi” come mi dicevano quando ero bambino.

1.175 commenti

Giorgio Giuliani · 14 Maggio, 2020 alle 13:46

Molto corretta la piramide di diffusione di malattia che è anche alla base di ogni ragionamento sulle necessità assistenziali della popolazione. Se la vedesse il mio maestro di epidemiologia clinica di un tempo, Donato Greco, credo la approverebbe senza riserve. Vorrei fare un’osservazione stando sul pezzo come si suole dire nel gergo giornalistico che piace tanto a Claudio Maffei. Oggi la attenzione primaria e prevalente per l’assistenza al COVID-19 deve andare al territorio e, nel territorio, alla valutazione dell’intervento dei medici di medicina generale. Senza voler fare nei loro confronti nessun atto di accusa o critica mi pare che la storia recente ci abbia insegnato che troppo spesso questi colleghi sono stati lasciati soli o sono stati inadeguati rispetto alle necessità assistenziali di questa nuova malattia. Sono infatti molti i casi che non sono stati diagnosticati rapidamente, o non sono stati assistiti rapidamente, o infine non hanno ricevuto una diagnostica strumentale di base rapida. Ed è proprio la mancanza di rapidità che ha favorito la diffusione del virus. Credo quindi che la massima attenzione, pignola e psicastenica, debba andare alla veloce e capillare costruzione di una rete di USCA (unità di intervento rapido per il coronavirus) e al loro monitoraggio, che suggerirei mediante registrazioni dei loro atti e interventi condivise, ad es in rete. Credo che solo se esisterà e sarà operativa ed efficiente questa rete territoriale potremmo sperare di uscire abbastanza indenni da questa pandemia. Naturalmente tutto ciò se non avrà ragione il nostro amico e collega Massimo Clementi che scommette per una riduzione della patogenicità del virus. Spero di vedere a breve nelle vostre pagine, magari in quelle dei documenti, che abbisognano di una pass di ingresso, i nodi USCA delle Marche, la loro localizzazione e numeri di telefono per raggiungerli con i resoconti dei loro interventi. Ed infine un bravo ai promotori di questa iniziativa Tach4Care!

    Carlos Chiatti · 16 Maggio, 2020 alle 12:01

    Gent.mo Giorgio, grazie davvero per le sue parole. Mi pare siamo assolutamente in linea su tutto. Buona giornata, Carlos

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