Universal Health Coverage in Italy: lights and shades of the Italian National Health Service which celebrated its 40th anniversary

Declining number of general practitioners can impair influenza vaccination uptake among Italian older adults: Results from a panel analysis

BACKGROUND

Seasonal influenza vaccination coverage in Italian older adults is insufficient and well below the minimum target of 75%. In Italy, most influenza vaccine doses are administered by general practitioners (GPs), whose number has been declining. In parallel, the number of patients per GP and GP workload increased dramatically, which theoretically may impair vaccination counselling. In this ecological study, we aimed to assess whether influenza vaccination coverage in older adults is associated with the density of GPs having high number of patients.

METHODS

The study outcome was the influenza vaccination coverage rate in adults aged ≥ 65 years and registered in 20 Italian regions over the last 23 years. The independent variable of interest was the proportion of GPs with more than 1,500 adult patients, which is an imposed normative ceiling. This latter variable was considered as a proxy of GP overload. By adopting a panel regression approach, different specifications of fixed- and random-effects models were run to assess the association of interest, when adjusted for several social structural, economic and healthcare-related variables.

RESULTS

Over the last two decades, most regions showed a negative association between influenza vaccination coverage rates and the density of GPs with a high number of patients. This latter negative association was confirmed (P < 0.05) in different panel model specifications. In particular, in the fully adjusted two-way fixed-effects model, each 10% increase in the number of GPs with more than 1,500 patients was associated with a 1.7% decrease in influenza vaccination coverage. However, this association was present only in region-years where at least 18% of GPs were deemed overloaded.

CONCLUSIONS

In the upcoming years, the number of Italian GPs is projected to decline further. At the same time, the aging Italian population will determine an even greater workload for GPs. This study demonstrated that increased GP workload may partially explain the spatiotemporal variation in influenza vaccination uptake in the Italian elderly. With the imperative of increasing or at least maintaining influenza vaccination coverage rates, several short- and mid-term initiatives should be implemented in order to optimize GP workload during seasonal immunization campaigns.

[National health systems, legislation, and social determinants: a comparative study of Brazil, Spain, Portugal, and Italy]

This is a documentary, exploratory, descriptive study, which is part of a multicenter international study assessing the national health systems with a care model based on primary health care of Brazil, Spain, Italy, and Portugal, funded by the Brazilian National Research Council (CNPq, acronym in Portuguese). It aims to identify the basic health legislation, the right to health, and the doctrinal and organizational principles of each country with a focus on the impact of social determinants of health on the national health systems. The results showed these countries have similar legislation and doctrinal principles, with a constitutional right to health, based on primary health care, and with a care model of the family health type. The challenges identified were low birth rate and high life expectancy at birth in European countries and criteria for access to medication and care financing. Based on our findings, the countries with higher investment in a structural basis, ensuring more dignified, solid, and vigilant socioeconomic and sanitary conditions, provide an important differentiation in responsiveness and sustainability of the national health system and direct impact on the quality of life.

Artificial intelligence of imaging and clinical neurological data for predictive, preventive and personalized (P3) medicine for Parkinson Disease: The NeuroArtP3 protocol for a multi-center research study

BACKGROUND

The burden of Parkinson Disease (PD) represents a key public health issue and it is essential to develop innovative and cost-effective approaches to promote sustainable diagnostic and therapeutic interventions. In this perspective the adoption of a P3 (predictive, preventive and personalized) medicine approach seems to be pivotal. The NeuroArtP3 (NET-2018-12366666) is a four-year multi-site project co-funded by the Italian Ministry of Health, bringing together clinical and computational centers operating in the field of neurology, including PD.

OBJECTIVE

The core objectives of the project are: i) to harmonize the collection of data across the participating centers, ii) to structure standardized disease-specific datasets and iii) to advance knowledge on disease's trajectories through machine learning analysis.

METHODS

The 4-years study combines two consecutive research components: i) a multi-center retrospective observational phase; ii) a multi-center prospective observational phase. The retrospective phase aims at collecting data of the patients admitted at the participating clinical centers. Whereas the prospective phase aims at collecting the same variables of the retrospective study in newly diagnosed patients who will be enrolled at the same centers.

RESULTS

The participating clinical centers are the Provincial Health Services (APSS) of Trento (Italy) as the center responsible for the PD study and the IRCCS San Martino Hospital of Genoa (Italy) as the promoter center of the NeuroartP3 project. The computational centers responsible for data analysis are the Bruno Kessler Foundation of Trento (Italy) with TrentinoSalute4.0 -Competence Center for Digital Health of the Province of Trento (Italy) and the LISCOMPlab University of Genoa (Italy).

CONCLUSIONS

The work behind this observational study protocol shows how it is possible and viable to systematize data collection procedures in order to feed research and to advance the implementation of a P3 approach into the clinical practice through the use of AI models.

Does Maintained Medical Aid Coverage Affect Healthy Lifestyle Factors, Metabolic Syndrome-Related Health Status, and Individuals' Use of Healthcare Services?

Concerns about the moral hazards and usage of universal health insurance require examination. This study aimed to analyze changes in lifestyle, metabolic syndrome-related health status, and individuals' tendency to use healthcare services according to changes in the eligibility status of medical aid recipients. This paper reports a retrospective cohort study that involved analyzing data from 2366 medical aid recipients aged 40 years or older who underwent national health screenings in 2012 and 2014. Of the recipients, 1606 participants continued to be eligible for medical aid (the "maintained" group) and 760 changed from being medical aid recipients to National Health Insurance (NHI) enrollees (the "changed" group). Compared to the "changed" group, the "maintained" group was less likely to quit smoking, more likely to begin smoking, less likely to reduce binge drinking to moderate drinking, and had a significant increase in blood glucose and waist circumference. Annual total medical expenses also increased significantly in the "maintained" group. Since the mere strengthening of healthcare coverage may lead to moral hazards and the failure to link individuals' tendency to use healthcare services and outcomes, establishing mechanisms is necessary to educate people about the health-related outcomes of maintaining a healthy lifestyle and ensure the appropriate use of healthcare services.

Changes in private health service utilisation and access to the Italian National Health Service between 2006 and 2019: a cross-sectional comparative study

OBJECTIVES

Previous research highlighted that in the early 2000s a significant share of the Italian population used and paid out of pocket for private healthcare services even when they could potentially have received the same treatments from the National Health Service (NHS). The decrease in public investments in healthcare and the increase in health needs due to the population ageing may have modified the use of private health services and equity of access to the Italian NHS. This study aims to investigate the change in the prevalence of individuals who have fully paid out of pocket for accessing healthcare services in Italy between 2006 and 2019 and the main reasons behind this choice.

DESIGN

Cross-sectional comparative study.

PARTICIPANTS AND COMPARISON

Two representative samples of the Italian population were collected in 2006 and 2019.

OUTCOME MEASURES

Prevalence of access to fully paid out-of-pocket private health services; type of service of the last fully paid out-of-pocket access; main reasons for the last fully paid out-of-pocket access.

RESULTS

We found an increase in the prevalence of people who declared having fully paid out of pocket at least one access to health services during their lifetime from 79.0% in 2006 to 91.9% in 2019 (adjusted OR 2.66; 95% CI 1.98 to 3.58). 'To avoid waiting times' was the main reason and it was significantly more frequent in 2019 compared with 2006 (adjusted OR 1.75; 95% CI 1.45 to 2.11).

CONCLUSIONS

This comparative study, conducted the year before the outbreak of the COVID-19 pandemic, highlighted an increase in the prevalence of Italian residents who have fully paid out of pocket for access to health services to overcome long waiting times. Our findings may indicate a reduced access and possible worsening of the equity of access to the public and universalistic Italian NHS between 2006 and 2019.

Epidemiology of multiple sclerosis in the Campania Region (Italy): Derivation and validation of an algorithm to calculate the 2015-2020 incidence

OBJECTIVE

We aim to validate an algorithm based on routinely-collected healthcare data to detect incidence of multiple sclerosis (MS) in the Campania Region (South Italy) and to explore its spatial and temporal variations.

METHODS

We included individuals resident in the Campania Region who had at least one MS record in administrative datasets (drug prescriptions, hospital discharge, outpatients), from 2015 to 2020. We merged administrative to the clinical datasets to ascertain the actual date of diagnosis, and validated the minimum interval from our study baseline (Jan 1, 2015) to first MS records in administrative datasets to detect incident cases. We used Bayesian approach to explore geographical distribution, also including deprivation index as a covariate in the estimation model. We used the capture-recapture method to estimate the proportion of undetected cases.

RESULTS

The best performance was achieved by the 12-month interval algorithm, detecting 2,150 incident MS cases, with 74.4% sensitivity (95%CI = 64.1%, 85.9%) and 95.3% specificity (95%CI = 90.7%, 99.8%). The cumulative incidence was 36.68 (95%CI = 35.15, 38.26) per 100,000 from 2016 to 2020. The mean annual incidence was 7.34 (95%CI = 7.03, 7.65) per 100,000 people-year. The geographical distribution of MS relative risk shows a decreasing east-west incidence gradient. The number of expected MS cases was 11% higher than the detected cases.

CONCLUSIONS

We validated a case-finding algorithm based on administrative data to estimate MS incidence, and its spatial/temporal variations. This algorithm provides up-to-date estimates of MS incidence, and will be used in future studies to evaluate changes in MS incidence in relation to different risk factors.

Trends in cutaneous melanoma mortality in Italy from 1982 to 2016

BACKGROUND

In Italy, comprehensive national studies, about mortality rates for cutaneous melanoma, are missing. The aim of this study was to analyze the trend of cutaneous melanoma mortality in Italy from 1982 to 2016.

METHODS

Data on death certificates were obtained from Italian National Institute of Statistics (ISTAT: Istituto nazionale di STATistica, Indagine sulle cause di morte). Mortality rates were age-standardized on the European population 2013 and presented per 100,000 individuals. Age-adjusted mortality rates (AMRs) were calculated by sex, age group, and geographic areas. To identify changes in mortality rate trends, a joinpoint regression model was used, and the annual percent change (APC) was estimated.

RESULTS

In Italy, a total number of 49,312 patients (44.0% women) died for cutaneous melanoma from 1982 to 2016. Melanoma mortality rates significantly increased in the study period in both sexes, with higher AMR values and a steeper increase in men (from 2.71 to 4.02; APC: 1.43; 95% CI 1.26-1.61) than women (from 1.94-2.10; APC: 0.23; 95% CI 0.00-0.46). The largest difference between men and women was observed in patients aged ≥65 years with APC of 2.17 in men (95% CI 1.97-2.37) and 0.37 in women (95% CI 0.08-0.66).

CONCLUSION

In conclusion, the melanoma mortality rate in Italy progressively increased especially in elderly men. Several hypotheses might explain the observed age and geographic differences such as sun exposure habits or different strategies of prevention campaigns.

How Can the EU Beating Cancer Plan Help in Tackling Lung Cancer, Colorectal Cancer, Breast Cancer and Melanoma?

Cancer is the second leading cause of mortality in EU countries, and the needs to tackle cancer are obvious. New scientific understanding, techniques and methodologies are opening up horizons for significant improvements in diagnosis and care. However, take-up is uneven, research needs and potential outstrip currently available resources, manifestly beneficial practices—such as population-level screening for lung cancer—are still not generalised, and the quality of life of patients and survivors is only beginning to be given attention it merits. This paper, mainly based on a series of multistakeholder expert workshops organised by the European Alliance for Personalised Medicine (EAPM), looks at some of those specifics in the interest of planning a way forward. Part of this exercise also involves taking account of the specific nature of Europe and its constituent countries, where the complexities of planning a way forward are redoubled by the wide variations in national and regional approaches to cancer, local epidemiology and the wide disparities in health systems. Despite all the differences between cancers and national and regional resources and approaches to cancer care, there is a common objective in pursuing broader and more equal access to the best available care for all European citizens.

Public-private partnership in health care organizations. How to cope with complexity issues: a comparative case-study between Italy and the US

Purpose

Health-care systems around the globe share several pressing challenges – including increasing costs and patient outcomes. Innovative arrangements, such as public–private partnerships (PPP) can be adopted to help address these challenges. Although the promise of PPPs is great, so are its peril if the arrangements are not managed and regulated adequately through the contracting process. Yet, PPP arrangements can introduce their own unique set of problems. This paper aims to analyze how PPPs contracting accounts for three major problems identified reviewing the: performance measurement and audit; determination of compensation and risk management–related issues.

Design/methodology/approach

The authors used a case study approach to analyze contracting among health-care PPPs in two countries: Italy and the USA. With a structured review performed on Scopus database using a keywords Boolean research, the authors identified three recurring major issues to investigate in two selected cases, one per country. For each major issue, the authors defined several sub-issues retrieved from a widely used institutional framework. In each sub-issue, a documental analysis on all published information related to the signed contract has been performed identifying the approaches used by the two organizations.

Findings

The authors find that PPP contracting in the USA case seems to be oriented more toward managing institutional change as well as more flexibility in the deductibility and compensation determination for organizations and providers, suggesting this organization is more oriented to change in general. The authors find that PPP contracting in Italy more clearly delineate the allocation of risk between organizations that engage in PPPs, suggesting a more practical approach.

Practical implications

PPP is complex. Contracting helps manage the complexity of these arrangements. This case study approach to PPP contracting highlights the variation in contracting approaches across two different countries. Policymakers and health-care managers need to ensure that PPP contracting clearly delineates auditing and performance measurement, compensation and risk management.

Originality/value

The authors’ analysis sheds light on the different approaches to arranging health-care PPPs in two different country settings. More research should be done to connect these different approaches to important outcomes, such as patient and organizational finances, as well as expanding the scope of countries adopting PPP in health care.

Symptom clusters in cancer patients: An Italian survey to validate and describe unwarranted clinical variation, inequality in access to healthcare, knowledge, and risk of malpractice

Background and aims:

The perceptions of professionals involved in cancer care regarding the importance of their symptoms-specific knowledge, unwarranted clinical variation (UCV), and inequalities in access to healthcare are still underdescribed. This study aims to confirm the construct validity of a previously initially developed questionnaire and describe nurses’ perceptions about the relevance of their knowledge referred to cancer symptoms management, the UCV, the inequalities in access to healthcare, and malpractice risk.

Method:

A cross-sectional pan-national study was conducted using a convenience sample, collecting data through a previously initially validated questionnaire. Construct validity was corroborated through confirmatory factor analysis, and descriptive statistics were employed for summarizing the questionnaire’s scores. The scores between the nurses working in accredited cancer centers and nurses employed in general hospitals were inferentially compared.

Results:

The sample comprised 810 nurses, 480 were nurses working in accredited cancer centers, and 330 were nurses working in general hospitals. The questionnaire showed adequate construct validity and reliability. Nurses perceived the cluster of psychosocial symptoms with a greater risk of UCV and inequalities in access to cancer services than the cluster of physical symptoms.

Discussion and conclusions:

A paradigm shift aimed at integrating psychosocial cancer symptoms in the care paths emerged as pivotal for improving cancer care in Italy.

Incentives for voluntary health insurance in a national health system: Evidence from Italy

OBJECTIVES

The paper evaluates the extent to which the government's policy to encourage the purchase of voluntary health insurance (VHI) may have led to income-related horizontal inequity in access to health care in a universal health care system (NHS).

METHODS

Ad hoc tax return data for the universe of Italian taxpayers for years 2009-2016 are used to estimate the tax benefits granted to taxpayers who hold VHI, the redistributive impact, and the public budget effect. The income elasticity of tax benefits is estimated using tax return data and considering some taxpayers' characteristics (income class, gender, age, and geographic area). Standard inequality indices are computed to assess income-related horizontal inequity in access to health care.

RESULTS

Tax incentives, especially those granted to employer-paid health insurance, have a sizeable impact on tax revenue and introduce into the Italian NHS significant income-related horizontal and vertical inequity in access to health care. The results suggest a distributional profile of tax incentives that is highly concentrated in favor of wealthier taxpayers.

CONCLUSION

Our analysis adds novel evidence that may contribute to the current debate on whether and to what extent countries in which all citizens have access to free healthcare and equal standards of healthcare services should subsidize VHI, especially when the coverage doubles the healthcare services provided by universal public insurance. We show that VHI reduces tax revenues and introduces disparities among citizens in terms of access to healthcare services.

Intellectual capital-based performance improvement: a study in healthcare sector

Background

Knowledge resources are in most productive sectors distinctive in terms of competitiveness. Still, in the health sector, they can have an impact on the health of the population, help make the organisations more efficient and can help improve decision-making processes. The purpose of this paper is to investigate the Intellectual Capital impact on healthcare organization’ performance in the Italian healthcare system.

Methods

The theoretical framework linked to intellectual Capital in the health sector and the performance evaluation related to efficiency supports the analysis carried out in two stages to determine the right placement of resources and the exogenous variables that influence performance level. The evaluation of the impact of the ICs on performance is determined through the Data envelopment analysis. The incidence of the exogenous variables has been established through linear regression.

Results

Empirical results in Italy show some IC components influence organization ‘performance (Essential Levels of Assistance) and could be used for defining the policy of allocation of resources in healthcare sector. The efficiency of 16 regions considered in 2016 based on Slack-Based-Model constant returns-to-scale (SBM-CRS) and Slack-Based-Model variable returns-to-scale (SBM-VRS) identifies a different ability to balance IC and performance. Current healthcare expenditure and the number of residents is correlated with the identified efficiency and performance levels.

Conclusions

This paper embeds an innovative link between healthcare performance, in term of efficiency and IC which aligns resource management with future strategy. The study provides a new decision-making approach.

Differentiation in Healthcare Financing in EU Countries

The main aim of this work was to identify and present the situation and changes in the level of expenditure on healthcare in the European Union in the years 2013–2017. This involved an analysis of the available literature on healthcare financing, data from the EUROSTAT database. For this work, the comparative method was used, dynamics indicators were used, the Gini concentration coefficient was calculated, and the degree of concentration was presented using the Lorenz curve. Pearson’s linear correlation coefficients were also used. A descriptive, tabular and graphic method was used to present the test results that were obtained. A high concentration of expenditure on healthcare was found in the EU countries with the largest population and that are the most economically developed. These results also relate to these expenses on a per capita basis. The main factor differentiating the level of healthcare financing was the level of economic development. This regularity was confirmed in the statement of expenditure per capita, the relationship between this expenditure and the value of GDP and the results obtained when calculating the correlation between expenditure and economic development. In addition to the economic situation, an important factor determining the amount of expenditure on healthcare was the percentage of the country’s population that are older people.

Multiple Sclerosis in the Campania Region (South Italy): Algorithm Validation and 2015-2017 Prevalence

We aim to validate a case-finding algorithm to detect individuals with multiple sclerosis (MS) using routinely collected healthcare data, and to assess the prevalence of MS in the Campania Region (South Italy). To identify individuals with MS living in the Campania Region, we employed an algorithm using different routinely collected healthcare administrative databases (hospital discharges, drug prescriptions, outpatient consultations with payment exemptions), from 1 January 2015 to 31 December 2017. The algorithm was validated towards the clinical registry from the largest regional MS centre (n = 1460). We used the direct method to standardise the prevalence rate and the capture-recapture method to estimate the proportion of undetected cases. The case-finding algorithm including individuals with at least one MS record during the study period captured 5362 MS patients (females = 64.4%; age = 44.6 ± 12.9 years), with 99.0% sensitivity (95% CI = 98.3%, 99.4%). Standardised prevalence rate per 100,000 people was 89.8 (95% CI = 87.4, 92.2) (111.8 for females [95% CI = 108.1, 115.6] and 66.2 for males [95% CI = 63.2, 69.2]). The number of expected MS cases was 2.7% higher than cases we detected. We developed a case-finding algorithm for MS using routinely collected healthcare data from the Campania Region, which was validated towards a clinical dataset, with high sensitivity and low proportion of undetected cases. Our prevalence estimates are in line with those reported by international studies conducted using similar methods. In the future, this cohort could be used for studies with high granularity of clinical, environmental, healthcare resource utilisation, and pharmacoeconomic variables.

Revisiting early-stage COVID-19 strategy options

Background: Early-stage interventions in a potential pandemic are important to understand as they can make the difference between runaway exponential growth that is hard to turn back and stopping the spread before it gets that far. COVID19 is an interesting case study because there have been very different outcomes in different localities. These variations are best studied after the fact if precision is the goal; while a pandemic is still unfolding less precise analysis is of value in attempting to guide localities to learn lessons of those that preceded them. Methods: I examine three factors that could differentiate strategy: asymptomatic spread, differences in use of the Bacillus Calmette-Guerin (BCG) tuberculosis vaccine and cloth face masks. Results: Differences in disease progression as well as the possibility of alternative strategies to prevent COVID-19 from entering the runaway phase or damping it down later can be elucidated by a study of asymptomatic infection. A study to demonstrate not only what fraction are asymptomatic but how contagious they are will also inform policy on universal mask wearing. Conclusions: While a COVID-19 outbreak is at a level that makes accurate trace-and test possible, investigation of asymptomatic transmission is viable and should be attempted to enhance understanding of spread and variability in the disease as well as policy options for slowing the spread.

Revisiting early-stage COVID-19 strategy options

Background: Early-stage interventions in a potential pandemic are important to understand as they can make the difference between runaway exponential growth that is hard to turn back and stopping the spread before it gets that far. COVID19 is an interesting case study because there have been very different outcomes in different localities. These variations are best studied after the fact if precision is the goal; while a pandemic is still unfolding less precise analysis is of value in attempting to guide localities to learn lessons of those that preceded them. Methods: I examine two factors that could differentiate strategy: asymptomatic spread and the risks of basing strategy on untested claims, such as potential protective value of the Bacillus Calmette-Guerin (BCG) tuberculosis vaccine. Results: Differences in disease progression as well as the possibility of alternative strategies to prevent COVID-19 from entering the runaway phase or damping it down later can be elucidated by a study of asymptomatic infection. An early study to demonstrate not only what fraction are asymptomatic but how contagious they are would have informed policy on nonpharmaceutical interventions but could still be of value to understand containment during vaccine roll out. Conclusions: When a COVID-19 outbreak is at a level that makes accurate trace-and test possible, investigation of asymptomatic transmission is viable and should be attempted to enhance understanding of spread and variability in the disease as well as policy options for slowing the spread. Understanding mild cases could shed light on the disease in the longer term, including whether vaccines prevent contagiousness.

Revisiting early-stage COVID-19 strategy options

Background: Early-stage interventions in a potential pandemic are important to understand as they can make the difference between runaway exponential growth that is hard to turn back and stopping the spread before it gets that far. COVID19 is an interesting case study because there have been very different outcomes in different localities. These variations are best studied after the fact if precision is the goal; while a pandemic is still unfolding less precise analysis is of value in attempting to guide localities in the early stages to learn lessons of those that preceded them. Methods: I examine three factors that could differentiate strategy: asymptomatic spread, differences in use of the Bacillus Calmette-Guerin (BCG) tuberculosis vaccine and cloth face masks. Results: These differences point to the possibility of alternative strategies to prevent COVID-19 from entering the runaway phase. The most promising is testing all contacts of anyone who has tested positive, not only those who are symptomatic. In principle such a study should be able to demonstrate not only what fraction are asymptomatic but also measure asymptomatic transmission by another round of contact tracing. Should this demonstrate asymptomatic transmission, then all contacts of anyone who tests positive should be isolated and tested, and only released from quarantine when it is clear that they are past incubation and not positive. Conclusions: Before a COVID-19 outbreak reaches the runaway phase where exponential growth makes accurate trace-and test impossible, a strategy that takes into account asymptomatic transmission is viable and should be attempted to avoid the necessity for a prolonged lock down.

The campaign "This Is Public Health" in Italy, set up by a team of Public Health Schools in Northern Italy

Despite the great effort to raise awareness among health promotion, nowadays Public Health policies are not often recognized as important tools. For this reason, the Health in All Policies (HiAP) approach is instrumental in tackling this information gap. In 2018, the US Association of Schools & Programs of Public Health (ASPPH) launched an international campaign called “This is Public Health” (TIPH), whose aim was “to brand public health and raise awareness of how it affects individuals, communities and populations”. The Association of Schools of Public Health in the European Region (ASPHER), in coordination with ASPPH, decided to create a European campaign to support and to reproduce the American one, by opening a challenge among the European Public Health Schools. The Schools and Programs of PH of Vita-Salute “San Raffaele” University, Milan, University of Parma, University of Pavia and Politecnico of Milan won this bid. In this “briefing on” we present a report on the Italian project for raising awareness of Public Health among general population and health care personell.

COVID-19 in Italy: impact of containment measures and prevalence estimates of infection in the general population

Since the beginning of the COVID-19 epidemic in Italy, the Italian Government implemented several restrictive measures to contain the spread of the infection. Data shows that, among these measures, the lockdown implemented as of 9 March had a positive impact, in particular  the central and southern regions of Italy, while other actions appeared to be less effective. When the true prevalence of a disease is unknown, it is possible estimate it, based on mortality data and the assumptive case-fatality rate of the disease. Given these assumptions, the estimated period-prevalence of COVID-19 in Italy varies from 0.35% in Sicity to 13.3% in Lombardy.