982520

research-article2020
EJO0010.1177/1120672120982520European Journal of OphthalmologyGrosso et al.

EJO European
Journal of
Ophthalmology
Original research article

European Journal of Ophthalmology

Suppression of Covid-19 outbreak

1­–9
© The Author(s) 2020
Article reuse guidelines:
among healthcare workers at the sagepub.com/journals-permissions
https://doi.org/10.1177/1120672120982520
DOI: 10.1177/1120672120982520

Treviso Regional Hospital, Italy journals.sagepub.com/home/ejo

and lessons for ophthalmologists

Andrea Grosso1 , Roberto Rigoli2, Stefano Formentini2,

Giovanni Di Perri3, Piergiorgio Scotton2, Giancarlo Dapavo4,
Mauro Fioretto1 and Giuseppe Scarpa2

Abstract
Purpose: To describe a strategy to reduce Covid-19 spread among healthcare workers and provide ophthalmologists
with recommendations useful for a possible second wave of Covid-19 in Autumn.
Methods: Epidemiological surveillance at the Cà Foncello Hospital (Veneto, Italy) since 24 February 2020 to 24 April
2020 when the municipality of Treviso was hit by the Covid-19 outbreak. The number of naso-pharigeal (NP) swabs
performed was 7010.
Results: The number of infected among healthcare workers was 209/ 3924 (5.32%): medical doctors: 28 cases / 498
(5.6%). None among ophthalmologists; specialized nurses: 86/1294 (6.4%) None in the ophthalmic unit; intermediate care
technicians: 68/463 (14.7%). The 46% of the positive tested were asymptomatic. We share key suggested actions for the
reorganization in ophthalmological services: be part of a global epidemiological local strategy of containment (Testing,
Tracing, Treating); protect your department: Keep on screening patients by telephone interview before entering the
hospital; promote continuous and appropriate use of PPE both for doctors and for patients; make any effort to obtain
a continuous flow of patients in every line of the ophthalmic service; treat appropriately any single patient with vision
threatening condition; avoid unnecessary or futile testings and examinations.
Conclusion: The Treviso model shows that it is possible and safe to keep on performing high risk hospital activities like
ophthalmology, even in the epicenter of covid outbreak, if adequate actions are performed. We discuss about the value
of NP swabs and serological tests as a strategy in case of a second wave of infections.

Keywords
Epidemiological surveillance, nasopharyngeal swabs, asymptomatic cases, serological tests, ophthalmology
reorganization, healthcare workers, mitigation phase, containment

Date received: 11 July 2020; accepted: 28 November 2020

Introduction
1
The COVID-19 pandemic quickly overwhelmed the pub-  ivision of Ophthalmology, Santo Spirito Hospital Casale Monferrato,
D
Alessandria AL, Italy
lic health and health-care delivery systems in Italy and 2
Azienda ULSS n 2 Marca Trevigiana, Treviso, Veneto, Italy
throughout the world. The effects of Covid-19 pandemic 3
University of Turin School of Medicine, Torino, Piemonte, Italy
varied according to the magnitude of loco-regional SARS- 4
Cardinal Massaia Hospital of Asti, Asti, Piemonte, Italy
CoV-2 diffusion as well as to the heterogeneity of social Corresponding author:
and health-care systems in the world. In Italy the incidence Andrea Grosso, Division of Ophthalmology, Santo Spirito Hospital
and prevalence of SARS-CoV-2 infection were the high- Casale Monferrato, Alessandria AL 15100, Italy.
est in Northern regions and much milder in Central and Email: 78andreagrosso@gmail.com
2 European Journal of Ophthalmology 00(0)
Southern areas, and the organizational responses to face
the occupational risk of ophtalmologists and other medi-
cal outpatient activities differed accordingly. In Italy the
prevalent hospital-centric model in Lombardy was found
to be inadequate in coping with the coronavirus outbreak.
The comparison between two adjacent Northern regions,
where two different approaches were followed, properly
describes the inadequacy of an hospital-based strategy.
In Lombardy, as in most Italian regions, a passive case
detection strategy was applied (as advised by the Italian
Ministry of Health), while in Veneto an active case detec-
tion plan based on contact tracing was instead followed.
As of 1 April 2020 the number of patients admitted to the
Hospital in Lombardy was 51.5% compared to 25.1% in
Veneto Region: there were 44,733 cumulative cases in
Lombardy and 9625 in Veneto; the numbers of deaths
were 7593 and 499, respectively. The death-to-case ratio
was 3.3 times higher in Lombardy than in Veneto (17%
vs 5%).1
The percentage of hospital admissions in Lombardy
was similar to the percentage reported in Wuhan (41%)
and remarks the fact that nosocomial transmission appears
to have played a role in transmission in Lombardy.1,2
As of 11 July 2020, 172 medical doctors have died
of Covid-19 in Italy: the majority of them came from
Lombardy and a minority from Veneto.3
It comes up that protecting healthcare workers is essen-
tial both for the containment of the infection as well for
providing the best possible care to all other patients who
require hospitalization.
We need to re-orient our wisdom towards a community-
based paradigm of health-care delivery facing emergent
infectious diseases: well planned community surveillance
at local level is of pivotal importance to trace and test sus-
pect or symptomatic cases and their contacts in order to also
identify asymptomatic patients as confirmed by the analy-
sis led by Prof. Andrea Crisanti and his group in Veneto.
Notably, 43.2% (95% CI 32.2–54.7%) of the confirmed
SARSCoV- 2 infections detected across the two surveys
conducted in the municipality of Vò, were asymptomatic.4
The issue of detecting asymptomatic SARS-CoV-2 infec-
tions is crucial, as a sizeable proportion of community
transmission occurs from asymptomatic patients.
Given the scarcity of human resources, antiviral drugs,
and ventilators, non-pharmaceutical interventions are the
more common responses to any pandemic, at least in the
near term.5 In the acute phase of the outbreak in Italy it
was mandatory to put all our efforts to contain the advance
of the Coronavirus with severe lockdown measures
extended across the Nation and by increasing the num-
ber of critical care beds. According to the epidemiologi-
cal data that indicate, as of 11 July 2020, a deflection in
the cumulative number of patients infected in Italy it is
now essential rethink the strategies to re-open our daily
ophthalmological practices. We need to minimize the risks
for both ophthalmologists and patients. In other words we
should not miss a long term strategy: computer modeling
may assist us for crafting disease containment strategies.6
However models cannot address ethical and legal ques-
tions, instead models must be combined with ethical and
legal judgments to make policy decisions.6,7 Currently,
there are many debatable controversies about this novel
coronavirus, for example, the dynamics of infection, rein-
fection, climate effects, fatality rate. Papers on modeling
studies concerning the biological, epidemiological, immu-
nological, molecular, and virological aspects of COVID-
19 may only be used as general indications and estimates
on the impact of Covid-19 outbreak derived from model-
based analysis were not in agreement with the facts.8–11
Every medical sub-specialty has specific risk profiles.
Ophthalmologists are at high risk as well as otorhinolaryn-
gologist and dental specialists. We cannot get the message
that ophthalmic diseases may be delayed without devastat-
ing effects on the behavior of our patients, by compromis-
ing their autonomy.12,13
Although optimal precautions must be taken in any
case, timely periodic monitoring of community diffusion
of SARS-CoV-2 infection might actually help to estimate
and stratify the occupational risk entailed by frontal medi-
cal activities.
The aim of this report is to focus to the results of epi-
demiological surveillance (nasopharingeal swabs) at the
Cà Foncello Treviso Hospital, Veneto Region, Italy to pro-
duce good clinical practices useful for the re-organization
of ophthalmic services in case of a second wave of infec-
tions in the Autumn.
In the Phase I of the outbreak most ophthalmic clinics
have decided to reduce their practices to urgent cases only
and in some areas the opthalmic services were completely
suspended (in Italy, e.g. Gavazzeni and Castelli Hospitals
in Bergamo, Humanitas University, personal communica-
tion Prof. M. Romano).
In the Phase II and III it is time to gradually re-open
our services, based on local epidemiological surveillance
and inspired by the “MAKE NO MISTAKE” strategy.
We need to share protocols and controversial issues about
clinic management, staff protection and environmental
protections.
The ophthalmic practice has specific peculiarities:
• Close contact between ophthalmologists and
patients during the slit lamp biomicroscope exam-
inations: we already know that asymptomatic
patients may eliminate the virus. In a study con-
ducted in the municipality of Vo Euganeo town
43.2% of local people tested with nasopharyngeal
swabs resulted positive but totally asymptomatic.4
Further, researchers at the Spallanzani national
Centre for infectious diseases in Rome observed
that ocular involvement of SARS-CoV-2 may
Grosso et al. 3
occur early in the COVID-19 course, suggesting
that measures to prevent transmission via this route
must be implemented as early as possible.14
• Contact with the conjunctiva and tears. The SARS-
CoV-2 RNA has been detected in conjunctival
secretions collected in patients with COVID-19
from a hospital in China.15
• It has been shown that ocular fluids from SARS-
CoV-2-infected patients may contain infectious
virus, and hence may be a potential source of infec-
tion. Therefore it is essential recommend an appro-
priate use of personal protective equipment (PPE)
for ophthalmologists during clinical examination,
because ocular mucosa may be not only a site of
virus entry but also a source of contagion.
• High volumes of patients, especially old frail peo-
ple with comorbidities and immuno-depression.
• Prolonged exposure to the risk for the opthalmologists.
Materials and methods
Structured reorganization during the Covid-19
pandemic: Comparisons between different
scenarios
Right now it is clear we are only seeing the tip of the ice-
berg: people who are so sick they need hospitalization or
intensive care. What is concerning is the notion that there
is a lot of inapparent or mild disease out there.
Decisions on reopening eye clinics to routine care and
resuming elective eye surgery will need to be made in
consideration of numerous factors. These include but are
not limited to evolving country and region restrictions to
non essential services, local/regional new case rates (local
epidemiological surveillance), availability of PPE and
access to COVID-19 testing for high risk categories (Risk
assessment). A crucial point on which possibly basing the
long term re-opening strategy as well as to make safer our
clinical practice both for doctors and patients, is to define
the best clinical application of serological testing in com-
bination with nasopharyngeal swabs. Rapid- response
tests need to be confirmed by nasopharyngeal swabs. The
results of serological tests for the readmission of health-
care workers is not documented to date. In this circum-
stance, the rapid response of the nasopharyngeal swabs is
essential.13,16
Treviso Cà Foncello hospital model
Treviso includes an area of 885,000 inhabitants in the
Veneto Region, Italy and it was early and hardly hit by
the Covid-19 outbreak. Public authorities in Veneto region
have decided to make as many nasopharyngeal (NP) swabs
as possible according with the “3T” active strategy: test,
trace and treat, deploying a combination of nasopharingeal
swabs and monitoring people who were in contact with
those who had tested positive.
All the medical and paramedical personnel work as
employees of National Health Service (NHS).
The epidemiological surveillance was performed
according to the occupational medicine services and
under the direction of the chief medical officer (SF).
All the healthcare workers signed a consent form before
making the swabs. All the data are registered with the
health management at the Cà Foncello Hospital, Treviso,
Veneto, Italy.
Testing for COVID-19 is currently done on viral genetic
material from NP swabs, using a workhorse tool of molec-
ular biology known as reverse transcription polymerase
chain reaction (RT-PCR). Two separate negative PCR tests
within 48 h were performed prior to returning to the clinic.
Quarantine for 14 days from last contact was imposed in
cases of contact with a confirmed case.
The admission to the hospital was restricted to only
severe cases, with different specific area dedicated to
severe but stable cases, severe unstable, with prompt trans-
fer to intensive care unit (ICU) if necessary. An efficient
contact tracing was made in liaison with general practi-
tioners by a specific informatic software and symptomatic
patients were isolated at home. Patients were surveilled at
home with repeated phone interview performed by local
Public Health Department with the possibility to make NP
swabs at home.
We report the data collected since 24 February 2020 to
24 April 2020 when the municipality of Treviso was hit by
the Covid-19 outbreak. All the personnel working in the
Hospital, that is, 3924 subjects, were analyzed. The num-
ber of NP swabs performed was 7010.
The Treviso model was the following: the NP swabs
were performed to the contacts of tested positives and
extended to all personnel in the wards where a tested posi-
tive occurred. Further NP swabs were systematically per-
formed to all the personnel. The NP were repeated within
specific interval in case of tested negatives. The current
strategy included NP swabs every 10 days for high-risk
personnel (infectious, intensive care units, Covid areas,
ophthalmologists, dental specialists, otorhinolaryngolo-
gist, emergency department, pneumology units) and every
20 days to the personnel in the other wards.
Results
The number of total infected among healthcare workers at
the Treviso Cà Foncello Hospital was 209/ 3924:
- medical doctors: 28 cases / 498 (5.6%). None
among ophthalmologists.
- specialized nurses: 86/ 1294 (6.4%). None in the
ophthalmic unit.
- Intermediate care technicians: 68/463 (14.7%)
4 European Journal of Ophthalmology 00(0)

Table 1.  NP swabs results among medical doctors and their Table 3.  Results of NP swabs among intermediate-care
affiliation. technicians.

Ward Tested positive (n) Total personnel (%) Ward Tested positive (n) Total personnel (%)
Geriatric medicine 6 12 (50%) Geriatric medicine 14 30 (46%)
Gynecology 6 24 (25%) Gynecology 6 31 (19.3%)
Cardiology 3 19 (15%) Internal medicine 15 30 (50%)
Internal medicine 2 11 (18%) Rehabilitation 5 18 (27.7%)
Anesthesiology 2 48 (4%) Suem 1 23 (4.3%)
Suem None 8 (0%) Infectious diseases 1 11 (9%)
Infectious diseases None 8 (0%) Pneumology 1 11 (9%)
Pneumology None 12 (0%) Ophthalmology None 34 (0%)
Ophthalmology None 11 (0%) Emergency 1 34 (3%)

Table 2.  Results of NP swabs among nurses. Table 4.  Results among administrative staffs.

Ward Tested positive (n) Total personnel (%) Ward Tested positive (n) Total personnel (%)

Geriatric medicine 21 44 (47%) Nuclear medicine 1 1 (100%)

Gynecology 11 73 (15%)
Internal medicine 6 36 (16%)
Anesthesiology 1 118 (0.8%)
Suem 1 34 (3%)
Infectious diseases None 34 (0%)
Pneumology 1 31 (3%)
Ophthalmology None 11 (0%)
Emergency 9 85 (10%)
Severe forms of infections among health care workers with
admission in intensive care units were: 5, no deaths reported.
In the Table 1 we show the NP swabs results among
medical doctors and their affiliation.
In the Table 2 we show the results of NP swabs among
nurses.
In the Table 3 the results of NP swabs among interme-
diate-care technicians are presented.
In the Table 4 we show the results among administra-
tive staffs.
Notably, none tested positive among fisics and biologists.
The NP swabs performed at the Treviso Cà Foncello
Hospital allowed us to focus the attention to the health
care workers in a Hub Hospital in Veneto Region, Italy
in one of the epicenters of the Covid-19 outbreak in
Italy. The total number of health care workers in the
Hospital is 3924, among them 209 tested positives with
a global 5.32%. When we do a subgroup analyses we
may verify that the majority of positive cases were in the
following wards: geriatrics, internal medicine, gynecol-
ogy, rehabilitation.
Notably the tested positives were in low percentage in
the following wards: infectious diseases, anesthesiology,
pneumology, health care workers in the ambulance and
medical cars (SUEM) and emergency department.
The analysis of different groups among healthcare
workers allowed us to identify the high risk personnel:
Geriatrics 1 1 (100%)
Neurosurgery 1 2 (50%)
intermediate care technicians (14.6%) followed by spe-
cialized nurses (6.64%), medical doctors (5.6%), adminis-
trative staff (4.8%), fisics (0%), and biologists (0%).
In particular, in Covid areas (Infectious diseases wards,
intensive care units, dedicated sections for the reception
and management of Covid-19 patients) the number of
tested positive was lower than the tested positives in geri-
atrics and internal medicine wards.
Notably the 46% of the positive tested among healthcare
workers were asymptomatic according to the clinical notes
evaluated by the internal occupational medical service.
A campaign of serological tests targeted to at risk cat-
egories such as health care workers, police forces, person-
nel working in supermarkets and staff working in food
services is ongoing in the Treviso municipality.
Those data show that the community based strategy
in Veneto Region, Italy may be effective in reducing
the impact of pandemic both for general population and
healthcare workers.
Discussion
Will the Covid-19 pandemic change our ophthalmic activ-
ity? It already has.
We share key suggested actions within the readers for
the more appropriate clinical management of the patients
in the ophthalmic services.
1) Be part of a global epidemiological local strategy
of containment (Testing, Tracing, Treating).
2) Protect your department: Keep on screening
patients by telephone interview before entering
the hospital.
Grosso et al. 5
3) Promote continuous and appropriate use of PPE
both for doctors and for patients.
4) Make any effort to obtain a continuous flow of
patients in every line of the ophthalmic service.
5) Treat appropriately any single patient with vision
threatening condition.
6) Avoid unnecessary or futile testings and
examinations.
Correct classification of ophthalmic
practice
The ophthalmic practice needs to be equated to otorhi-
nolaryngologist and dental specialists: the directions of
Medical Services in the Hospitals should make precise
directives: this is a crucial point to obtain the appropriate
PPE due the shortage of PPE (e.g. in Italian hospitals at the
moment there is a quota of facial respirators N95 or FFP2).
Patients flow regulations
It is necessary to carry out a census and volumetry of activ-
ity areas: we need to know the capacity of waiting rooms
to estimate the number of patients that can wait to respect
the distancing measures (Spacing chairs in waiting room).
The list of daily patients booked needs to take the analyses
of flow of patients into consideration.
Triage of patients
A triage procedure is essential a three levels:
- at the entrance to the hospitals;
- telephone triage the day before the clinical appoint-
ments scheduled;
- at the entrance of wards.
Basic survey to identify patients with possible exposure to
SARS-CoV-2 should be performed before patients are admit-
ted to the Hospital as well as the check of temperature (non
contact). This should include questions about symptoms
(fever, dry cough, sore throat, headache, loss of taste/smell,
conjunctivitis) and proximity to a validated or suspected
COVID-19 case as well as travel to an endemic region.
It is also mandatory that patients are re-called the day
before the appointment in order to rule out suggestive
symptoms. A third check point is necessary at the entrance
of the wards with a regulation in the flow of the patients to
the visit rooms.
Organization of specific dedicated
areas to isolate at risk patients
Childs, pregnant womens, diabetics, patients with car-
diovascular diseases, elderly subjects, immunodepressed
patients should be isolated and protected in specific areas.
According to the performance status verified by their gen-
eral practitioner the Direction of medical services at the
Treviso Cà Foncello Hospital since March has arranged
specific care pathways and waiting rooms for patients with
different types of immunodepression, cardiovascular dis-
eases and diabetes.17–21 The nurses at the entrance of wards
collect the clinical data from oral and written interviews.
Rescheduling of appointments
The flow and the number of patients needs to be re-calcu-
lated based on available spaces and taking the extended
times for sanification required after each visit into account.
A 30 min space between appointments in the outpatient
clinics is highly recommended.
It may be necessary to extend the daily activities 7 days
out of seven: it means an extraordinary plan for health-care
workers and administrative staff with multiple shifts and
new hires.
Change the modalities of execution of
visits and telemedicine
With the exception for specific cases, only the patient
is admitted for the clinical visit. No accompanying per-
son unless essential. All staff and all patients must wear
masks at all time including slit lamp examination. Patients
wear a surgical mask or a ffp2 mask. Hand hygiene for
both patients and doctors is mandatory. All magazines are
removed from waiting area.
In the Hospital the refraction tests should be done only
if necessary. A specific group of nurses is dedicated for
the sanification procedures. Non contact diagnostic tests
should be preferred: for example rebound tonometer, indi-
rect ophthalmoscope. Disposable eye drops are preferred.
Avoid contact tonometer, avoid pneumotonometer. The slit
lamp examination with enhanced plastic breath shield may
be used for short time.
We encourage tele health: video examination visits and
remote telephone-based interviews were set for non-urgent
patient visits to try to reduce direct patient–physician
encounter, according to literature.21,22 Furthermore, dif-
ferent companies have made available specific softwares
to store images in Icloud and ophthalmologists may have
access to the images remotely.
Diagnostic tests
For screening and monitoring purposes in patients with glau-
coma we should minimize the execution of visual fields, pos-
sibly shifting to alternative more rapid tests, as optic nerve
analysis. During the phone triage a selection of urgent cases
may be done and patients need to wear surgical masks dur-
ing the examination. The OCT and other no-contact devices
6 European Journal of Ophthalmology 00(0)
(autorefractometer, corneal maps, endothelial count) may be
used with specific disinfection protocols, appropriate inter-
vals between patients and ventilation of premises.
In all cases, a disinfection protocol for all potentially
contaminated equipment (slit lamp biomicroscope, sur-
faces, lens) is needed. Effective agents against this family
of virus are21–23: Ethanol at concentration 70%, Sodium
hypochlorite at concentration 0.05%–0.5%, Sodium chlo-
rite at concentration of 0.23%, povidone-iodine, at con-
centration of 10%, glutaraldehyde at concentration of 2%,
isopropanolol at concentration of 50%, benzalkonium
chloride at concentration of 0.05, Formaldehyde at con-
centration of 0.7%.
Endovitreal therapies
- Reduce the flow of patients (appropriate intervals
between each patients);
- Organize dedicated areas to perform intravitreal
injections: in many Hospitals (such as in Casale
Monferrato) there is a unique block of surgical rooms
where in the era pre-Covid intravitreal injections were
also performed. In a effort to separate patients who
undergo intravitreal therapies the Direction of medi-
cal services at the Cà Foncello Hospital in Treviso has
arranged new dedicated and isolated spaces.
- Minimize post-op controls and use phone or email
contact to follow the patients up;
- Rethink strategies to control the progression of the
macular pathology, from pro-re-nata (PRN) regi-
mens towards treat and extend modalities and OCT
based decisions: changes to treatment paradigms
in the management of patients with choroidal neo-
vascularization that focus on extending duration of
treatment may play an important role for elderly
patients prone to complications due to infectious
diseases;
- Rethink the use of sustained release devices to treat
the macular edema in diabetic patients. It may be a
feasible and cost-effective option after a strict risk
assessment (use of medications to control the IOP,
history of glaucoma). Given that elderly patients
and diabetic patients have a higher risk of mortality
from Covid-19 infection we need to reduce the risk
of exposure.18,19
Surgical activity
According to the regular surveys performed by the
Direction of Medical Services at the Treviso Cà Foncello
Hospital it was shown that longer people stay in the
Hospital, more likely to develop Covid-19 complications.
Daily surgeries (i.e. cataract surgery) should be preferred
with early discharge of the patients from the hospital. For
these patients it is important to dedicate a fast track.
NP swabs should be done to all patients admitted to
hospital as inpatients inside the hospital area (i.e. vitreo-
retinal surgery in complex cases, corneal transplantation,
trauma) when it is expected that patients remain in the
wards for more than 1 day. The outpatient flow should be
kept separated and distinct from inpatients flow as much
as possible.
We should prioritize our surgical activity: for example
elective cataract surgery should have a high priority. We
perform nearly 100% of cataract surgery under topical
anesthesia. In the Cà Foncello Treviso Hospital no corre-
lation between the type of anestehesia and risk of infec-
tions was found according to the surveys of the Direction
of Medical Services.
We believe that the bilateral same day intravitreal thera-
pies may increase the risk of endophtalmitis independently
from Covid-19 emergency: the direction of medical ser-
vices in the Cà Foncello Hospital in Treviso does not allow
this procedure for medical legal issues.
As of 5 July at the Treviso Cà Foncello Hospital the sur-
gical prohylaxis with povidone-iodine is the gold standard
to prevent endophthalmitis. Bilateral 1 day cataract sur-
gery should be avoided.
Screening and serological tests to
patients and ophthalmologists
We know that patients with Covid-19 infection may be
asymptomatic4,24–26 and shedding seems to be highest in
the earliest stage.14
The identification of “carriers” (i.e. asymptomatic
patients who are shedding the virus) and potentially con-
tagious subjects by diagnostic tests and their isolation rep-
resent the more effective strategy especially for healthcare
workers.
Testing for COVID-19 is currently done on viral genetic
material from nose and throat swabs, using a workhorse
tool of molecular biology known as reverse transcription
polymerase chain reaction (RT-PCR) that allow to amplify
the genetic material. Nasopharyngeal (NP) swab rather
than oropharyngeal (OP) swab is recommended for early
diagnosis or screening because it provides higher diagnos-
tic yields, is better tolerated by the patient and is safer for
the operator.
Since February to end of June all healthcare work-
ers in high risk units at the Treviso Cà Foncello Hospital
underwent NP swabs every 10 days. According to local
epidemiological surveillance at the beginning of July the
ophthalmic Unit is a Covid-19 free unit and all the person-
nel will undergo NP swabs every month.
Coronaviruses have a number of molecular targets
within their positive-sense, single-stranded RNA genome
that can be used for PCR assays. These include struc-
tural proteins, including envelope glycoproteins spike
(S), envelope (E), transmembrane (M), helicase (Hel),
Grosso et al. 7
and nucleocapsid (N). In Italy we generally search for the
products of sequence E, but there are some cases where the
patient is negative for E but positive for other structural
proteins. Furthermore there are some patients negatives at
the nose and throat swabs but positive at other biological
fluids (i.e. bronchoalveolar lavage).
Serology measures the host response to infection and
is an indirect measure of infection that is best utilized
retrospectively. Serological methods are rapidly being
developed and have proven to be useful in confirming
COVID-19 infection. Serology previously has had an
important role in the epidemiology of SARS27,28 and other
coronavirus outbreaks.29 Rapid lateral flow assays for both
IgM and IgG antibodies undoubtably will play an impor-
tant role in COVID-19 and should allow the burden of
infection, the role of asymptomatic infections, the basic
reproduction number, and the overall mortality to be deter-
mined. However, IgM responses are notoriously non-spe-
cific, and given the weeks required to develop specific IgG
responses, serology detection is not likely to play a role in
active case management except to diagnose/confirm late
COVID-19 cases or to determine the immunity of health-
care workers. Seroconversion occurred after 7 days in 50%
of patients (14 days in all), but was not followed by a rapid
decline in viral load.30 The issue with serological tests is
the possible presence of false positive results: in this case
patients can undergo to NP swabs for consistency. Based
on preliminary results the serological test were consistent
with the clinical history of the patients.
The rapid version of serological test (providing the
result in few minutes) was found to have a reasonable sen-
sitivity/specificity profile and might contribute to manage
daily outpatient activities. A negative result indicates that
the subject (either a patient or a doctor) was COVID-19-
free until 15–16 days before the test was performed and if
no exposures to potentially infected persons did occur in
the last period, COVID-19 is unlikely (although it cannot
be completely ruled out as a neglected contact might have
inadvertently taken place). If a circumstance of possible
recent exposure is instead reported, the subject must be
isolated and further testing planned. In case of a positive
result, PCR testing for SARS-CoV-2 infection is manda-
tory. These rapid-response tests should be provided to all
ophthalmologists and possibly patients. In this way health-
care services may be re-assured that personnel with nega-
tive results may start working in Hospital, private practice,
long-term facilities or Hospices for elderly people or criti-
cal patients.
The NP swabs should be performed to patients sched-
uled for ophthalmic surgery (with more than 1 day in the
hospital) and the patients should be operated by 24–72 h
with a strict home isolation. As of 5 July patients who
undergo 1 day cataract surgery are not screened by NP
swabs at the Treviso Cà Foncello Hospital but these
practices my change according to local epidemiological
surveillance. We believe that the key strategy in living
with the covid-19 virus is to be flexible with the suggested
actions with a compromise between caution and preser-
vations of economical activities. This strategy at the Cà
Foncello Hospital in Treviso in March 2020 was essential
to keep the Hospital a safe place for non Covid patients.
The results of our study are of outmost importance during
this second wave of infections in Italy and were integrated
in the current regulations in the Veneto Region (Act for
control the Covid-19 outbreak). The joint screening by NP
swabs and serological tests for both health care workers
and patients is the key factor for the clinical surveillance in
an integrated hospital infection control strategy.
Medical legal issues
One of the issues to deal with is how we prioritize the
appointments and surgical activity during the Covid-19
pandemic.
It is possible that patients judged non urgent cases by
triage, still ask for a consultation: in this case it is important
that patients sign a consent form where they declare that
are aware about the possibility to get an infection in the
Hospital, although the precautions and protocols ongoing.7
Further when our protocols to treat patients with age-
related macular degeneration differ from the registered
studies (i.e. treat and extend protocols) patients need to
be properly informed. It is of pivotal importance to cre-
ate a therapeutical alliance between patients and doctors.
Therefore patients should be informed about the risk of
shortage of ANTI VEGF drugs, the possibility to suspend
the therapies or delay the therapies according to the Covid-
19 epidemiological curve.31–34
New guidelines for the management of patients who
undergo cataract operation are recommended: age, first
or second eye, performance status and ophthalmological
comorbidities need to be taken into consideration.
Conclusion
In this paper we discuss an integrated model between
community and Hospital, the so called “Veneto” model,
that allowed to keep low the number of positives among
health care professionals (below the 6%) and keep going
to deliver care to Non Covid patients in the first terrible
wave of Covid-19 in March in Italy. The administration
of NP swabs and the use of PPE at the Cà Foncello hos-
pital in Treviso changed according to the risk of medical
personnel based on a criterion of proportionality (level of
exposure, epidemiological survey).
The personnel involved in the most critical areas of
the hospital in Treviso did not contracted the virus: these
results were an unexpected evidence. The infectious dis-
eases, the intensive care, the pneumology units, the depart-
ment of emergency, the ophthalmic department resulted
8 European Journal of Ophthalmology 00(0)
highly exposed to the Covid-19 but the rates of infection
were low. In the ophthalmology department two Covid
tested positives patients were managed as inpatients by the
personnel and all urgent surgeries and activities were regu-
larly performed since 24 February 2020 to 24 April 2020
but the NP swabs revealed all personnel negative tested.
The Treviso Model in the Veneto Region, Italy clearly
shows that it is possible to efficiently protect health care
workers from Covid-19 infection even in the eye of the
storm. The more you are aware and professional the less you
get the infection. The true risk is where you do not expect it.
The Covid-19 may become a nosocomial infection. In
the high specialized wards the cultural preparedness and the
correct use of personal protective equipment (PPE) resulted
in less tested positives than other areas in the Hospital.
The Treviso strategy based on high testing instead on
targeting testing allowed to keep the percentage of infected
among health care workers below the 6% and 0% among
ophthalmologists with none admitted to the intensive units.
These results are very useful in case of a second wave of
infections in Autumn.35
An integrated hospital infection control strategy at the
Cà Foncello Hospital in Treviso, consisting of dedicated
areas for infected patients, strict measures for PPE use for
all medical personnel and clinical surveillance by sero-
logical tests and NP swabs according to a risk assessment
model, was shown successful to prevent infection among
health care workers.36,37
10. Eubank S, Eckstrand I, Lewis B, et al. Commentary
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Andrea Grosso https://orcid.org/0000-0002-6235-4459
Compliance with ethical standards
All the medical and paramedical personnel work as employees of
National Healh Service (NHS).
The epidemiological surveillance was performed according to
the occupational medicine services and under the direction of the
chief medical officer (SF). All the healthcare workers signed a
consent form before making the swabs. All the data are registered
with the health management register at the Cà Foncello Hospital,
Treviso, Veneto, Italy.
References
1. Binkin N, Salmaso S, Michieletto F, et al. Protecting our
health care workers while protecting our communities dur-
ing the covid 19 pandemic: a comparison of approaches and
early outcomes in two italian regions, Italy. medRxiv. DOI:
10.1101/2020.04.10.20060707.
2. Wu Z and McGoogan J. Characteristics of and important
lessons from the Coronavirus 2019 outbreak in China: sum-
mary of a report of 72314 cases from the Chinese Center
for Disease Control and Prevention. JAMA 2020; 323(13):
1239–1242.
3. Italian Federation of Medical Doctors. Statistics for the
Italy, portale.fnomceo.it and www.iss.it (accessed 28 June
2020).
4. Lavezzo E, Franchin E, Ciavarella C, et al. Suppression of
Covid -19 outbreak in the municipality of Vò, Italy. Nature
2020; 584(7821): 425–429.
5. Remuzzi A and Remuzzi G. COVID-19 and Italy: what
next? Lancet 2020; 395:1225–1228.
6. Germann T. Los Alamos National Lab, www.lan.gov
(accessed 17 May 2020).
7. Stanley ML, Hamburg M, Sparling PF, et al. Ethical and
Legal Considerations in Mitigating Pandemic Disease:
Workshop Institute of Medicine (US) Forum on Microbial
Threats. Washington (DC): National Academies Press
(US), 2007. The National Academies Collection: Reports
funded by National Institutes of Health. PMID: 21595110
NBK54167. DOI: 10.17226/11917.
8. Verity R, Okell LC, Dorigatti I, et al. Estimates of the sever-
ity of coronavirus disease 2019: a model-based analysis.
Lancet Infect Dis 2020; 20: 669–677.
9. Wynants L, Van Calster B, Bonten MMJ, et al. Prediction
models for diagnosis and prognosis of covid-19 infection:
systematic review and critical appraisal. BMJ 2020 369:
m1328.
on Ferguson, et al., “Impact of Non-pharmaceutical
Interventions (NPIs) to Reduce COVID-19 Mortality and
Healthcare Demand”. Bull Math Biol 2020; 82: 52.
11. The Age, https://www.theage.com.au/world/asia/corona-
virus-pandemic-puzzle-why-do-some-nations-fare-worse-
than-others-20200511-p54rx5.html (accessed 11 May 2020).
12. Olivia Li JP, Shantha J, Wong TY, et al. (2020) Preparedness
among ophthalmologists: during and beyond the COVID-19
pandemic. Ophthalmology 2020; 127: 569–572.
13. Anelli F, Leoni G, Monaco R, et al. Italian doctors call for
protecting healthcare workers and boosting community
surveillance during Covid 19 outbreak. BMJ 2020; 368:
m1254.
14. Colavita F, Lapa D, Carletti F, et al. SARS-CoV-2 isolation
from ocular secretions of a patient with COVID-19 in Italy
with prolonged viral RNA detection. Ann Intern Med 2020;
M20: 1176.
15. Xia J, Tong J, Liu M, et al. Evaluation of coronavirus in
tears and conjunctival secretions of patients with SARS-
CoV-2 infection. J Med Virol 2020; 92(6): 589–594.
16. Parke DW. Returning to ophthalmology practice, www.aao.
org (accessed 25 April 2020).
17. Razanamahery J, Soumagne T, Humbert S, et al. Does type
of immunosupression influence the course of Covid-19
infection? J Infect 2020; 81(2): e132–e135.
18. Covid-19 Surveillance Group. Characteristics of Covid-19
patients dying in Italy: report based on available data on
March 20th, 2020, Rome Istituto Superiore di Sanità, www.
Grosso et al. 9
epicentro.iss.it/coronavirus/bollettino/ Report-Covid -19 _
20 marzo_eng-pdf (accessed 11 May 2020).
19. Guan W, Ni Z, Hu Y, et al. China medical treatment expert
group for Covid-19. Clinical characteristics of coronavirus
disease in China. N Engl J Med 2020; 382(18): 1708–1720.
20. Minotti C, Tirelli F, Barbieri E, et al. How is immunosup-
pressive status affecting children and adults in SARS-CoV-2
infection? A systematic review. J Infect 2020; 81(1): e61–e66.
21. Romano MR, Montericcio A, Montalbano C, et al. Facing
COVID-19 in ophthalmology department. Curr Eye Res
2020; 45(6): 653–658.
22. Lim LW, Yip LW, Tay HW, et al. Sustainable practice of
ophthalmology during COVID-19: challenges and solutions.
Graefes Arch Clin Exp Ophthalmol 2020; 258(7): 1427–1436.
23. European Centre for Disease Prevention and Control. Interim
guidance for environmental cleaning in non-healthcare facil-
ities exposed to SARS-CoV-2. ECDC: Stockholm, 2020.
24. Lu X, Zhang L, Du H, et al. Chinese pediatric novel corona-
virus study team. (2020) SARS-CoV-2 infection in children.
N Engl J Med 2020; 382: 1663–1665.
25. Pan X, Chen D, Xia Y, et al. Asymptomatic cases in a fam-
ily cluster with SARS-CoV-2 infection. Lancet Infect Dis
2020; 20: 410–411.
26. Luo SH, Liu W, Liu ZJ, et al. (2020) A confirmed asymp-
tomatic carrier of 2019 novel coronavirus (SARS-CoV-2).
Chin Med J (Engl) 2020; 133: 1123–1125.
27. Zhang W, Du RH, Li B, et al. Molecular and serological inves-
tigation of 2019-nCoV infected patients: implication of multi-
ple shedding routes. Emerg Microbes Infect 2020; 9: 386–389.
28. Chen X, Zhou B, Li M, et al. Serology of severe acute res-
piratory syndrome: implications for surveillance and out-
come. J Infect Dis 2004; 189:1158–1163.
29. Chan CM, Tse H and Wong SS, Examination of seropreva-
lence of coronavirus HKU1 infection with S protein-based
ELISA and neutralization assay against viral spike pseudo-
typed virus. J Clin Virol 2009; 45: 54–60.
30. Tang Y, Schmitz JE, Persing DH, et al. The laboratory diag-
nosis of COVID-19 infection: current issues and challenges.
J Clin Microbiol 2020; 58(6): e00512-20.
31. Borrelli E, Grosso D, Vella G, et al. Short-term outcomes
of patients with neovascular exudative AMD: the effect of
COVID-19 pandemic. Graefes Arch Clin Exp Ophthalmol.
2020; 258(12): 2621–2628.
32. Borrelli E, Grosso D, Vella G, et al. Impact of COVID-19
on outpatient visits and intravitreal treatments in a referral
retina unit: let’s be ready for a plausible “rebound effect”.
Graefes Arch Clin Exp Ophthalmol. DOI: 10.1007/s00417-
020-04858-7
33. Toro MD, Brézin AP, Burdon M, et al. Early impact of COVID-
19 outbreak on eye care: insights from EUROCOVCAT
group. Eur J Ophthalmol 2020, Epub ahead of print 24
September 2020. DOI: 10.1177/1120672120960339.
34. Rahul R. How COVID-19 may change the future of ret-
ina practice when we think of what the future may hold,
it behooves us to think from a public health perspective.
Retina Today 2020, May-June 2020.
35. Borrelli E, Sacconi R, Querques L, et al. Taking the right
measures to control COVID-19 in ophthalmology: the
experience of a tertiary eye care referral center in Italy. Eye
2020; 34: 1175–1176.
36. Grossi U, Zanus G and Felice C. Coronavirus disease 2019
in Italy: the Veneto model. Infect Control Hosp Epidemiol
2020, Epub ahead of print 11 May 2020. DOI: 10.1017/
ice.2020.225.
37. Cattelan AM, Sasset L, Di Meco E, et al. An integrated
strategy for the prevention of SARS-CoV-2 infection in
healthcare workers: a prospective observational study. Int J
Environ Res Public Health 2020;17(16): 5785.