Biagio Pedalino is a public health epidemiologist currently working as an international consultant. He previously served at the Centers for Disease Control and Prevention (CDC) in Atlanta as the Field Epidemiology Training Program (FETP) team lead for West Africa. He was formerly a Resident Advisor to the Morocco FETP and a Scientific Coordinator of the European Programme for Intervention Epidemiology Training (EPIET) at the European Centre for Disease Prevention and Control (ECDC). He has also held positions with the World Health Organization (WHO) and Sanofi Pasteur MSD, among others. He a medical doctor specialized in public health and a 2003 graduate of EPIET.

You have been involved since early on in the response to COVID-19 in Italy. Describe your work there.

In Italy, my role in the response to the COVID-19 pandemic was initially as an “informed citizen”; I had no official role in any local public health institutions, but given my experience in outbreak investigation and response, I was providing information and data interpretation to local media, local businesses and employers. After March 9, the beginning of the lockdown in Italy, I kept my role as a referent expert for the local and regional media giving regular (weekly) interviews to clarify the data, providing interpretation and recommendations on the regulations issues by the Italian government.

Describe your current work acting as expert epidemiologist for the mayor of Trapani around reopening.

Trapani (with a population of 80,000) is a small town in Sicily, Italy with a specific role as the “capital” of the whole province of Trapani (which has around 400,000 inhabitants); therefore, its mayor plays certainly a major role specifically for the town, with an advisory role for the other mayors of the different towns of the province.

Given the uncertainty and vagueness of the regulations that were issued when approaching the end of the lockdown in early May, the mayor advertised a position as “expert epidemiologist” within the administration to provide technical advice and to formulate recommendations to reopen a number of public venues under his responsibility. He also offered my expertise to local business owners (i.e., restaurants, gyms, bars, hairdressers, among others) that may need some help in reorganizing their businesses according to the anti-COVID-19 preventive measures. I had never worked in my hometown as an epidemiologist and thus had the opportunity to visit my own hometown with a different eye, and formulate recommendations to the other citizens to be able to access all venues safely.

What factors is Trapani considering in reopening? How has that been going?

In Italy, a scientific committee (including the Istituto Superiore di Sanità, the national technical institute of the Ministry of Health) has been established since the beginning of the pandemic. In Sicily, one of the Italian regions, a similar structure has been formed. By definition, if a recommendation is issued by the central authorities, it has to be followed by the regions, or it can be adapted by the regional authorities if appropriate. The regional authorities may issue general recommendations and delegate the mayors to formulate specific recommendations for each of the venues under their responsibilities.

This is basically my role: to be aware of all (national and regional recommendations and regulations) and formulate local recommendations according to the local needs. Besides the basic preventive measures (i.e., physical distancing, protective mask-wearing, and frequent hand-washing), these had to be completed for each of the local venues, taking into account, for instance: the size of the venue (to make sure that a certain limited number of persons would access) and the nature of the event or activities (whether it is a market, a public garden, a beach). An additional role was also to go through each and every single safety plan submitted by the owners of activities (public events, event organizers [cinemas, theaters, etc.]) who were asking the local administration for permission to hold the events.

What are the biggest challenges you have experienced, and how have you dealt with them? Were any of these challenges unanticipated or unforeseen?

In Italy, as in most of the Western countries, such an outbreak had never occurred. Italy, in particular, was not particularly hit by SARS, and the MERS was geographically very limited. Therefore, the only outbreak that the general population is “used to” is the seasonal flu epidemic, and the risk perception is so low that vaccination coverage for flu is consequently very low. Besides this, but very much linked to it, is that in the initial phase of the epidemic, the current pandemic was wrongly compared to a “more serious flu epidemic.” Therefore, the perception of the risk in the general population was very inaccurate. It was only in early March, when the number of deaths was increasing dramatically (the main reason for the lockdown) that the general population started understanding the seriousness of the situation. Still, there are a number of people believing the conspiracy theory, the “no-vax community” and of course, now that the government allowed basically an almost full reopening, the perception of the general population is that the pandemic is over: people are going to the beach, they barely have a mask with them, there are no fines or penalties for people not respecting the rules, etc. Unforeseen or unexpected, none of what has happened was such, the reaction from the general population is the same all over the world during an outbreak.

What is the experience like as an epidemiologist working with elected officials? Do you have any advice for other epidemiologists on working effectively with elected officials?

The role of an epidemiologist has to remain technical, an objective step-back from any potential economic interest (that may move the reopening), and formulate the recommendations driven only by the epidemiological situation. Of course what we, as epidemiologists, can formulate are evidence-based recommendations, and this is the easy part. The more challenging part is to receive a full endorsement by the elected officials. So far, however, there has been a full alignment between the formulated recommendations and what, in the end, has been implemented. The public health goal is fully shared in the interest of the well-being and protection of the general population.

One thing that has been a bit difficult to explain is that an epidemic can evolve in any direction overnight, and that it depends only on what we actually do about it, and that this also applies to the recommendations, which have to be dynamic, flexible, and adapted to the epidemiological situation.

As an example: in the early stages of the epidemic, it was common practice to sanitize the streets, which was quite a “theatrical action” to implement and very visible. After a while, though, WHO started discouraging this practice, and the local temperatures are now such that it is highly unlikely that the virus can survive in the environment long enough after being released by an infected person and infect a susceptible person. It was not easy to explain that the sanitization of the streets was no longer needed, and the answer was, “It’s been three months that we [have been doing] it; what would people say if we stop?”

Combating misinformation, and in some cases stigma, has been a significant challenge during this pandemic. Has this affected your work? How have you dealt with it?

Indeed so; as I was mentioning earlier, in Italy, this pandemic was “presented” first as a “more serious flu,” and it has been a challenge to even explain how we (the international public health community) cannot know the virus and not have all the answers.

The only way I could use to deal with this particular situation has been to be constantly and continuously informed from the WHO, CDC, etc., websites about the latest news on the virus and its transmission and be able to respond to any question by citing a scientific and reliable source of information, rather than a newspaper.

Would you like to share anything else?

Should any of my colleagues find themselves in a similar position, my humble advice would be to make sure that the elected officials keep open, clear, continuous and transparent communication with the general public to build upon and keep their trust high in order to make sure that, if they provide them with a recommendation, the general public would follow. Being an elected official in times of a pandemic must be a very difficult task, and the lack of trust in the general public would make it impossible. Good luck.