Intended for healthcare professionals

Rapid response to:


Covid-19: a puzzle with many missing pieces

BMJ 2020; 368 doi: (Published 19 February 2020) Cite this as: BMJ 2020;368:m627

Read our latest coverage of the Coronavirus outbreak

Linked Research

Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARS-Cov-2)

Rapid Response:

Family Doctors, Environment and COVID-19 in Italy: experiences, suggestions and proposals

Dear Editor,

Thanks to the project funded by the Italian Ministry of Health (MoH) in 2017, the Italian Network of Sentinel Physicians for the Environment (in Italian RIMSA) is underway[1].

Some of the main activities of the network are:

• A modular object-oriented dynamic learning environment (Moodle) platform for training initiatives and an e-learning community of practice.
• A WhatsApp chat group (WCG) (115 professionals), mainly involving Family Doctors (FDs) throughout Italy, providing scientific reports and daily news dealing with Environment and Health (EH) setting.
• A few local pilot experiences of Sentinel Physicians to address some EH concerns (i.e. diseases in urban, industrial, agricultural and mixed area) devoted to training FDs on environmental threats as well as collecting EH data.


From February 2020, the outbreak of COVID-19 has captured most of the interest of the participants of the RIMSA WCG. WhatsApp is representing a powerful and helpful tool at the time of the COVID-19 pandemic. Even the World Health Organization has started using WhatsApp as a communication tool for the general public [2].

The abrupt overall socio-sanitary change generated by the epidemic has caused new needs in knowledge building and sharing processes, which had to be implemented according to the lockdown phase.

The dedicated section of the Moodle platform dealing with COVID-19 provides a repository of relevant international and national scientific articles, documents and news. These are classified by topic and specific thematic areas (i.e., epidemiology, therapy, laws, journal news) to facilitate the navigation. To further promote the sharing of information, a dedicated forum section has also been created.

Based on RIMSA's experience with the WCG and the Moodle platform, some general take-home messages on the role of FDs in the COVID-19 emergency can be profitably shared:

• Some GPs have observed cases of interstitial pneumonia already in late January 2020, before the first Italian case of COVID-19 infection was officially identified in Codogno (Lombardy Region).
• Despite no systematic assessments having been carried out, one hypothesis under (speculative) development is that the regions where health care systems are mainly based on hospital activities are showing the highest case fatality rates, much more than in the areas where FDs have been more involved in contact tracing and patients management;
• FDs can be handy to capture more quickly new cases, either in terms of timely surveillance and, above all, in triggering immediate and appropriate health interventions as well as in allowing the right level of patient's seclusion, far better than in hospitals.

Basically, according to Li [3] "FDs have a 'first in, last out' role in COVID-19 pandemic.

Furthermore, it should be underlined that epidemiological Primary Health Care (PHC) based surveillance could be essential in the "coming year to anticipate the possibility of resurgence." [4].

COVID-19 and the Environment

In this field, many issues should be further investigated. Still, it is undoubtedly necessary to point out that the origin and the effects of COVID-19 pandemic are inextricably linked to the Environment as a whole [5-19].

The authors believe that Sentinel Physicians for the Environment contributions could be beneficial in investigating the COVID-19 trend as well as the relationship between environmental determinants, mainly air pollution, heat, humidity. As such RIMSA is committed to promoting some initiatives involving local FDs' networks.

Finally, ethical issues must be taken into due consideration: COVID-19 pandemic and the deteriorated environment affect, first and foremost, vulnerable and most deprived people.

In sum, we think that the contributions by Sentinel Physicians for the Environment could be beneficial to investigate the COVID-19 trend as well as the relationship between environmental determinants, mainly air pollution, heat, humidity. We are committed to arranging some initiatives involving local FDs networks.

Last but not least, we are actively available to be involved and promote some international initiatives dealing with COVID-19 pandemics, such as the one shared by WONCA[20] and the environment [21].

In some cases, comparisons between similar initiatives across countries may provide an opportunity for enhanced understanding of several complex social and environmental factors overlapping in affecting COVID-19 virus transmission.

Such knowledge would depend on collaboration by FDs with national surveys conducted by epidemiologists, and this could be combined with the role of primary care services as contributing to public health response in terms of case identification and contact tracing at the community level. This is expected to result in an improvement of existing interventions at the community level, as well as in the identification of possible novel ones.

Based on the success of similar approaches in Germany and South Korea, the overall benefit of involving FDs and primary health care services into public health responses to COVID-19 could be substantial at the global level.


This paper attempts to highlight that the environmental sensitivity of individual physicians and knowledge of their area, together with clinical expertise, can help detect critical situations and encourage appropriate actions to prevent recurrent threats.

But they need to be supported by providing them instruments to gather sound and evidence-based scientific knowledge both in terms of information and document delivered in timely and proper manner and specific, effective, and motivating training.

Starting from a voluntary initiative such as a WhatsApp chat network, we showed that it could be better developed by using a community of practice device such as Moodle.

This lesson should be taken into proper account in the case of COVID-19 pandemic, but also in facing other global threats such as Climate Change and environmental pollution at the local level.

Corresponding Author:
Dr Paolo Lauriola, MD, Associate
Italian National Research Council, Institute of Clinical Physiology,
Unit of Environmental Epidemiology and disease registries.
Scientific Coordinator, RIMSA (ISDE-FNOMCeO);
Via Cimone, 41100 Modena
skype: plauriola

1. Vitalia Murgia, Primary care paediatrician, RIMSA (ISDE-FNOMCeO), Italy
2. Francesco Romizi, Journalist, communication manager of the International Society Doctors for the Environment ISDE Italia, RIMSA (ISDE-FNOMCeO), Italy
3. Roberto Romizi, Family doctor, International Society Doctors for the Environment (ISDE) Italy
4. Paula de Waal, Università Ca' Foscari Venezia, Italy
5. Fabrizio Bianchi, Epidemiology Unit, Institute of Clinical Physiology, National Research Council, Pisa, Italy
6. Francesco De Tommasi, Family doctor - Local Health Authority, BA; RIMSA (ISDE-FNOMCeO), Italy
7. Marco Calgaro, Family doctor - Local Health Authority, 13 Novara; RIMSA (ISDE-FNOMCeO), Italy
8. Samantha Pegoraro, Italian Climate Network; RIMSA (ISDE-FNOMCeO), Italy
9. Maria Grazia Santamaria, Family doctor, Local Health Authority, Foggia; RIMSA (ISDE-FNOMCeO) Italy,
10. Alice Serafini, General Practitioners’ training course trainee, Local Health Authority Modena; RIMSA (ISDE-FNOMCeO) Italy
11. Emanuele Vinci,” Health and Environment” working group, National Medical Boards Federation (FNOMCeO), Italy
12. Giovanni Leonardi, Epidemiologist, London School of Hygiene and topical Medicine, UK
13. Paolo Lauriola. Scientific Coordinator, RIMSA (ISDE-FNOMCeO); Epidemiology Unit, Institute of Clinical Physiology, National Research Council, Pisa, Italy

1. Lauriola P, Pegoraro S, Serafini A, Murgia V, Di Ciaula A, De Tommasi F, Ross Ai, Santamaria M, Toffol G, Bianchi R, Romizi R, Vinci V, Behbod B, Zeka A, Verheij R, Leonardi G, Agius R, (2018)The Role of General Practices for Monitoring and Protecting the Environment and Health. Results and Proposals of the Italian Project Aimed at Creating an "Italian Network of Sentinel Physicians for the Environment" (RIMSA) within an International Perspective, J Family Med Community Health 5(5): 1160. DOI
3. Li DKT. Challenges and responsibilities of family doctors in the new global coronavirus outbreak. Fam Med Com Health, 2020;8:e000333. DOI:10.1136/ fmch-2020-000333
4. Kissler SM, Tedijanto C, Goldstein E, GradmmYH1, Lipsitchm M.Projecting the transmission dynamics of SARS-CoV-2 through the post-pandemic period. Science 14 Apr 2020: DOI: 10.1126/science.abb5793
5. Katherine F. Smith, Michael Goldberg, Samantha Rosenthal, Lynn Carlson, Jane Chen, Cici Chen and Sohini Ramachandran.. Global rise in human infectious disease outbreaks. (2014) J. R. Soc. Interface.1120140950
6. Qu, G., LI X, Hu L, et al. "An Imperative Need for Research on the Role of Environmental Factors in Transmission of Novel Coronavirus (COVID-19)." Environmental Science & Technology
7. Ghirga G. COVID-19 and air pollution BMJ (2020);368:m627
8. Bianchi F, Cibella F. COVID-19: a puzzle with many missing pieces BMJ (2020);368:m627
9. Lubrano C. Colao A Covid-19: a puzzle with many missing pieces. Air pollution, climate and obesity could be the COVID 19 puzzle missing pieces BMJ 2020;368:m627
10. Conticini E, Frediani B, Caro D, Can atmospheric Pollution be considered a co-factor in extremely high level of SARS-CoV-2 lethality in Northern Italy? Environmental Pollution, (2020)
11. Sajadi HM Habibzadeh P Vintzileo A et Temperature and Latitude Analysis to Predict Potential Spread and Seasonality for COVID-19 January 2020SSRN Electronic Journal (2020) DOI: 10.2139/ssrn.3550308
12. Wang, J., Tang, K., Feng, K., & Lv, W. High temperature and high humidity reduce the transmission of COVID-19. (2020). Available at SSRN 3551767.
13. Oliveiros, B., Caramelo, L., Ferreira, N. C., & Caramelo, F. Role of temperature and humidity in the modulation of the doubling time of COVID-19 cases. . (2020). medRxiv.
14. Luo, W., Majumder, M., Liu, D., Poirier, C., Mandl, K., Lipsitch, M., & Santillana, M. The role of absolute humidity on transmission rates of the COVID-19 outbreak. (2020) medRxiv..
15. Wang, M., Jiang, A., Gong, L., Luo, L., Guo, W., Li, C., et al. Temperature significant change COVID-19 Transmission in 429 cities. (2020). medRxiv.
16. Chen, B., Liang, H., Yuan, X., Hu, Y., Xu, M., Zhao, Y., et al, X.). Roles of meteorological conditions in COVID-19 transmission on a worldwide scale. (2020medRxiv.
17. Notari, A. Temperature dependence of COVID-19 transmission. arXiv preprint (2020). arXiv:2003.12417.
18. Morawska, L. and J. Cao "Airborne transmission of SARS-CoV-2: The world should face the reality." Environ Int (2020). 139: 105730.
19. Ogen Y., Assessing nitrogen dioxide (NO2) levels as a contributing factor to coronavirus (COVID-19) fatality, Science of the Total Environment 726 (2020) 138605.

Competing interests: No competing interests

25 April 2020
Paolo Lauriola
Vitalia Murgia, Francesco Romizi, Roberto Romizi, Paula de Waal, Fabrizio Bianchi, Francesco De Tommasi, Marco Calgaro, Samantha Pegoraro, Maria Grazia Santamaria, Alice Serafini, Emanuele Vinci, Giovanni Leonardi.
Italian National Research Council, Institute of Clinical Physiology,
Via Cimone, 55 41100 Modena