Inappropriate risk perception for SARS-CoV-2 infection among Italian HCWs in the eve of COVID-19 pandemic.

Sir, Italy has been recently involved in the outbreak of severe interstitial pneumonia associated with the previously unknown Coronavirus SARS-CoV-2 (1,2). Even before the notification of the first autochthonous cases, the SARS-CoV-2 associated syndrome (COVID-19) had raised an intense attention in the public opinion (3), with a counterproductive over-abundance of mixed quality information. As even Italian healthcare workers (HCWs) were not spared by subsequent misunderstandings and knowledge gaps during the previous influenza pandemic of 2009 (4), we performed a web-based survey (Google® Modules), specifically aimed to characterize knowledge status and risk perceptions in a sample from participating to 6 Facebook discussion groups (181,684 total unique members at the time of the study). The questionnaire was made available between February 1st and 7th, 2020, i.e. around 2 weeks before the first COVID-19 was officially diagnosed in Italian residents.   Overall, the sampled population included 2106 respondents (Table 1), and 39.3% were HCWs. Even though HCWs were more likely to exhibit a better understanding of SARS-CoV-2/COVID-19 related issues (aOR 2.195, 95%CI 1.809 to 2.664), they were not exempt for misunderstandings, particularly on actual incidence and lethality of COVID-19. Interestingly, most of respondents were aware of the main clinical features of COVID-19, with HCWs more frequently acknowledging that the COVID-19 may run pauci- or even asymptomatic (86.3% vs. 79.1%), resembling an Influenza-Like Illness (i.e. fever, cough, headache, etc.), with a potential latency up to 14 days (85·9% vs· 80·3%), eventually spreading by droplets (98.5% vs. 92.7%) rather through running water (92.3% vs· 79.8%), or blood/body fluids (88.0% vs. 70.4%).   Retrospectively, the assessment of preventive measures and risk perception appears somewhat worrisome. For instance, while HCWs were more likely to acknowledge as an appropriate preventive measure wearing a filtering mask (i.e. N95/FFP2/3 mask; aOR 2.296, 95%CI 1.507 to 3.946), around ¼ of HCWs failed to recognize the importance of such personal protective equipment, while 7.4% felt as appropriate the wearing of a surgical mask. Moreover, not only COVID-19 was appropriately acknowledged as a severe disease by only 62.0% of respondents, with no differences between HCWs and non-HCWs, but an even smaller share (i.e. 8.0%) reported any concern for being infected by SARS-CoV-2 in Italy. In fact, at the time of the survey SARS-CoV-2 was more properly associated with international travelers (26.7%).   Our results are therefore of certain interests for several reasons. First at all, early epidemiological reports on the Italian cases of COVID-19 hint towards some failures in the initial management of incident cases (5-6). In fact, in our survey a large share of respondents substantially overlooked the risk to interact with SARS-CoV-2 positive subjects, that was otherwise perceived as a not-so-severe disease (i.e. "nothing more than a seasonal flu", as often described in some social media) (7). Moreover, around a 1/3 of HCWs participating to the study presumptively did not use proper personal protective equipment for the airways interacting with possible COVID-19 cases, either underestimating the infection risk or being unable to recognize early symptoms. Actually, the base of evidence shared by participants at the time of the study substantially ignored that COVID-19 may be characterized by dermatologic and gastro-intestinal symptoms (8-9). As most of infections may be actually pauci- or asymptomatic, such early exposure in the healthcare settings may have contributed to the quick spreading of SARS-CoV-2 epidemic in Northern Italy.   Therefore, despite the intrinsic limits of a convenience sampling, web-based survey (10), our study stresses the importance to improve the overall quality of information on COVID-19 conveyed not only in HCWs, but also in the general population. Moreover, our data may contribute to clarify the early stages of SARS-CoV-2 pandemic in Italy.