“An embarrassing Covid-19”: It could be the title of a short story by Calvino or a rhyme by Rodari, but it's what we're witnessing these days. The increasing frequency of SARS-CoV-2 infections in various areas of the world, including Italy, has forced mainstream media to address it again. However, it's often discussed with a sort of embarrassment and only for the sake of reporting. When discussing possible countermeasures, the discomfort becomes even more apparent.

Why? One of the worst aspects of communication during the pandemic has been the reliance on “pundits”, among whom many are well-qualified in the clinical field of patient care, but not necessarily equipped with public health experience and tools. Opinions can easily be exploited, and polarization has often been associated with political rather than scientific ideologies. There's rarely been an explanation of the decision-making process and the criteria guiding it, or the reasons for choosing among different alternatives. To many, it seemed that one opinion was as valid as another.

Now that we are facing the increasing frequency of Covid-19 cases again, many feel that taking a stand for or against one or more recommendations (use of masks? isolation of the infected? vaccination?) can also have ideological connotations, in the absence of stated rational elements. This is where the discomfort arises. When it's unclear on what basis decisions are made, it's evident that space for “opinions” becomes predominant, and the discussion moves away from a rational approach.

Indeed, in our country, there doesn't seem to be (or at least it's not known) a consolidated and transparent process that allows understanding how health authorities formulate recommendations. Even the presence of scientific data isn't always decisive in public health decisions, and moving from evidence to recommendations isn't automatic: it depends on the strength of the evidence, the context in which it was obtained, the feasibility of the recommendations, and their acceptability. Evaluating the quality of available evidence and defining the strength of the resulting recommendations has been the method used abroad for years to draft guidelines.

Last September 12, 2023, the US Advisory Committee on Immunization Practice (ACIP) met (broadcasted live on the web) to evaluate scientific evidence regarding the Covid vaccination to be proposed in the US and to examine how to move from evidence to public health recommendations. All the slides presented are available online, and the amount of data displayed covered many aspects, from current epidemiology, long-Covid, circulating variants, the economic evaluation of the disease, to available vaccines. A lengthy presentation assessed the strength of the evidence presented and considered various aspects to move from evidence to recommendations: public health, benefits, risks, perception by the target population, acceptability of vaccination, feasibility and practical aspects of the offer, required resources, and finally, vaccination equity.

Among the public health aspects, for example, the offer of further Covid vaccination for young people up to 18 years of age is compared in terms of deaths with other already recommended vaccinations (against meningitis, chickenpox, rotavirus, etc), highlighting that, albeit over different time spans, the number of deaths attributed to Covid-19 is far greater than that of other diseases for which vaccination is already recommended. For adults, the comparison with the flu results in even more evident favor for the Covid vaccination. Particular emphasis is placed on equity aspects, which are discussed for each of the aspects covered (benefits, risks, acceptability, feasibility, etc.), and it's evident that there are significant differences between different ethnicities, age groups, and geographical areas regarding risk factors for severe Covid-19 complications.

Without concluding that the ACIP example is the only or the best one, the underlying issue is to set rules, make them known, and apply them transparently for everyone.

Another point worth considering is data availability. If there were a consolidated evaluation method, we would know what data we need to decide and which studies and surveillance we need to equip ourselves with to actually evaluate objective elements. Adherence to public health recommendations would certainly be more convinced if they were also based on timely and accessible results from solid studies conducted in our country. The Italian Association of Epidemiology has called for transparency in decision-making processes, and it would indeed be appropriate to continue to demand established and known rules without always relying on the more or less justified wave of popular sentiment or other conveniences, and bring the discussion back to a less embarrassing ground.