San Pietro in Cerro (PC), 05/18/2020 to Prime Minister

to Minister of Health

to Minister for Youth Policies and Sports

to Minister for Equal Opportunities and Family

to Minister for European Affairs

to Minister of Economic Development

to Minister of Agricultural, Food and Forestry Policies

to Minister of Environment and Land and Sea Protection

to Minister of Infrastructure and Transport

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to Ministry of Labor and Social Policies

to Ministry of Education

To Ministry of University and Research

Healthy lifestyles, environmental sustainability and transversality as integrative strategies to phase 2 of the Covid-19 emergency (second dispatch)

Dear Mr. Conte, dear Ministers, we are well aware that it is not easy to take responsibility to establish a response strategy to the current Covid-19 emergency and we appreciate your commitment.

In this second phase, we are sure it is important to look beyond the emergency and find the right route to avoid similar tragedies in the future.

Surely Covid-19 has caught us unprepared, since, from an individual, sanitary and social point of view we are ‘frail’. Neglected 'frailty' in the past can and must become, today's starting point for a society that rebuilds itself.

This epidemic has shown a void in the system: the lack of a pervasive and effective health promotion strategy, that has created an Italian population that is more frail and vulnerable also to infections, especially the elderly. We must fill the above-said void focusing on health promotion, aware that we identify the main determinants of collective health in lifestyles and environmental sustainability. We shall keep in mind that a major paradigm change is needed: we cannot think of promoting health as it has been done in recent decades. We want to bring to your

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attention the European Position Paper produced by the SALUS European Network that clearly expresses our points of view regarding the previous topics [1]. We propose two macro-strategies to reduce the prevalence and severity of the state ​ of frailty (preventable [2,3] and reversible [4,5] condition) of the Italian population and ​ ​ the consequent social and sanitary damage: 1. promotion of healthy lifestyles 2. environmental sustainability

Promotion of healthy lifestyles According to the report of the Istituto Superiore di Sanità, the average age of the deceased for COVID-19 was 80 years, with on average 3.3 chronic pathologies (hypertension, diabetes, and ischemic heart disease the most frequent) [6]. The inactivity consequent to this period of restrictive measures, risks to produce further deleterious effects on the elderly [7], also aggravated by the scarce exposure to solar rays.

Due to this matter, we think it is reasonable to integrate the measures proposed for phase 2 with innovative strategies based on health promotion at population level to reduce the prevalence and seriousness of the frailty state of Italians, especially the elderly. Such strategies, based on strong scientific evidence, should then be continued over time to prevent similar effects in the future.

The North Karelia Project [8], in Finland, a virtuous European historical example of empowerment; showed the effectiveness of health promotion strategies. After 25 years the annual cardiovascular disease mortality across Finland was reduced by 65%. Lung cancer mortality also declined by more than 70% in North Karelia and almost 60% across Finland, along with a 45% reduction in all-cause mortality [9].

We believe we can also recreate that experience in Italy, to drastically reduce those frailties that make us a high-risk country, in case of epidemics and pandemics. The objection often raised to these proposals is the long-term outlook in the expected results of a health promotion campaign. There is strong scientific evidence that proves the beneficial effects within an already more limited time frame [10]; we, ​

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therefore, believe it is important to immediately insert this strategy among the conceived measures for phase 2.

Yet, if we evaluate response times, the two strategies currently indicated in phase 2, vaccinations and serological tests, which have received more attention, require more complex studies whom results are not certain; as matter of fact, we do not know if this infection develops an immunity that protects against a second infection [12].

As a consequence, it would be reasonable to immediately integrate new public health strategies, which require shorter implementation time sustained by evidence of effectiveness ([5, 13, 14], to give three examples). Strategies centered on health promotion, often underestimated, have repeatedly proven to greatly reduce total mortality (table 1). For example the benefits of physical activity, that include anti-infective effects, are documented in the materials attached to the website related to note [7].

Table 1 (from Pillole di Educazione Sanitaria, n. 143/2018 - www.fondazioneallinearesanitaesalute.org - Dr. Alberto Donzelli) ​

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Below we indicate two valid and influential scientific documents that can be used to promote health at population level: ● WCRF/ AICR Third Expert Report, Diet, Nutrition, Physical Activity, and Cancer: A ​ ​ ​ Global Perspective [15]; ● The Lancet Commission. Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems. Volume 393, issue 10170, p447-492, February 02, 2019 [16]. It should be added that in Europe, our country is the first for mortality due to antibiotic resistance (about a third of the deaths across Europe). The frailty state increases the risk of infections, including those from resistant microorganisms. The phenomenon of antibiotic resistance, associated with an epidemic like the one we are experiencing, increases the risk of death due to the ineffectiveness of antibiotics in superinfections following COVID-19. In the proposals section, we will also talk about effective measures to combat antibiotic resistance.

Environmental sustainability In relation to the causes for a greater mortality, unquestionable above all in Lombardy and in some provinces of Northern Italy, numerous hypotheses have been formulated, to be carefully examined. One of these concerns the direct relationship between the concentration of atmospheric particulate matter with a diameter of fewer than 10 microns (PM10 - particulate matter) and the number of SARS-CoV-2 infected [17]. In fact, it is true that atmospheric aerosols can carry, in addition to dangerous chemical compounds, also microorganisms and other materials of biological origin (bacteria, spores, pollens, viruses, fungi, algae, vegetable particles, fecal residues from farms, etc.) [18]. However, as far as we know, it is not biologically plausible that an extremely diluted viral load, as we find in external environments, is sufficient to infect [18]. However, a problem could exist in the presence of infected subjects in closed environments (starting from hospitals and rest homes, up to homes), where the dilution of the viral loads emitted can be much less than in the open air, and where synergy with particulate matter could be more important. There are suggestions that the

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transmission of the virus in the hospital setting may involve a large part of hospitalized patients [19]. It has been suggested that infection rates in certain parts of Northern Italy may be linked to atmospheric particulates pollution [17] in the Po Valley compared to other Italian areas. The Covid-19 Repository of Epidemiology and Prevention also contains articles with additional documentation on the matter [20,21]. The hypothesis of the impact of fine particulate matter is reinforced by an online preprint article by researchers from Harvard School of Public Health [22].

An analysis carried out by Dr. Lorenzo Del Moro (Philosophical Scientific Committee of SALUS European network) and Dr. Alberto Donzelli (Scientific Committee of the Italian Foundation Allineare Sanità e Salute) showed that 8 out of the 11 Italian Municipalities with a greater increase in mortality from 1 January to April 4, 2020, are among the Municipalities that exceeded, for 9 or 10 years (from 2010 to 2019), the fine dust limit (PM10), according to the Dossier of Italian NGO Legambiente [23]. The chronic damage hypothesis (endothelial, and not only) from atmospheric pollution that acts by enhancing the effects of the virus needs further evaluation. We feel that, also in the case of environmental pollution, the Government can do a lot to reduce systemic frailty that has turned some areas of our country more exposed to infectious risk than others.

Hence, we ask for the integration of extraordinary measures within the current strategy to quickly reduce environmental pollution, by acting on mobility, intensive farming, industrial production, up to individual behavior.

Italy, stimulated by this difficult period, could be a European leader in achieving the European Union's 2030 targets on pollution and climate change, proposing innovative solutions. The ability to innovate is one of the characteristic qualities of our people.

What do we propose? 1. The activation of an Emergency and Integrated Health Promotion Plan, ​ ​ strongly based on healthy lifestyles, especially aimed at the elderly population,

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and extended on a national level, as a reference framework for the Regions and Autonomous Provinces, recognizing the added value that some professional figures of Traditional and Complementary Medicine represent in the field of health promotion in line with other European Countries [1]; 2. The introduction of a new National Action Plan against Antimicrobial ​ Resistance that integrates the following fundamental aspects, to be brought as proposals also at European level, given the new European Action Plan: a. To popularise best practices for healthy lifestyles promotion; b. To discourage the prescription of antibiotics for human and animal use for trivial conditions that do not require them, and for purposes other than the treatment of specific diseases, leaving possible exceptions at the doctors and veterinarians autonomy; c. To promote a strong reduction in the consumption of animal proteins, especially of red and processed meats; d. To abolish trade-in medicated feed with antibiotics; e. To highlight in labeling the products of animal origin that come from intensive farms. At the following link a video contribution from the SALUS Philosophical and Scientific Committee: https://www.youtube.com/watch?v=iHpwpS_xtlk; ​ 3. Promote the birth of EUROSALUS in Italy, a European research center focused ​ on health promotion and environmental sustainability, to adequately monitor results and risk factors reduction and to identify effective, safe and economic strategies for health promotion; 4. The activation of specific and concrete experimentation, that we are ready to ​ ​ implement as SALUS European Network during the incoming months: a. SOS - SALUS Online Support: an institutional youtube channel that can ​ spread positive, constructive and scientific evidence-based messages to promote health and environmental sustainability through the adoption of simple daily choices; b. Matter of style - Vademecum on good daily practices to be spread among the elderly, to reduce frailty and increase the response capacity to infections;

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c. SALUS APP - a free app for Italian citizens that identifies their infection profile risk and suggests useful strategies to improve it, through simple daily practices. We hope to reach at least one million Italian citizens and ignite a lifestyle change that grows from the bottom up. This application could also be useful for epidemiologic territorial services, as it would provide anonymous data on the local population frailty, allowing for a more targeted calibration of interventions to combat infections.

What do we ask for? The SALUS European Network and all the signatory organizations of this open letter ask to create a roundtable discussion with the addressed ministries, to go deeply into details of the concrete proposals set out above, to collaborate and support government commitment, during this difficult phase that the country is experiencing. We are confident that, animated by a spirit of responsibility and solidarity, Italian citizens are ready to build a healthier and more sustainable future starting today.

We look forward to your kind reply.

Best Regards dr. Lorenzo Del Moro Coordinator - Philosophical Scientific Committee SALUS [email protected] mob. + 39 - 3408645417

Federico Palla Technical Coordinator - European SALUS network [email protected] mob. +39 - 3492201254

Milena Simeoni Creator and Project manager of SALUS [email protected]

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mob. +39 - 3283326157

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The following signatory organizations:

Italian no profit organizations

GASoresina

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Italian companies

Other european no profit organizations

Grecia UK Grecia Francia Spagna Germania

Other european companies

Switzerland Europe UK Portugal Spain Portugal

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Romania UK Poland Greece Romania UK

France

The open letter is also signed by the following politicians: Eleonora Evi - MEP - Movimento 5 Stelle ​ Rosa D’Amato - MEP - Movimento 5 Stelle ​ Carmen Di Lauro - italian MP - Movimento 5 Stelle ​

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What is SALUS? The SALUS proposal was born on April 10, 2019, with an international conference held at the European Parliament in Brussels entitled "SALUS, focusing on health promotion" (at the link the registration of the conference). ​ ​ From that experience, a network of organizations was born which today has 30 member bodies in 10 European countries. On 17 December 2019, the SALUS Interest Group was born at the European Parliament in Strasbourg, with the participation of 7 MEPs: Eleonora Evi (NA), Patrizia Toia (S&D), Rosa D'Amato (NA), Mara Bizzotto ( ID), Carlo Fidanza (ECR), Sirpa Pietikainen (EPP) and Tilly Metz (Greens).

Contacts: Dr. Lorenzo Del Moro Coordinator of the Philosophical-Scientific Committee SALUS [email protected] mobs. +39 - 3408645417

Federico Palla Technical Coordinator - SALUS European Network [email protected] mobs. +39 - 3492201254

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Bibliographic references: [1] Position Paper SALUS 2.0 [2] Levine, ME, Suarez, JA, Brandhorst, S., Balasubramanian, P., Cheng, CW, Madia, F., ... Longo, VD (2014). Low protein intake is associated with a major reduction in IGF ‐ 1, cancer, and overall mortality in the 65 and younger but not older population. Cell Metabolism, 19 (3), 407–417. [3] C Kralj et al. Healthy aging A systematic review of risk factors. Department of Health Service & Population Research. King's Global Health Institute Reports Research Report 2018 No. 1. [4] Francisco José Tarazona-Santabalbina et al. J Am Med Dir Assoc. 2016 May 1; 17 (5): 426-33. [5] Tze Pin Ng et al. Am J Med. 2015 Nov; 128 (11): 1225-1236.e1. ​ ​ [6] https://www.epicentro.iss.it/coronavirus/bollettino/Report-COVID-2019_20_aprile.pdf ​ [7] https://www.quotidianosanita.it/lavoro-e-professioni/article.php?article_id=84153 ​ [8] Erkki Vartiainen. The North Karelia Project: Cardiovascular disease prevention in Finland. Glob Cardiol Sci Pract. 2018 Jun 30; 2018 (2): 13. [9] Pekka Puska. Successful prevention of non-communicable diseases: 25 year experiences with North Karelia Project in Finland. Public Health Medicine 2002; 4 (1): 5-7 [10] Pedro F. Saint-Maurice et al. JAMA Netw Open. , 2019; 2 (3): e190355. [11] Chubak J. Am J Med 2006; 119: 937. [12] https://www.nature.com/articles/d41586-020-01115-z. ​ ​ [13] Lawrence A. David et al. Nature. 2014 Jan 23; 505 (7484): 559–563. [14] R. Estruch, E. Ros, J. Salas-Salvadó, M.-I. Covas, D. Corella, F. Arós, et al., "Primary Prevention of Cardiovascular Disease with a Mediterranean Diet," New England Journal of Medicine 368 (2013): 1279–90. [15] https://www.wcrf.org/dietandcancer ​ [16] THE LANCET COMMISSIONS. Food in the Anthropocene: the EAT – Lancet Commission on healthy diets from sustainable food systems. VOLUME 393, ISSUE 10170, P447-492, FEBRUARY 02,2019. [17] www.simaonlus.it/wpsima/wp-content/uploads/2020/03/COVID19_Position-Paper_Relazione-cir-l %E2%80%99effetto-dell%E2%80%99 pollution-da-particolato-atmosferico-e -the-spread-of-the-virus-popolazione.pdf [18] https://repo.epiprev.it/index.php/2020/04/17/atmospheric-pollution-and-epidemic-covid-19-the- position-of-the-network-italian-environment-and-health [19] Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. Published online February 7, 2020.

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[20] https://repo.epiprev.it/index.php/2020/04/02/potential-effects-of-airborne-particulate-matter-o n-spreading-pathophysiology-and- prognosis-of-a-viral-respiratory-infection / [21] https://repo.epiprev.it/index.php/2020/04/17/evaluation-of-possible-relationship-in-atmospheric -pollution-and-diffusion-of-sars-cov-2 / [22] Wu X et al. Exposure to air pollution and COVID-19 mortality in the United States. April 5, 2020, preprint. [23] https://www.legambiente.it/wp-content/uploads/2020/01/Malaria-di-citta-2020.pdf ​

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