Disparities in access to COVID-19 vaccine in Verona, Italy: a cohort study using local health immunization data

Introduction

Migrant populations worldwide were disproportionately impacted by the COVID-19 pandemic. Although substantial resources have been invested in scaling COVID-19 vaccination campaigns, globally vaccine rate and uptake remained low among migrants from across many countries. This study aimed to explore the country of birth as a factor influencing access to the COVID-19 vaccine.

Methods

This retrospective cohort study included adults vaccinated against SARS-CoV-2 receiving at least one dose in the Verona province between 27 December 2020 and 31 December 2021. Time-to-vaccination was estimated as the difference between the actual date of each person's first dose of COVID-19 vaccination and the date in which the local health authorities opened vaccination reservations for the corresponding age group. The birth country was classified based on both the World Health Organization regions and the World Bank country-level economic classification. Results were reported as the average marginal effect (AME) with corresponding 0.95 confidence intervals (CI).

Results

During the study period, 7,54,004 first doses were administered and 5,06,734 (F = 2,46,399, 48.6%) were included after applying the exclusion criteria, with a mean age of 51.2 years (SD 19.4). Migrants were 85,989 (17.0%, F = 40,277, 46.8%), with a mean age of 42.4 years (SD 13.3). The mean time-to-vaccination for the whole sample was 46.9 days (SD 45.9), 41.8 days (SD 43.5) in the Italian population, and 71.6 days (SD 49.1) in the migrant one (p < 0.001). The AME of the time-to-vaccination compared to the Italian population was higher by 27.6 [0.95 CI 25.4-29.8], 24.5 [0.95 CI 24.0-24.9], 30.5 [0.95 CI 30.1-31.0] and 7.3 [0.95 CI 6.2-8.3] days for migrants from low-, low-middle-, upper-middle- and high-income countries, respectively. Considering the WHO region, the AME of the time-to-vaccination compared to the Italian group was higher by 31.5 [0.95 CI 30.6-32.5], 31.1 [0.95 CI 30.6-31.5], and 29.2 [0.95 CI 28.5-29.9] days for migrants from African, European, and East-Mediterranean regions, respectively. Overall, time-to-vaccination decreased with increasing age (p < 0.001). Although both migrants and Italians mainly used hub centers (>90%), migrants also used pharmacies and local health units as alternative sites (2.9% and 1.5%, respectively), while Italians (3.3%) and migrants from the European region (4.2%) relied more on family doctors.

Conclusion

The birth country of migrants influenced access to COVID-19 vaccine both in terms of time-to-vaccination and vaccination points used, especially for the LIC migrant group. Public health authorities should take socio-cultural and economic factors into consideration for tailored communication to people from migrant communities and for planning a mass vaccination campaign.

Inequality in access to COVID-19 vaccines: an annual experience in Verona (Italy)

 

COVID-19 vaccination campaigns involved massive resources worldwide. However, the disparity in vaccine accessibility is a global issue. The study evaluated whether birthplace is a barrier to healthcare access in a high-income country (HIC). The retrospective cohort study included fully vaccinated adults in the Verona district between 27/12/2020 and 31/12/2021. In Italy, the vaccination was opened at different times according to the risk category. Two multiple linear regression models explored the relationship between (1) days before getting the first shot (IV) and (2) the distance between the municipality of residence and the vaccination point, and age, sex, and Income Group (IG, as defined by the World Bank). Distance (km) was estimated with Q-GIS. Results are reported as Marginal Effect at the Mean (MEM) with a confidence interval of 0.95. 500,001 first doses were included, with a mean age of 47 years (SD = 21) and a mean IV of 47.5 days. 6% of the sample was UpperMiddle (UMIC), 6% Lower-Middle (LMIC), and 0.3% Low-Income Countries (LIC). The mean age was higher for HIC (p < 0.05). Male outnumbered females in LMIC (61%) and LIC (69%), but not in HIC and UMIC (p < 0.001). LMIC and LIC were vaccinated at local facilities (5.8%) and pharmacies (4.2%) more than other groups (3%) and at hub centers less (p < 0.05). The IV was lower for subjects from HIC (p < 0.05) with a MEM of 24 [22; 26] for LIC, 21 [21; 22] for LMIC and 27 [26; 27] for UMIC. Men from UMIC (9 [4; 14]), LMIC (7 [6; 8]) and LIC (4 [3; 5]) had a higher IV than women. All variables being equal, IV decreased with age (MEM -0.48 [-0.49; -0.47]). Distance was shorter for LMIC and LIC than for HIC (p < 0.05). The MEM on the distance of the Income group was -2.8 [-3.5; -2.2] for LIC and -2.0 [-2.1; -1.8] for LMIC (p < 0.05). The Income Group of one’s birth country is a barrier to vaccine accessibility in Italy, a HIC. Hence, we address public health workers to improve access to vaccination in community settings to narrow this gap.

Key messages

• Birthplace Income Group could be linked to vaccine accessibility in High Income Countries.

• Public Health stakeholders should consider community and social barriers to healthcare access when planning health interventions.

Screening for hepatitis B virus infection among refugees diagnosed with latent tuberculosis in an Italian community

Background

Refugees are a growing population in the EU-27 area with specific health needs that are to be addressed in the most rapid and effective way at their arrival in the host country. Screening for Hepatitis B Virus infection is offered to specific categories and it could be useful and effective to extend its indications. The aim of this study was to define the epidemiological profile regarding Hepatitis B Virus infection in re-fugees hosted in the Asylum Seekers Centers of Verona (Italy), diagnosed with latent tuberculosis infection and eligible for chemoprophylaxis.

Methods

We conducted a retrospective study in 715 refugees diagnosed with latent tuberculosis infection from January 1st, 2015 to December 31st, 2017. Screening for Hepatitis B Virus infection was offered to la-tent tuberculosis infection patients who were due to commence treatment. Subjects were tested for Hepatitis B surface Antigen and Hepatitis B core antigen total antibodies. None of the screened patients reported previous vaccination for hepatitis B.

Results

Among the 715 refugees diagnosed with latent tuberculosis infection, 593 were eligible for treatment for latent tuberculosis infection. Of these, 211 (35.6%) accepted to be screened for Hepatitis B Virus infection. One hundred and ninety-five of the 211 (92.4%) came from African countries, and 16 (7.6%) from Asia; the majority (80.9%) were males. Median age was 23 years (95% CI 22-24). Of the 211, 58 individuals (27.5%) were Hepatitis B surface Antigen and Hepatitis B core antigen total antibodies positive; 74 (35.1%) were Hepatitis B surface Antigen negative and Hepatitis B core antigen total antibodies positive; and 79 (37.4%) were Hepatitis B surface Antigen and Hepatitis B core antigen total antibodies negative. Male gender and African origin were associated with a lower probability of being Hepatitis B surface Antigen- and Hepatitis B core antigen total antibodies-negative.

Conclusions

Screening for Hepatitis B Virus is of paramount importance not only for the control and prevention of infection, but also in terms of long-term healthcare issues. Making screening more systematic can have an important impact on public health, while always considering cost-effectiveness and promotion of awareness among ethnic groups in order to gain their compliance to treatment/vaccination.

Active TB screening among homeless people attending soup kitchens in Verona (Italy)

Background

The hard-to-reach populations, including the homeless, are particularly vulnerable to the development of active tuberculosis. According to the World Health Organization, tuberculosis rates among the homeless in industrialized Countries are up to 20 times higher if compared with the general popula-tion, representing a relevant public health problem. The aim of our study was to describe the results of an active tuberculosis screening applied in order to find out suspected active TB cases among the homeless in Verona.

Methods

As part of a partnership between the non-profit association Medici per la Pace and one of the Local Health Units of Veneto Region (ULSS 9 Scaligera) in 2018, a tuberculosis screening, based on thoracic radiographs, was offered to the homeless guests of two Verona's soup kitchens.

Results

The studied population included 139 people, and three cases of suspected active tuberculosis, all in males, were observed. Among these, two received a diagnostic confirmation of active tuberculosis (a prevalence of 1.44% - CI: 0,17 - 5,1). Moreover, radiographic patterns of tuberculosis aftermaths were found in six additional subjects.

Conclusions

Interventions specifically dedicated to hard-to-reach populations, can be useful in identifying tuberculosis active cases and controlling the disease in low tuberculosis burden countries. In particular, the active research of subjects, the screening carried out with mobile X-ray, and also the constant caring of the patients with active disease, could be the right method to keep under control this relevant public health problem.

Extended screening for infectious diseases among newly-arrived asylum seekers from Africa and Asia, Verona province, Italy, April 2014 to June 2015

Management of health issues presented by newly-arrived migrants is often limited to communicable diseases even though other health issues may be more prevalent. We report the results of infectious disease screening proposed to 462 recently-arrived asylum seekers over 14 years of age in Verona province between April 2014 and June 2015. Methods: Screening for latent tuberculosis (TB) was performed via tuberculin skin test (TST) and/or QuantiFERON-TB Gold in-tube assay and/or chest X-ray. An ELISA was used to screen for syphilis. Stool microscopy was used to screen for helminthic infections, and serology was also used for strongyloidiasis and schistosomiasis. Screening for the latter also included urine filtration and microscopy. Results: Most individuals came from sub-Saharan Africa (77.5%), with others coming from Asia (21.0%) and North Africa (1.5%). The prevalence of viral diseases/markers of human immunodeficiency virus (HIV) infection was 1.3%, HCV infection was 0.85% and hepatitis B virus surface antigen was 11.6%. Serological tests for syphilis were positive in 3.7% of individuals. Of 125 individuals screened for TB via the TST, 44.8% were positive and of 118 screened via the assay, 44.0% were positive. Of 458 individuals tested for strongyloidiasis, 91 (19.9%) were positive, and 76 of 358 (21.2%) individuals from sub-Saharan Africa were positive for schistosomiasis. Conclusions: The screening of viral diseases is questionable because of low prevalence and/or long-term, expensive treatments. For opposing reasons, helminthic infections are probably worth to be targeted by screening strategies in asylum seekers of selected countries of origin.

Profile of Trypanosoma cruzi infection in a tropical medicine reference center, Northern Italy

BACKGROUND

Chagas disease (CD) is endemic in Central and South America, Mexico and even in some areas of the United States. However, cases have been increasingly recorded also in non-endemic countries. The estimated number of infected people in Europe is in a wide range of 14000 to 181000 subjects, mostly resident in Spain, Italy and the United Kingdom.

METHODOLOGY/PRINCIPAL FINDINGS

Retrospective, observational study describing the characteristics of patients with CD who attended the Centre for Tropical Diseases (Negrar, Verona, Italy) between 2005 and 2013. All the patients affected by CD underwent chest X-ray, ECG, echocardiography, barium X-ray of the oesophagus and colonic enema. They were classified in the indeterminate, cardiac, digestive or mixed category according to the results of the screening tests. Treatment with benznidazole (or nifurtimox in case of intolerance to the first line therapy) was offered to all patients, excluding the ones with advanced cardiomiopathy, pregnant and lactating women. Patients included were 332 (73.9% women). We classified 68.1% of patients as having Indeterminate Chagas, 11.1% Cardiac Chagas, 18.7% as Digestive Chagas and 2.1% as Mixed Form. Three hundred and twenty-one patients (96.7%) were treated with benznidazole, and most of them (83.2%) completed the treatment. At least one adverse effect was reported by 27.7% of patients, but they were mostly mild. Only a couple of patients received nifurtimox as second line treatment.

CONCLUSIONS/SIGNIFICANCE

Our case series represents the largest cohort of T. cruzi infected patients diagnosed and treated in Italy. An improvement of the access to diagnosis and cure is still needed, considering that about 9200 infected people are estimated to live in Italy. In general, there is an urgent need of common guidelines to better classify and manage patients with CD in non-endemic countries.

Epilepsy triggered by mefloquine in an adult traveler to Uganda

We report a case of a traveler who visited Uganda for 8 d, and took mefloquine one tablet/week for malaria prophylaxis. After the second dose, he suffered from two episodes of loss of consciousness with seizures, therefore mefloquine was discontinued. During the flight back after full recovery, seizures reoccurred while he was on board, he was disembarked in Addis Ababa and then transferred to Nairobi. After repatriation to Italy, he experienced four other similar episodes. The patient was still on full dose anticonvulsant therapy one year and a half after, as any attempt at reduced dose was unsuccessful. Currently, three agents (mefloquine, atovaquone/proguanil, and doxycycline) are recommended for malaria chemoprophylaxis, with similar efficacy but different adverse event profiles, regimens, and prices. Considering that mefloquine is associated with a higher risk of neurologic and psychiatric adverse events than the alternative regimens, we suggest considering mefloquine as a second line choice after atovaquone/proguanil and doxycycline for short-term travelers.

Coccidioidomycosis: first imported case in Italy

We report a case of pulmonary coccidioidomycosis imported from the United States to Italy. This disease should enter in the differential diagnosis of any febrile patient (especially if presenting with pulmonary symptoms, with or without hypereosinophilia) coming from Coccidioides immitis endemic areas.

[The 3rd national workshop on defecography: the functional radiology of (neo) rectal ampullae (ileal reservoir, colo-anal anastomosis, continent perineal colostomy)]

A survey was made in 13 Italian centers with a questionnaire concerning the (a) indications, (b) postoperative complications, (c) functional results and (d) diagnostic imaging modalities related to the making of an ileal or colonic (neo) rectum. Ulcerative colitis (100%), familial polyposis (61.5%) and Crohn's disease (15.3%) were the most common indications for an ileal pouch; rectal cancer (7.96%), chronic inflammatory diseases (15.3%), diverticulosis, rectal prolapse, redundant colon and imperforate anus (7.6% each) were the most common indications for a colonic pouch. Postoperative complications included pelvic abscess (14%), sinus tract/dehiscence (10%) and bowel obstruction (9%). When compared with the S and W variants, the J-shaped ileoanal pouch proved superior because urgency and fecal retention rates were lower (18.4% vs. 44.4% and 23% vs. 28.6%, p < 0.01 and p < 0.05, respectively), despite slightly more frequent staining episodes (15.8% vs. 11.1%; p < 0.05). As for colonic ampullae, fecal retention and provoked evacuation were more frequent in the J pouch and after gracileplasty; urgency and incontinence in the straight colo-anal anastomosis (33.3% vs. 22.2% and 41.6% vs. 33.3%, respectively). The functional outcome was assessed by anal endosonography (available in 4/13 centers), defecography and anorectal manometry. Abnormal findings included: (a) reduced capacity, barium leakage, anal gaping, sphincter damage (urgency and incontinence); (b) barium retention, pouch dilatation, split evacuation, knobs and strictures (fecal retention).

[Diseases detected with defecographic examination in 300 patients]

Defecography is a radiological examination providing morphological details of the anorectal tract. Over almost 3 years, 300 patients were examined. The authors report on the method and the pathologic conditions they observed. The patients were seated in latero-lateral position on a radiolucent water-filled commode: lead marks were taped to define perianal skin. 150 ml of high-density barium paste were introduced into the rectum and radiographs were then acquired, at rest and during squeezing and straining. All examination phases, especially the study of dynamic evacuation, were recorded on a videotape connected to a brilliance intensifier. From their experience, the authors conclude that defecography is a valuable tool in the diagnosis and evaluation of: rectocele, occult rectal prolapse, and elevator ani tone. The technique proved less useful in the evaluation of fecal incontinence. The authors strongly suggest that the patient be previously examined by a coloproctologist. Defecography is thought to help the surgeon in the choice of therapy, together with other diagnostic procedures and with clinical history.