Rheumatic diseases in migrant patients resident in Tuscany: epidemiological data analysis and single-center experience

OBJECTIVE

In the last decades, the number of foreigners in Tuscany has considerably increased with a multiethnic distribution. We reviewed the main rheumatic diseases in the foreign population resident in Tuscany and also reported the experience at the Rheumatology Division of the University Hospital of Careggi, Florence, in order to identify the areas of origin of these patients and the main rheumatic diseases observed in them.

METHODS

The collaboration with the Tuscan Region provided data about foreign patients residing in Tuscany on January 1, 2021 (country of origin, chronic diseases). Moreover, we conducted a retrospective review of the clinical charts of our Rheumatologic Division from January 1, 2019, to December 31, 2020.

RESULTS

In Tuscany, on January 1, 2021, there were 61,373 patients with chronic inflammatory rheumatic diseases, and 3994 of them (6.51%) were foreigners. Most patients were born in Europe (39.03%), followed by the Balkans (15%), South America (11.27%), and North Africa (10.31%). Inflammatory joint diseases, Sjögren syndrome, and systemic lupus erythematosus were the most frequent diseases. In the period 2019-2020, 511 foreign patients visited our Rheumatology Division and mainly originated from the Balkans (34.64%), South America (18%), and European countries (16.44%). In these patients, chronic inflammatory joint diseases and connective tissue diseases (systemic sclerosis, Sjögren syndrome, and systemic lupus erythematosus) were the most prevalent diseases.

CONCLUSIONS

This study provides a picture of the rheumatic diseases affecting foreign patients residing in Tuscany that are in agreement with the epidemiological data previously provided.

Prevalence and features of SARS-CoV-2 infection in prisons in Tuscany

BACKGROUND

Prisons can be a reservoir for infectious diseases, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), due to the very intimate nature of the living spaces and the large number of people forced to share them.

AIM

To investigate the SARS-CoV-2 epidemiology in prisons, this study evaluated the infection incidence rate in prisoners who underwent nasopharyngeal swabs.

METHODS

This is an observational cohort study. Data collection included information on prisoners who underwent nasopharyngeal swab testing for SARS-CoV-2 and the results. Nasopharyngeal swab tests for SARS-CoV-2 were performed between 15 February 2021 and 31 May 2021 for prisoners with symptoms and all new arrivals to the facility. Another section included information on the diagnosis of the disease according to the International Classification of Diseases, Ninth Revision, and Clinical Modification.

RESULTS

Up until the 31 May 2021, 79.2% of the prisoner cohort (n = 1744) agreed to a nasopharyngeal swab test (n = 1381). Of these, 1288 were negative (93.3%) and 85 were positive (6.2%). A significant association [relative risk (RR)] was found only for the risk of SARS-CoV-2 infection among foreigners compared to Italians [RR = 2.4, 95% confidence interval (CI): 1.2-4.8]. A positive association with SARS-CoV-2 infection was also found for inmates with at least one nervous system disorder (RR = 4, 95%CI: 1.8-9.1). The SARS-CoV-2 incidence rate among prisoners is significantly lower than in the general population in Tuscany (standardized incidence ratio 0.7, 95%CI: 0.6-0.9).

CONCLUSION

In the prisoner cohort, screening and rapid access to health care for the immigrant population were critical to limiting virus transmission and subsequent morbidity and mortality in this vulnerable population.

Exposure to low levels of hydrogen sulphide and its impact on chronic obstructive pulmonary disease and lung function in the geothermal area of Mt. Amiata in Italy: The cross-sectional InVETTA study

BACKGROUND

The geothermal power plants for electricity production currently active in Italy are all located in Mt. Amiata area in the Tuscany region. A cross-sectional survey was conducted in the framework of the regional project "InVETTA-Biomonitoring Survey and Epidemiological Evaluations for the Protection of Health in the Amiata Territories", using objective measures of lung function to investigate the role of hydrogen sulphide (H2S) in affecting the respiratory health of the population living in this area.

METHODS

2018 adults aged 18-70 were enrolled during 2017-2019. Home and workplace addresses of participants were geocoded. Dispersion modelling was used to evaluate the spatial variability of exposure to H2S from the geothermal power plants' emissions. We estimated average long-term historical exposure to H2S and more recent exposure indicators. Chronic Obstructive Pulmonary Disease (COPD) was defined according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Multivariable logistic regressions were performed to investigate associations between outcome and exposure.

RESULTS

Our findings did not showed any evidence of an association between increasing H2S exposure and lung function impairments. Some risk reductions were observed: a -32.8% (p = 0.003) for FEV1<80% and a -51.7% (p = 0.001) risk decrease for FVC<80% were associated with interquartile increase (13.8 μg/m3) of H2S levels.

CONCLUSION

Our study provides no evidence that chronic exposure to low levels of H2S is associated with decrements in pulmonary function, suggesting that ambient H2S exposure may benefit lung function.

Mental Health of Children and Adolescents before and during the COVID-19 Pandemic: How Did the Lockdown Modify Psychiatric Emergencies in Tuscany, Italy?

The COVID-19 pandemic has deeply impacted several aspects of the lives of children and adolescents. We analyzed the trends of psychiatric disorders in the emergency room. The analysis comprised the pre-pandemic (2018-2019) and the pandemic years (2020-2021). We conducted a retrospective observational epidemiological study that compared admissions during the two periods on a sample of 1311 patients aged between 4 and 18, focusing on new admissions vs. relapse, demographic variables, lockdown severity, presentation of psychiatric symptoms, diagnosis, severity, and outcome. Over the two-year pandemic period, we observed a 33% decrease in admissions to the emergency room for non-psychiatric disorders and a 200% increase in admissions for psychiatric emergencies. This increase is concentrated in periods with fewer restrictions and in the second year of the pandemic. We also observed a greater impact of psychiatric disorders on female patients, a greater severity of psychiatric disorders, a change in diagnoses associated with the presentation of symptoms, and an increase in hospitalizations. The children's psychiatric emergency service faced an "emergency within the emergency". In the future, it will be necessary to continue the follow-up of these patients, strengthen the field of study of gender psychiatry, and intensify our efforts towards prevention.

Levels and determinants of urinary and blood metals in the geothermal area of Mt. Amiata in Tuscany (Italy)

Natural sources and anthropogenic activities are responsible for the widespread presence of heavy metals in the environment in the volcanic and geothermal area of Mt. Amiata (Tuscany, Italy). This study evaluates the extent of the population exposure to metals and describes the major individual and environmental determinants. A human biomonitoring survey was carried out to determine the concentrations of arsenic (As), mercury (Hg), thallium (Tl), antimony (Sb), cadmium (Cd), nickel (Ni), chromium (Cr), cobalt (Co), vanadium (V), and manganese (Mn). The associations between socio-demographics, lifestyle, diet, environmental exposure, and metal concentrations were evaluated using multiple log-linear regression models, adjusted for urinary creatinine. A total of 2034 urine and blood samples were collected. Adjusted geometric averages were higher in women (except for blood Hg) and younger subjects (except for Tl and Cd). Smoking was associated with Cd, As, and V. Some dietary habits (rice, fish, and wine consumption) were associated with As, Hg, Co, and Ni. Amalgam dental fillings and contact lenses were associated with Hg levels, piercing with As, Co, and Ni. Among environmental determinants, urinary As levels were higher in subjects using the aqueduct water for drinking/cooking. The consumption of locally grown fruits and vegetables was associated with Hg, Tl, and Co. Exposure to geothermal plant emissions was associated only with Tl.

Case-Control Study on the Routes of Transmission of SARS-CoV-2 after the Third Pandemic Wave in Tuscany, Central Italy

The emergence of hyper-transmissible SARS-CoV-2 variants that rapidly became prevalent throughout the world in 2022 made it clear that extensive vaccination campaigns cannot represent the sole measure to stop COVID-19. However, the effectiveness of control and mitigation strategies, such as the closure of non-essential businesses and services, is debated. To assess the individual behaviours mostly associated with SARS-CoV-2 infection, a questionnaire-based case-control study was carried out in Tuscany, Central Italy, from May to October 2021. At the testing sites, individuals were invited to answer an online questionnaire after being notified regarding the test result. The questionnaire collected information about test result, general characteristics of the respondents, and behaviours and places attended in the week prior to the test/symptoms onset. We analysed 440 questionnaires. Behavioural differences between positive and negative subjects were assessed through logistic regression models, adjusting for a fixed set of confounders. A ridge regression model was also specified. Attending nightclubs, open-air bars or restaurants and crowded clubs, outdoor sporting events, crowded public transportation, and working in healthcare were associated with an increased infection risk. A negative association with infection, besides face mask use, was observed for attending open-air shows and sporting events in indoor spaces, visiting and hosting friends, attending courses in indoor spaces, performing sport activities (both indoor and outdoor), attending private parties, religious ceremonies, libraries, and indoor restaurants. These results might suggest that during the study period people maintained a particularly responsible and prudent approach when engaging in everyday activities to avoid spreading the virus.

Long-term exposure to low-level arsenic in drinking water is associated with cause-specific mortality and hospitalization in the Mt. Amiata area (Tuscany, Italy)

BACKGROUND

Arsenic in drinking water is a global public health concern. This study aims to investigate the association between chronic low-level exposure to arsenic in drinking water and health outcomes in the volcanic area of Mt. Amiata in Italy, using a residential cohort study design.

METHODS

Chronic exposure to arsenic in drinking water was evaluated using monitoring data collected by the water supplier. A time-weighted average arsenic exposure was estimated for the period 2005-2010. The population-based cohort included people living in five municipalities in the Mt. Amiata area between 01/01/1998 and 31/12/2019. Residence addresses were georeferenced and each subject was matched with arsenic exposure and socio-economic status. Mortality and hospital discharge data were selected from administrative health databases. Cox proportional hazard models were used to test the associations between arsenic exposure and outcomes, with age as the temporal axis and adjusting for gender, socio-economic status and calendar period.

RESULTS

The residential cohort was composed of 30,910 subjects for a total of 407,213 person-years. Analyses reported risk increases associated with exposure to arsenic concentrations in drinking water > 10 µg/l for non-accidental mortality (HR = 1.07 95%CI:1.01-1.13) and malignant neoplasms in women (HR = 1.14 95%CI:0.97-1.35). Long-term exposure to arsenic concentrations > 10 µg/l resulted positively associated with several hospitalization outcomes: non-accidental causes (HR = 1.06 95%CI:1.03-1.09), malignant neoplasms (HR = 1.10 95%CI:1.02-1.19), lung cancer (HR = 1.85 95%CI:1.14-3.02) and breast cancer (HR = 1.23 95%CI:0.99-1.51), endocrine disorders (HR = 1.13 95%CI:1.02-1.26), cardiovascular (HR = 1.12 95%CI:1.06-1.18) and respiratory diseases (HR = 1.10 95%CI:1.03-1.18). Some risk excesses were also observed for an exposure to arsenic levels below the regulatory standard, with evidence of exposure-related trends.

CONCLUSIONS

Our population-based cohort study in the volcanic area of Mt. Amiata showed that chronic exposure to arsenic concentrations in drinking water above the current regulatory limit was associated with a plurality of outcomes, in terms of both mortality and hospitalization. Moreover, some signs of associations emerge even at very low levels of exposure, ​​below the current regulatory limit, highlighting the need to monitor arsenic concentrations continuously and implement policies to reduce concentrations in the environment as far as possible.

Prevalence study of mental disorders in an Italian region. Preliminary report

BACKGROUND

Mental disorders are a major public health problem. However, over the last few years, there have been few studies aimed at evaluating their diffusion. Therefore, this study aimed at evaluating: the prevalence of the most frequent psychiatric disorders in the general population residing in Tuscany using a clinical scale administered by trainee in psychiatry.

METHODS

The study was carried out on a representative sample of the general population aged > 18 years, randomly extracted from the register of patients in the Tuscany region, adopting a proportional sampling method stratified by gender, age group and Local Health Units (LHU). Each person was contacted by letter followed by a phone call from an operator who makes an appointment with the trainee in psychiatry. The diagnostic interview conducted was the Mini-International Neuropsychiatric Interview (MINI). Point and lifetime prevalence by gender and age group were calculated. Differences and associations were considered statistically significant if their p-values were less than 0.05.

RESULTS

Of the 408 people involved, 390 people were enrolled (of which 52.6% female). The 28.5% of the sample had been affected by a psychiatric disorder during their lifetime. In their lifetime, the most represented psychiatric disorders were major depressive episode (20.4%), major depressive disorder (17.0%) and panic disorder (10.3%), more frequent in the female than the male group. Current conditions were predominantly major depressive episode (3.1%) and agoraphobia (2.8%). A 5.9% rate of current suicidal ideation was also found.

CONCLUSIONS

In the general population, 28.5% of people reported a psychiatric disorder during their lifetime. This prevalence is considerably higher than that reported in a previous study carried out in central Italy.

Foreigners living in Tuscany at the time of coronavirus outbreak

Background

During the coronavirus outbreak, a worldwide state of emergency and lockdown significantly affected the volunteer services for foreigners. The SARS-CoV-2 surveillance program was strengthened among migrants arriving in Italy. However, few screening measures for SARS-CoV2 infection have been conducted on the foreign population already present in Italy. In Tuscany, a great effort was made to know the epidemiological features of coronavirus outbreaks in the foreigners. Based on these premises, this study describes the prevalence and characteristics of SARS-CoV-2 infection in foreigners present in the Tuscan territory during the months of the highest incidence of this pandemic.

Methods

Ministry of Health established the COVID-19 surveillance and predisposed the methods for reporting cases of SARS-CoV-2 infection in agreement with the Department of Infectious Diseases of the Istituto Superiore di Sanità. Data on SARS-CoV-2, updated daily, were collected based on the platform of the Istituto Superiore di Sanità.For each patient were available data on diagnosis, gender, age, nationality, exposure place, hospitalization and symptoms severity. Symptoms severity was classified using a 6-level scale (asymptomatic, paucisymptomatic, mild symptoms, severe symptoms, critic, and died).

Results

By July 14, 2020, 10,090 SARS-CoV-2 cases were recorded. Out of 10,090 cases, 8,947 were Italians (88.7%), 608 foreigners (6%); in 535 patients (5.3%) citizenship was missing. The average age of foreigners was 44.1 years (range: 42.9-45.4), compared to 61.1 years (range: 60.7-61.5) of Italians. Chronic pathologies affected 16.8% of foreigners (14.0% -20.0%) and 36.4% of Italians (35.4% -37.4%). Foreigners with asymptomatic or mild symptoms of COVID-19 were 81.7% (78.4% -84.6%), while the Italians were 67% (66.6% -68.5%). Foreigners with severe COVID-19 were 15.2% (12.6% -18.4%) and Italians were 17.6% (16.8% -18.4%). Foreigners in critical conditions were 1.0% (0.5% -2.2%) and Italians were 2.6% (2.3% -3.0%). 38.6% (33.7% -43.7%) of foreigners were infected at the workplace as a health or social-health worker, compared to 24.2% (23.1% -25.4%) of Italians.

Conclusion

The time between the onset of symptoms and the execution of the laboratory tests was similar between foreigners and Italians. The foreigners infected by SARS-COV-2 were younger compared to the Italians. Foreigners showed few comorbidities, and asymptomatic or mild symptomatic COVID-19, and consequently, a low lethality index. National and Tuscany policy decisions are needed to create equity in the access to the health care system for immigrants and their families, regardless of their immigration status.

Community Concern about the Health Effects of Pollutants: Risk Perception in an Italian Geothermal Area

Geothermal fluids for electricity and heat production have long been exploited in the Mt. Amiata area (Tuscany, Italy). Public concern about the health impact of geothermal plants has been present from the outset. Several factors influence the way people perceive risk; therefore, the objective of the present research is to develop indicators of risk perception and assess indices differences in relation to some questionnaire variables. A cross-sectional survey was conducted in the Amiata area on 2029 subjects aged 18-77. From the questionnaire section about risk perception from environmental hazards, four indicators were developed and analysed. A total of 64% of the subjects considered the environmental situation to be acceptable or excellent, 32% serious but reversible, and 4% serious and irreversible; as the values of the various perception indicators increased, an upward trend was observed in the averages. Risk perception was higher among women and young people, and was associated with higher education. Those who smelled bad odours in their surroundings reported higher risk perception. Furthermore, risk perception was higher in four municipalities. The results represent the basis for further investigations to analyse the link among risk perception indicators, exposure parameters, and health status.

Predictors of delayed vaccination in infants born in Tuscany, Italy: an area based cohort study

Background

Timely vaccination is essential to protect infants from vaccine-preventable diseases. The aim of the study was to evaluate the determinants of vaccination timeliness for hexavalent (HEXA) and measles-mumps-rubella (MMR) vaccines.

Methods

The study is part of the PREHMO project funded by Tuscany Region, Italy. Data on the 2017 and 2018 full birth cohorts of Tuscany (N = 41,493) were retrieved from the Birth Registry and linked to those of the Vaccine Registry up to 24 months after birth. Sociodemographic and at birth characteristics of mothers and infants were retrieved. The primary outcome was the timeliness of HEXA 1st and 3rd doses, and MMR 1st dose. Timeliness was defined as the administration of the dose a day after the period recommended by the vaccination schedule. Multiple logistic regression models were performed.

Results

For all the vaccines considered, a significantly increased risk of delayed vaccination was observed in preterm infants and in infants born in hospital of second level of newborn care, while infants conceived by assisted reproductive technologies and first-born infants showed a significantly decreased risk for delayed vaccination. Multiple births, small for gestational age status, maternal unemployment, and rural residence were significantly associated with an increased risk of delayed HEXA-1 vaccination (OR 1.31, 95%CI 1.13-1.51; OR 1.12, 95%CI 1.03-1.22; OR 1.06, 95%CI 1.01-1.13; and OR 1.1, 95%CI 1.03-1.16). As for MMR vaccination, a low maternal education was significantly associated with high risk of delay (OR 1.12, 95%CI 1.06-1.18), while rural residence, maternal foreign nationality and female sex were significantly associated with a decreased risk of delay (OR 0.91, 95%CI 0.87-0.96; OR 0.82, 95%CI 0.78-0.87; and OR 0.95, 95%CI 0.91-0.99).

Conclusions

Several common and vaccine-specific predictors of vaccination timeliness were identified. Strategies to improve a timely vaccination should take into account these predictors.

Key messages

• Several maternal and infants factors may influence vaccination timeliness of routine immunization in childhood.

• Tailored vaccination strategies are needed to improve vaccination timeliness in infants at high-risk of delayed vaccination.

Trends of risk behaviors in adolescents: a 10-year study in a representative sample of Tuscany, Italy

Background

The aim of the study was to evaluate the trends of prevalence of several health risk behaviors (HRBs) and health conditions over a 10-years period in a representative sample of adolescents of Tuscany Region, Italy.

Methods

The study had a repeated cross-sectional design, data from the last four survey waves of EDIT surveillance (2008-2018) were used. EDIT surveillance investigates HRBs in a representative sample of students attending the upper secondary schools of Tuscany. Prevalence of 17 HRBs and health conditions were considered and analyzed by age, sex, and socioeconomic status (SES).

Results

A total of 21.943 students were surveyed from 2008 to 2018. Declining trends in the participation in smoking, cocaine use, driving under the influence of alcohol and drugs, and problem gambling were observed, while alcohol abuse and at-risk sexual behaviors remained unchanged or increased during the study period. During the most recent survey males resulted more frequently involved in most of the HRBs, while females more frequently reported physical inactivity, regular smoking and not using a condom. Female participation in smoking and alcohol abuse behaviors, fruit and vegetables consumption, and bullying worsened over the study period. Smoking, poor dietary habits, physical inactivity, high distress level, and obesity were more frequently observed in low SES students than in high SES students.

Conclusions

In conclusion findings showed various different tendencies in adolescent participation in HRBs over the course of the last decade; concerning trends in at-risk sexual behaviors and alcohol consumption and females’ risk-taking behavior on the rise require careful monitoring and intervention.

Key messages

• Distinct tendencies according to sex, socio-economic condition and specific health risk behavior were observed in adolescent participation in health risk behaviors over the course of the last decade.

• Health promotion and prevention interventions tailored on specific health risk behaviors and population groups are needed.

Early factors associated with risk of developmental coordination disorder in very preterm children: A prospective area-based cohort study in Italy

BACKGROUND

Developmental coordination disorder (DCD) is a motor disorder of unknown aetiology that may have long-term consequences on daily activities, and psychological and physical health. Studies investigating risk factors for DCD have so far provided inconsistent results.

OBJECTIVES

To assess, using a parent-report screening tool, risk of DCD in school-age very preterm children born in Italy, and investigate the associated early biomedical and sociodemographic factors.

METHODS

A prospective area-based cohort (804 children, response rate 73.4%) was assessed at 8-11 years of age in three Italian regions. Perinatal data were abstracted from medical records. DCD risk was measured using the Italian-validated version of the Developmental Coordination Disorder Questionnaire (DCDQ-IT). For this study, children with cognitive deficit (i.e. intelligence quotient <70), cerebral palsy, severe vision and hearing disabilities, and other impairments affecting movement were excluded. A total of 629 children were analysed. We used inverse probability weighting to account for loss to follow-up, and multilevel, multivariable modified Poisson models to obtain adjusted risk ratio (aRR) and 95% confidence interval (CI). Missing values in the covariates were imputed.

RESULTS

195 children (weighted proportion 31.8%, 95% CI 28.2, 35.6) scored positive on the DCDQ-IT, corresponding to the 15th centile of the reference Movement-ABC test. Factors associated with overall DCD risk were male sex (aRR 1.35, 95% CI 1.05, 1.73), intrauterine growth restriction (aRR 1.45, 95% CI 1.14, 1.85), retinopathy of prematurity (aRR 1.62, 95% CI 1.07, 2.45), and older maternal age at delivery (aRR 1.39, 95% CI 1.09, 1.77). Complete maternal milk feeding at discharge from the neonatal unit and higher parental socio-economic status were associated with decreased risk.

CONCLUSIONS

Both biomedical and sociodemographic factors increase DCD risk. These findings can contribute to elucidating the origins of this disorder, and assist in the identification of children at risk for early referral and intervention.

Delayed Start of Routine Vaccination in Preterm and Small-for-Gestational-Age Infants: An Area-Based Cohort Study from the Tuscany Region, Italy

Preterm and small-for-gestational-age (SGA) infants are more susceptible to vaccine-preventable diseases. To evaluate routine vaccination timeliness in these high-risk groups, a full birth cohort of infants (n = 41,502) born in 2017 and 2018 in Tuscany was retrospectively followed up until 24 months of age. Infants were classified by gestational age (GA) and SGA status. The vaccinations included: hexavalent (HEXA), measles-mumps-rubella, varicella, pneumococcal conjugate (PCV), and meningococcal C conjugate. Time-to-event (Kaplan–Meier) analyses were conducted to evaluate the timing of vaccination according to GA; logistic models were performed to evaluate the associations between GA and SGA with vaccination timeliness. Time-to-event analyses show that the rate of delayed vaccine receipt increased with decreasing GA for all the vaccinations, with a less marked gradient in later vaccine doses. Compared to full-term infants, very preterm infants significantly showed an increased odds ratio (OR) for delayed vaccination in all the vaccinations, while moderate/late preterm infants only showed an increased OR for HEXA-1, HEXA-3, PCV-1, and PCV-3. SGA infants had a significantly higher risk of delayed vaccination only for HEXA-1 and PCV-1 compared to non-SGA infants. In conclusion, vaccinations among preterm and SGA infants showed considerable delay. Tailored public health programs to improve vaccination timeliness are required in these high-risk groups.

[The impact of the COVID-19 pandemic on the Italian and foreign population in the various phases: the results of an interregional multicentre project]

OBJECTIVES

to analyze the difference of the SARS-CoV-2 infection impact between Italian and foreigner subjects, evaluating the trend of infections and access to diagnostic tests (molecular or antigenic swabs for the detection of SARS- CoV-2) in the two different populations, inducing the detection of new positive cases in the population.

DESIGN

retrospective population study for the period February 2020-June 2021.

SETTING AND PARTICIPANTS

Italian and foreign resident population on 1st January of the years 2020 and 2021 in the Regions participating to the project: Piedmont, Lombardy, Veneto, Emilia-Romagna (Northern Italy), Tuscany, Lazio (Central Italy), and Sicily (Southern Italy).

MAIN OUTCOME MEASURES

in the two populations, for every week and aggregated by macropandemic period were calculated: • the test rate (people tested on the population); • the swab positivity rate (positive subjects on those who are tested); • the new positives (positive subjects on study population); • the percentage of foreigners among the new positive cases. The ratio of the value of the indicators in the foreign and Italian populations (with 95% confidence interval) was calculated to evaluate the association between nationality (Italian vs not Italian) and outcome. The analyses were conducted at the regional level and at pool level.

RESULTS

the trend of new positives by nationality (Italian vs not Italian) has a similar tendency in the different pandemic waves. However, the incidence of new positives during pandemic waves among foreigners is lower than in Italians, while it tends to increase during intermediate periods. Except for the summer periods, foreigners are less tested than Italians, but the percentage of new positives out of the total of new ones tested is higher among foreigners compared to Italians. The relative weight of new positives among foreigners tends to increase in periods with the greatest risk of inflow of SARS-CoV-2 for foreigners.

CONCLUSIONS

the epidemic trends in the two populations are similar, although foreigners tend to show lower incidence values, probably in part because they are tested less frequently. Furthermore, in foreigners compared to Italians, there is a greater risk of contracting SARS-CoV-2 infection, especially in periods of relaxation of containment Coronavirus measures, reopening of national borders, production and commercial activities.

Trends in Adolescent Health Risk Behaviors and Wellbeing: A 10 Year Observation from the EDIT Surveillance of Tuscany Region, Italy

Background: The aim of this study was to evaluate the trends of prevalence of health risk behaviors (HRBs) and health conditions over a 10 year period (2008-2018) in a representative sample of adolescents of Tuscany Region, Italy. Methods: This was a repeated cross-sectional (four survey waves) study. The prevalence of 17 HRBs and health conditions were analyzed by age, sex, and socioeconomic status (SES). Results: A total of 21,943 students were surveyed. During the study period, decreases in smoking participation, cocaine use, driving under the influence of alcohol and drugs, and problem gambling were observed, while alcohol abuse and at-risk sexual behaviors remained unchanged or increased. Males resulted more frequently involved in most of the HRBs, while females more frequently reported physical inactivity, regular smoking, and not using a condom. Female participation in smoking and alcohol abuse behaviors, fruit and vegetable consumption, and bullying worsened over the study period. Smoking, poor dietary habits, physical inactivity, high distress level, and obesity were more frequently observed in low-SES students than in high-SES students. Conclusions: The findings showed different tendencies in adolescent participation in HRBs over the last decade; concerning trends in at-risk sexual behaviors and alcohol consumption and females' risk-taking behavior on the rise require careful monitoring.

The Prevalence of Several Risky Driving Behaviors and Associated Crash Risk in Adolescent: A Population-Based Study of Tuscany Region

Objectives: To evaluate the prevalence of numerous risky driving behaviors (RDBs) and the associated risk of road traffic accidents (RTA) in a population-based sample of adolescent drivers (14–19 years) of Tuscany, Italy.

Methods: The frequency of participation -by age and sex- often RDBs were investigated: Multivariable analyses were performed to evaluate the association between RDBs and the risk of RTA and severe RTA.

Results: 2,737 adolescents were included in the study. Talking to passenger(s), listening to loud music, speeding, and texting showed the highest weekly participation rates. For all the considered RDBs, the frequency of participation significantly increased with age. Males reported a significantly higher participation in speeding, DUI of alcohol or drugs; while females reported listening to loud music and talking to passenger(s) more frequently. All the considered RDBs were significantly associated with the risk of RTA and severe RTA.

Conclusion: The prevalence of RDBs and the associated risk of RTA largely varied in adolescents. Findings provide evidence for tailoring prevention interventions and suggest the need to include common- but traditionally overlooked- RDBs in road safety campaigns.

Alcohol Addiction: One Entity or Different Entities? A DSM-4-Based Attempt Toward a Geographicization of Alcohol Addiction and Abuse

AIM

To examine whether in Europe perceptions of 'alcoholism' differ in a discrete manner according to geographical area.

METHOD

Secondary analysis of a data set from a European project carried out in 2013-2014 among 1767 patients treated in alcohol addiction units of nine countries/regions across Europe. The experience of all 11 DSM-4 criteria used for diagnosing 'alcohol dependence' and 'alcohol abuse' were assessed in patient interviews. The analysis was performed through Multiple Correspondence Analysis.

RESULTS

The symptoms of 'alcohol dependence' and 'alcohol abuse', posited by DSM-IV, were distributed according to three discrete geographical patterns: a macro-area mainly centered on drinking beer and spirit, a culture traditionally oriented toward wine and a mixed intermediate alcoholic beverage situation.

CONCLUSION

These patterns of perception seem to parallel the diverse drinking cultures of Europe.

SARS-CoV-2 Vaccination and the Bridge between First and Fourth Dose: Where Are We?

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has induced the explosion of vaccine research. Currently, according to the data of the World Health Organization, there are several vaccines in clinical (145) and preclinical (195) stages, while at least 10 are already in clinical phase 4 (post-marketing). Vaccines have proven to be safe, effective, and able to reduce the spread of SARS-CoV-2 infection and its variants, as well as the clinical consequences of the development of coronavirus disease-19 (COVID-19). In the two-dose primary vaccination, different time intervals between the two doses have been used. Recently, special attention has been paid to assessing the immunogenicity following booster administration. The third dose of the vaccine against COVID-19 may be administered at least 8 weeks after the second dose. In Israel, a fourth dose has already been approved in immunocompromised groups. The main objective of this review is to describe the principal results of studies on the effectiveness of first-to-fourth dose vaccination to reduce reinfection by variants and the incidence of severe disease/death caused by COVID-19. Vaccines have shown a high level of protection from symptomatic infection and reinfection by variants after a third dose. Accelerating mass third-dose vaccination could potentially induce immunogenicity against variants.

Risk of Sars-CoV-2 infection and disease severity in people at socioeconomic disadvantage in Italy

Background

Evidence accumulated in the past months indicating that COVID-19 affects people at socioeconomic (SE) disadvantage more strongly. This is embodied by the COVID-19 syndemic concept, i.e., the biological, economic, and social interactions between non-communicable diseases and COVID-19 increase a person's susceptibility to infection and worse health outcomes. Here, we explored the relationship among the SE position and the risk of Sars-CoV-2 infection and disease severity in Tuscany and Apulia, two Italian regions, during the 1st(Feb-Jun2020) and 2nd(Sep-Dec2020) epidemic waves.

Methods

We included all individuals tested (only for Apulia) and/or resulted positive for SARS-CoV2(for Tuscany and Apulia) and reported to regional surveillance system. We linked surveillance data with the deprivation index (DI)(1-5 scale; DI = 5 highest deprivation) of the area of living. We calculated the relative risk (RR) of acquiring Sars-CoV-2, COVID-19-related hospitalization, and death of deprived individuals compared with people in the highest SEP-we adjusted for gender and age.

Results

A total of 159507 (82897 F; 76610 M) individuals with prior or current Sars-CoV-2 infection were included in our study, 71320 from Apulia and 88187 from Tuscany. For people aged over 30, and with a DI &gt; 2, the RR of acquiring the infection increased for individuals with higher DI. The RR of being hospitalized and of death, were significantly higher for people over 30 with DI = 5. In Apulia, test positivity rate was comparable across all population groups during the 1stwave, while it increased among individuals with higher DI during the 2ndwave.

Conclusions

According to our results, SE disadvantage is associated with an increased risk of acquiring Sars-CoV-2, and to suffer from severe outcomes when infected. Based on available data, diagnostic test access was more equitable during 1stepidemic wave. This study calls for targeted health policies and actions to protect those with the greatest SE vulnerability.

Key messages

Available Italian data, indicate that higher socioeconomic disadvantage is associated with an increased risk of acquiring Sars-CoV-2, and to suffer from severe outcomes when infected. Our study highlights the importance of adopting targeted health policies and action to protect those with the greatest socioeconomic vulnerability and enhance equity.

Substance Abuse Disorder and Viral Infections (Hepatitis, HIV): A Multicenter Study in Tuscan Prisons

Aims of this study were to define the prevalence of people with a substance use disorder (SUD) in Tuscan prisons and the relationship of such disorders with chronic viral hepatitis C or B (HCV, HBV) and human immunodeficiency virus (HIV). Of 3,291 adult prisoners, 3,100 were enrolled. Of the 3,100 inmates, 912 (29.4%) had at least one psychiatric disorder, 17.8% had a SUD/alcohol use disorder, 6.1% had adaptation disorder, and 5.5% had personality disorder. Of the drug users, 28.9% had at least one infectious disease such as HCV, HBV, and HIV. The probability of contracting HBV was higher in women than in men and in people over 50 years. The probability of contracting HCV was higher in prisoners aged 40-49, particularly among those who used opioids. Accurate national and global data on SUD and its association with HBV, HCV, and HIV are needed to permit accurate estimation of its impact in these settings.

Thallium Contamination of Drinking Water: Health Implications in a Residential Cohort Study in Tuscany (Italy)

In 2014–2015, concentrations of thallium above the recommended reference value (EPA: 2 µg/L) were measured in some parts of the drinking water distribution system in the municipality of Pietrasanta (Tuscany, Italy). An extensive campaign of water samples and human biomonitoring surveys were implemented to quantify the exposure of population. A residential cohort epidemiological study was carried out on the population of the municipality of Pietrasanta, aimed at comparing the health status of residents in the areas affected by thallium contamination with residents living in the rest of the municipality. Cohort included people residing in the municipality of Pietrasanta from 1 January 2000 to 31 December 2015. Residence addresses were georeferenced and each subject living in one of the three contaminated areas were defined as exposed. Mortality, hospital discharge data and adverse pregnancy outcomes were taken from administrative health databases. Cox proportional hazard models and logistic models were used to test the association between thallium exposure and health outcome. This study did not show any excess of risk in terms of mortality and hospitalization in the population residing in the areas served by thallium-contaminated aqueduct branches, compared to the rest of the not contaminated area. Increased risks for low birth weight (OR = 1.43 95% CI 0.91–2.25) and pre-term birth (OR = 1.40 95% CI 0.82–2.37) were observed. In view of the paucity of epidemiological studies on thallium, this study is an important contribution to the state of knowledge of the health effects of chronic exposures to low concentrations of thallium.

Psychopathological consequences and dysfunctional behaviours during the COVID-19 epidemic in italy: A longitudinal study before and after the lockdown

Introduction

In the first months of 2020 the COVID-19 epidemic spread in Italy, and the Italian government implemented a general lockdown. These events are at high risk for psychiatric symptoms in the general population, including anxiety/depression and post-traumatic stress symptoms (PTSS).

Objectives

To characterize the psychopathological correlates of the spread of COVID-19 and lockdown in a sample of subjects from the Italian population, with a before-after follow-up.

Methods

Six weeks after the lockdown, 671 subjects aged 18-60 years completed the Brief Symptom Inventory and Impact of Event Scale-Revised, for the evaluation of psychopathology and PTSS respectively. Environmental factors and subjectively-perceived deteriorations related to COVID-19 were also investigated. Pre-COVID-19 data on psychopathology, collected in December 2019/January 2020, were available for 130 subjects and were used for longitudinal analyses.

Results

With respect to males, female subjects more frequently reported deteriorations of relations (21.5% vs 10.9%), household arguments (26.0% vs 12.6%), sleep quality (47.6% vs 26.6%), episodes of overeating (22.5% vs 12.5%), worries for oneself (19% vs 8.9%) and for loved ones (55.7% vs 36.5%). These changes were associated with increased psychopathology, PTSS, and numerous environmental conditions, including significant economic damage from COVID-19/lockdown. Longitudinal analyses showed an increase in phobic anxiety in the whole sample, and in depression for female subjects only, following the spread of COVID-19. Pre-existing psychopathology was a significant predictor of PTSS.

Conclusions

COVID-19 epidemic and lockdown have a high impact on psychopathology and PTSS. Female subjects and those with pre-existing psychopathology were found to be more vulnerable and may need additional support.

Disclosure

No significant relationships.

Obesity as a risk factor for hospitalization in COronaVirus Disease-19 (COVID-19) patients: Analysis of the Tuscany regional database

BACKGROUND AND AIMS

Aim of the present study is to determine the role of obesity as a risk factor for COronaVirus Disease-19 (COVID-19) hospitalization.

METHODS AND RESULTS

This observational study was performed using Istituto Superiore di Sanità (ISS) Tuscany COVID-19 database by the Agenzia Regionale Sanità (ARS), including all COVID-19 cases registered until April 30th, 2020, with reported information on chronic diseases. The principal outcome was hospitalization. An age and gender-adjusted logistic regression model was used to assess the association of clinical and demographic characteristics with hospitalization. Further multivariate models were applied. Of 4481 included subjects (36.9% aged over 70 years), 1907 (42.6%) were admitted to hospital. Obesity was associated with hospitalization after adjusting for age and gender. The association of obesity with hospitalization retained statistical significance in a fully adjusted model, including possible confounders (OR: 2.99 [IC 95% 2.04-4.37]). The effect of obesity was more evident in younger (<70 years) than in older (≥70 years) subjects.

CONCLUSIONS

The present data confirm that obesity is associated with an increased risk of hospitalization in patients with COVID-19. Interestingly, the association of obesity with hospitalization was greater in younger (<70 years) patients.

A longitudinal observation of general psychopathology before the COVID-19 outbreak and during lockdown in Italy

OBJECTIVE

Italy has been largely involved by the COVID-19 pandemic. The present study aimed at evaluating the impact of the lockdown during the pandemic on mental health adopting both a longitudinal and a cross-sectional design. Accordingly, the study investigated general psychopathology a few weeks before the COVID-19 outbreak (T0) and during lockdown (T1), and the associations between lockdown-related environmental conditions, self-perceived worsening in daily living and psychopathology.

METHODS

130 subjects (aged 18-60 years) were included in the longitudinal design, and an additional subsample of 541 subjects was recruited for the in-lockdown evaluation. Socio-demographic data and the Brief Symptom Inventory were collected both at T0 and T1. Moreover, at T1 an online survey was administered for the evaluation of lockdown-related environmental conditions and self-perceived variations in daily living induced by quarantine, along with the Impact of Event Scale-Revised.

RESULTS

Longitudinal analysis showed that phobic anxiety and depressive symptoms increased at T1 as compared with T0, whereas interpersonal sensitivity and paranoid ideation decreased. Pre-existing general psychopathology predicted COVID-19-related post-traumatic symptomatology. Cross-sectional analyses underlined that self-perceived deteriorations in various areas of daily living were associated with general and post-traumatic psychopathology, and with several lockdown-related conditions, especially economic damage.

CONCLUSION

The present study underlined a different trend of increased internalizing and decreased interpersonal symptoms during COVID-19 quarantine in Italy. Furthermore, the results showed that subjects with pre-existing psychopathology and those reporting economic damage during the pandemic were more likely to develop deterioration of their mental health.

Human biomonitoring to assess exposure to thallium following the contamination of drinking water

In 2014, in some parts of the water distribution system of the municipality of Pietrasanta (Tuscany, Italy), thallium (Tl) levels above the recommended limits were measured and some restrictions to water usage for drinking and food preparation were imposed. The study aimed to assess Tl exposure and possible health effects by means of a human biomonitoring survey. In the 2014–2016 time frame, 2154 urine and 254 hair samples were taken from different population groups and from a control group. The levels of Tl found in urine and hair were statistically higher in exposed groups than in controls and compared to the reference values for the general population. Concentrations in urine were significantly associated with the geographical origin of the sample, the consumption of drinking water and food grown in local gardens. A significant association was found between urine and hair. No positive associations were found between the Tl levels in hair or urine and several self-reported symptoms and health effects, except for sleep disturbance. The study indicates that the concentration of Tl in drinking water can be traced by urine analysis. Urine and hair have proven to be biological matrices that can be effectively used for the evaluation of Tl exposure. To date, the study represents the most extensive human biomonitoring campaign for the evaluation of the Tl exposure available at international level.

Update on Hepatitis C Epidemiology: Unaware and Untreated Infected Population Could Be the Key to Elimination

Globally, the World Health Organization (WHO) estimates that 71 million people have chronic hepatitis C virus (HCV) infection. A significant number of these will develop cirrhosis or liver cancer. Currently, during the COVID-19 outbreak, a high mortality rate has been found in patients with COVID-19 and cirrhosis. New direct-acting antiviral agents can cure more than 90% of HCV-infected patients. The new WHO strategy has introduced global goals against viral hepatitis, including a 30% reduction in new HCV cases and a 10% reduction in mortality by 2020. HCV transmission has changed considerably, reflecting both the evolution of medicine and health and social changes. The HCV is usually spread through blood-to-blood contact. After the discovery of HCV in 1989, antibody screening has drastically decreased the incidence of post-transfusion hepatitis. Nowadays, routine blood donor screening by nucleic acid amplification testing for the presence of HCV RNA has been introduced in many countries. It is conceivable that HCV screening could be offered to people born between 1946 and 1964 in the developed world and to people at high risk for HCV infection such as those who have received blood transfusions, blood products or organ donations before the 1990s, prisoners, health care workers, drug users and infants born to HCV-infected women. To achieve HCV elimination, health programmes should include improvement to access to health care services, increased screening and new projects to identify a submerged portion of patients with HCV infection. Submerged people with HCV infection are both people who are unaware of their condition and people diagnosed with HCV but not yet treated. Based on these premises, this review will examine and discuss the epidemiological changes in contracting HCV, highlighting the ways in which to identify a submerged portion of patients with HCV infection.

Treatment for COVID-19: An overview

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by coronavirus-2 (SARS-CoV-2) that causes a severe acute respiratory syndrome, a characteristic hyperinflammatory response, vascular damage, microangiopathy, angiogenesis and widespread thrombosis. Four stages of COVID-19 have been identified: the first stage is characterised by upper respiratory tract infection; the second by the onset of dyspnoea and pneumonia; the third by a worsening clinical scenario dominated by a cytokine storm and the consequent hyperinflammatory state; and the fourth by death or recovery. Currently, no treatment can act specifically against the SARS-CoV-2 infection. Based on the pathological features and different clinical phases of COVID-19, particularly in patients with moderate to severe COVID-19, the classes of drugs used are antiviral agents, inflammation inhibitors/antirheumatic drugs, low molecular weight heparins, plasma, and hyperimmune immunoglobulins. During this emergency period of the COVID-19 outbreak, clinical researchers are using and testing a variety of possible treatments. Based on these premises, this review aims to discuss the most updated pharmacological treatments to effectively act against the SARS-CoV-2 infection and support researchers and clinicians in relation to any current and future developments in curing COVID-19 patients.

Patterns of risky driving behaviors among Tuscan adolescent drivers: a cluster analysis

Background

Adolescents have a high risk of road traffic accident (RTA) because of their high engagement in risky driving behaviors (RDBs); to date, very few studies have investigated the patterns of RDBs. The aim of the study is to identify distinctive RDBs patterns and to examine their associations with RTAs in a sample of adolescent drivers

Methods

The EDIT project is a cross-sectional survey carried out in a representative sample (6.824) of Tuscany Region students aged 14-19 years. The study analyses a subsample of students who reported to drive/ride at least once a week (2764). Self-reported frequency in the last year of the following RDBs was determined: talking on phone; texting; using GPS; talking to passengers; smoking; eating; listening to loud music; fatigued driving; speeding; and driving under the influence (DUI) of alcohol or drugs. A cluster analysis was conducted to identify RDBs patterns. A multivariate model was used to evaluate the difference in the risk of RTA across clusters; ANOVA and post-hoc pairwise comparisons were used to further characterize cluster membership

Results

Four distinct RDBs clusters were identified: “safe”(45.6%), “average”(21.8%), “careless but not DUI”(21.5%) and “reckless and DUI”(11.2%) drivers. When compared with “safe” drivers, “careless but not DUI” and “reckless and DUI” drivers showed a significantly higher risk of RTA (respectively, OR 1.68, 95%CI 1.29-2.18, p &lt; 0.001; OR 2.88; 95%CI 2.10-3.95, p &lt; 0.001). Clusters were characterized by several significant differences in sociodemographic variables, cell-phone use, quality of the relationships with parents, school performances, mental health and well-being, health behaviors, gaming, bullying and risky sexual behaviors

Conclusions

RDBs evidently occur in typical patterns that are linked with different RTA risks. Several domains of adolescent life seem to be involved in cluster membership. An awareness of this clustering enables to better targeting adolescents at higher risk of RTA

Key messages

RDBs occur in patterns in adolescents, and indicators of risky behaviors and of mental and social well-being may help to identify RDBs clusters at high risk of road traffic accidents. Multimodal prevention approaches in risky driving behaviors are likely to be more successful than targeting a single behavior in adolescents.

[Chronic diseases and risk of symptomatic COVID-19: results of a case-population study on a sample of patients in the Local Health Unit 'Toscana Centro' (Tuscany Region, Central Italy)]

BACKGROUND

the COVID-19 pandemic represents a challenge for health systems around the world, with just under 10,000 cases in Tuscany Region (Central Italy) and about 4,500 in the Local Health Unit (LHU) 'Toscana Centro', updated on 11 May 2020. The risk factors reported are several, including age, being male, and some chronic diseases such as hypertension, diabetes, respiratory and cardiovascular diseases. However, the relative importance of chronic diseases is still to be explored.

OBJECTIVES

to evaluate the role of chronic diseases on the risk to develop clinically evident (at least mild symptomatic) forms of SARS-CoV-2 infection in the population of the LHU Toscana Centro.

DESIGN

case-population study.

SETTING AND PARTICIPANTS

'case' is a subject with SARS-CoV-2 positive swab with at least mild clinical status, who lives in the LHU Toscana Centro area; 'controls' are all people residing in the LHU Toscana Centro area at 1 January 2020. People aged under 30 and patients living in nursing care homes are excluded from the analysis.

MAIN OUTCOME MEASURES

the analysis assesses the effect of gender, age, neoplasm, and the main chronic diseases on the onset of an infection with at least mild symptoms by calculating odds ratios (OR) by multivariate logistic regression models (to produce adjusted OR by potential confounders).

RESULTS

among the 1,840 cases, compared to the general population, the presence of males and over-60-year-old people is greater. Almost all the considered chronic diseases are more frequent among the cases, compared to the general population. A chronic patient has a 68% greater risk to be positive with at least mild symptoms. Many of the considered diseases show an effect on the risk of getting COVID-19 in a symptomatic form, which remains even adjusting by other comorbidities. The main ones include heart failure, psychiatric disorders, Parkinson's disease, and rheumatic diseases.

CONCLUSIONS

these results confirm evidence already shown in other studies on COVID-19 patients and add information on the chronic diseases attributable risk in the population, referred to the symptomatic forms and adjusted by age, gender or the possible copresence of more diseases. These risk estimates should guide prevention interventions by health services in order to protect the chronic patients affected by the pathologies most at risk.

Covid-19 and the role of smoking: the protocol of the multicentric prospective study COSMO-IT (COvid19 and SMOking in ITaly)

The emergency caused by Covid-19 pandemic raised interest in studying lifestyles and comorbidities as important determinants of poor Covid-19 prognosis. Data on tobacco smoking, alcohol consumption and obesity are still limited, while no data are available on the role of e-cigarettes and heated tobacco products (HTP). To clarify the role of tobacco smoking and other lifestyle habits on COVID-19 severity and progression, we designed a longitudinal observational study titled COvid19 and SMOking in ITaly (COSMO-IT). About 30 Italian hospitals in North, Centre and South of Italy joined the study. Its main aims are: 1) to quantify the role of tobacco smoking and smoking cessation on the severity and progression of COVID-19 in hospitalized patients; 2) to compare smoking prevalence and severity of the disease in relation to smoking in hospitalized COVID-19 patients versus patients treated at home; 3) to quantify the association between other lifestyle factors, such as e-cigarette and HTP use, alcohol and obesity and the risk of unfavourable COVID-19 outcomes. Socio-demographic, lifestyle and medical history information will be gathered for around 3000 hospitalized and 700-1000 home-isolated, laboratory-confirmed, COVID-19 patients. Given the current absence of a vaccine against SARS-COV-2 and the lack of a specific treatment for COVID-19, prevention strategies are of extreme importance. This project, designed to highly contribute to the international scientific debate on the role of avoidable lifestyle habits on COVID-19 severity, will provide valuable epidemiological data in order to support important recommendations to prevent COVID-19 incidence, progression and mortality.

Trends in cardiovascular diseases burden and vascular risk factors in Italy: The Global Burden of Disease study 1990-2017

AIMS

An exhaustive and updated estimation of cardiovascular disease burden and vascular risk factors is still lacking in European countries. This study aims to fill this gap assessing the global Italian cardiovascular disease burden and its changes from 1990 to 2017 and comparing the Italian situation with European countries.

METHODS

All accessible data sources from the 2017 Global Burden of Disease study were used to estimate the cardiovascular disease prevalence, mortality and disability-adjusted life years and cardiovascular disease attributable risk factors burden in Italy from 1990 to 2017. Furthermore, we compared the cardiovascular disease burden within the 28 European Union countries.

RESULTS

Since 1990, we observed a significant decrease of cardiovascular disease burden, particularly in the age-standardised prevalence (-12.7%), mortality rate (-53.8%), and disability-adjusted life years rate (-55.5%). Similar improvements were observed in the majority of European countries. However, we found an increase in all-ages prevalence of cardiovascular diseases from 5.75 m to 7.49 m Italian residents. Cardiovascular diseases still remain the first cause of death (34.8% of total mortality). More than 80% of the cardiovascular disease burden could be attributed to known modifiable risk factors such as high systolic blood pressure, dietary risks, high low density lipoprotein cholesterol, and impaired kidney function.

CONCLUSIONS

Our study shows a decline in cardiovascular mortality and disability-adjusted life years, which reflects the success in reducing disability, premature death and early incidence of cardiovascular diseases. However, the burden of cardiovascular diseases is still high. An approach that includes the cooperation and coordination of all stakeholders of the Italian National Health System is required to further reduce this burden.

Sport participation moderates association between bullying and depressive symptoms in Italian adolescents

BACKGROUND

A high rate of bullying episodes has been reported in Italian schools, as well as its association with psychopathology in adolescents. However, information regarding moderators of this interaction are still lacking. This study explored whether gender, exercise frequency, and sport participation exerted a protective effect on the association between bullying and depressive symptoms in Italian students.

METHODS

Researchers obtained data from 4,829 Italian youth ages 13 to 21 using the self-report Epidemiologia dell'Infortunistica Stradale survey (EDIT) developed by the Regional Health Agency of Tuscany, Italy. Three structural equation models were run to assess moderators of the association between bullying and depressive symptoms. Moderators examined in the models included gender, exercise frequency, and sport participation.

RESULTS

The association between bullying and depressive symptoms was stronger for females (B=0.95, SE=0.04, p< .001) than for males (B=0.45, SE=0.00, p< .001) and for students who did not play sports (B=0.74, SE=0.09, p< .001) than for those who played sports (B=0.61, SE=0.06, p< .001). Females may be more affected by the depressive effects of bullying than males.

CONCLUSIONS

Participation in sports buffers against the effects of bullying and may prove a helpful strategy for increasing exercise, positive peer interactions, and mood in adolescents.

LIMITATIONS

The cross-sectional nature of the study, the possible role of BMI as a confounding factor and the use of a not widely used measure of depression.

Risk and adverse outcomes of gestational diabetes in migrants: A population cohort study

AIMS

To evaluate the risk of gestational diabetes (GDM) and of neonatal/maternal complications (macrosomia, large for gestational age (LGA), cesarean sections, preterm deliveries, neonatal distress and fetal malformations) among women coming from High Migration Pressure Countries (HMPC), compared to native (Italian) mothers.

METHODS

Risks of GDM and related neonatal/maternal complications were evaluated in a cohort of 581,073 Italian compared with 105,111 HMPC women of age 15-45 yr, resident in Tuscany, Italy along years 2012-2017, delivering 122,652 singleton live births (18,596 from HMPC mothers).

RESULTS

HMPC women, compared to Italian ones, were at higher risk of GDM (OR: 1.586; 1.509-1.666;p < 0.0001), peaking for women originating from South Asia (OR:3.0.49; 2.618-3.553;p < 0.0001). GDM was associated with increased risk of preterm delivery and cesarean sections, while migrants, regardless of GDM, were burdened by a higher risk of all considered complications. The rise in all these risks, including macrosomia or LGA however, disappeared, after addition of interaction term GDM × HMPC ethnicity.

CONCLUSION

Compared to Italian mothers, HMPC women had higher risk of GDM and of all considered adverse events. The addiction of the interaction term GDM × HMPC ethnicity in the predictive model, however reversed the rise in risk of all HMPC associated adverse outcomes.

Health effects associated with short-term exposure to hydrogen sulfide from geothermal power plants: a case-crossover study in the geothermal areas in Tuscany

OBJECTIVE

Thirty-four geothermal power plants for the production of electricity are currently active in the geothermal areas in Tuscany. The present study aimed to investigate the association between short-term exposure to hydrogen sulfide (H₂S) and acute health outcomes.

METHODS

This study used individual data on non-accidental, cardiovascular and respiratory mortality, urgent hospital admissions (HA) and emergency department (ED) visits for cardiorespiratory diseases occurring from 2000 to 2017. All cases were georeferenced and matched to daily H₂S data, derived from 18 monitoring sites. A case-crossover design following the matched pair interval approach was applied and conditional logistic regression models were fitted to estimate odds ratios and their 90% confidence intervals, adjusting for a set of time-dependent variables, such as influenza epidemics, holidays and temperature.

RESULTS

A total of 8054 deaths, 30,527 HA and 15,263 ED visits occurred. Mortality for non-accidental (OR = 1.11, 90% CI 1.02-1.22) and cardiovascular causes (OR = 1.22, 90% CI 1.03-1.44) were associated with an increase of 10 µg/m³ of H₂S daily levels only among men. Hospital admissions for respiratory diseases were positively associated with H₂S exposure: OR = 1.11 (90% CI 1.00-1.22) among women. No associations were observed in ED visits analyses.

CONCLUSIONS

In this case-crossover study in the Tuscan geothermal areas, short-term exposure to H₂S was weakly associated with some mortality and morbidity outcomes. Our findings did not show a clear pattern as the results were not homogeneous between mortality and morbidity data or between men and women.

Hepatitis B vaccination and immunotherapies: an update

World Health Organization (WHO) estimates that 257 million people were living with chronic hepatitis B virus (HBV) infection. Highest HBV prevalence was found in the WHO Western Pacific Region (6.2%) and in the WHO African Region (6.1%). The HBV vaccine is the best protection against chronic HBV infection and its complications. Globally, routine infant immunization against HBV has increased with an estimated coverage of 84% in 2017. Nevertheless, in many countries further efforts are needed to implement this coverage and ensure national immunization programs for people at major risk for HBV infection. Therapeutic vaccination in chronic HBV infected patients can cause anti-HBV immune responses able to remove and/or cure infected hepatocytes. It shows promising results in murine model and human trials, but these results need to be consolidated by further multicenter clinical studies. In particular, the efficacy of therapeutic vaccine seems to improve by combination therapies.

Interconnected clusters of invasive meningococcal disease due to Neisseria meningitidis serogroup C ST-11 (cc11), involving bisexuals and men who have sex with men, with discos and gay-venues hotspots of transmission, Tuscany, Italy, 2015 to 2016

In 2015 an increased incidence of invasive meningococcal disease due to serogroup-C (MenC) occurred in Tuscany, Italy. This led the Regional Health Authority of Tuscany to implement a reactive immunisation campaign and to launch an epidemiological field investigation aiming to address targeted immunisation interventions. In 2011–14, 10 MenC cases had been reported compared with 62 cases in 2015–16. The case fatality rate was 21% (n = 13) and 51 cases (82.3%) were confirmed as C:P1.5–1,10–8:F3–6:ST-11(cc11). Overall, 17 clusters were recognised. Six discos and four gay-venues were found to have a role as transmission-hotspots, having been attended by 20 and 14 cases in the 10 days before symptoms onset. Ten and three cases occurred, respectively, among men who have sex with men (MSM) and bisexual individuals, who were involved in 11 clusters. In addition, heterosexual cases (n = 5) attending gay-venues were also found. Secondary cases were not identified. Molecular typing indicated close relationship with MenC clusters recently described among gay, bisexual and other MSM in Europe and the United States, suggesting a possible international spread of the serogroup-C-variant P1.5–1,10–8:F3–6:ST-11(cc11) in this population-group; however, epidemiological links were not identified. In December 2016, a targeted vaccination campaign involving discos and lesbian, gay, bisexual, and transgender (LGBT) associations was implemented. During 2017, 10 cases of MenC occurred, compared with 32 and 30 cases reported in 2015 and 2016 respectively, suggesting the effectiveness of the reactive and targeted immunisation programmes.

Genomic analysis of Neisseria meningitidis carriage isolates during an outbreak of serogroup C clonal complex 11, Tuscany, Italy

Background

In 2015–2016, a cross-sectional carriage survey was performed in Tuscany Region, Italy, during an outbreak of invasive meningococcal disease due to Neisseria meningitidis serogroup C clonal complex 11 (MenC:cc11). This study aims to evaluate the genomic profile of meningococcal carriage isolates collected during the survey.

Methods

Whole-genome sequencing (WGS) was performed using Illumina MiSeq on 85 cultivated meningococcal carriage isolates received at the Dept. of Infectious Disease, National Institute of Health (Istituto Superiore di Sanità, ISS), as National Reference Laboratory (NRL) for Invasive Meningococcal Disease (IMD). De novo assembled genomes were scanned by the BIGSdb platform to assign: the genotypic profiles, the cgMLST, the vaccine antigen variants and allele types of antimicrobial resistance associated genes, together with denitrification pathway loci.

Results

Capsule null and non-groupable meningococci accounted for 52.9% and 10.6%, respectively. Among the remaining carriage isolates, serogroup B was the predominant (71.0%). Serogroup C meningococci were culture negative and unavailable for WGS. Overall, 64 genotypic profiles were identified and, based on cgMLST, isolates clustered according to clonal complexes. Eight isolates (9.4%) harbored at least one gene encoding a 4CMenB vaccine antigen. Mutated penA alleles were found in more than 82%. Finally, complete aniA and norB coding sequences were detected among 71.8% of carriage isolates.

Conclusions

Meningococcal carriage isolates collected during the MenC:cc11 outbreak were characterized by an extensive genetic diversity. The lack of outbreak-related isolates among carriage might be attributable to the high transmissibility with low duration of colonization of MenC:cc11 meningococci.

Epidemiological, demographic and clinical data on chronic viral hepatitis C in Tuscany

BACKGROUND

Recent introduction of direct antiviral agents (DAAs) has completely changed the scenario regarding hepatitis C virus (HCV) treatment. Certain countries' economic health programs prioritize DAAs according to specific clinical features of HCV-infected patients. The aim of this study was to define epidemiological, demographic and clinical characteristics of HCV-infected patients in the Tuscany region of central Italy.

METHODS

We enrolled HCV patients with chronic viral hepatitis who were referred to the outpatient services of 16 hospitals in Tuscany from 1 January 2015 to 31 December 2015. Case report forms contained patient information including main demographic data, blood chemistry data, viral hepatitis markers, instrumental evaluations (liver biopsy or transient elastometry, liver ultrasound), eligibility for DAAs, and liver transplantation or therapy already in progress.

RESULTS

Of all patients considered, 2919 HCV patients were enrolled (mean age: 57.44 ± 15.15; 54% males, 46% females). All routes of transmission were well represented (intravenous drug use in 20.7%; nosocomial/dental care in 20.6%; and coagulation factors/blood transfusions in 13.3%). Diabetes was the highest represented comorbidity (20.8%), followed by metabolic syndrome (15.5%) and ischemic heart disease (6.2%). The most prevalent HCV genotypes were 1b (47.4%) and 2 (16.5%). In the whole cohort of patients, 32.8% were cirrhotic (40 patients were listed for liver transplantation). Signs of portal hypertension were present mostly in the group older than 45 years (92.3%). Extrahepatic HCV-related diseases were present in 13.3% of cases (cryoglobulinemic syndrome in 58.3% and B-cell non-Hodgkin's lymphoma in 10.5%).

CONCLUSIONS

Our study provides evidence of a high prevalence of epidemiological changes in HCV infection with a major prevalence of advanced liver disease, such as portal hypertension, in this elderly cohort of patients.

Health effects associated with chronic exposure to low-level hydrogen sulfide from geothermoelectric power plants. A residential cohort study in the geothermal area of Mt. Amiata in Tuscany

BACKGROUND

Geothermal power plants for the production of electricity are currently active in Mt. Amiata, Italy. The present study aimed to investigate the association between chronic low-level exposure to H₂S and health outcomes, using a residential cohort study design.

METHODS

Spatial variability of exposure to chronic levels of H₂S was evaluated using dispersion modelling. Cohorts included people residing in six municipalities of the geothermal district from 01/01/1998 to 31/12/2016. Residence addresses were georeferenced and each subject was matched with H₂S exposure metrics and socio-economic status available at census tract level. Mortality and hospital discharge data for neoplasms and diseases of the respiratory, central nervous and cardiovascular systems were taken from administrative health databases. Cox proportional hazard models were used to test the association between H₂S exposure and outcomes, with age as the temporal axis and adjusting for gender, socio-economic status and calendar period.

RESULTS

The residential cohort was composed of 33,804 subjects for a total of 391,002 person-years. Analyses reported risk increases associated with high exposure to H₂S for respiratory diseases (HR = 1.12 95%CI: 1.00-1.25 for mortality data; HR = 1.02 95%CI: 0.98-1.06 for morbidity data), COPD and disorders of the peripheral nervous system. Neoplasms were negatively associated with increased H₂S exposure.

CONCLUSIONS

The most consistent findings were reported for respiratory diseases. Associations with increased H₂S exposure were coherent in both mortality and hospitalization analyses, for both genders, with evidence of exposure-related trends. No positive associations were found for cancer or cardiovascular diseases.

Risk of Developmental Coordination Disorder in Italian very preterm children at school age compared to general population controls

BACKGROUND

Developmental Coordination Disorder (DCD) is a neurodevelopmental disorder that involves difficulties in goal-directed motor coordination, with ineffective control of fine and gross motor movements in the absence of sensory impairment or neurological condition. DCD is frequently reported in children born very preterm (VP) who survive without CP.

AIMS

To measure the risk of DCD at school age in a large area-based cohort of VP children and general population controls, adjusting for gender, birth weight by gestational age and age at assessment.

METHODS

VP children (N = 608) were part of a prospective cohort study in Italy. Controls (N = 370) were participants in the DCDQ-Italian validation study in the same age range. The Italian version of Developmental Coordination Disorder Questionnaire (DCDQ-Italian) was used to measure the performances in motor coordination during ordinary activities from the parental point of view. Multivariable regression analysis was used to obtain adjusted risk ratios of screening positive for DCD.

RESULTS

VP children had scores significantly lower than peers, and about 30% of them appeared at risk of DCD using the 15th percentile cut-off of the Italian validation study. Birth-weight <10th percentile for gestational age and male gender were significant predictors. A slight trend effect was present, with extremely preterm children (<28 weeks gestation) showing the highest risk.

CONCLUSIONS

Our study confirmed the higher DCD risk in VP children, particularly when males and SGA.

Screening for hepatitis B virus and accelerated vaccination schedule in prison: A pilot multicenter study

BACKGROUND AND AIM

Vaccine against hepatitis B virus (HBV) is highly effective in preventing HBV infection. The aims of this study were to (1) increase the epidemiological knowledge on the impact of HBV in Tuscany region prisons by registering the results of serum screening on a clinical medical record and (2) increase the anti-HBV vaccination using an accelerated schedule.

METHODS

Our study population was composed of all detainees present in prisons and all constrained from freedom or at institutions in the Tuscany region and not vaccinated at these facilities from 1 December 2016 to 31 May 2017.

RESULTS

Of 17 detention facilities in the Tuscany region, 15 were enrolled in the study. On 28 February 2017, there were 3068 detainees present in these institutions. Considering the 1075 subjects screened for HBV serum markers, 730 (67.9%) were susceptible to infection and needed to be vaccinated. Five hundred and ninety-six agreed to be vaccinated (82%); 27 (2.5%) of our subjects had an isolated anti-HBc, 20 (1.9%) were HBV infected (HBsAg+), 127 (11.8%) had previous HBV infection (anti-HBs+, anti-HBc+ and HBsAg-), and 171 had been previously vaccinated. Five hundred and fifty-five inmates (95.1%) received the first vaccine dose, and 404 (83%) underwent the third dose at day 21.

CONCLUSION

This study showed that of a high percentage of subjects who underwent screening, more than half needed to be vaccinated. Moreover, our study reached very high levels of vaccination coverage, considering both the entire enrolled population and the new inmates.

Carriage rates and risk factors during an outbreak of invasive meningococcal disease due to Neisseria meningitidis serogroup C ST-11 (cc11) in Tuscany, Italy: a cross-sectional study

Background

During 2015–2016 an outbreak of invasive meningococcal disease due to N. meningitidis serogroup C ST-11 (cc11) occurred in Tuscany, Italy. The outbreak affected mainly the age group 20–30 years, men who have sex with men, and the area located between the cities of Firenze, Prato and Empoli, with discos and gay-venues associated-clusters. A cross-sectional-survey was conducted to assess the prevalence and risk factors for meningococcal-carriage, in order to address public health interventions.

Methods

A convenience sample of people aged 11–45 years provided oropharyngeal swab specimens and completed questionnaires on risk factors for meningococcal carriage during a 3 months study-period, conducted either in the outbreak-area and in a control-area not affected by the outbreak (cities of Grosseto and Siena). Isolates were tested by culture plus polymerase chain reaction. Serogroup C meningococcal isolates were further characterized using multilocus sequence typing. Univariate and multivariate analyses were performed to estimate adjusted odds ratios (AORs) for meningococcal carriage.

Results

A total of 2285 oropharyngeal samples were collected. Overall, meningococcal carriage prevalence was 4.8% (n = 110), with nonencapsulated meningococci most prevalent (2.3%; n = 52). Among encapsulated meningococci, serogroup B was the most prevalent (1.8%; n = 41), followed by serogroup Y (0.5%; n = 11) and serogroup C (0.2%; n = 4); one carrier of serogroup E and one of serogroup Z, were also found (0.04%). Three individuals from the city of Empoli were found to carry the outbreak strain, C:ST-11 (cc11); this city also had the highest serogroup C carriage prevalence (0.5%). At the multivariate analyses, risk factors for meningococcal carriage were: illicit-drugs consumption (AOR 6.30; p < 0.01), active smoking (AOR 2.78; p = 0.01), disco/clubs/parties attendance (AOR 2.06; p = 0.04), being aged 20–30 years (AOR 3.08; p < 0.01), and have had same-sex intercourses (AOR 6.69; p < 0.01).

Conclusions

A low prevalence of meningococcal serogroup C carriage in an area affected by an outbreak due to the hypervirulent N. meningitidis serogroup C ST-11 (cc11) strain was found. The city of Empoli had the highest attack-rate during the outbreak and also the highest meningococcal serogroup C carriage-prevalence due to the outbreak-strain. Multivariate analyses underlined a convergence of risk factors, which partially confirmed those observed among meningococcal outbreak-cases, and that should be considered in targeted immunization campaigns.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3598-3) contains supplementary material, which is available to authorized users.

Lung function in a cohort of 5-year-old children born very preterm

OBJECTIVE

We assessed lung function and respiratory health in an area-based prospective cohort of preschool children born very preterm.

DESIGN

Lung function was measured by interrupter respiratory resistance (Rint) and forced oscillation technique (FOT) (respiratory resistance (Rrs8), reactance (Xrs8), and area under the reactance curve (AX)) at a median age of 5.2 years in a cohort of 194 children born at 22-31 weeks of gestational age (GA) in Tuscany, Italy. Respiratory symptoms and hospitalizations were also assessed.

RESULTS

Mean (SD) lung function Z-scores were impaired in preterm children for Rint (0.72 (1.13)), Xrs8 (-0.28 (1.34)), and AX (0.29 (1.41)). However, only a relatively small proportion of children (14.5-17.4%) had values beyond the 95th centile or below the 5th. Children with bronchopulmonary dysplasia (BPD) (n = 24) had slightly but not significantly impaired lung function indices in comparison with those without BPD (n = 170). In a multivariable analysis, lower GA was associated with worse lung function indices. Fifty-five percent of children had a history of wheezing ever and 21% had been hospitalized in their lifetime because of lower respiratory infections; 31% had wheezing in the last 12 months and this was associated with increased Rrs8 (P = 0.04) and AX (P = 0.08), and with decreased Xrs8 (P = 0.04) Z-scores.

CONCLUSIONS

Irrespectively of BPD preschool children born very preterm had impaired lung function indices, as measured by Rint and FOT, and a slightly higher burden of respiratory problems than the general population. GA seems to be crucial for lung development.

Health effects among a cohort exposed to low-level arsenic in a geothermal area of Tuscany, Italy

BACKGROUND

Studies on low-level As exposure have not found an association with cancer, while increased risks were reported for skin lesions, respiratory and cardiovascular diseases and reproductive outcomes. Prospective observational studies with individual exposure measures are needed to study low-level As exposure effects. In a geothermal area in Southern Tuscany (Italy), characterized by a natural presence of As in drinking water (< 50 µg/l), As urinary concentrations were measured in a survey in 1998 and cohort members were followed to evaluate the effects on health.

METHODS

Around 900 subjects (20-55 years old) randomly sampled in 4 municipalities of the area (Monte Amiata), have been followed from 1999 to 2015, by hospitalisation and mortality registries. Standardized Hospitalisation Ratios (SHRs) were performed, compared to a reference area. Competing-risks regression models were performed to test the association between As urinary concentration and risk of first hospitalisation.

RESULTS

SHRs show various increased risks, more frequently among males. Internal analyses show a positive association between As and skin diseases in the general population, the Hazard Ratio (HR) for 1 µg/l increase of As urinary concentration is 1.06 (90%CI 1.01-1.11) and in males, HR 1.08 (90%CI 1.02-1.14), between As and circulatory system diseases in males, HR 1.03 (90%CI 1.01-1.05).

CONCLUSIONS

The results suggest an effect on skin diseases and circulatory system diseases and, considering the relative young age of cohort members, they could be considered also as predictive of future severer diseases.

Meningococcal C conjugate vaccine effectiveness before and during an outbreak of invasive meningococcal disease due to Neisseria meningitidis serogroup C/cc11, Tuscany, Italy

INTRODUCTION

In Tuscany, Italy, where a universal immunization program with monovalent meningococcal C conjugate vaccine (MCC) was introduced in 2005, an outbreak of invasive meningococcal disease (IMD) due to the hypervirulent strain of Neisseria meningitidis C/cc11 occurred in 2015-2016, leading to an immunization reactive campaign using either the tetravalent (ACWY) meningococcal conjugate or the MCC vaccine. During the outbreak, IMD serogroup C (MenC) cases were also reported among vaccinated individuals. This study aimed to characterize meningococcal C conjugate vaccines (MenC-vaccines) failures and to estimate their effectiveness since the introduction (2005-2016) and during the outbreak (2015-2016).

METHODS

MenC cases and related vaccine-failures were drawn from the National Surveillance System of Invasive Bacterial Disease (IBD) for the period 2006-2016. A retrospective cohort-study, including the Tuscany' population of the birth-cohorts 1994-2014, was carried out. Based on annual reports of vaccination, person-years of MenC-vaccines exposed and unexposed individuals were calculated by calendar-year, birth-cohort, and local health unit. Adjusted (by birth-cohort, local health unit, and calendar-year) risk-ratios (ARR) of MenC invasive disease for vaccinated vs unvaccinated were estimated by the Poisson model. Vaccine-effectiveness (VE) was estimated as: VE = 1-ARR.

RESULTS

In the period 2006-2016, 85 MenC-invasive disease cases were reported; 61 (71.8%) from 2015 to 2016. Twelve vaccine failures occurred, all of them during the outbreak. The time-interval from immunization to IMD onset was 20 days in one case, from 9 months to 3 years in six cases, and ≥7 years in five cases. VE was, 100% (95%CI not estimable, p = 0.03) before the outbreak (2006-2014) and 77% (95%CI 36-92, p < 0.01) during the outbreak; VE was 80% (95%CI 54-92, p < 0.01) during the overall period.

CONCLUSIONS

In Tuscany, MenC-vaccine failures occurred exclusively during the 2015-2016 outbreak. Most of them occurred several years after vaccination. VE during the outbreak-period was rather high supporting an effective protection induced by MenC-vaccines.

Clinical epidemiology of chronic viral hepatitis B: A Tuscany real-world large-scale cohort study

AIM

To build a regional database of chronic patients to define the clinical epidemiology of hepatitis B virus (HBV)-infected patients in the Tuscan public health care system.

METHODS

This study used a cross-sectional cohort design. We evaluated chronic viral hepatitis patients with HBV referred to the outpatient services of 16 hospital units. Information in the case report forms included main demographic data, blood chemistry data, viral hepatitis markers, instrumental evaluations, and eligibility for treatment or ongoing therapy and liver transplantation.

RESULTS

Of 4015 chronic viral hepatitis patients, 1096 (27.3%) were HBV infected. The case report form was correctly completed for only 833 patients (64% males, 36% females; mean age 50.1 ± 15.4). Of these HBV-infected patients, 73% were Caucasian, 21% Asian, 4% Central African, 1% North African and 1% American. Stratifying patients by age and nationality, we found that 21.7% of HBV-infected patients were aged < 34 years (only 2.8% were Italian). The most represented routes of transmission were nosocomial/dental procedures (23%), mother-to-child (17%) and sexual transmission (12%). The most represented HBV genotypes were D (72%) and A (14%). Of the patients, 24.7% of patients were HBeAg positive, and 75.3% were HBeAg negative. Of the HBV patients 7% were anti-HDV positive. In the whole cohort, 26.9% were cirrhotic (35.8% aged < 45 years), and 47% were eligible for or currently undergoing treatment, of whom 41.9 % were cirrhotic.

CONCLUSION

Only 27.3% of chronic viral hepatitis patients were HBV infected. Our results provide evidence of HBV infection in people aged < 34 years, especially in the foreign population not protected by vaccination. In our cohort of patients, liver cirrhosis was also found in young adults.

The effects of ozone on human health

Ozone is a highly reactive, oxidative gas associated with adverse health outcome, including mortality and morbidity. Data from monitoring sites worldwide show levels of ozone often exceeding EU legislation threshold and the more restrictive WHO guidelines for the protection of human health. Well-established evidence has been produced for short-term effects, especially on respiratory and cardiovascular systems, associated to ozone exposure. Less conclusive is the evidence for long-term effects, reporting suggestive associations with respiratory mortality, new-onset asthma in children and increased respiratory symptom effects in asthmatics. The growing epidemiological evidence and the increasing availability of routinely collected data on air pollutant concentrations and health statistics allow to produce robust estimates in health impact assessment routine. Most recent estimates indicate that in 2013 in EU-28, 16,000 premature deaths, equivalent to 192,000 years of life lost, are attributable to ozone exposure. Italy shows very high health impact estimates among EU countries, reporting 3380 premature deaths and 61 years of life lost (per 100,000 inhabitants) attributable to ozone exposure.

Emerging Trends in Epidemiology of Hepatitis B Virus Infection

Although a vaccine against hepatitis B virus (HBV) has been available since 1982, the prevalence of adults with chronic HBV infection in sub-Saharan Africa and East Asia is still estimated at 5-10%. A high rate of chronic infections is also found in the Amazon and the southern parts of eastern and central Europe. In the Middle East and the Indian subcontinent, the prevalence is 2-5%. Less than 1% of the population of Western Europe and North America is chronically infected. Given the high prevalence of infections (such as hepatitis) among inmates, prison is considered a reservoir for facilitating such infections. Based on these premises, this current review examines and discusses emerging trends in the epidemiology of HBV infection, with particular attention to HBV infection in prison. The hepatitis B surface antigen (HBsAg) prevalence in prisoners in west and central Africa is very high (23.5%). The Centers for Disease Control and Prevention has highlighted the importance of HBV blood screening and subsequent anti-HBV vaccination in the prison population. The vaccination was recommended for all inmates, representing an opportunity to prevent HBV infection in a high-risk population. In these subjects, an accelerated hepatitis B immunisation schedule may result in rapid seroconversion for early short-term protection. Therefore, it is necessary to seek collaboration among public health officials, clinicians and correctional authorities to implement a vaccination programme.

Epidemiology of Kawasaki disease in Italy: surveillance from national hospitalization records

Kawasaki disease is a systemic vasculitis with an acute and self-limited course. The incidence of the disease differs widely among ethnic groups and is higher in the Asian populations. In Italy, no recent data are available. We studied the epidemiology of Kawasaki disease in the years 2008-2013 in children 0-14 years old in Italy using hospital ICD-9 discharge codes with a thorough data cleaning for duplicates in order to select the first hospital admission for the disease. The disease peaked in the first 2 years of life, with 85.5% of cases under 5 years. Male/female ratio was 1.4:1. The incidence rate was 5.7 per 100,000 children 0-14 years old and 14.7 for children younger than 5 years. The incidence rose slightly during the study period and had a seasonal distribution, with higher incidence in spring. A coronary artery aneurysm was recorded in 2.2% of the patients younger than 5 years of age.

CONCLUSION

This is the first epidemiologic study on Kawasaki disease incidence in the country of Italy. Figures are in line but slightly higher than those reported for other European countries. What is known: • Kawasaki disease is more common in Asian populations. • European incidence data are scarce. What is new: • Epidemiological data in Italy show similar incidence, albeit slightly higher, than in other European countries. • Incidence data slightly rose in the recent past.