Religious pilgrimage and COVID-19. An observational report in Italy from contact tracing activities

Issue/Problem

Religious Mass Gathering (MG) represent one of public health challenges for Health Authorities due to potential spread of communicable diseases. This is much more true during a pandemic as COVID-19. Surveillance is crucial to prevent further spreading of infectious disease related to a religious MG.

Description of the problem

During international contact tracing activities an increase of reporting of COVID-cases with a travel history to a Catholic shrine in Europe was observed, despite travel restrictions put in place. In order to promote public health actions as risk communication, a risk evaluation was conducted. A descriptive analysis was carried out: personal and vaccination data were collected; for cases, date and type of positive tests, date of symptoms’ onset were collected; for high-risk contacts, date and type of negative tests at the end of follow-up were collected. Frequencies were calculated.

Results

Six journeys back from Medjugorje were identified, with at least one positive case. All trips took place between 18/09/2021 and 29/10/2021. 31 positive cases out of 160 travellers were identified, with number of cases per travel ranging from 1 to 11.

Lessons

Religious MG represent an important global health issue. Even though a specific surveillance was not activated, international contact tracing activities turned out a great source of epidemic intelligence and consequent surveillance and control activities led to risk assessment and communication actions.

Key messages

• In the pandemic context, where travel restrictions were put in place, surveillance for Religious MG should be always implemented.

• Cooperation among all the stakeholders involved as Church, travel agency, Regional Health Systems and Government Bodies has to be promoted for specific surveillance in religious MG events.

International Health Regulations core capacities monitoring in 2020-2021 at Italian Points of Entry

 

Under the International Health Regulations (IHR) 2005 States Parties (SP) are required to develop and maintain core public health capacities and report related progress to World Health Organization (WHO) annually,including those related to Points of Entry (PoEs).Using an appropriate tool,provided by WHO, Italian PoEs assessments in 2020 and 2021 were conducted to have the status quo,describe any differences among years and promote corrective actions if required. The tool was designed in 2009 to support SP in ascertaining prior capacities in PoEs and monitoring their progress in order to designate PoEs under IHR.The tool was translated in Italian.Coordination and communication among authorities involved in each PoE (C1),core capacity at all times (C2) and at PHEIC (Public Health Emergency of International Concern) (C3) were assessed by cross border health Authorities for 2020 and 2021.For each of these sections the maximum score is 100%. For each year,a descriptive analysis was conducted and any differences in scores between the two years were noted.The presence of a contingency and vectors’ control plans was also investigated.The assessment was completed respectively for 2020 and 2021 by 24 and 25 airports, 53 and 52 ports. C1 in 2020 resulted on average 89% for airports and 95% for ports, in 2021 respectively 90% and 95%; C2 in 2020 resulted on average 64% for airports and 63% for ports, in 2021 respectively 63% and 64%; C3 in 2020 resulted on average 68% for airports and 61% for ports,in 2021 respectively 63% and 58%.Few differences in scores between 2020 and 2021 were noted in some PoEs. 4 PoEs declared the presence of a contingency plan only in 2021.Few PoEs stated to not have a vectors’ control plan in both years.The assessment pointed out a good level of coordination and communication among all the stakeholders involved, including the Italian Red Cross,but it revealed lower scores for the other IHR core capacities. Improvement actions have to be pursued surely.

Key messages

• The specified tool helps cross border and national Authorities to understand strengths and weaknesses in each PoE and leads to develop a specific plan of action to overcome potential gaps.

• Maintaining a good level of core capacities at points of entry is fundamental to protect national public health.

Are vaccine shortages a relevant public health issue in Europe?

Background

National immunisation programmes depend on an adequate supply of vaccines but shortages have become more frequent globally in recent years. Vaccine shortages can lead to missed opportunities for vaccination and a greater risk of occurrence of vaccine-preventable diseases (VPD).

Methods

The EU-Joint Action on Vaccination is a European Commission-funded project* which aims to strengthen cooperation between European countries against VPDs, including improvement of vaccine supply and preparedness. In this context, from February to May 2019, we conducted a survey amongst persons in charge of national immunisation programmes or of vaccine supply/procurement in EU/EEA, to collect information on vaccine shortages in the previous three years.

Results

Twenty-one of 28 invited countries responded, of which 19 reported at least one shortage, for a total of 115 shortage events. The median number of shortages per country was 5 (range 0-15). At the time of survey completion, there were ongoing shortages in six countries. DT/dt-containing combination vaccines, hepatitis A, hepatitis B and BCG vaccines were the most frequently involved vaccines. Supply and production issues, and global shortage, were the most frequent causes. Median duration of shortages was five months; 34% caused a disruption in immunization services. Procurement and purchase methods varied by country. Only half of countries have recommendations or procedures in place to address shortages.

Conclusions

Vaccine shortages are a serious public health issue in the EU. Causes are complex and multifaceted and more research is needed to understand the economic and market-related causes. Improved communication between public health authorities, manufacturers and regulatory agencies is essential. Procurement and tender mechanisms should be improved. In case of vaccine shortages, all countries should have procedures or recommendation in place regarding the use of alternative vaccines or vaccination schedules.

Key messages

Vaccine shortages are a relevant public health issue in the EU. More research is needed on the complex and multifaceted causes of vaccine shortages. Timely communication between supply and demand is needed and procurement and tender mechanisms should be improved.

An outbreak of severe invasive meningococcal disease due to a capsular switched Neisseria meningitidis hypervirulent strain B:cc11

OBJECTIVES

The aim was to investigate an outbreak of invasive meningococcal disease (IMD) in Southern Sardinia.

METHODS

Epidemiological and microbiological investigations were performed. The latter included antimicrobial susceptibility testing and whole-genome sequencing (WGS).

RESULTS

Seven individuals with severe IMD were found to be infected with serogroup B (MenB) Neisseria meningitidis in the first quarter of 2018. Five of the seven cases (five males; mean age 19 years; range 18-21 years; CFR 40%) were due to a unique strain B:P1.5-1,10-8:F3-6:ST-11(cc11), probably switched from the hypervirulent C-cc11, as confirmed by WGS. All five patients had attended the same nightclub in the 2 weeks prior to symptom onset. Public health measures, including chemoprophylaxis of contacts and active immunization against MenB, were implemented.

CONCLUSIONS

We observed five IMD cases due to the same switched MenB strain. The hypervirulent B:P1.5-1,10-8:F3-6:ST-11(cc11) strain, probably switched from C-cc11, is of concern due to the observed high virulence and case fatality rates. All the patients shared the same place of probable exposure. The molecular characterization of the invasive strain allowed the outbreak to be confirmed, which was then controlled through timely public health action.

Human Rickettsia aeschlimannii infection: first case with acute hepatitis and review of the literature

OBJECTIVE

Rickettsia conorii is responsible for the Mediterranean Spotted Fever. Recently, new rickettsial species have been recognized in Europe and implicated in human diseases. Clinical features often differ greatly from each other, but non-severe liver involvement is frequently observed during any rickettsial infection.

CASE REPORT

We describe the unique case of a patient presented with significant high aminotransferase levels due to the first human R. aeschlimannii infection ever detected in Italy. The hypothesis of rickettsiosis was made on the basis of a comprehensive medical history and was confirmed by serological tests. Molecular analyses made on a sample of hepatic tissue revealed the presence of a rickettsial species never found before in human liver.

CONCLUSIONS

A brief review of the literature is reported to highlight how relevant this case is and to remind that rickettsioses should be in the differential diagnoses of acute hepatitis, considering mostly the recent spread of new rickettsial species.

Transmission of HIV Drug Resistance and the Predicted Effect on Current First-line Regimens in Europe

Transmitted human immunodeficiency virus drug resistance in Europe is stable at around 8%. The impact of baseline mutation patterns on susceptibility to antiretroviral drugs should be addressed using clinical guidelines. The impact on baseline susceptibility is largest for nonnucleoside reverse transcriptase inhibitors.

Background. Numerous studies have shown that baseline drug resistance patterns may influence the outcome of antiretroviral therapy. Therefore, guidelines recommend drug resistance testing to guide the choice of initial regimen. In addition to optimizing individual patient management, these baseline resistance data enable transmitted drug resistance (TDR) to be surveyed for public health purposes. The SPREAD program systematically collects data to gain insight into TDR occurring in Europe since 2001.

Methods. Demographic, clinical, and virological data from 4140 antiretroviral-naive human immunodeficiency virus (HIV)–infected individuals from 26 countries who were newly diagnosed between 2008 and 2010 were analyzed. Evidence of TDR was defined using the WHO list for surveillance of drug resistance mutations. Prevalence of TDR was assessed over time by comparing the results to SPREAD data from 2002 to 2007. Baseline susceptibility to antiretroviral drugs was predicted using the Stanford HIVdb program version 7.0.

Results. The overall prevalence of TDR did not change significantly over time and was 8.3% (95% confidence interval, 7.2%–9.5%) in 2008–2010. The most frequent indicators of TDR were nucleoside reverse transcriptase inhibitor (NRTI) mutations (4.5%), followed by nonnucleoside reverse transcriptase inhibitor (NNRTI) mutations (2.9%) and protease inhibitor mutations (2.0%). Baseline mutations were most predictive of reduced susceptibility to initial NNRTI-based regimens: 4.5% and 6.5% of patient isolates were predicted to have resistance to regimens containing efavirenz or rilpivirine, respectively, independent of current NRTI backbones.

Conclusions. Although TDR was highest for NRTIs, the impact of baseline drug resistance patterns on susceptibility was largest for NNRTIs. The prevalence of TDR assessed by epidemiological surveys does not clearly indicate to what degree susceptibility to different drug classes is affected.

Continuous increase in HIV-1 incidence after the year 2000 among men who have sex with men in Rome: insights from a 25-year retrospective cohort study

To assess trends in HIV-1 incidence and risk factors for seroconversion among men who have sex with men (MSM) resident in Rome, Italy, a retrospective longitudinal cohort study was conducted over 25 years. Incidence rates and trends were modelled using Poisson regression and risk factors were assessed by multivariate Cox models. Of 1,862 HIV-1-negative individuals, 347 seroconverted during follow-up. HIV-1 incidence rates increased from 5.2/100 persons/year (p/y) in 1986 (95% confidence interval (CI): 2.3–11.5) to 9.2/00 p/y in 1992 (95% CI: 6.4–13.0), decreased to 1.3/100 p/y in 2001 and increased until 2009 (11.7/100 p/y; 95% CI: 7.4–18.6). The risk of HIV-1 seroconversion increased during the study period in younger MSM (incidence rate ratio (IRR) = 17.18; 95% CI: 9.74–30.32 in 16–32 year-olds and IRR = 5.09; 95% CI: 2.92–8.87 in 33–41 year-olds) and in those who acquired syphilis (IRR = 7.71; 95% CI: 5.00–11.88). In contrast, the risk of seroconversion decreased among highly educated MSM (IRR = 0.54; 95% CI: 0.35–0.82) and those without Italian citizenship (IRR = 0.45; 95% CI: 0.28–0.71). The HIV epidemic in MSM living in Rome continues to expand. Targeted prevention programmes against sexually transmitted infections to enhance knowledge transfer and behavioural skills are urgently required.

Investigation of an imported case of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection in Florence, Italy, May to June 2013

On 31 May 2013, the first case of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection in Italy was laboratory confirmed in a previously healthy adult man, who developed pneumonia with moderate respiratory distress after returning from a holiday in Jordan. Two secondary cases were identified through contact tracing, among family members and colleagues who had not previously travelled abroad. Both secondary cases developed mild illness. All three patients recovered fully.

Bacterial Isolates from Severe Infections and Their Antibiotic Susceptibility Patterns in Italy: a Nationwide Study in the Hospital Setting

The most frequent agents of severe bacterial infections and their antibiotic susceptibility patterns were determined in patients admitted to 45 Italian hospitals over the years 2002-2003. The most common diagnoses were: sepsis (33.8%), pneumonia (9.4%), intravascular catheter-associated infections (9.3%) and ventilator-associated pneumonia (8.1%). Overall, 5115 bacterial isolates were identified from 4228 patients. Three bacterial species, Staphylococcus aureus, Pseudomonas aeruginosa and Escherichia coli, accounted for more than 50% of the isolates. Other prevalent bacterial isolates were Staphylococcus epidermidis and Enterococcus faecalis, while Acinetobacter baumanii ranked third among all Intensive Care Unit (ICU) isolates. 7% of S. aureus had intermediate resistance to vancomycin. Although E. faecalis displayed no vancomycin resistance, 34% of vancomycin-resistant isolates were found among Enterococcus faecium, one of the highest rates found to date, emphasizing the difference between these two enterococcal species. All the Gram-positive pathogens were susceptible to linezolid, with the exception of approximately 2% of the enterococcal isolates that were intermediate with a minimum inhibitory concentration (MIC)=4 microg/ml. Almost 10% of Escherichia coli, 14% of Klebsiella pneumoniae, 22% of Serratia marcescens and 50% of Enterobacter cloacae were non-susceptible to cefotaxime. Amikacin was the most active antibiotic against P. aeruginosa that showed lack of susceptibility to ceftazidime, gentamicin, piperacillin and ciprofloxacin ranging from 20 to 35%. Finally, Acinetobacter baumanii showed a high level of resistance to all the antibiotics tested including imipenem (58%). The results obtained in this study, the first of its kind in Italy, offer indications for guiding empirical therapy and implementing specific interventions to fight antibiotic-resistant bacterial infections and their transmission in the hospital setting in Italy.

HIV treatment as prevention: population effect vs. individual protection?

There are compelling data suggesting that antiretroviral (ARV) drugs can prevent the transmission of HIV: 1) ARV therapy reduces the intrinsic risk of transmission by cutting down the viral load in infected people; 2) ARVs may be used to prevent transmission in uninfected subjects who experienced high risk exposures. Despite these encouraging preliminary results, there are several questions that need to be answered before recommending the use of ARV among uninfected subjects: 1) the efficacy of these strategies amongst women is not yet established; 2) the cost-effectiveness of pre-exposure prophylaxis (PrEP) in the long term is undefined since PrEP efficacy may depend on adherence; 3) treating uninfected individuals may be counter-effective, as it may increase risky behavior due to the belief that ARV drugs have unlimited protective power. In conclusion, the public-health use of ARV drugs represents a new paradigm in the field of HIV prevention. However, ARV treatment cannot be considered as a substitute for other measures for preventing transmission but a complement to individual protection. In particular, post-exposure prophylaxis may be used in selected cases, whereas PrEP appears to be a highly costly method with limited public-health potential and possible safety concerns.

Probable autochthonous introduced malaria cases in Italy in 2009-2011 and the risk of local vector-borne transmission

We describe two cases of probable autochthonous introduced Plasmodium vivax malaria that occurred in 2009 and 2011 in two sites of South-Central Italy. Although the sources of the infections were not detected, local transmission could not be disproved and therefore the cases were classified as autochthonous. Sporadic P. vivax cases transmitted by indigenous vectors may be considered possible in some areas of the country where vector abundance and environmental conditions are favourable to malaria transmission.

Probable autochthonous introduced malaria cases in Italy in 2009–2011 and the risk of local vector-borne transmission

We describe two cases of probable autochthonous introduced Plasmodium vivax malaria that occurred in 2009 and 2011 in two sites of South-Central Italy. Although the sources of the infections were not detected, local transmission could not be disproved and therefore the cases were classified as autochthonous. Sporadic P. vivax cases transmitted by indigenous vectors may be considered possible in some areas of the country where vector abundance and environmental conditions are favourable to malaria transmission.

Circulation of West Nile virus lineage 1 and 2 during an outbreak in Italy

In 2011, from 26 September to 16 October, a small outbreak of West Nile virus (WNV) disease occurred on the island of Sardinia (Italy). According to the national case definition, six cases with acute neurological disease were confirmed in hospitalized patients, and four of them died; one of these was only 34 years old. In two case, WNV RNA was detected in urine, suggesting renal involvement. Sequence analysis showed lineage 1 and 2 circulation.

Epidemiological surveillance of West Nile neuroinvasive diseases in Italy, 2008 to 2011

Binary file ES_Abstracts_Final_ECDC.txt matches

Epidemiological surveillance of West Nile neuroinvasive diseases in Italy, 2008 to 2011

We describe the geographical and temporal distribution of West Nile neuroinvasive diseases (WNND) cases in Italy from 2008 to 2011. The increasing number of confirmed human cases from eight in 2008 to 18 in 2009 and the occurrence of the virus in a larger geographical area in 2009 (moving from east to west) prompted the Ministry of Health to publish, in spring 2010, a national programme for WNND human surveillance, comprising veterinary and vector surveillance. Subsequently, in 2011, a new national plan on integrated human surveillance of imported and autochthonous vector-borne diseases (chikungunya, dengue and West Nile disease) was issued. Between 2008 and 2011, 43 cases of WNND were reported from five regions in Italy with a case fatality rate of 16%. The incidence of WNND during the entire study period was 0.55 per 100,000 population (range: 0.06–0.23 per 100,000). During 2011, two new regions (Friuli-Venezia Giulia and Sardinia) reported confirmed cases in humans. Integrated human, entomological and animal surveillance for West Nile virus is a public health priority in Italy and will be maintained during 2012.

Acute respiratory distress syndrome due to influenza virus A/H1N1v in a patient with HIV/HCV co-infection

The clinical severity of human infection with the novel influenza virus A/H1N1v has not been completely defined, especially in HIV/hepatitis C virus (HCV) infected patients. Although most patients develop mild to moderate symptoms, severe disease may occur in a limited proportion of cases. We report the case of a 44-year-old man infected with HIV and HCV with a high CD4 cell count who developed acute respiratory distress syndrome associated with influenza virus A/H1N1v infection. The patient recovered completely after oseltamivir therapy and mechanical ventilation.

Prevalence of IgM and IgG antibodies to West Nile virus among blood donors in an affected area of north-eastern Italy, summer 2009

Following reports of West Nile neuroinvasive disease in the north-eastern area of Italy in 2009, all blood donations dating from the period between 1 August and 31 October 2009 in the Rovigo province of the Veneto region were routinely checked to exclude those with a positive nucleic acid test for West Nile virus (WNV). Only one of 5,726 blood donations was positive (17.5 per 100,000 donations; 95% confidence interval (CI): 0.4–97.3). In addition, a selection of 2,507 blood donations collected during the period from 20 July to 15 November 2009 were screened by ELISA for IgG and IgM antibodies against WNV. A positive result was received for 94 of them. The positive sera were further evaluated using immunofluorescence and plaque reduction neutralisation test (PRNT), in which only 17 sera were confirmed positive. This corresponds to a prevalence of 6.8 per 1,000 sera (95% CI: 4.0–10.9). In a case-control study that matched each of the 17 PRNT-positive sera with four negative sera with the same date of donation and same donation centre, we did not find a significant association with age and sex of the donor; donors who worked mainly outdoors were significantly more at risk to have a positive PRNT for WNV.

Prevalence of antibodies to phleboviruses and flaviviruses in Peja, Kosovo

In order to investigate the current and past activity of phlebovirus and flavivirus in Kosovo, a seroprevalence study among 200 blood donors was performed. Positive results were obtained for the phleboviruses TOSV and SFNV, and for a flavivirus of the Japanese Encephalitis group. No positive results for TBEV were observed.

Molecular surveillance of pandemic influenza A(H1N1) viruses circulating in Italy from May 2009 to February 2010: association between haemagglutinin mutations and clinical outcome

Haemagglutinin sequences of pandemic influenza A(H1N1) viruses circulating in Italy were examined, focusing on amino acid changes at position 222 because of its suggested pathogenic relevance. Among 169 patients, the D222G substitution was detected in three of 52 (5.8%) severe cases and in one of 117 (0.9%) mild cases, whereas the D222E mutation was more frequent and evenly distributed in mild (31.6%) and severe cases (38.4%). A cluster of D222E viruses among school children confirms reported human-to-human transmission of viruses mutated at amino acid position 222.

Viral hepatitis, HIV, human herpes virus and Treponema pallidum infection in haemodialysis patients from Kosovo, 2005

The serological status of hepatitis viruses and other infectious diseases in the 66 dialysed patients of one haemodialysis unit in Kosovo were studied, comparing the data with a large group of blood donors and out-patients. All dialysed patients were hepatitis A virus (HAV) positive. Prevalence of hepatitis B surface antigen (HBsAg), hepatitis B surface antibodies (anti-HBs), and hepatitis B core antibodies (anti-HBc) was 14 of 66, 21% (95% confidence interval (CI): 12-33%), 5 of 66, 8% (95%CI: 5-22%), and 50 of 66, 76% (95%CI: 64-85%), respectively. Antibodies to hepatitis C virus (anti-HCV) prevalence was 57 of 66, 86% (95%CI: 76-94%). No human immunodeficiency virus (HIV) positive case was found. Prevalence of past herpes simplex virus type 2 (HSV-2) infection was 29% (95%CI: 18-41%). Two patients (3%, 95%CI: 0-10%) were positive for Treponema pallidum and 18% (95%CI: 10-30%) were human herpesvirus 8 (HHV-8) antibody positive. Four hundred and fifty-two subjects were recruited for comparison. Markers of past HAV infection was associated with haemodialysis (Fisher s exact test p-value=0.037). Dialysed patients were at a higher risk of being HBsAg positive than others: the sex- and age-adjusted odds ratio (OR) was 5.18 (95%CI: 1.87-14.32). Anti-HBc positivity was strongly associated with haemodialysis: the sex- and age-adjusted OR was 6.43 (95%CI: 3.22-12-85). Anti-HCV positivity was 86% and 1% in presence and absence of haemodialysis, respectively. The Fisher s exact test for association proved a strong association between haemodialysis and HCV (p-value<0.0001). The OR for association between haemodialysis and HSV-2 positivity was 3.20 (95%CI: 1.46-7.00). Significant associations were also observed between haemodialysis status and antibodies to Treponema pallidum (Fisher s exact test p-value=0.044). In Kosovo, the prevalence of viral hepatitis infection and other viral infections and Treponema pallidum among dialysed patients is high, indicating major ongoing nosocomial transmission.

Viral hepatitis, HIV, human herpes virus and Treponema pallidum infection in haemodialysis patients from Kosovo, 2005

Binary file ES_Abstracts_Final_ECDC.txt matches

West Nile virus transmission with human cases in Italy, August - September 2009

In 2009, to date 16 human cases of West Nile neuroinvasive disease (WNND) have been reported in Italy, in three regions: Veneto, Emilia-Romagna and Lombardia. The number of cases is higher compared with last year when nine cases were identified (eight cases of WNND and one case of West Nile fever) and the geographical distribution indicates spread from east to west.

West Nile virus transmission with human cases in Italy, August - September 2009

In 2009, to date 16 human cases of West Nile neuroinvasive disease (WNND) have been reported in Italy, in three regions: Veneto, Emilia-Romagna and Lombardia. The number of cases is higher compared with last year when nine cases were identified (eight cases of WNND and one case of West Nile fever) and the geographical distribution indicates spread from east to west.

Non-B HIV type 1 subtypes among men who have sex with men in Rome, Italy

An increase in the circulation of HIV-1 non-B subtypes has been observed in recent years in Western European countries. Due to the lack of data on the circulation of HIV-1 non-B subtypes among European HIV-1-infected men who have sex with men (MSM), a biomolecular study was conducted in Rome, Italy. HIV-1 partial pol gene sequences from 111 MSM individuals (76 drug naive and 35 drug experienced) were collected during the years 2004-2006. All these sequences were analyzed using the REGA HIV-1 Subtyping Tool, and aligned using CLUSTAL X followed by manual editing using the Bioedit software. A BLAST search for non-B subtype sequences was also performed. Twenty-six (23.4%) MSM were not Italians. Eight individuals (7.2%) were diagnosed as HIV infected before 1991, 20 (18.0%) between 1991 and 1999, and 83 (74.8%) from 2000 to 2006. Fifteen (15/111, 13.5%) individuals were infected with the non-B subtype. The percentage of infection with HIV-1 non-B subtypes was 8.2% (7/85) among Italian MSM and 30.8% (8/26) among the non-Italians (OR = 4.95 95% IC: 1.40-17.87). Individuals infected with the non-B subtype were significantly younger than those infected with the HIV-1 B subtype (28 years vs. 34 years, p = 0.003). The CRFs were more prevalent (8.1%) than pure subtypes (5.4%), which were distributed as follows: subtype C (2.6%), subtype A1 (1.7%), and subtype F1 (0.9%). Major mutations conferring resistance to antiretroviral drugs (ARV) were not found among HIV-1 non-B subtype drug-naive patients but were found in two ARV-experienced individuals. The data show that viral diversity is likely increasing in a population group that had been previously characterized by the circulation of HIV-1 subtype B.

Mortality at ages 50-59 and deprivation at early and late stages of the life course in Wales

BACKGROUND

Most previous studies have examined the association between mortality and deprivation at only one point in time. However, risk accumulates over the life course. The design of the study was ecological. Its aims were to explain inequalities in total and cause-specific mortality between geographical areas in relation to the lifestyle and health behaviours of the resident populations and the area levels of deprivation in 1981 and in 1921-40.

METHODS

Data on health behaviour from the 1985 Heartbeat Wales Community Survey were evaluated in light of Welsh mortality rates for the period 1981-99, 1981 census data on socioeconomic position and the infant mortality rates in 1921-40. Negative binomial models were carried out to investigate the district-level association of mortality with deprivation (infant mortality in 1921-40, Carstairs score in 1981, combined index of deprivation) independently from the personal habits and characteristics of the resident population.

RESULTS

There was an increased risk of death in deprived areas compared with more wealthy ones. Both infant mortality (a proxy of material deprivation during the time in which the 50-59-year-old individuals were born or were children) and Carstairs scores (a proxy of deprivation during adulthood) were strongly associated with recent mortality. Deprivation had stronger effects in women than in men, the only exception being the effects of later life deprivation on lung cancer.

CONCLUSIONS

Area characteristics at different points of time may help to explain geographical inequality in mortality.

Infection with chikungunya virus in Italy: an outbreak in a temperate region

BACKGROUND

Chikungunya virus (CHIKV), which is transmitted by Aedes spp mosquitoes, has recently caused several outbreaks on islands in the Indian Ocean and on the Indian subcontinent. We report on an outbreak in Italy.

METHODS

After reports of a large number of cases of febrile illness of unknown origin in two contiguous villages in northeastern Italy, an outbreak investigation was done to identify the primary source of infection and modes of transmission. An active surveillance system was also implemented. The clinical case definition was presentation with fever and joint pain. Blood samples were gathered and analysed by PCR and serological assays to identify the causal agent. Locally captured mosquitoes were also tested by PCR. Phylogenetic analysis of the CHIKV E1 region was done.

FINDINGS

Analysis of samples from human beings and from mosquitoes showed that the outbreak was caused by CHIKV. We identified 205 cases of infection with CHIKV between July 4 and Sept 27, 2007. The presumed index case was a man from India who developed symptoms while visiting relatives in one of the villages. Phylogenetic analysis showed a high similarity between the strains found in Italy and those identified during an earlier outbreak on islands in the Indian Ocean. The disease was fairly mild in nearly all cases, with only one reported death.

INTERPRETATION

This outbreak of CHIKV disease in a non-tropical area was to some extent unexpected and emphasises the need for preparedness and response to emerging infectious threats in the era of globalisation.

Human herpesvirus 8 and human herpesvirus 2 infections in prison population

Incarcerated persons have high rates of infectious diseases. Few data on the prevalence of sexually transmitted diseases in prisoners are available. This multi-center cross-sectional study enrolled 973 inmates from eight Italian prisons. Demographic and behavioral data were collected using an anonymous standardized questionnaire and antibodies to HIV, HCV, HBV, HSV-2, and HHV-8 were detected in a blood sample obtained from each person at the time of the enrollment in the study. Two hundred and two out of the 973 subjects (20.7%) had antibodies against HHV-8. HHV-8-seropositive subjects were more likely to be older than 30 years with a higher educational level. HHV-8 infection was associated significantly with HBV (P < 0.001) and HSV-2 (P = 0.004) seropositivity and with previous imprisonments. Multivariate analysis showed that HHV-8 infection in Italian inmates was associated with HBV (P < 0.001) and HSV-2 (P = 0.002) seropositivity otherwise among foreigners inmates HHV-8 was significantly associated with HBV infection (P = 0.05). One hundred and eighty-six (21.2%) prisoners had anti-HSV-2 antibodies. At multivariate analysis HSV-2-positivity was significantly associated with HIV (P < 0.001) and HHV-8 infections (P = 0.003), whereas it was inversely associated with HCV infection (0.004). A relatively high seroprevalence of HHV-8 and HSV-2 among Italian prison inmates was found. The association of HHV-8 and HSV-2 infections suggest sexual transmission of these viruses among Italian prison inmates.

The Changing Face of the HIV Epidemic in Northern Sardinia: Increased Diagnoses among Pregnant Women

BACKGROUND

Combination antiretroviral therapy has reduced both HIV/AIDS related morbidity and mortality. However, while the number of new AIDS diagnosis progressively declined in Europe from 1997 to 2004, new HIV infection diagnoses showed an increase since 1998. Unfortunately, there is no national HIV reporting system in Italy, and no information is available from the South and the islands.

METHODS

Data on new HIV infections diagnosed in northern Sardinia between 1997 and 2004 were retrospectively collected. Thus, two four years periods (1997-2000 vs 2001-2004) were compared in order to assess changes in the characteristics of newly diagnosed individuals.

RESULTS

Overall, 156 new HIV infection diagnoses occurred during the study period, 87 (55.8%) in males and 69 (44.2%) in females. The incidence rate per 100,000 inhabitants showed a progressive decline from 1997 (5.9) to 2001 (3.3), followed by a rapid increase in 2002 (5.0) and a new decline in 2004 (3.5). Median age progressively increased over the study period, from 33 years in 1997 to 38 in 2004. Males (55.8%) were more frequently affected than females (44.2%), who showed a trend toward a slight but progressive proportional increase. With regard to the exposure category, 95 (60.9%) individuals were heterosexual contacts, 38 (24.4%) injection drug users (IDU), 17 (10.9%) homosexual men, and 6 (3.8%) not determined (ND). There was a proportional increase for homosexual men (+7.5%) and heterosexual contacts (-7.9%), while IDU showed a slight decrease ( 2.7%). Heterosexual intercourse was the main exposure category both for women (78%) and men (47.1%), but man-to-man sex increased in the last study period. IDU still accounted for 20.3% and 27.5% of the cases among women and men, respectively. An increase in the proportion of new diagnoses in pregnant women, from 8.6% to 20.6%, was also observed. All pregnant women diagnosed in the first four years period were Italian, whereas 4 of the 7 (57.1%) women diagnosed thereafter were foreigner. Finally, the proportion of new HIV diagnoses in foreigners showed a marked increase, from 2.4% to 17.6%; of them 71.4% originated from sub-Saharan Africa.

CONCLUSIONS

Our results suggest that the HIV epidemic is far from being controlled in our Region. Prevention campaigns targeted to homosexual men, women and migrants are needed. Non-HIV specialists, such as gynaecologists and obstetricians, as well as general practitioners, should routinely offer HIV testing to pregnant women.

Demographic Indicators and Risk of Infection with Human Herpesvirus Type 8 in Central Italy

BACKGROUND

A cross-sectional study was conducted in Latium and Abruzzo Regions (Central Italy) to estimate the prevalence of infection with human herpesvirus type 8 (HHV-8) and the association between demographic indicators and risk of HHV-8 infection.

PATIENTS AND METHODS

Sera from 416 healthy individuals (>or=45 years of age), originally recruited in a multicentric case-control study on classic Kaposi's sarcoma (KS), were tested for antibodies against HHV-8. The association between demographic indicators (i.e., urban/rural residence, occupation) and HHV-8 seropositivity was assessed by means of multiple logistic regression (MLR) odds ratios (OR) and 95% confidence intervals (CI), adjusted for age and occupation.

RESULTS

Overall, 20.4% of the study participants had antibodies against HHV-8, 23.2% of the men and 17.0% of the women (p = 0.15). HHV-8 seropositivity rates significantly increased with age (p = 0.01), from 10.0% in those under 65 years of age to 24.9% in 75 years or older (MLROR = 2.4). By multivariate analysis, a significantly 2-fold higher risk of HHV-8 was found in individuals living in rural areas, as compared to those living in metropolitan/urban areas (MLR-OR = 2.0, 95% CI: 1.1-3.5), and in farmers, as compared to white collars (MLR-OR = 2.1, 95% CI: 1.1-4.1).

CONCLUSIONS

The study findings suggest that demographic factors such as age, urban/rural residence, and occupation are associated with HHV-8 seropositivity among adult individuals living in central Italy.

Increasing proportion of late testers among AIDS cases in Italy, 1996–2002

In recent years, the proportion of individuals who are unaware of being infected with HIV when diagnosed with AIDS (defined as 'late testers') has dramatically increased in several European countries, including Italy. We evaluated the extent and determinants of late testing and its impact in terms of AIDS-defining illnesses among AIDS cases reported to the Italian National AIDS Registry since 1996. Late testers were defined as those persons whose first positive HIV test result was within six months of the AIDS diagnosis. Late testers were more likely to be heterosexual contacts or MSWM, as opposed to IDUs. They were also more likely to come from low prevalence areas of Italy or from foreign countries. At AIDS diagnosis, late testers were less likely to be undergoing HAART or prophylaxis against PCP/toxoplasmosis, compared to non-late testers. The mean CD4 cell count at AIDS diagnosis was significantly lower among late testers. PCP, toxoplasmosis and Kaposi's sarcoma were more frequently diagnosed as an AIDS-defining illness in late testers, who also had a significantly higher risk of presenting with multiple concomitant AIDS-defining illnesses. In conclusion, late testing results in missed opportunities for preventing and treating HIV infection, leading to an increased risk of developing preventable opportunistic infections and death.

Immunosuppression and Cancer: A Comparison of Risks in Recipients of Organ Transplants and in HIV-Positive Individuals

The comparison of cancers occurring excessively among HIV-infected and transplanted individuals may help to elucidate the relationship between immune surveillance, viral infections, and cancer. A longitudinal study was conducted on 2002 HIV-infected Italian subjects, 6072 HIV-infected French individuals, and 2878 Italian recipients of solid organ transplants. Standardized incidence ratios (SIR) and 95% confidence intervals (CI) were computed to quantify the risk for cancer, compared with the French and Italian general populations. The SIRs for all cancers were 9.8 (95% CI: 9.0-10.6) for HIV-infected individuals versus 2.2 (95% CI: 1.9-2.5) for transplant recipients. In both groups, most of the excess risk was attributable to virus-related cancers, such as Kaposi's sarcoma (KS; SIR = 451 in HIV-positive individuals, 125 in transplant recipients), non-Hodgkin's lymphoma (NHL; SIR = 62.1 and 11.1, respectively), and liver cancer (SIR = 9.4 and 4.1, respectively). Significantly increased SIRs for anal cancer and Hodgkin's lymphoma were found only among HIV-positive individuals. Among women younger than 40 years of age, a more than 10-fold increase in cervical cancer risk was found in both groups. Among HIV-infected individuals treatment with highly active antiretroviral therapies drastically reduced SIRs for KS and NHL only. These results show that HIV-infected individuals and transplant recipients share a similar pattern of cancer risk, largely due to virus-related cancers.