Poliovirus and Other Enteroviruses from Environmental Surveillance in Italy, 2009-2015

Within the initiatives for poliomyelitis eradication by WHO, Italy activated an environmental surveillance (ES) in 2005. ES complements clinical Acute Flaccid Paralysis (AFP) surveillance for possible polio cases, detects poliovirus circulation in environmental sewage, and is used to monitor transmission in communities. In addition to polioviruses, the analyses comprised: (i) the monitoring of the presence of non-polio enteroviruses in sewage samples and (ii) the temporal and geographical distribution of the detected viruses. From 2009 to 2015, 2880 sewage samples were collected from eight cities participating in the surveillance. Overall, 1479 samples resulted positive for enteroviruses. No wild-type polioviruses were found, although four Sabin-like polioviruses were detected. The low degree of mutation found in the genomes of these four isolates suggests that these viruses have had a limited circulation in the population. All non-polio enteroviruses belonged to species B and the most frequent serotype was CV-B5, followed by CV-B4, E-11, E-6, E-7, CV-B3, and CV-B2. Variations in the frequency of different serotypes were also observed in different seasons and/or Italian areas. Environmental surveillance in Italy, as part of the 'WHO global polio eradication program', is a powerful tool to augment the polio surveillance and to investigate the silent circulation or the re-emergence of enteroviruses in the population.

Spotted Fever Group Rickettsiae in Ixodes Ricinus and Haemaphysalis Punctata Ticks in Italy

In this study Ixodes ricinus and Haemaphysalis punctata ticks are examined. For the first time we detected Rickettsia conorii in I. ricinus and H. punctata, and Rickettsia sibirica in I. ricinus. Our results raise the question of whether other spotted fever group rickettsiae, in addition to R. conorii subsp. conorii and R. conorii subsp. israelensis, are involved in bacterial diseases in Italy and whether I. ricinus and H. punctata can act as new vectors for these rickettsiae.

Tick-borne encephalitis in north-east Italy: a 14-year retrospective study, January 2000 to December 2013

Italy is considered at low incidence of tick-borne encephalitis (TBE), and the occurrence of human cases of TBE appears to be geographically restricted to the north east of the country. However, most information to date derives from case series, with no systematic data collection. To estimate incidence rates (IR) and spatial distribution of TBE cases, we conducted a retrospective study in north-eastern Italy. Data were collected through the infectious disease units and public health districts of three regions (Friuli Venezia Giulia, Trentino Alto Adige and Veneto) between 2000 and 2013. Overall, 367 cases were identified (IR: 0.38/100,000). The cases' median age was 56 years and 257 (70%) were male. Central nervous system involvement was reported in 307 cases (84%). Annual fluctuations in case numbers occurred, with peaks in 2006 and in 2013, when 44 and 42 cases were respectively observed. A strong seasonality effect was noted, with the highest number of cases in July. In terms of geographical location, three main endemic foci with high TBE IR (>10/100,000) were identified in three provinces, namely Belluno (Veneto region), Udine (Friuli Venezia Giulia) and Trento (Trentino Alto-Adige). When investigating the whole study area in terms of altitude, the IR between 400 and 600 m was greater (2.41/100,000) than at other altitudes (p<0.01). In conclusion, the incidence of TBE in Italy is relatively low, even considering only the three known affected regions. However, three endemic foci at high risk were identified. In these areas, where the risk of TBEV infection is likely high, more active offer of TBE vaccination could be considered.

Investigations on California serogroup orthobunyaviruses in the Tyrols: first description of Tahyna virus in the Alps

Seroprevalence rates for immunoglobulin G (IgG) antibodies to Tahyna virus (TAHV) and Inkoo virus (INKV) were determined in sera of 1630 blood donors from North, East, and South Tyrol by immunofluorescence assays (IFAs) and confirmatory serum neutralization tests (SNTs). Ten sera (0.6%) reacted positive by TAHV IFA, five of which (0.3%) were confirmed by SNT. Eleven sera (0.7%) reacted positive in the INKV IFA; only one thereof (0.06%) was verified by subsequent SNT. To identify the source of infections, mosquitoes were trapped at 18 sampling sites in the study area, resulting in the collection of 2571 adult mosquitoes: 1254 individuals of the genus Aedes (48.8% of total) including A. albopictus, 640 Culex (24.9%), 303 Coquillettidia (11.8%), 252 Ochlerotatus (9.8%), 49 Anopheles (1.9%), and 73 mosquitoes of the genus Culiseta (2.8%). The mosquitoes were pooled according to species, trapping site, and time, and were tested by RT-PCR for the presence of California serogroup orthobunyavirus nucleic acids. PCR amplification products were obtained in five of 195 pools (2.6%), and all were identified as TAHVs by subsequent sequencing. This represents the first evidence of TAHV circulation and human exposure in the Tyrols and in the alpine region in general. Interestingly, all TAHV sequences were identified in Culex pipiens/torrentium mosquitoes. Whether other California serogroup orthobunyaviruses such as INKV are also circulating in this area is subject of further investigations on larger numbers of mosquitoes.

Risk assessment of transfusion-associated babesiosis in Tyrol: appraisal by seroepidemiology and polymerase chain reaction

BACKGROUND

After malaria, babesiosis is the second most common transfusion-transmitted parasitic disease in the United States. In Europe, one reported transfusion case, concerning Babesia microti, occurred in Germany.

STUDY DESIGN AND METHODS

Due to the fact that Babesia spp. are present in Tyrolean ticks, the aim of this study is to assess the occurrence of immunoglobulin (Ig)G antibodies against the Babesia divergens complex, including B. divergens and Babesia venatorum (EU1), as well as B. microti by screening a representative collective of 988 blood donors from North and East Tyrol (Austria) with indirect immunofluorescence antibody test. Additionally, we investigated 206 local ixodid ticks for the presence of babesial DNA by polymerase chain reaction.

RESULTS

Seroprevalence data resulted in rates of 2.1% for IgG antibodies against the B. divergens complex and 0.6% against B. microti in Tyrolean blood donors. All sera could be confirmed by independent retesting. Our data indicate that cross-reactivity is high between B. divergens and B. venatorum and lower than 19.8% between B. divergens and B. microti.

CONCLUSIONS

This study shows that Babesia spp. are present in the Tyrols, which blood donors come into serologic contact with, and that we have to consider how to sustain blood product safety concerning this new challenge. Additionally, it is the first description of B. venatorum in the Tyrols, found in one Ixodes ricinus at the Italian border.

Detection of Enteroviruses in Influent and Effluent Flow Samples from Wastewater Treatment Plants in Italy

This study evaluated the presence and seasonal distribution of polio and other enteroviruses in four wastewater treatment plants in three cities in Italy, using different treatment systems. Detection of enteroviruses was carried out by virus isolation in cell cultures after concentration of water samples collected at both inlet and outlet of the treatment plants, following the methods described in the WHO guidelines. Viral serotypes isolated before and after water treatment were compared. Forty-eight non-polio enteroviruses were isolated from 312 samples collected at the inlet of the four wastewater treatment plants, 35 of which were Coxsackievirus type B (72.9 %) and 13 Echovirus (27.1 %). After treatment, 2 CVB3, 1 CVB5, and 1 Echo 6 were isolated. CVB3 and Echo 6 serotypes were also detected in samples collected at the inlet of the TP, in the same month and year. The high rate of detection of infectious enteroviruses in inlet sewage samples (30.1 %) indicates wide diffusion of these viruses in the populations linked to the collectors. The incomplete removal of infectious viruses following sewage treatment highlights possible risks for public health relate to treated waters discharge into the environment.

Spotted fever group--Rickettsiae in the Tyrols: evidence by seroepidemiology and PCR

The aim of our study was to assess the occurrence of Rickettsia in the inner-alpine valleys of the Eastern Alps and to determine the amount of seroreaction among the local human population. Ticks were investigated by PCR and the percentage of seropositives was determined among local blood donors by an in-house immunofluorescence assay. The local cut-off titre for screening of IgG was set at 1 : 128 with a well-characterised low-risk collective according to WHO-guidelines. Positive sera were confirmed by independent re-testing. Rickettsia is present in ticks north and south of the continental divide. Of 259 ticks investigated, 12.4% are positive for Rickettsia. Of over 1200 blood donors tested so far, 7.7% bear IgG at a titre of 1 : 128 or higher against R. helvetica. R. helvetica is present in the study area, causes immunoreaction among local residents and is associated with anamnestic erythema. Furthermore, screening with a second Spotted Fever Group Rickettsia indicates that significant parts of the Tyrolean population are exposed to a Rickettsia other than R. helvetica.

[The role of the public health personnel in the Prevention Department (in the Hygiene Services and Public Health Care and Hygiene of Food and Nutrition): proposal for the future of public health care]

A global and local discussion on Public Health relevance is taking place, including the future role and organization of its services. Noteworthy becomes the role played by Public Health Specialists. This work presents the results of a workshop, carried out following the Guilbert methodology, whose aim was to define Public Health Doctors functions and their related activities. The programme involved 30 professionals from Triveneto area (North Eastern Italy), working in Prevention Departments at National Health Service and Universities. The key-functions identified were: 1) Health status assessment and identification of community risk factors, 2) Health Promotion, 3) Prevention, 4) Protection, 5) Planning, 6) Communication, 7) Professional Training, 8) Alliances and resources for complex Public Health programs, 9) Crisis management in Public Health, 10) Research. For each function activities were identified, meaning concerning areas and contents that must be warranted by professionals. This experience allowed to share existing attitudes and experiences present in Triveneto area, and it can stand as a feasible instrument for different settings. Nevertheless, it appears mandatory explaining at each level in the society role and functions of Prevention Departments.

Costal cartilage grafting for repair of a recurrent tracheoesophageal fistula in a 1.6-kg baby with esophageal atresia

A large intraoperative tracheal tear occurred during correction of a type III esophageal atresia in a 1,630-g premature baby. It was repaired by primary suture. Recurrence of the tracheoesophageal fistula (TEF) was treated operatively with esophageal exclusion and costal cartilage grafting (CCG) onto the tracheal defect. At 3 months of age, successful esophageal reconstruction was performed using a posterior mediastinal colonic interposition. On 27-month follow-up, the child was symptom-free and thriving. Surgical options for TEF recurrence and intraoperative management of the tracheal air leak are discussed. CCG is advocated as an attractive material for tracheal repair even in low-weight prematures.

An experimental model of gastroschisis using fetoendoscopy: preliminary results and technical considerations

BACKGROUND

The aim of this study was to show the feasibility of an experimental model of gastroschisis using fetoendoscopic surgery on sheep fetuses, and also to perform amnioinfusion until delivery using an in-dwelling intraamniotic catheter.

METHODS

We analyzed the data from 18 pregnant ewes having 26 fetuses, which underwent surgery at 80 days of gestation (full term, 145 days). The fetendo technique was used to create a gastroschisis in 15 fetuses. The fetal abdominal wall was opened on the left side of the cord using scissors. The omentum and the intestinal loops were eviscerated using atraumatic forceps. Eleven fetuses were used as a control group. Twenty-one fetuses underwent amnioinfusion; a simple exteriorized catheter was used in seven cases and an intraamniotic catheter with an implantable port was used in the other 14. All ewes and fetuses were killed at the end of the experiment by an intravenous injection of pentotal; thereafter, the fetuses underwent necropsy.

RESULTS

Twelve fetuses died and 14 survived (53.8%); seven of the 15 that underwent gastroschisis survived (46.7%). An amniotic infection occurred in nine fetuses (34.6%); of these, six died and three that were administered antibiotics survived.

CONCLUSIONS

Our experience shows that this experimental model of gastroschisis is feasible and reproducible, and that a repeated amnioinfusion can be performed with an in-dwelling catheter in pregnant ewes. The use of an implantable port is safer than a simple exteriorized catheter.

Prevalence of antibodies to Leptospira serovars in sheep and goats in Alto Adige-South Tyrol

Serum samples from 313 sheep and 95 goats were collected during November 1993 in 26 localities in Alto Adige-South Tyrol and tested by microscopic agglutination test for antibodies to 28 serovars of the genus Leptospira. At the time of blood collection all the animals appeared healthy with no clinical sign suggestive of leptospirosis. The observed seroprevalence in sheep was 6.1%, whereas the seropositivity rate for goat serum samples was 2.1%. The highest serological prevalence in sheep was recorded for serovar castellonis, followed by poi, sejroe, hardjo subtype hardjobovis, copenhageni, and cynopteri. Titres to poi were the only ones found in goats. These findings, which are proof of Leptospira infection in Alto Adige-South Tyrol, indicate that foci of several serovars exist in this region.

[Contralateral transinguinal laparoscopy in unilateral inguinal hernia]

BACKGROUND

Indication for surgical exploration of the contralateral groin during unilateral herniorraphy in children is the subject of a worldwide debate. Routine exploration based on the likelihood of a patent processus vaginalis (PV) according to age, gender or side to some extent leads to unnecessary procedures, while routine abstention may leave a peritoneal sac, likely to later induce a symptomatic hernia in about 10% of cases.

METHODS AND PATIENTS

One hundred and twenty-five children aged from 1 month to 15 years underwent transinguinal laparoscopic assessment of the contralateral groin, using a 3 mm trocar and a 70 degrees telescope gently introduced through the exposed PV. Surgical exploration was performed only in those patients who exhibited a patent PV, and in patients where the groin was poorly visualized due to technical problems.

RESULTS

Regardless of age, contralateral surgery was not considered in 88 (70%) of the 125 children. Among the 37 patients that were operated upon, eight had a negative exploration due to an erroneous endoscopic evaluation. Surgery was avoided in 35 (56%) of the 62 infants aged less than 2 years, including nine of the 13 prematures who were previously routinely operated upon. Conversely, in the 63 older patients who were readily spared from surgical exploration, the videoscopic evaluation allowed appropriate selection for contralateral surgery in six.

CONCLUSION

A routine policy, either of surgery or observation, is no longer indicated as a quick, safe and cost-effective method is available to detect a patent PV. The transinguinal laparoscopy is safe and could be easily performed by surgeons already skilled in pediatric herniorraphy. Therefore, the videoscopic transinguinal contralateral evaluation is worth being promoted to ensure an appropriate surgery tailored to the anatomical features.

Antigenic and genomic analysis of a Borrelia burgdorferi sensu stricto strain isolated from Ixodes ricinus ticks in Alto Adige-South Tyrol, Italy

A Borrelia burgdorferi sensu lato strain isolated from IXodes ricinus ticks in Alto Adige-South Tyrol (Northern Italy) was analyzed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) of whole cell proteins, Western immunoblotting analysis (WBA) with polyclonal and monoclonal antibodies, and pulsed-field gel electrophoresis (PFGE). The isolate named BZ6 was identified as belonging to the genospecies B. burgdorferi sensu stricto on the basis of its protein profile and its reactivity with monoclonal and polyclonal antibodies. The PFGE study performed with the two rare-cutting restriction enzymes MluI and SmaI confirmed the SDS-PAGE and WBA characterizations, but showed a genetic diversity between the isolate and two out of the three B. burgdorferi sensu stricto strains used in this study as controls, the American type strain B31 and the locally isolated strain BZ1. No difference in the PFGE patterns between the isolate BZ6 and the Swiss strain IRS was noted. Our findings show the value of PFGE analysis for classifying B. burgdorferi sensu lato isolates and for revealing their genetic diversity, and its usefulness for epidemiological investigations.

[Surgical approach on rabbit embryos. A model trial of bladder exstrophy]

We describe herein a new model of surgical approach of an early mammalian embryo. Indeed the developmental mechanisms of numerous congenital anomalies, such as bladder exstrophy, remain obscure, and progresses in their knowledge must be achieved to propose better treatments. But up to now all the successful reports in experimental models of early produced malformations concerned birds or batracians, whose development is very different from human. We used the rabbit. Twenty-five time matted does were operated at 12.5 days of gestation. Out of their 247 embryos, 99 underwent a surgical procedure. Forty-eight were injured in order to produce an exstrophy. In 18 cases, the embryo extruded from the uterine cavity and could not be reintegrated, and 2 sacs were found empty. The remaining 31 were only exteriorized. Nine additional does received intravenous teratogen at 12.5 days of gestation. In the group of operated embryos we obtained 6 full-term fetuses, one of whom had a cloacal exstrophy. No exstrophy was noted among the intact embryos, neither in the 87 fetuses submitted to the teratogen. We conclude that: it is possible to operate on an early mammalian embryo, and to obtain further growth until term and that the exstrophy we observed in one case resulted from the surgical specific procedure.

Surgical approach of an early mammalian embryo: the rabbit model

We describe an experimental surgical model in early rabbit embryo (12.5 days of gestation). Twenty-one embryos were operated, of which 9 survived the first postoperative week and 5 had normal further growth until term. As far as we can ascertain, this is the first successful report of a surgical approach in early mammalian embryos. We think that this model may be useful for workers involved in the study of early congenital malformations.

Artificial urinary sphincter implantation for neurogenic bladder: a multi-institutional study in 107 children

OBJECTIVES

To evaluate the outcome of implantation of the AMS 800 artificial urinary sphincter in children with neurogenic bladder.

PATIENTS AND METHODS

The records of 107 children (74 boys and 33 girls) treated for neurogenic urinary incontinence by implantation of the AMS 800 artificial sphincter between 1983 and 1993 were reviewed retrospectively. The underlying cause of incontinence in 92 patients was spina bifida, the mean age at implantation was 13.7 years and 30 patients had undergone previous bladder neck surgery. Implantation was carried out in combination with another surgical procedure in 24.3% of patients. The mean follow-up was 61 months (minimum 12).

RESULTS

The mean operational life of the sphincter was 56 months. No deaths occurred but removal of the artificial sphincter was necessary in 20 patients (19%). Surgical revision was not required in 44 patients (41%) but at least one revision was performed in 63 and more than one in 42. There were 21 mechanical failures, 40 surgical complications and 39 cases involving changes in the dynamics of bladder function. Of the 87 children (81%) in whom the device is still in place, 72 are completely continent (83%), 10 are slightly wet, and five are incontinent. The overall success rate was 77%.

CONCLUSIONS

The results emphasize that for successful implantation of an artificial urinary sphincter in children, the pre-operative bladder capacity must be sufficient and previous surgery should not have been performed on the bladder neck, the site of choice for implantation in children. Sphincterotomy is not always necessary in paediatric patients. Children and parents should be informed of the high complication rate and the need for long-term follow-up.

Antibodies to Borrelia burgdorferi in sheep and goats. Alto Adige-South Tyrol, Italy

A serologic survey for antibodies to Borrelia burgdorferi was conducted on sheep and goat serum samples collected in Alto Adige-South Tyrol, Italy, in 1990. Sera were tested by Indirect Immune Fluorescence Assay (IIFA) and Microbial Adherence Immobilization Assay (MAIA). IIFA and/or MAIA anti-B. burgdorferi antibodies were detected in 14.1% of the 269 sheep and 36.8% of the 133 goats examined. IIFA and MAIA were both positive in 4 out of 38 positive sheep sera (10.5%) and 21 out of 49 positive goat sera (42.8%). These discrepancies suggest that MAIA- and IIFA-detected antibodies do differ from each other. The detection by MAIA of antibodies sensitizing B. burgdorferi to the killing effect of complement seems to be a valid parameter to evaluate the acquired immunity of sheep and goats to B. burgdorferi infections.

Heterozygous endothelin receptor B (EDNRB) mutations in isolated Hirschsprung disease

Hirschsprung disease (HSCR, aganglionic megacolon) is a frequent congenital malformation regarded as a multigenic neurocristopathy. Two susceptibility genes have been recently identified in HSCR, namely the RET proto-oncogene and the endothelin B receptor (EDNRB) gene. Hitherto however, homozygosity for EDNRB mutations accounted for the HSCR-Waardenburg syndrome (WS) association. Here, we report heterozygous EDNRB missense mutations (G57S, R319W and P383L) in isolated HSCR. These data might suggest that EDNRB mutations could be dosage sensitive: heterozygosity would predispose to isolated HSCR with incomplete penetrance, while homozygosity would result in more complex neurocristopathies associating HSCR and WS features. In addition, the present data give further support to the role of the endothelin-signalling pathway in the development of neural crest-derived enteric neurons.

Genetic and phenotypic characterization of Borrelia burgdorferi strains isolated from Ixodes ricinus ticks in the Province of Bolzano, Italy

Lyme disease is caused by three borrelial species, B. burgdorferi sensu stricto, B. garinii and Borrelia group VS461. In a restricted biotope of the Bolzano province, in the Caldaro community, five clones of two borrelial variants were isolated from Ixodes ricinus ticks. A preliminary serological study showed that the two variants cross-reacted with B. burgdorferi B31 and B. garinii N34 strains, respectively. The isolates were genomically related with strains B31 and N34, respectively, sharing a similar plasmid and restriction fragment length polymorphism profile with these strains. The phenotypic pattern of the Caldaro isolates-namely their protein and antigenic profile-showed infra-subspecific variation compared to related strains B31 and N34 respectively. The observed phenotypic variability between strains isolated from the same biotope and in the same tick host strongly indicated the variability of gene-encoded characters is a constant characteristic of borrelial strains, even when from the same ecological niche.

Pediatric endoscopic surgery: pride and prejudice

82 endoscopic surgical procedures (abdominal: 77; thoracic: 5) were performed by the same surgeon on 75 children aged from 1 month to 17 years (median 8.1 years) during the two-year period from January 1991 to December 1992. Due to the multispecialization of the Children's Hospital, a variety of pathologies were explored or treated with appendectomy accounting for 33% (27/82). There were no perioperative deaths. Three major complications occurred (1 post-appendectomy peritonitis, 1 hemorrhage during splenectomy and 1 post-operative occlusion). 14 patients required conversion to open surgery. Indications for endoscopic exploration of advanced lesions, prospective indications, and policy when confronted with a healthy appendix are discussed.

Vasculitic mononeuritis multiplex in patient with Lyme disease

Lyme borreliosis is an infectious disease caused by the spirochete Borrelia burgdorferi. Neurological complications are frequently reported but the pathogenesis remains largely unknown. We report on a patient with positive borrelia antibodies at ELISA and immunoblotting and with histological and immunofluorescence study of peripheral nerve biopsy consistent with vasculitic neuropathy.