Assessing vaccine hesitancy and health literacy using a new Italian vaccine confidence index and a modified Italian medical term recognition test: A cross-sectional survey on Italian parents

The decline in children's vaccination coverage and the resurgence of preventable infectious diseases draw attention to parents' vaccine hesitancy. Our study introduces two validated tools to independently assess vaccine hesitancy and health literacy among parents with school-age children. We developed a Vaccine Confidence Index (VCI) from 10 Likert items, exploring their relationships through exploratory and confirmatory factor analyses. We modified the IMETER (Italian medical term recognition test) to measure health literacy. We assessed the internal consistency of the modified IMETER and the 10 Likert items using Cronbach's alpha test (α) and McDonald's omega total coefficient (ω) with good results (ω = 0.92, α = 0.90; ω = 0.87, α = 0.82 respectively). We used these tools within a questionnaire conducted on 743 parents recruited from pediatric clinic waiting rooms in Italy, collecting demographic data, information sources on vaccines and vaccine-preventable diseases knowledge. The VCI resulting from factor analyses consisted of six items on a ten-point Likert scale, reflecting the ratio of positive to negative items. The survey revealed significant variations in the VCI according to individual features such as education, use of social networks, or Health institutions as sources of information. Multivariate logistic regression identified an association between vaccine intention and the VCI. Health literacy was functional for 91.2% of participants, but knowledge about vaccine-preventable diseases was generally low. The VCI showed no significant association with health literacy and vaccine-preventable diseases knowledge. The VCI and the modified IMETER effectively assess vaccination attitude and health literacy, offering valuable public health tools for tailoring vaccination campaigns to hesitant population subgroups.

Exploring the Possible Use of AI Chatbots in Public Health Education: Feasibility Study

BACKGROUND

Artificial intelligence (AI) is a rapidly developing field with the potential to transform various aspects of health care and public health, including medical training. During the "Hygiene and Public Health" course for fifth-year medical students, a practical training session was conducted on vaccination using AI chatbots as an educational supportive tool. Before receiving specific training on vaccination, the students were given a web-based test extracted from the Italian National Medical Residency Test. After completing the test, a critical correction of each question was performed assisted by AI chatbots.

OBJECTIVE

The main aim of this study was to identify whether AI chatbots can be considered educational support tools for training in public health. The secondary objective was to assess the performance of different AI chatbots on complex multiple-choice medical questions in the Italian language.

METHODS

A test composed of 15 multiple-choice questions on vaccination was extracted from the Italian National Medical Residency Test using targeted keywords and administered to medical students via Google Forms and to different AI chatbot models (Bing Chat, ChatGPT, Chatsonic, Google Bard, and YouChat). The correction of the test was conducted in the classroom, focusing on the critical evaluation of the explanations provided by the chatbot. A Mann-Whitney U test was conducted to compare the performances of medical students and AI chatbots. Student feedback was collected anonymously at the end of the training experience.

RESULTS

In total, 36 medical students and 5 AI chatbot models completed the test. The students achieved an average score of 8.22 (SD 2.65) out of 15, while the AI chatbots scored an average of 12.22 (SD 2.77). The results indicated a statistically significant difference in performance between the 2 groups (U=49.5, P<.001), with a large effect size (r=0.69). When divided by question type (direct, scenario-based, and negative), significant differences were observed in direct (P<.001) and scenario-based (P<.001) questions, but not in negative questions (P=.48). The students reported a high level of satisfaction (7.9/10) with the educational experience, expressing a strong desire to repeat the experience (7.6/10).

CONCLUSIONS

This study demonstrated the efficacy of AI chatbots in answering complex medical questions related to vaccination and providing valuable educational support. Their performance significantly surpassed that of medical students in direct and scenario-based questions. The responsible and critical use of AI chatbots can enhance medical education, making it an essential aspect to integrate into the educational system.

ChatGPT and the rise of large language models: the new AI-driven infodemic threat in public health

Large Language Models (LLMs) have recently gathered attention with the release of ChatGPT, a user-centered chatbot released by OpenAI. In this perspective article, we retrace the evolution of LLMs to understand the revolution brought by ChatGPT in the artificial intelligence (AI) field. The opportunities offered by LLMs in supporting scientific research are multiple and various models have already been tested in Natural Language Processing (NLP) tasks in this domain. The impact of ChatGPT has been huge for the general public and the research community, with many authors using the chatbot to write part of their articles and some papers even listing ChatGPT as an author. Alarming ethical and practical challenges emerge from the use of LLMs, particularly in the medical field for the potential impact on public health. Infodemic is a trending topic in public health and the ability of LLMs to rapidly produce vast amounts of text could leverage misinformation spread at an unprecedented scale, this could create an "AI-driven infodemic," a novel public health threat. Policies to contrast this phenomenon need to be rapidly elaborated, the inability to accurately detect artificial-intelligence-produced text is an unresolved issue.

“Laboratorium Repository”: a training tool for the Healthcare Workforce

Background

The COVID-19 pandemic highlighted the need to redefine the healthcare workforce (HCW) competencies to face future emergencies linked to emerging infectious diseases, environmental, climate and social crises. As recently stated by WHO, there is a need to identify standards for education and competencies training for HCW in emergency and preparedness (E&P). The Italian National Institute of Health, in agreement with the deliberation of the G20 Health Ministers under the Italian Presidency, is developing an educational program named “Laboratorium” which includes a free access digital repository aimed to share selected documents and tools at the International Public HCW (PHCW) to increase the competencies in E&P response.

Objectives

A range of web domains selected according to their reliability was monitored using a keyword search tool for any relevant material published from February 14th up to April 28th, 2022. We included any publications, training materials, epidemiological data, initiatives, and communication items that addressed the topic of interest. Each item was submitted for approval by a scientific board and, if appropriate, classified by typology, language, topic, and country before publication.

Results

To date, out of 6197 items, 418 fulfilled the inclusion criteria. For the type of content, we included guidelines/recommendations (75), epidemiological data (58), websites (34), online courses (15) and books (16). PHCW was the most representative target group (361), followed by other stakeholders (127), hospital practitioners (90), primary care (87). The most represented topic was infectious diseases/SARS-CoV-2 (277) followed by vaccines (88), emergency interventions (34), emerging diseases (17), policies (26), public health preparedness (32).

Conclusions

Future training for PHCW should be designed with a modular approach with different levels of usability. The Laboratorium Repository provides a core of items for learning according to one's training needs

Key messages

Screening for Antimicrobial-Resistant Gram-negative bacteria in hospitalised patients, and risk of progression from colonisation to infection: Systematic review

BACKGROUND

Transmission of antimicrobial-resistant Gram-negative bacteria (AMR-GNB) among hospitalised patients can lead to new cases of carriage, infection and outbreaks, hence the need for early carrier identification. We aim to explore two key elements that may guide control policies for colonisation/infection in hospital settings: screening practices on admission to hospital wards and risk of developing infection from colonisation.

METHODS

We searched on PubMed, Scopus and Cochrane databases for studies published from 2010 up to 2021 reporting on adult patients hospitalised in high-income countries.

RESULTS

The search retrieved 11853 articles. After screening, 100 studies were included. Combining target patient groups and setting type, we identified six screening approaches. The most reported approach was all admitted patients to high-risk (HR) wards (49.4%). The overall prevalence of AMR-GNB was 13.8% (95%CI 9.3-19.0) with significant differences across regions and time. Risk of progression to infection among colonised patients was 11.0% (95%CI 8.0-14.3) and varied according to setting and pathogens' group (p value<0.0001), with higher values reported for Klebsiella species (18.1%; 95%CI 8.9-29.3).

CONCLUSIONS

While providing a comprehensive overview of the screening approaches, our study underlines the considerable burden of AMR-GNB colonisation and risk of progression to infection in hospitals by pathogen, setting and time.

Evaluation of the direct and indirect impact of the COVID-19 pandemic in Tuscan nursing homes

Background

Residents in long-term care facilities (LTCFs) are at higher risk of contracting and developing serious outcomes from COVID-19. Despite the media attention and the specific survey launched by the Istituto Superiore di Sanità, official data on Italian LTCFs are scarce. The objective of our study was to provide an estimate of the direct and indirect impact of COVID-19 in Tuscan LTCFs by assessing the rate of hospital admissions and the overall mortality rate among LTCF residents in 2020, comparing them with those observed in the period 2018-2019.

Methods

For the analysis two regional administrative data flows were linked. The first one providing data on the number of LTCFs residents - and deaths - affiliated with the regional health system, while the second on hospital discharges. The monthly hospitalization and mortality rates for 2020 were compared with those of the two previous years.

Results

The number of residents in LTCFs decreased significantly (-10.4%) and consistently in 2020 compared to the average of the previous two years. The rate of total admissions decreased slightly in 2020 (32.5%, -8.2% compared to 2018/19). However, excluding admissions due to COVID-19, the reduction was more pronounced (-21.9%), with large monthly variations (-33% and -43% in March and November 2020) statistically significant (RR2020/2018-19=0.66 and 0.57; 95%CI: 0.57-0.77; 0.48-0.68). A total of 581 admissions for COVID-19 occurred in 2020, with a monthly average of 0.6% and two peaks observed in April and November (1.86%; 1.82%). The overall mortality rate increased by 31% (2018/19= 18.6%; 2020= 24.4%), with a maximum (+201%) in November 2020 (RR2020/2018-19=3.01; 95%CI: 2.5-3.56).

Conclusions

The impact of the pandemic on Tuscan LTCFs in terms of deaths and patient care by hospitals has been considerable, with the greatest reduction in hospital admissions occurring mostly in the months characterised by the highest mortality rate and admissions for COVID-19.

Key messages

The direct and indirect impact of the pandemic on Tuscan LTCFs has been considerable, probably due to the reorganisation of LTCF services and limited coordination with hospital health care. The greatest reduction in hospital admissions, especially those not COVID-related, occurred mostly during the months characterised by the highest mortality rate and admissions for COVID-19.

Covid-19 vaccine management (Comirnaty and mrna-1273 Moderna) in a teaching hospital in Italy: a short report on the vaccination campaign

Objectives

In this article, we aim to share our experience in the hospital reorganization made to conduct the SARS-CoV-2 vaccination campaign, based on the principles of flexibility and adaptability.

Study design

A descriptive study.

Methods

The data concerning the organization of the vaccination campaign were taken from the operative protocol developed by the hospital dedicated task force, composed by experts in hygiene, public health, occupational medicine, pharmacists, nurses, hospital quality, and disaster managers. Data about the numbers of vaccine administered daily were collected by the Innovation and Development Operative Unit database.

Results

Vaccinations against COVID-19 started across the EU on the 27th of December 2020. The first phase of the vaccination campaign carried out in our hospital was directed to healthcare workers immunization including medical residents, social care operators, administrative staff and technicians, students of medicine, and health professions trainees. The second phase was enlarged to the coverage of extremely fragile subjects. Thanks to the massive employment of healthcare workers and the establishment of dynamic pathways, it was possible to achieve short turnaround times and a large number of doses administered daily, with peaks of 870 vaccines per day. From the 27th of December up to the 14th of March a total of 26,341 doses of Pfizer have been administered. 13,584 were first doses and 12,757 were second doses. From the 4th to the 14th of March, 296 first doses of Moderna were dispensed. It was necessary to implement adequate spaces and areas adopting anti-contagion safety measures: waiting area for subjects to be vaccinated, working rooms for the dilution of the vaccine and the storage of the material, vaccination rooms, post-vaccination observation areas, room for observation, and treatment of any adverse reactions, with an emergency cart available in each working area.

Conclusions

The teaching hospital of Pisa faced the beginning of the immunization campaign readjusting its spaces, planning an adequate hospital vaccination area and providing an organization plan to ensure the achievement of the targets of the campaign. This represented a challenge due to limited vaccine doses supplied and the multisectoral teams of professionals to coordinate in the shortest time and the safest way possible. The organizational model adopted proved to be adequate and therefore exploited also for the second phase aimed to extremely fragile subjects.

Evaluation of Flu Vaccination Coverage among Healthcare Workers during a 3 Years' Study Period and Attitude towards Influenza and Potential COVID-19 Vaccination in the Context of the Pandemic

(1) Background: vaccination of healthcare workers (HCWs) against seasonal influenza is considered the most effective way to protect HCWs, ensure patient's safety and to maintain essential health care services during influenza epidemics. With the present study we aimed to evaluate the efficacy of incremental bundles of measures implemented during the last three flu campaigns and to assess the attitudes towards influenza vaccination and a potential vaccine against COVID-19 among HCWs, in a large university hospital in Pisa, Italy. (2) Methods: We described measures implemented during 2018/2019, 2019/2020 and 2020/2021 and assessed their impact on flu vaccine coverage (VC) among employees and residents in Pisa university hospital. We considered sex, profession and ward to investigate differences in uptake. In addition, in 2020 a survey was developed and distributed to all employees to evaluate flu and COVID-19 vaccines attitudes. (3) Results: during the 2018/19 and 2019/20 flu campaigns the overall VC rate among HCWs was, respectively, 10.2% and 11.9%. In 2020/21 the overall VC rate jumped to 39.3% (+ 230.6%). Results from the survey indicated a more positive attitude towards flu vaccine as compared to COVID-19 vaccines among the 10.6% of the staff members who responded to the survey. In addition, 70.97% of HCWs totally agreed that being vaccinated against influenza would be more important than the previous years because of COVID-19 emergency. (4) Conclusions: a significant increase in VC was observed in 2020/21, especially among those sub-groups with consistently lower uptake in previous years. The COVID-19 pandemic positively influenced flu vaccination uptake during the 2020/21 season.

Collection, transport and storage procedures for blood culture specimens in adult patients: recommendations from a board of Italian experts

Bloodstream infections (BSIs) remain a potentially life-threatening condition. The gold standard for the diagnosis of BSI is still blood cultures (BCs), and the diagnostic yield depends on clinical and technical factors that have an impact on collection and transportation. Hence, monitoring of the entire pre-analytical process from blood collection to transportation to the microbiology laboratory is critical. To optimize the clinical impact of the diagnostic and therapeutic procedures, a multidisciplinary approach and univocal protocols are mandatory. A board of specialists discussed the available evidence on the pre-analytical process and produced the present document to guide physicians and nurses on the ideal execution of BC: (1) timing and preparation for blood collection; (2) skin antisepsis; (3) blood volume; (4) sampling method and safety; (5) medium to be used; (6) time to BC transportation; and (7) quality assurance and quality management.

Increased Risk of Acquisition of New Delhi Metallo-Beta-Lactamase-Producing Carbapenem-Resistant Enterobacterales (NDM-CRE) among a Cohort of COVID-19 Patients in a Teaching Hospital in Tuscany, Italy

We describe the epidemiology of New Delhi Metallo-Beta-Lactamase-Producing Carbapenem-Resistant Enterobacterales (NDM-CRE) colonization/infection in a cohort of COVID-19 patients in an Italian teaching hospital. These patients had an increased risk of NDM-CRE acquisition versus the usual patients (75.9 vs. 25.3 cases/10,000 patient days). The co-infection significantly increased the duration of hospital stay (32.9 vs. 15.8 days).

Evaluation of Microbial Adhesion and Biofilm Formation on Nano-Structured and Nano-Coated Ortho-Prosthetic Materials by a Dynamic Model

The bio-engineering technologies of medical devices through nano-structuring and coating was recently proposed to improve biocompatibility and to reduce microbial adhesion in the prevention of implantable device-related infections. Our aim was to evaluate the ability of new nano-structured and coated materials to prevent the adhesion and biofilm formation, according to the American Standard Test Method ASTM-E2647-13. The materials composition was determined by X-ray Fluorescence and Laser Induced Breakdown Spectroscopy. Silver release was evaluated by Inductively Coupled Plasma Mass Spectrometry analysis. The gene expression levels of the Quorum Sensing Las and Rhl system were evaluated by the ΔΔCt method. The Log bacterial density (Log CFU/cm²) on TiAl6V4 was 4.41 ± 0.76 and 4.63 ± 1.01 on TiAl6V4-AgNPs compared to 2.57 ± 0.70 on CoCr and 2.73 ± 0.61 on CoCr-AgNPs (P < 0.0001, A.N.O.V.A.- one way test). The silver release was found to be equal to 17.8 ± 0.2 µg/L after the batch phase and 1.3 ± 0.1 µg/L during continuous flow. The rhlR gene resulted in a 2.70-fold increased expression in biofilm growth on the silver nanoparticles (AgNPs) coating. In conclusion, CoCr showed a greater ability to reduce microbial adhesion, independently of the AgNPs coating. The silver release resulted in promoting the up-regulation of the Rhl system. Further investigation should be conducted to optimize the effectiveness of the coating.

Improving Cleaning and Disinfection of High-Touch Surfaces in Intensive Care during Carbapenem-Resistant Acinetobacter baumannii Endemo-Epidemic Situations

Aims: High-touch surfaces cleaning and disinfection require the adoption of effective and proper executed protocols, especially during carbapenem-resistant Acinetobacter baumannii (CRAB) endemo-epidemic situations. We evaluated the effectiveness and residual disinfectant activity of disposable pre-impregnated wipes (Modified Operative Protocol, MOP) in reducing environmental bioburden versus a two-step Standard Operative Protocol (SOP) in a 12-bed Intensive Care Unit. Methods: Five high-touch surfaces were cleaned and disinfected either according to the SOP (alcohol-based cleaning and chlorine-based disinfection) or using quaternary ammonium compounds-based disposable wipes (MOP). Sampling was performed before each procedure and at 0.5, 2.5, 4.5 and 6.5 h after (560 sites). Total viable count (TVC) was evaluated according to Italian hygiene standard (<50 CFU/24 cm²). Clinical and environmental CRAB strains isolated were genotyped. Results: On non-electromedical surfaces the difference between TVC before procedure and at each of the following times was significant only for the MOP (p < 0.05, Wilcoxon test). Using the MOP, only 7.4% (10/135) of sites showed TVC >50 CFU/24 cm² (hygiene failures) versus 18.9% (25/132) after SOP (p < 0.05, Fisher’s Exact test). On infusion pumps a higher number of hygiene failures was observed after the SOP (7/44, 15.9%) compared with the MOP (4/45, 8.9%). Genotyping highlighted a common source of infection. Conclusion: On high-touch surfaces, the use of disposable wipes by in-house auxiliary nurses may represent a more effective alternative to standard cleaning and disinfection procedure performed by outsourced cleaning services, showing effectiveness in reducing microbial contamination and residual disinfection activity up to 6.5 h.

A nosocomial measles outbreak in Italy, February-April 2017

We describe a nosocomial outbreak of measles that occurred in an Italian hospital during the first months of 2017, involving 35 persons and including healthcare workers, support personnel working in the hospital, visitors and community contacts. Late diagnosis of the first case, support personnel not being promptly recognised as hospital workers and diffusion of the infection in the emergency department had a major role in sustaining this outbreak.

Post-graduate medical education in public health: the case of Italy and a call for action

Public health technical expertise is of crucial importance to inform decision makers' action in the field of health and its broader determinants. Improving education and training of public health professionals for both practice and research is the starting point to strengthen the role of public health so that current health challenges can be efficiently tackled. At the Association of Schools of Public Health in the European Region (ASPHER) Deans' & Directors' 2017 Annual Retreat, we presented the structure and management of public health training system in Italy, and we reported recent data on Italian public health specialists' educational experience, employment opportunities and job satisfaction. Public health training in Italy is implemented in the context of the post-graduate medical education residency programme in Hygiene and Preventive Medicine, delivered by 34 University-based Schools of Public Health. We report relatively high employment rates across the county and wide spectrum of career opportunities for young public health specialists. However, job security is low and training expectations only partially met. We call upon other Schools of Public Health to scale up the survey within the broad ASPHER community in a shared and coordinated action of systematically collecting useful data that can inform the development of public health education and training models, their implementation and fruitful interaction with population health, health systems and services.

Skin antisepsis with chlorhexidine versus iodine for the prevention of surgical site infection: A systematic review and meta-analysis

BACKGROUND

Surgical site infection (SSI) is one of the most frequent health care-associated infections. One of the practices to reduce their incidence is preoperative skin antisepsis. Two of the most commonly active components used are chlorhexidine gluconate and povidone iodine. Of 3 reviews conducted between 2010 and 2012 comparing antiseptics, 2 were in favor of chlorhexidine; however, the latest was unable to draw conclusions.

PURPOSE

To verify whether recent evidence supports the hypothesis that chlorhexidine in preoperative antisepsis is more efficient than other antiseptics in reducing SSI rates.

PROCEDURES

We conducted a systematic review from 2000-2014 in all languages. The primary end point was SSI incidence and secondary skin bacterial colonization.

RESULTS

Nineteen studies were included. Meta-analysis were conducted for comparable studies for both outcomes. The results of the meta-analysis, including all of the studies in which chlorhexidine was compared with iodophor, were in favor of chlorhexidine for both SSI incidence (risk ratio [RR], 0.70; 95% confidence interval [CI], 0.52-0.92) and bacterial skin colonization (RR, 0.45; 95% CI, 0.36-0.55).

CONCLUSIONS

There is moderate-quality evidence supporting the use of chlorhexidine for preoperative skin antisepsis and high-quality evidence that the use of chlorhexidine is associated with fewer positive skin cultures. Further rigorous trials will be welcomed to attain stronger evidence as to the best antiseptic to be used before surgery.