Burden of disease scenarios for 204 countries and territories, 2022-2050: a forecasting analysis for the Global Burden of Disease Study 2021

BACKGROUND

Future trends in disease burden and drivers of health are of great interest to policy makers and the public at large. This information can be used for policy and long-term health investment, planning, and prioritisation. We have expanded and improved upon previous forecasts produced as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) and provide a reference forecast (the most likely future), and alternative scenarios assessing disease burden trajectories if selected sets of risk factors were eliminated from current levels by 2050.

METHODS

Using forecasts of major drivers of health such as the Socio-demographic Index (SDI; a composite measure of lag-distributed income per capita, mean years of education, and total fertility under 25 years of age) and the full set of risk factor exposures captured by GBD, we provide cause-specific forecasts of mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) by age and sex from 2022 to 2050 for 204 countries and territories, 21 GBD regions, seven super-regions, and the world. All analyses were done at the cause-specific level so that only risk factors deemed causal by the GBD comparative risk assessment influenced future trajectories of mortality for each disease. Cause-specific mortality was modelled using mixed-effects models with SDI and time as the main covariates, and the combined impact of causal risk factors as an offset in the model. At the all-cause mortality level, we captured unexplained variation by modelling residuals with an autoregressive integrated moving average model with drift attenuation. These all-cause forecasts constrained the cause-specific forecasts at successively deeper levels of the GBD cause hierarchy using cascading mortality models, thus ensuring a robust estimate of cause-specific mortality. For non-fatal measures (eg, low back pain), incidence and prevalence were forecasted from mixed-effects models with SDI as the main covariate, and YLDs were computed from the resulting prevalence forecasts and average disability weights from GBD. Alternative future scenarios were constructed by replacing appropriate reference trajectories for risk factors with hypothetical trajectories of gradual elimination of risk factor exposure from current levels to 2050. The scenarios were constructed from various sets of risk factors: environmental risks (Safer Environment scenario), risks associated with communicable, maternal, neonatal, and nutritional diseases (CMNNs; Improved Childhood Nutrition and Vaccination scenario), risks associated with major non-communicable diseases (NCDs; Improved Behavioural and Metabolic Risks scenario), and the combined effects of these three scenarios. Using the Shared Socioeconomic Pathways climate scenarios SSP2-4.5 as reference and SSP1-1.9 as an optimistic alternative in the Safer Environment scenario, we accounted for climate change impact on health by using the most recent Intergovernmental Panel on Climate Change temperature forecasts and published trajectories of ambient air pollution for the same two scenarios. Life expectancy and healthy life expectancy were computed using standard methods. The forecasting framework includes computing the age-sex-specific future population for each location and separately for each scenario. 95% uncertainty intervals (UIs) for each individual future estimate were derived from the 2·5th and 97·5th percentiles of distributions generated from propagating 500 draws through the multistage computational pipeline.

FINDINGS

In the reference scenario forecast, global and super-regional life expectancy increased from 2022 to 2050, but improvement was at a slower pace than in the three decades preceding the COVID-19 pandemic (beginning in 2020). Gains in future life expectancy were forecasted to be greatest in super-regions with comparatively low life expectancies (such as sub-Saharan Africa) compared with super-regions with higher life expectancies (such as the high-income super-region), leading to a trend towards convergence in life expectancy across locations between now and 2050. At the super-region level, forecasted healthy life expectancy patterns were similar to those of life expectancies. Forecasts for the reference scenario found that health will improve in the coming decades, with all-cause age-standardised DALY rates decreasing in every GBD super-region. The total DALY burden measured in counts, however, will increase in every super-region, largely a function of population ageing and growth. We also forecasted that both DALY counts and age-standardised DALY rates will continue to shift from CMNNs to NCDs, with the most pronounced shifts occurring in sub-Saharan Africa (60·1% [95% UI 56·8-63·1] of DALYs were from CMNNs in 2022 compared with 35·8% [31·0-45·0] in 2050) and south Asia (31·7% [29·2-34·1] to 15·5% [13·7-17·5]). This shift is reflected in the leading global causes of DALYs, with the top four causes in 2050 being ischaemic heart disease, stroke, diabetes, and chronic obstructive pulmonary disease, compared with 2022, with ischaemic heart disease, neonatal disorders, stroke, and lower respiratory infections at the top. The global proportion of DALYs due to YLDs likewise increased from 33·8% (27·4-40·3) to 41·1% (33·9-48·1) from 2022 to 2050, demonstrating an important shift in overall disease burden towards morbidity and away from premature death. The largest shift of this kind was forecasted for sub-Saharan Africa, from 20·1% (15·6-25·3) of DALYs due to YLDs in 2022 to 35·6% (26·5-43·0) in 2050. In the assessment of alternative future scenarios, the combined effects of the scenarios (Safer Environment, Improved Childhood Nutrition and Vaccination, and Improved Behavioural and Metabolic Risks scenarios) demonstrated an important decrease in the global burden of DALYs in 2050 of 15·4% (13·5-17·5) compared with the reference scenario, with decreases across super-regions ranging from 10·4% (9·7-11·3) in the high-income super-region to 23·9% (20·7-27·3) in north Africa and the Middle East. The Safer Environment scenario had its largest decrease in sub-Saharan Africa (5·2% [3·5-6·8]), the Improved Behavioural and Metabolic Risks scenario in north Africa and the Middle East (23·2% [20·2-26·5]), and the Improved Nutrition and Vaccination scenario in sub-Saharan Africa (2·0% [-0·6 to 3·6]).

INTERPRETATION

Globally, life expectancy and age-standardised disease burden were forecasted to improve between 2022 and 2050, with the majority of the burden continuing to shift from CMNNs to NCDs. That said, continued progress on reducing the CMNN disease burden will be dependent on maintaining investment in and policy emphasis on CMNN disease prevention and treatment. Mostly due to growth and ageing of populations, the number of deaths and DALYs due to all causes combined will generally increase. By constructing alternative future scenarios wherein certain risk exposures are eliminated by 2050, we have shown that opportunities exist to substantially improve health outcomes in the future through concerted efforts to prevent exposure to well established risk factors and to expand access to key health interventions.

FUNDING

Bill & Melinda Gates Foundation.

Do we protect ourselves against West Nile Virus? A systematic review on knowledge, attitudes, and practices and their determinants

BACKGROUND

West Nile virus (WNV) is a mosquito-borne flavivirus. In humans, 80% of infections are asymptomatic, while approximately 20% experience influenza-like symptoms. Fewer than 1% develop the neuroinvasive form which can lead to encephalitis, meningitis, acute flaccid paralysis, and even death. The global spread of the virus to areas where it was not previously present has become a growing concern. Since the 2000 s, there have been numerous outbreaks affecting local and travelling populations worldwide. Given the lack of a vaccine, preventative measures are primarily focused on surveillance, vector control, and the use of personal protective behaviours (PPBs). The importance of PPBs is central to public health recommendations. However, translating these messages into coherent action by the public can prove challenging, as the uptake of such measures is inevitably influenced by socio-economic factors, awareness, knowledge, and risk perception.

METHODS

A PRISMA-based systematic research was conducted on EMBASE, PubMed/MEDLINE, and Web of Science databases. PROSPERO registration number CRD42023459714. Quality of studies included in the final stage was evaluated using the Critical Appraisal Checklist for Cross-Sectional Study (CEBMa).

RESULTS

2963 articles were screened, and 17 studies were included in the final round. Out of these, six were deemed of high quality, ten were of medium quality, and one was of low quality. In almost all studies considered, both awareness and knowledge of WNV transmission were above 90%, while concern about WNV ranged from 50% to 80%. Concern about the safety of repellents, either with or without DEET, ranged from 27% to 70%. The percentage of people actually using repellents ranged from 30% to 75%, with the lowest usage reported among individuals over 60 years old (29%) and pregnant women (33%), and the highest among students aged 9-11 (75%). Concern for West Nile Virus (WNV) was consistently linked to an increase in taking preventative measures, including the use of repellents, by two to four times across studies. The school-based intervention was effective in increasing the practice of removing standing water (AOR=4.6; 2.7-8.0) and wearing long clothing (AOR=2.4; 95%CI: 1.3-4.3), but did not have a significant impact on the use of repellents.

CONCLUSIONS

The present systematic review provides an overview of the knowledge, attitudes, and practices (KAP) of WNV and their determinants. While concern about West Nile Virus (WNV) and its effects can be a significant motivator, it is important to promote evidence-based personal protective behaviours (PPBs) to counter unwarranted fears. For example, the use of repellents among the most vulnerable age groups. Given the geographical expansion of WNV, it is necessary to target the entire population preventively, including those who are difficult to reach and areas not yet endemic. The findings of this investigation could have significant implications for public health and support well-informed and effective communication strategies and interventions.

Determinants of menstrual dysfunction in the female athlete triad: A cross-sectional study in Italian athletes

BACKGROUND

In 1992 the American College of Sports Medicine first described the Female Athlete Triad. The Triad is a metabolic injury involving three distinct clinical traits: low energy availability, with possible eating disorder, low bone mineral density and menstrual dysfunction (MD). Although the estimated prevalence of the Triad is low (1.2 %), single factors are common in female athletes, at all competitive levels and ages. Even though the Triad was described over two decades ago, the interrelation of the three diagnostics components is still debated: additional evidence is required to improve the multidisciplinary treatment approach for this complex condition. MD is one of the first signs of energy impairment. The present study aims at investigating MD determinants and predictors in female athletes, to allow an early diagnosis of the Triad and to implement adequate preventive strategies.

MATERIALS AND METHODS

An original structured questionnaire was composed to detect the presence of MD risk factors. Included participants were active female athletes within reproductive age range (15-40 years old). Anthropometric parameters and training-related factors, possibly affecting the regularity of the menstrual cycle, were investigated.

RESULTS

Respondents were 288 female athletes. Among them, 73.3 % were under 25 years of age; 6.6 % resulted underweight; 30.6 % reported to follow a meal plan/diet and 13.9 % declared to be a smoker. Lean sports were practiced by 30.6 % of responders. Body-weight congruence was detected in in 79.9 % of participants, whereas overestimation of body image was found in 16.3 % of athletes. Irregular menstrual cycle, a possible MD predictor, was present in 33.0 % of athletes, with 41.1 % practicing some lean sport (p = 0.007). Also, overestimation of body image suggested an increased risk of menstrual irregularity (p = 0.001). BMI <18.5 or BMI >30 could also act as risk factor, although significance was not fully obtained (p = 0.053). Overall, practice of lean sports and overestimation of body image appeared good determinants of increased menstrual irregularity (AOR 2.02 and 3.83, respectively).

CONCLUSIONS

Menstrual irregularity in female athletes can be considered an early predictor of MD: risk is further increased in athletes of lean sports and reporting an overestimation of self-perceived body image. Screenings and awareness programs should specifically address female athletes, because of their vulnerable-group profile. In order to define a standardized at-risk profile for Triad onset and sequelae likelihood, evaluation of menstrual regularity should especially be considered, in conjunction with the assessment of other indicators of energy availability (e.g. TEE, lean and fat mass, BMC). Testing for sport-derived stress and disordered eating attitudes is also recommended. Preventive strategy should involve the proactive engagement of sport clubs and periodic competitive sport medical assessment.

An Italian Validation of the 5-Item Attitudes to Mental Illness Questionnaire (AMIQ): A Useful Tool for Rapid Assessment of Stigma, Acceptance, and Tolerance

Stigma negatively impacts individuals, families, and communities, affecting relationships, education, and employment and leading to an additional burden on mental health. Assessing public attitudes towards people with mental health conditions is crucial, especially in terms of public health. Therefore, the Attitudes to Mental Illness Questionnaire (AMIQ) was validated and adapted to the Italian cultural context. Translation followed four phases, involving bilingual speakers, comparison, back-translation, and expert review. In the pre-test phase, the questionnaire was administered to 21 participants anonymously. The validation test involved 213 subjects. Statistical analyses included exploratory and confirmatory factor analysis, and McDonald's Omega and Cronbach's alpha to assess the internal consistency. The results indicate good internal consistency (Omega = 0.71; Alpha = 0.72), and confirmatory factor analysis (CFI = 0.971) validated the questionnaire's construct. The study's findings align with the original validation, underscoring the questionnaire's robustness. Overall, understanding public attitudes is crucial for public health interventions combating stigma and fostering positive attitudes.

Trends in SARS-CoV-2 clinically confirmed cases and viral load in wastewater: A critical alignment for Padua city (NE Italy)

Since the beginning of the COVID-19 pandemic, wastewater-based epidemiology (WBE) has been depicted as a promising environmental surveillance tool and early warning system. Predictive models for the estimate of COVID-19 cases from wastewater viral loads also earned lot of interest and are currently under development. Hereby a pilot study that compares WBE surveillance data with confirmed cases, total hospitalizations, doses of vaccine administered and predominance of coronavirus variants. Composite 24hrs wastewater samples were collected weekly between September 2021 and July 2022 from Padua wastewater treatment plant. Samples were processed following a previously published method. One-step RT-qPCR was performed for quantification, adapting an Orf1b-nsp14 gene assay. Variant replacement was derived from the monthly bulletins of the Italian National Health Institute. Aggregate data on vaccine doses administered and on COVID-19 prevalence and hospitalizations were retrieved from official reports. Eighty-two samples were processed. Viral loads highlighted 3 major peaks in January, April and July 2022. Quantitation of SARS-CoV-2 in wastewater and clinical surveillance resulted temporally juxtaposable. However, variation of the two curves is not proportional. SARS-CoV-2 showed its highest peak in April, whereas maximum COVID-19 prevalence was achieved in January. Total hospitalizations followed the prevalence trend. Omicron BA.1 started to replace the Delta variant in December 2021. Subsequently, the shift towards Omicron BA.2 occurred between February and April 2022. Finally, BA.4/5 attested around June, somehow preceding the summer peak. Emergence of Omicron BA.1 over Delta could be a possible driver of the increase in both clinical cases and wastewater viral load in January 2022. In late March 2022, Omicron BA.2 replaced BA.1: this reflected in a steep increase of wastewater viral load, but not of COVID-19 confirmed cases. When a dramatic drop in the testing capacity of clinical surveillance occurred, WBE was possibly capable of detecting a substantial increase in viral circulation.

Emergency Department Syndromic Surveillance to Monitor Tick-Borne Diseases: A 6-Year Small-Area Analysis in Northeastern Italy

Tick-borne diseases (TBD) are endemic in Europe. However, surveillance is currently incomplete. Alternative strategies need to be considered. The aim of this study was to test an Emergency Department Syndromic Surveillance (EDSyS) system as a complementary data source to describe the impact of tick bites and TBD using a small-area analysis approach and to monitor the risk of TBD to target prevention. ED databases in the Local Health Authority 8 District (Veneto, Italy) were queried for tick-bite and TBD-related visits between January 2017 and December 2022. Hospitalisations were also collected. Events involving the resident population were used to calculate incidence rates. A total of 4187 ED visits for tick-bite and 143 for TBD were recorded; in addition, 62 TBD-related hospitalisations (of which 72.6% in over 50 s and 22.6% in over 65 s). ED visits peaked in spring and in autumn, followed by a 4-week lag in the increase in hospital admissions. The small-area analysis identified two areas at higher risk of bites and TBD. The use of a EDSyS system allowed two natural foci to be identified. This approach proved useful in predicting temporal and geographic risk of TBD and in identifying local endemic areas, thus enabling an effective multidisciplinary prevention strategy.

The HIV paradox: Perinatal mortality is lower in HIV-positive mothers-A field case-control study in Ethiopia

OBJECTIVE

Sub-Saharan African countries have the highest perinatal mortality rates. Although HIV is a risk factor for perinatal death, antioretroviral therapy (ART) programs have been associated with better outcomes. We aimed to investigate how maternal HIV affects perinatal mortality.

METHODS

The authors performed a nested case-control study at Saint Luke Hospital, Wolisso, Ethiopia. Data on sociodemographic characteristics, current maternal conditions, obstetric history, and antenatal care (ANC) services utilization were collected. The association between perinatal mortality and HIV was assessed with logistic regression adjusting for potential confounders.

RESULTS

A total of 3525 birthing women were enrolled, including 1175 cases and 2350 controls. Perinatal mortality was lower among HIV-positive women (18.3% vs. 33.6%, P = 0.007). Crude analysis showed a protective effect of HIV (odds ratio, 0.442 [95% confidence interval, 0.241-0.810]), which remained after adjustment (adjusted odds ratio, 0.483 [95% confidence interval, 0.246-0.947]). Among HIV-negative women, access to ANC for women from rural areas was almost half (18.8% vs. 36.2%; P < 0.001), whereas in HIV-positive women, no differences were noted (P = 0.795).

CONCLUSION

Among HIV-positive mothers, perinatal mortality was halved and differences in access to ANC services by area were eliminated. These data highlight the benefits of integrating ANC and HIV services in promoting access to the health care system, reducing inequalities and improving neonatal mortality.

Factors influencing long-term persistence of anti-HBs after hepatitis B vaccination

Long-term immunity after HBV vaccination is still debated. When assessing immune persistence, several variables must be considered, the clear definition of which is crucial. Our aim was to assess protection 10-20 years after primary vaccination and to estimate the effect of age at first dose, sex and time elapsed between doses on long-term protection. We conducted a retrospective cohort study between January 2004 and December 2020. Antibody titres above 10 IU/L were considered protective. Geometric mean titres (GMT) were calculated. The effect of the above variables on long-term protection was assessed by logistic regression analysis. Included participants were 9459. Among those vaccinated during infancy, GMT gradually increased from 11 IU/L (first dose in 1st trimester of life) to 68 IU/L (4th trimester), while the proportion of individuals <10 IU/L remained stable between 1st and 2nd trimester (51%) and it decreased substantially in 3rd (28%) and even more so in the 4th (18%). A one-month delay in first and third dose administration was correlated with a -16% (AOR: 0.84; 95% CI: 0.78-0.91) and a -11% (AOR: 0.89; 95% CI: 0.85-0.94) risk of a titre <10 IU/L, respectively, ~20 years after immunisation. In contrast, similar changes do not comparably affect vaccination in adolescence. The start of vaccination at the third month of age is a compromise between the development of acceptable immunogenicity and the need to protect the infant as early as possible. However, the chance of slightly delaying the vaccine administration within the first year of life may be considered given the impact on long-term persistence of anti-HBs.

Spread of SARS-CoV-2 at school through the pandemic waves: a population-based cohort study in Italy

Background

To limit SARS-CoV-2 transmission, proactive closure of schools is often believed by policy-makers and public an effective strategy. While evidence on the role of students in the spread is ongoing, effects of closure on children's well-being are well known. The number of secondary cases per class has been considered one of main driving criteria to mandate for distance learning. We aimed to calculate the rate of secondary infections per classroom and to identify factors associated with the development of school clusters.

Methods

We conducted a population-based cohort study between October 2020 and November 2021 in the province of Venice, Italy, a catchment area of 600,000 inhabitants. Primary, middle and high-schools were included.

Results

We identified 1,623 primary cases of SARS-CoV-2 infection in students. Of these, 72.5% did not lead to any secondary case in the school setting, 15.6% to 1, and 11.9% to 2+ contagions. The so-called second wave (Oct-Dec 2020) was associated with a lower occurrence of 2+ contagions (AOR=0.37; 95%CI: 0.24-0.56) than the fourth (Sep-Nov 2021). Both primary (AOR=1.74; 95%CI: 1.16-2.63) and middle schools (AOR=1.76 95%CI: 1,14-2,72) showed higher odds than high schools for cluster generation of 2+ cases. The involvement of 2+ secondary cases was lesser associated with the index case being a student rather than school staff (AOR=0.42; 95%CI: 0.29-0.60). The number of 2+ cases clusters per week followed a time trend in line with the general population incidence.

Conclusions

The school environment does not facilitate viral spread, but rather reflects transmission in the community. Appropriate measures (use of airway protection devices, interpersonal distancing, frequent hand and respiratory hygiene) and timely case tracking make school a safe place. Given the documented negative effects of school closures on children's learning and well-being, maintaining school attendance is as essential as it is desirable.

Key messages

• A SARS-CoV-2 positive student at school does not generate secondary infections in 3 out of 4 cases. The risk of cluster generation is lower when the index case is a student rather than school staff.

• The school environment does not facilitate viral spread, but rather reflects transmission in the community. School attendance is essential considering the effects on children’s learning and wellbeing.

Long-term immunity after HBV vaccine: shall we consider a change? A 20-year-follow-up study

Introduction

Although vaccines against HBV have been available since the 1980s, the long-term immunity is still debated. When assessing immune persistence, a number of clearly defined variables must be taken into account. Often the expression ‘infant vaccination’ means the administration within the first year of life at any age, but a difference of a few months may imply a different antibody persistence over the years. This study assessed the anti-HBs titre 20 years after the primary vaccination course and estimated the effect of age at 1st dose and time interval between doses on long-term protection.

Methods

Data on age, sex and date of administration were collected. Inclusion criteria: born to negative mother, 3-dose schedule, no previous HBV infection, age at enrolment 18-24 years; age at 1st dose 2-12 months. Titres ≥10IU/l were considered protective. A logistic regression was performed, adjusting for sex, follow-up time and date of 1st dose and analysis.

Results

We included 5,485 participants (64% female). The mean anti-HBsAg increased from 46, 52, 85 to 193IU/l when the 1st dose was administered in the I, II, III or IV trimester of life, respectively. Similarly, the proportion of individuals with titre &lt;10IU/l decreased from 51 to 18% between the two extreme quarters. The risk of a titre &lt;10IU/l decreased with age at the 1st dose (AOR: 0.84; 95%CI: 0.78-0.91 per one-month increase) and time between the 2nd and 3rd doses (AOR: 0.89; 95%CI:0.85-0.94).

Conclusions

The mere presence of a titre &lt;10IU/l does not equate lack of protection. However, antibody levels are very different depending on the actual age of vaccination. One-month delay within the first year is associated with a -18% chance of a titre &lt;10IU/l 20 years later. Although this information needs to be combined with local epidemiology and surveillance to obtain an informed risk-benefit balance, the implications from a public health and economic perspective may be diverse and worth considering.

Key messages

• Still within the first year of life, a delay in the administration of the 1st dose of HBV vaccine and a longer time between the 2nd and 3rd dose imply a higher antibody persistence even 20 years later.

• Considering the local circulation of HBV and surveillance, this result could be taken into account to obtain an informed risk-benefit balance.

SARS-CoV-2 Contamination of Ambulance Surfaces and Effectiveness of Routine Decontamination Procedure: A Classic Hygiene Lesson for A Novel Pathogen

The efficacy of standard operating procedures (SOPs) for the decontamination of ambulances against SARS-CoV-2 has been debated. In Italy, the differential use of ambulances was implemented by regional health authorities, with selected vehicles being used exclusively for transporting COVID-19 patients. We investigated the presence of SARS-CoV-2 on high-touch surfaces in ambulances to assess contamination dynamics and the effectiveness of decontamination SOPs. Four high-touch surfaces were sampled before and after decontamination (T0; T1). The gloves of the EMS crew chief were also sampled. RNA extraction was performed with a commercial kit, followed by RT-qPCR molecular detection of SARS-CoV-2. A total of 11 transports were considered. Seven transports had at least one positive sample; all were related to a COVID-19 patient. Three of the negative transports had dealt with COVID-19 case, and one had dealt with a COVID-19-negative patient. One door handle and one oxygen knob were positive at T0, with negative T1 swabs. The monitors were positive in 5 transports at T0, yet they were never positive at T1. Three stretcher handles tested positive at T0, and two of them also at T1, possibly having bypassed decontamination during personnel dismounting. Gloves were contaminated in five transports, in which 1 to 3 additional samples (monitor, knob, stretcher) resulted as positive. Overall, the efficacy of decontamination SOPs was confirmed under the unprecedented conditions of the COVID-19 emergency. However, the importance of correct hand-hygiene and glove-disposal should be further emphasized through the dedicated training of EMS personnel.

Assessment of maternal and newborn services in Uganda based on the Effective Coverage framework

Background

The implementation of a health service does not necessarily equate to a health gain. Effective Coverage (EC) aims to capture the potential benefits of a health intervention by adjusting the crude coverage for quality. The aim of this study was to assess the EC of Antenatal Care (ANC), Institutional deliveries and Postnatal Care (PNC) in Oyam district, Uganda, considering the input (drugs and equipment) and the process dimension (components of care provided).

Methods

The study involved 19 Health Centers (HC), 12 type II, 6 type III and 1 type IV, having a catchment area of 15.603 expected deliveries per year. The analysis covered the period between April and September 2021. Data on crude coverage were retrieved from the District Health Information Software-2. Data used to assess quality domains were extracted from checklists compiled during Supportive Supervisions and were summarized by readiness and likelihood of quality care indices. The crude coverage of the interventions was adjusted to calculate the input-adjusted and the quality-adjusted coverage.

Results

The readiness index was 0.81 for ANC, 0.82 for institutional delivery and 0.88 for PNC, while the likelihood of quality of care was 0.73, 0.88 and 0.89 respectively. In all three areas, the loss of coverage was mainly due to lack of materials and equipment; HCs II showed lower quality indexes than HCs III, particularly for ANC (P = 0.007). Compared to the target population, EC was 40% for ANC4 visits, 48% for institutional deliveries and 77% for PNC visits. The gap between crude and EC was higher for ANC4 (-30%) compared with the one for institutional deliveries (-18%) and PNC (-23%).

Conclusions

EC is a useful indicator for monitoring maternal and neonatal services in low-resource countries, bringing gaps in crude coverage to the surface. Supportive Supervision provides an opportunity to assess EC at the facility level without additional resources and to support health authorities in setting priorities.

Key messages

Aetiology of influenza-like illnesses in the pre-COVID-19 season 2019-2020: role of coronaviruses

Background

Only a proportion of seasonal influenza-like illnesses (ILIs) can de facto be attributed to influenza viruses. This study investigated the aetiology of ILIs to estimate the prevalence of human coronaviruses (CoVs) and to analyse their clinical-epidemiological traits.

Methods

A sample of 613 outpatients (253 adults, 360 children) with ILI in Veneto Region, Italy, was included. ILI was defined according with the EU Decision 2018/945. Sigma-Virocult nasopharyngeal swab were used. Nucleic acids were extracted with the QiaAmp Viral RNA Mini Kit (Qiagen). Molecular detection of respiratory viruses was performed with commercial One-step RT qPCR reagents (Allplex® Respiratory Panels, Seegene). Information on age, sex, symptoms, co-infections and comorbidities was collected.

Results

CoVs were the 3rd most frequent pathogen in adults (7.5%, after influenza and rhinovirus) and the 4th in children (4.7%, after influenza, rhino- and adenovirus). Subtype distribution was similar, with OC43 the most frequent. Probability of CoV involvement was twice in males (AOR=2.16; 95%CI: 1.05-4.39), whereas no association with age was noted. Co-infection with other viruses was frequent in children (65% of cases). CoV symptoms were not peculiar, although respiratory tract involvement was less likely than influenza (AOR=0.13; 95%CI: 0.04-0.41). Among CoV outpatients, 36% had one or more chronic diseases, compared with 5.6% among influenza (p = 0.001).

Conclusions

Even before the COVID-19 pandemic, CoVs had a substantial role in ILI aetiology: 1 case of CoV every 3 influenza infections in adults. The higher prevalence of comorbidities among CoV positives compared to influenza indirectly shows the benefits of flu vaccines in individuals at higher risk. Careful surveillance of the viruses responsible for ILI continues to be desirable, including, but not limited to, detecting a possible change in the aetiology of ILI after the administration of SARS-CoV-2 vaccines in the population.

Key messages

• Pre-pandemic virological surveillance of influenza-like illnesses (ILIs) reveals how seasonal coronaviruses were the third most frequent respiratory pathogen in adults.

• Prevalence of comorbidities was significantly higher in patients with a coronavirus-related ILI compared to influenza, supporting the benefits of flu vaccination for high risk groups.

Body Mass Index and Antibody Persistence after Measles, Mumps, Rubella and Hepatitis B Vaccinations

Overweight and obesity may cause a reduced response to vaccination. The purpose of the present research was to study the relationship between current body mass index (BMI) and antibody persistence after vaccination against measles, mumps, and rubella (MMR) and hepatitis B virus (HBV) given during childhood, as per the current vaccination schedule. The study was conducted on 2185 students at the School of Medicine, University of Padua, Italy. The mean age of the participants was 20.3 years. After adjusting for sex, age at first dose of vaccine administered, age at last dose, and age at study enrollment, no significant association was found between lack of serologic protection and BMI for either the HBV vaccine or each component of the MMR vaccine. For the first time, the absence of this relationship was demonstrated for the MMR vaccine. Given the evidence currently available, further research on BMI and vaccines in general remains desirable.

Future Healthcare Workers and Hepatitis B Vaccination: A New Generation

Before the introduction of universal vaccination, hepatitis B caused high morbidity and mortality, especially among healthcare workers. In the present study, the immune status against hepatitis B was assessed in a cohort of 11,188 students of the degree courses of the School of Medicine of the University of Padua (Italy) who had been subjected to mandatory vaccination in childhood or adolescence and who will be future healthcare workers. The variables that influence the antibody response to vaccination are mainly the age at which the vaccine was administered and sex. If vaccination was administered before one year of age, there is a high probability (around 50%) of having an antibody titer lower than 10 IU/L compared to those vaccinated after one year of age (12.8%). The time between vaccine and analysis is not decisive. Furthermore, female sex, but only if vaccination was administered after one year of age, shows a significant (p = 0.0008) lower percentage of anti-HBs below 10 IU/L and a greater antibody titer (p < 0.0001). In conclusion, the differences related to the age of vaccination induce more doubts than answers. The only plausible hypothesis, in addition to the different immune responses (innate and adaptive), is the type of vaccine. This is not easy to verify because vaccination certificates rarely report it.

Sex-Biased Prevalence of Intestinal Parasitic Infections and Gender Inequality in Rural Nepal

OBJECTIVES

Intestinal parasitic infections (IPIs) are related to poverty and socioeconomic disparities. In rural Nepal, IPIs are highly endemic and gender inequality is still deeply rooted. This study provides a novel epidemiological assessment of IPIs in Nepal, juxtaposing spatial, age and sex stratification of prevalence.

METHODS

A PRISMA and PICO-based systematic review of peer-reviewed and grey literature provided IPI prevalence data for the Nepalese population. Demographic and environmental variables were considered to investigate differences related to dwelling area and sex. Variations among prevalence rates were calculated with 95% CI and significance level for odds ratio evaluated with chi-square test.

RESULTS

The IPI prevalence rate for the Nepalese general population was 37.6%. Moreover, IPI prevalence (52.3%) was significantly higher in rural areas than in urban areas (32.4%), and school-age girls (55.2%) were more infected than boys (48.6%).

CONCLUSIONS

The IPI infection rate appeared to be enhanced among young women living in rural Nepal, where they experienced low school attendance and heavy enrolment in agricultural work, as result of gender discrimination. Plausibly, these dynamics affect both girls' environmental exposure and fruition of periodic school-based preventive chemotherapy, thus increasing the chances of IPI infection.

Education level and hospitalization for ambulatory care sensitive conditions: an education approach is required

BACKGROUND

Studies in several different countries and settings suggest that ambulatory care-sensitive conditions (ACSCs)-related hospitalizations could be associated more with socioeconomic variables than with the quality of primary healthcare services. The aim of the present study was to analyze the potential links between education levels or other social determinants and ACSC-related hospitalization rates.

METHODS

We analyzed a total of 467 504 records of ordinary discharges after acute hospitalization in 2015-16 for patients 20-74 years old residing in the Veneto Region. We calculated the prevention quality indicators (PQIs) developed by the Agency for Healthcare Research and Quality. Rate ratios (RRs) and 95% confidence intervals (95% CIs) were estimated with a set of Poisson regressions to measure the relative risk by sociodemographic level.

RESULTS

Hospitalizations for ACSCs accounted for 3.9% of all hospital admissions (18 436 discharges), and the crude hospitalization rate for ACSCs among 20- to 74-year-olds was 26.6 per 10 000 inhabitants (95% CI, 25.8-27.4). For all conditions, we found a significant association with formal education. In the case of the overall composite PQI#90, e.g. poorly educated people (primary school or no schooling) were at significantly higher risk of hospitalization for ACSCs than the better educated (RR, 4.50; 95% CI, 4.13-4.91).

CONCLUSIONS

Currently available administrative data regarding ACSCs may be used effectively for reveal equity issues in the provision of health care. Our results indicate that an educational approach inside Primary Health Care could address the extra risk for preventable healthcare demands associated with poorly educated patients.

The effectiveness of maternity waiting homes in reducing perinatal mortality: a case-control study in Ethiopia

Background

The 2030 Agenda for Sustainable Development aims to reduce neonatal mortality to at least 12 per 1000 live births. Most of the causes can be prevented or cured. Access to quality healthcare during pregnancy and labour is the key to reduce perinatal deaths, and maternity waiting homes (MWHs) may have an impact, especially for women who live far from the healthcare system. We conducted a case–control study to evaluate the effectiveness of MWH in reducing perinatal mortality in a secondary hospital in Ethiopia.

Methods

We did a nested case–control study from January 2014 through December 2017. The enrolled cases were mothers whose childbirth resulted in stillbirth or early neonatal death. The controls were mothers with an alive baby at 7 days or with an alive baby on discharge. We collected demographic, anamnestic, pregnancy-related and obstetric-related data. The effectiveness of the MWH on perinatal death was assessed by a logistic regression model, adjusted for all other variables investigated as potential confounders. We also did a sensitivity analysis to explore the role of twin pregnancies.

Results

We included 1175 cases and 2350 controls. The crude analysis showed a protective effect of the MWH towards perinatal mortality (OR=0.700; 95% CI: 0.505 to 0.972), even more protective after adjustment for confounders (adjusted OR (AOR)=0.452; 95% CI: 0.293 to 0.698). Sensitivity analyses showed a consistent result, even excluding twin pregnancies (AOR=0.550; 95% CI: 0.330 to 0.917).

Conclusion

MWHs appear to reduce perinatal mortality by 55%. Our findings support the decision to invest in MWH to support pregnant women with higher quality and more comprehensive healthcare strategy, including quality antenatal care in peripheral primary care clinics, where risk factors can be recognised and women can be addressed for admission to MWH.

Persistence of Anti-Hbs after up to 30 Years in Health Care Workers Vaccinated against Hepatitis B Virus

The burden of hepatitis B virus (HBV) infection is a serious public health problem all over the world. Vaccination remains the most effective prevention measure, and safe and effective HBV vaccines have been available since 1982. Health care workers (HCWs) vaccinated against HBV and prospectively followed up for at least 14 years were classified by their antibody titers after primary vaccination as: poor responders (10–99 mIU/mL); moderate responders (100–999 mIU/mL); and good responders (≥1000 mIU/mL). The incidence of antibody loss was calculated for 1000 person-years and the anti-HBs persistence was calculated. The analysis concerned 539 HCWs: 494 good responders (91.7%); 37 moderate responders (6.9%); and eight poor responders (1.5%). The incidence of anti-HBs loss was 52.1 per 1000 person-years for the poor responders, 11.3 per 1000 person-years for the moderate responders, and 1.4 per 1000 person-years for the good responders. The mean persistence of anti-HBs differed significantly between the three groups, being: 19.2 years (95% CI: 15.6–22.8), 25.4 years (95% CI: 23.0–27.9), and 31.0 years (95% CI: 30.5–31.5) for the poor, moderate and good responders, respectively. In conclusion, our findings demonstrate a good persistence of protective anti-HBs titers in HCWs exposed to occupational risk for up to 30 years after a primary vaccination cycle (even without a booster dose) if their titer was initially higher than 100 mIU/mL.

SARS-CoV-2 RNA detection and persistence in wastewater samples: An experimental network for COVID-19 environmental surveillance in Padua, Veneto Region (NE Italy)

BACKGROUND

Clinical detection of SARS-CoV-2 RNA in stools supports the idea of wastewater-based epidemiology (WBE) as a precious tool for COVID-19 environmental surveillance. Successful detection of SARS-CoV-2 RNA in untreated wastewaters has been reported in several countries. This study investigated the presence and persistence of viral RNA in treated and untreated wastewaters in Padua, Italy. An urban experimental network of sampling sites was tested for prospective surveillance activities.

METHODS

Seven sampling sites (i.e. wastewater pumping stations, plant inlets and outlets) were selected from the two main municipal wastewater treatment plant systems. Eleven grab samples (9 untreated, 2 treated wastewaters) were collected on 2 dates. All samples were tested at t0 for SARS-CoV-2 RNA and t1 = 24 h to investigate its persistence, at room temperature and under refrigerated conditions. Overall, 33 sub-samples were concentrated by ultrafiltration and tested for molecular detection of viral RNA with two RT-qPCR assays.

RESULTS

At t0, positivity for at least one RT-qPCR assay was achieved by 4/9 untreated wastewater samples and 2/2 tertiary treated samples. A minimum SARS-CoV-2 titer of 4.8-4.9 log10 gc/L was estimated. At t1, three refrigerated subsamples were positive as well. The two RT-qPCR assays showed differential sensitivity, with the N assay detecting 90% of successful amplifications.

CONCLUSIONS

SARS-CoV-2 RNA was detected in untreated and treated wastewaters. Its persistence after 24 h was demonstrated in subsamples kept at 4 °C. Hospitalization data suggested an approximate WBE detection power of 1 COVID-19 case per 531 inhabitants. The possible role of WBE in COVID-19 environmental surveillance is strongly supported by our findings. WBE can also provide precious support in the decision-making process of restriction policies during the epidemic remission phase. Optimization and standardization of laboratory methods should be sought in the short term, so that results from different studies can be compared with reliability.

Effectiveness of individually tailored exercise on functional capacity and mobility in nursing home residents

Deterioration of physical and functional capacities is often seen in nursing homes. The present study aimed at assessing the effectiveness of an individually tailored physical exercise intervention on mobility and functional decline in nursing home residents in a 1-year follow-up period. Information on gender, age, education, profession and cognitive status was collected at baseline and at 6 and 12 months of the intervention. The decline in functional capacity and mobility was assessed using the Barthel index. Some 221 participants were included. Results from the multivariate logistic regression showed how residents who never participated in physical activities had a five-fold higher risk of mobility decline compared with residents who did engage for the whole follow-up time. A lower effect was seen in residents who participated for only 6 months. Although dementia appeared to be a significant predictor of decline, a substantial stabilisation in mobility capacity was noted in patients with both mild and severe dementia performing exercise. The findings suggest that preventing or slowing physical decline in nursing home residents is an achievable goal, and even those with a higher degree of cognitive decline may benefit from a tailored physical activity plan.

Promoting health and preventing non-communicable diseases: evaluation of the adherence of the Italian population to the Mediterranean Diet by using the PREDIMED questionnaire

Abstract

A health promotion program was conducted in the Veneto Region in Italy. Participants were screened for non-communicable diseases and were referred to the nutrition clinic. The aim of this study was to assess the adherence to the Mediterranean diet in the Italian population by using the "PREvención con DIeta MEDiterránea" questionnaire. The data showed that 63% of the participants were overweight, 57% presented hypercholesterolemia, 36% were hypertensive and 43% had high blood glucose levels. The results highlighted a low consumption of protective foods against non-communicable diseases such as fruit, vegetables, fresh fish, legumes and oily dried fruit. Overall, only 6% of the subjects who visited the nutritional clinic had the maximum adherence to the Mediterranean diet, 73% had an average adherence, followed by 21% with low adherence. Multivariable analysis between risk factors and socio-demographic characteristics and the adherence to Mediterranean diet revealed that male gender relates directly (p =0.002, AOR = 2.95) to a low adherence. There are three criteria in the questionnaire for a point in favour of Mediterranean diet which we believe to be inadequate, as they are not in accordance with the Italian guidelines for healthy eating. The "PREvención con DIeta MEDiterránea" questionnaire, if associated with a food frequency questionnaire or a food intake record, could become a useful tool for nutritional counseling in our Country.

Time-trend of hospitalizations for anogenital warts in Veneto region in the HPV vaccination era: a cross sectional study (2007-2018)

BACKGROUND

Human papillomavirus (HPV) is a common sexually transmitted pathogen and the cause of several cancers and of anogenital warts. With this study, we estimated the trend of hospitalizations for anogenital warts (AGWs) in the Veneto region (Italy) from 2007 to 2018.

METHODS

The analysis included all the hospital discharge records of public and accredited private hospitals occurred in Veneto residents in the timespan 2007-2018. The ICD9-CM code 078.11 considered were those associated with condyloma acuminatum and those associated with surgical interventions for vulval/vaginal warts, penile warts anal warts. Annual total and sex- and age-specific hospitalization rates and trends were calculated and correlated with the different HPV vaccine coverage over the study period.

RESULTS

We observed an overall reduction of hospitalization rates for AGWs: from 15.0 hospitalizations every 100,000 Veneto residents in years 2007-08 to 10.9 hospitalizations every 100,000 Veneto residents in year 2017-18 (- 37.4%; p < 0.05). Reduction has been caused by a drop in hospitalizations in females - from a rate of 20.4/100,000 in 2007-2008 to a rate of 10.8/100,000 in 2017-18 (AAPC: -7.1; 95%CI: - 10.6;-3.4); while in males, we observed a slight - but not statistically significant - increase in hospitalization rates.

CONCLUSION

The marked decline in hospitalization rates for AGWs in Veneto Region is probably attributable to the high coverage rates of HPV vaccination programs implemented since 2008.

The HIV paradox: perinatal mortality is lower in HIV+ mothers. A case-control study in Ethiopia

Background

In Ethiopia, HIV prevalence is 1.2% in 15-49-year-old women, peaking at 3% in aged 40-44. Nationally, efforts have made to provide HIV testing and treatment to all HIV+ subjects, and prevention of mother-to-child transmission. This may imply a closer monitor of health conditions for HIV+ pregnant women. Moreover, antenatal care (ANC) in the third trimester of pregnancy is associated with lower perinatal mortality (PNM). Considering this, we aimed at comparing PNM between HIV+ and HIV- mothers.

Methods

The study was conducted in Wolisso Hospital, Oromiya Region, Ethiopia, a second level hospital with a 1,000,000-catchment area. Cases were all mothers who experienced a perinatal death before hospital discharge. For each case, two mothers who gave birth to a baby alive until discharge were selected as controls. A regression model was built, considering maternal age, rural-urban residence, grand multiparity, twin pregnancy, maternal ongoing chronic/infectious disease and provision of ANC as potential confounders.

Results

Overall, 1175 cases and 2350 controls were included. HIV+ women (n = 71; 2,0%) showed a crude OR = 0.44 (95%CI: 0.24-0.81) for PNM and an adjusted aOR=0.50 (95%CI: 0.25-0.98) when controlling for the aforementioned confounders, including provision of ANC. While 69,0% of HIV+ women received specific ANC, only 24,2% of HIV- women did (p(χ2)&lt;0.001).

Conclusions

Our findings show how the risk of PNM is 50% less in HIV+ mothers. Because of their HIV-positive-status, they are more likely to be in contact with healthcare providers and, thus, to have higher chances to be addressed to ANC services. A large part of the contribution seems to reside in activities directly related to HIV control. This evidence supports national policies against HIV and suggests a considerable improvement of PNM by extending high quality ANC to all pregnant Ethiopian women. Paradoxically, HIV stands out for being a health threat that reduces PNM.

Key messages

In Wolisso hospital, a second level general hospital in Ethiopia, babies born to HIV+ women have a -50% risk of perinatal death. Extending high quality ANC is worth the effort: removing barriers to access and reaching all pregnant women would lead to a massive reduction in perinatal mortality.

Awareness of HPV and drivers of HPV vaccine uptake among university students: A quantitative, cross-sectional study

HPV vaccination is a milestone in primary prevention. However in Italy, vaccine coverage is still nowhere near the target of 95%. We investigated factors associated with inclination to get vaccinated in university students, as they are likely to have just assumed a central role in their healthcare decision-making. University students aged 18-25 were asked to fill in a questionnaire. The effect of socio-demographic and behavioural characteristics on HPV awareness was assessed with a logistic regression adjusting for age, gender, nationality, degree course, relationship, age at first intercourse, number of sexual partners, smoking, sexual orientation, past diagnosis of STDs and knowledge of people who had received HPV vaccine. A second regression adjusting also for information sources, awareness and knowledge investigated factors associated with inclination to receive vaccine. Nine thousand nine hundred and eighty-eight questionnaires were included (response rate 91.3%); awareness of HPV and vaccine was 83.3% and 69.9% respectively. Awareness (AOR: 3.3; 95% CI: 2.3-4.6) and a good knowledge positively affected acceptability, as well as a previous diagnosis of STDs and knowledge of vaccinated people. Healthcare workers (AOR: 1.6; 95% CI: 1.4-1.9) and family members (AOR: 1.7; 95% CI: 1.4-2.1) were the most influencing information sources, even if knowledge of vaccinated people was by far more persuasive (AOR: 2.7; 95% CI: 2.2-3.3). Only 12% of participants were acquainted with skin to skin HPV transmission, while 75% believed in a full effectiveness of condom; less than 22% associated HPV with cancer (other than cervical cancer). Efforts to increase awareness are likely to be worth considering that: awareness is the main determinant of vaccine acceptance; only 50% of individuals not interested in receiving vaccine were aware of it; males are much less aware (AOR: 0.09; 95% CI: 0.07-0.11). Moreover, this study spotlights some misconceptions around HPV and acknowledges a pivotal role of healthcare workers, family and peer influence.

Sexual and gender minorities among students in Italy: population estimate and risk behaviours

Background

Sexual and gender minorities (SGM) are at higher risk for stigma, discrimination and, ultimately, development of risky health behaviours than heterosexual counterparts. Latest demographic data on SGM population in Italy date back to 2011 census. The prevalence of risk behaviours among SGM university students has not been previously estimated in Italy. We aimed at estimating the population of SGM university students and assessing the prevalence of risk behaviours.

Methods

We conducted a cross-sectional survey involving a sample of 18-25 years old students. Participants were asked to complete an anonymous, self-administrated questionnaire on sexual identity/orientation, smoking, use of condom and sexual partners in the last 24 months. χ2 tests were performed.

Results

We collected 9,988 questionnaires (response rate 91.3%); 1.41% did not disclose sexual orientation. Transgender individuals were 0.12%. Among cisgenders males, 95.39% identified as hetero-, 2.52% as homo- and 2.02% as bisexual; 94.50% of females as hetero-, 1.28% as homo- and 4.21% as bisexual. While among men the proportion of smokers was 30.7% without significant differences among subgroups (p=.219), this proportion was 26.1%, 40,5% and 51.6% among hetero-, homo- and bisexual women (p&lt;.001); 62.4% of all males declared to use the condom without significant differences (p=.089), but 19.0% of homo- and 43.4% of bi- females did compared with 55.5% of heterosexual (p&lt;.001); 18,7% of hetero-, 49.4% of homo- and 32.4% of bisexual men declared to have had three or more partners (p&lt;.001); among hetero- women the proportion was 11.1%, while 12.5% and 26.3% among homo- and bisexuals.

Conclusions

SGMs were 5.26% of university students. Compared with hetero- counterparts, homo- and bisexual women showed a higher prevalence of all risk behaviours investigated. In contrast, homo- and bisexual men showed a similar behaviours compared with heterosexual men, except for a significantly higher number of partners.

Key messages

Sexual and gender minorities (SGMs) account for 5.26% of the investigated university student population; 4.54% of cisgender men and 5.49% of cisgender women are homo- or bisexual; trans are 0.12%. SGMs show unhealthier behaviours compared with heterosexual counterparts; in particular, bisexual women show higher prevalence of smoking and non-use of the condom.

Preventing the Risk of Hospitalization for Respiratory Complications of Influenza among the Elderly: Is There a Better Influenza Vaccination Strategy? A Retrospective Population Study

Influenza and its complications are an important public health concern, and vaccination remains the most effective prevention measure. However, the efficacy of vaccination depends on several variables, including the type of strategy adopted. The goal of this study was to assess the impact of different influenza vaccination strategies in preventing hospitalizations for influenza and its related respiratory complications. A retrospective cohort study was conducted on data routinely collected by the health services for six consecutive influenza seasons, considering the population aged 65 years or more at the time of their vaccination and living in northeastern Italy. Our analysis concerns 987,266 individuals vaccinated against influenza during the study period. The sample was a mean 78.0 ± 7.7 years old, and 5681 individuals (0.58%) were hospitalized for potentially influenza-related reasons. The hospitalization rate tended to increase over the years, not-significantly peaking in the 2016-2017 flu season (0.8%). Our main findings revealed that hospitalizations related to seasonal respiratory diseases were reduced as the use of the enhanced vaccine increased (R2 = 0.5234; p < 0.001). Multivariate analysis confirmed the significantly greater protective role of the enhanced vaccine over the conventional vaccination strategy, with adjusted Odds Ratio (adj OR) = 0.62 (95% CI: 0.59-0.66). A prior flu vaccination also had a protective role (adj OR: 0.752 (95% CI: 0.70-0.81)). Age, male sex, and H3N2 mismatch were directly associated with a higher risk of hospitalization for pneumonia. In the second part of our analysis, comparing MF59-adjuvanted trivalent inactivated vaccine (MF59-TIV) with conventional vaccines, we considered 479,397 individuals, of which 3176 (0.66%) were admitted to a hospital. The results show that using the former vaccine reduced the risk of hospitalization by 33% (adj OR: 0.67 (95% CI: 0.59-0.75)). This study contributes to the body of evidence of a greater efficacy of enhanced vaccines, and MF59-adjuvanted TIV in particular, over conventional vaccination strategies in the elderly.

The potential of mobile health clinics in chronic disease prevention and health promotion in universal healthcare systems. An on-field experiment

BACKGROUND

Mobile health clinics (MHCs) are recognized to facilitate access to healthcare services, especially in disadvantaged populations. Notwithstanding that in Europe a wide-ranging background in mobile screening units for cancer is shared, evidences about MHCs targeting also at other non-communicable diseases (NCDs) in universal health coverage systems are scarce. The aim of this study was to describe the population attracted with a MHC initiative and to assess the potential of this tool in prevention and control of NCDs.

METHODS

Our MHC was set up in a railway wagon. Standard body measurements, finger-stick glucose, total cholesterol and blood pressure were recorded. Participants were asked about smoking, physical activity, diet, compliance to national cancer screening programmes and ongoing pharmacological treatment. One-to-one counselling was then provided.

RESULTS

Participants (n = 839) showed a higher prevalence of overweight/obesity, insufficient intake of vegetables, sedentary lifestyle, and a lower compliance to cancer screening compared with reference population. Our initiative attracted groups at higher risk, such as foreigners, men and people aged from 50 to 69. The proportion of newly diagnosed or uncontrolled disease exceeded 40% of participants for both hypertension and hypercholesterolemia (7% for diabetes). Adherence rate to counselling was 99.4%.

CONCLUSIONS

The MHC was effective in attracting hard-to-reach groups and individuals who may have otherwise gone undiagnosed. MHCs can play a complementary role also in universal coverage health systems, raising self-awareness of unreached population and making access to primary health care easier.

Pharmacy-based interventions to increase vaccine uptake: report of a multidisciplinary stakeholders meeting

BACKGROUND

Despite the existence of efficacious vaccines, the burden of vaccine-preventable diseases remains high and the potential health benefits of paediatric, adolescent and adult vaccination are not being achieved due to suboptimal vaccine coverage rates. Based on emerging evidence that pharmacy-based vaccine interventions are feasible and effective, the European Interdisciplinary Council for Ageing (EICA) brought together stakeholders from the medical and pharmacy professions, the pharmaceutical industry, patient/ageing organisations and health authorities to consider the potential for pharmacy-based interventions to increase vaccine uptake. We report here the proceedings of this 3-day meeting held in March 2018 in San Servolo island, Venice, Italy, focussing firstly on examples from countries that have introduced pharmacy-based vaccination programmes, and secondly, listing the barriers and solutions proposed by the discussion groups.

CONCLUSIONS

A range of barriers to vaccine uptake have been identified, affecting all target groups, and in various countries and healthcare settings. Ease of accessibility is a potentially modifiable determinant in vaccine uptake, and thus, improving the diversity of settings where vaccines can be provided to adults, for example by enabling community pharmacists to vaccinate, may increase the number of available opportunities for vaccination.

Effects of maternity waiting homes on perinatal deaths in an Ethiopian hospital. A case-control study

Background

A Maternity Waiting Home (MWH) is a residential facility located near a medical facility, where women with high risk pregnancies can await and be transferred to the medical facility shortly before delivery or earlier if a complication arise. MWH are widespread in the developing countries, to reduce the long distances to reach health facilities. The aim of this study was to investigate whether MWH was an effective strategy in reducing perinatal deaths at Wolisso Hospital in Ethiopia, from 2014 to 2017. This hospital is supported by the Italian NGO Doctors With Africa CUAMM, with a strong commitment to reduce maternal and child mortality.

Methods

Through a case-control study, we compared perinatal mortality among women admitted via MWH and women admitted directly to the hospital. Cases were mothers who experienced at least a perinatal death before discharge. For each case, two mothers who gave birth to one or more babies alive until discharge were selected as controls. 3 groups of confounding variables were considered: maternal conditions or related to the current pregnancy, variables related to the delivery and neonatal characteristics. A regression model was built adjusting for each group. Statistically significant variables were combined in a final model.

Results

1175 cases and 2350 controls were included. Women admitted through MWH showed a OR 0.49 (95%CI:0.33-0.71; p &lt; 0.000) for perinatal mortality when adjusted for the maternal/current pregnancy conditions, and a OR 0.60 (95%CI:0.40-0.90, p = 0.013) when adjusted for the delivery variables. In the final model the risk of perinatal mortality for women admitted to MWH was 54% less than those admitted directly to the hospital (OR = 0.46, 95%CI:0.30-0.70; p &lt; 0.000).

Conclusions

Our results show a more than halved risk of perinatal death cases for women admitted to the hospital through a MWH in rural Ethiopia, and support the policy implemented by the government in building such structures nearby each hospital.

Key messages

Maternity Waiting Home is a structure near a health facility, where pregnant women at risk wait for their delivery. MWH is an easy and effective tool to reduce perinatal deaths in rural Ethiopia.

Awareness of HPV and drivers of HPV vaccine uptake among university students in Italy

Key messages

There is room for improving the awareness of HPV. Efforts are likely to be worth since it remains the main determinant of vaccine uptake. Awareness has been growing but a gender gap still persists. Communication should focus more on HPV involvement in neoplasia other than cervical cancer; transmission via skin to skin contact; multiple sex partnership; partial protection of condom.

Health professionals as parents are not immune to vaccine hesitancy – an Italian national survey

Key messages

Hesitancy is associated with lifestyle choices, experience of adverse reactions and socioeconomic status, while education and employment as health professional seem not to be relevant. Whether they are health professionals or not, parents’ attitude towards their child’s vaccinations is the same.

Opinions and beliefs in vaccine hesitant parents in Italy: what makes the difference

Key messages

While hesitant parents share some concerns with pro-vaccine, relevant opinion gaps may serve as warning lights, pointing at topics potentially harbouring the most sensitive drivers of hesitancy. Communication strategies should primarily focus on raising acquaintance of hesitant parents with benefits arising from herd immunity and compliance with the suggested vaccination schedule.

Self-reported health conditions among refugees and asylum-seekers (AS) in Italian hosting centres

Key messages

Migrants’ health in hosting centres is good; AS by sea, married and with higher education are more at risk, especially as regards mental health; depression warning signs must not go unnoticed. AS in hosting centres represent a heterogeneous population: they may benefit from a more tailored assistance, considering differences in travel conditions, cultural background and life expectations.

Do We Know the True Burden of Tick-Borne Encephalitis? A Cross-Sectional Study

INTRODUCTION

Tick-borne encephalitis (TBE) is an acute human arboviral infection of the central nervous system caused by a virus that is transmitted to humans mainly by tick bites. TBE is endemic in Europe and has become an increasingly important public health concern in recent years. Cases of TBE in Italy have occurred mainly in the north-east and central parts of the country. Vaccination is recommended for people who live in or visit areas at higher risk of tick bites.

OBJECTIVE

The aim of our study was to ascertain the burden of TBE in the Veneto Region (north-east Italy).

METHODS

Cases of TBE occurring in the region from January 1, 2007, to December 31, 2018, were extracted from the database of the mandatory notification system (MNS) and from hospital discharge records (HDRs) of admissions relating to a diagnostic code 063 according to the International Classification of Diseases, Ninth Revision, Clinical Modification. Capture-recapture methods were used to estimate the completeness of each data source (as a percentage of cases). Records including diagnostic codes 322.9 (Meningitis, unspecified) and 323.9 (Unspecified cause of encephalitis, myelitis, and encephalomyelitis) were also extracted from the HDR database. Municipalities were grouped by location, based on their elevation above sea level, as "mountains," "hills," or "lowlands". After selecting only the municipalities where cases of TBE had occurred, the proportion of cases of TBE out of the total cases of encephalitis and meningitis identified was calculated and used to estimate the number of cases of TBE potentially occurring in the municipalities that reported none. Then the observed and adjusted TBE rates per 100,000 population were calculated.

RESULTS

During the 12 years considered, a total of 281 cases of TBE were identified; 155 emerged from the HDRs and the MNS, 89 only from the MNS database, and 37 only from the HDRs. The degree of completeness of the data was 93.0% for the MNS and HDRs combined, 80.8% for the MNS alone, and 63.6% for the HDRs alone. The observed annual rate of TBE in the Veneto in recent years was calculated at 0.48 per 100,000 population, with the highest standardized rate in the province of Belluno (5.95 per 100,000 population). A significant rising trend in the number of cases observed in the latest period (2015-2018) was apparent for the mountainous areas in the region (average annual percent changes: 43.7 [95% CI 19.0-73.5]). The number of cases peaked in the mountains in the month of June (0.89 per 100,000), in hilly areas in July (0.23 per 100,000) and in the lowlands in October (0.04 per 100,000).

CONCLUSIONS

Our findings seem to confirm an underreporting of the cases of TBE and inadequate TBE surveillance in the Veneto, despite the clinical severity of the disease and the fact that it is mandatory to report all cases. The routine integration of different databases is crucial to the successful implementation and assessment of targeted prevention strategies and fundamental to public health decision-making on this issue.

Is depression a real risk factor for acute myocardial infarction mortality? A retrospective cohort study

BACKGROUND

Depression has been associated with a higher risk of cardiovascular events and a higher mortality in patients with one or more comorbidities. This study investigated whether continuative use of antidepressants (ADs), considered as a proxy of a state of depression, prior to acute myocardial infarction (AMI) is associated with a higher mortality afterwards. The outcome to assess was mortality by AD use.

METHODS

A retrospective cohort study was conducted in the Veneto Region on hospital discharge records with a primary diagnosis of AMI in 2002-2015. Subsequent deaths were ascertained from mortality records. Drug purchases were used to identify AD users. A descriptive analysis was conducted on patients' demographics and clinical data. Survival after discharge was assessed with a Kaplan-Meier survival analysis and Cox's multiple regression model.

RESULTS

Among 3985 hospital discharge records considered, 349 (8.8%) patients were classified as 'AD users'. The mean AMI-related hospitalization rate was 164.8/100,000 population/year, and declined significantly from 204.9 in 2002 to 130.0 in 2015, but only for AD users (- 40.4%). The mean overall follow-up was 4.6 ± 4.1 years. Overall, 523 patients (13.1%) died within 30 days of their AMI. The remainder survived a mean 5.3 ± 4.0 years. After adjusting for potential confounders, use of antidepressants was independently associated with mortality (adj OR = 1.75, 95% CI: 1.40-2.19).

CONCLUSIONS

Our findings show that AD users hospitalized for AMI have a worse prognosis in terms of mortality. The use of routinely-available records can prove an efficient way to monitor trends in the state of health of specific subpopulations, enabling the early identification of AMI survivors with a history of antidepressant use.

Perception and knowledge of HPV-related and vaccine-related conditions among a large cohort of university students in Italy

HPV is involved in cervical, anal, penile, vulvar and oropharyngeal cancers, as well as genital warts. It is important to investigate knowledge and attitudes among university students, considering in this age a shift in healthcare decision-making from parents to students themselves. The aim of this study was to estimate knowledge and perception of HPV in terms of potential shame for HPV-related conditions, trust in vaccine efficacy and worry for potential side effects. The study involved students (18-25 years old) from the Universities of Padua and Verona, Italy. Socio-demographic and behavioural characteristics were collected with a questionnaire (n = 9988). Female gender and older age were positively associated with higher knowledge. The adjusted logistic regression showed an association between the set of perceptions investigated and the vaccination status, while a direct connection with knowledge was not found. However, another adjusted linear regression showed that a good set of perceptions could be partially explained by a high level of knowledge. Perceptions seem to fill an intermediate position between the knowledge and the decision to get vaccinated. The potential shame deriving from asking for HPV-vaccination was not identified as a relevant barrier. Having received information from healthcare workers, family and school showed to be positively associated with the adhesion to the vaccination policy. This study identifies university students as a possible target for HPV vaccination and pinpoints specific areas that might be targeted as first to encourage vaccine uptake. Primary prevention together with screening programmes remains essential in further reducing the burden of HPV-related diseases.

Cross-sectional study on hospitalizations related to herpes zoster in an Italian region, 2008-2016

INTRODUCTION

To assess the burden of herpes zoster (HZ) by analyzing HZ-related hospital admissions.

METHODS

We conducted a population-based descriptive cross-sectional study on all hospitalizations for HZ among the resident population admitted to all public and accredited private hospitals in the Veneto Region (north-east Italy) during the years 2008-2016. HZ hospitalizations were identified from the International Classification of Diseases codes in the hospital discharge records.

RESULTS

During the period considered, we identified 3566 HZ-associated admissions, 194 (5.4%) of which were readmissions within 30 days. A complicated HZ diagnosis was mentioned for 44.4% of the patients admitted once and for 65.9% of those admitted twice. In the sample as a whole, 27.0% of patients had at least one comorbidity. Overall, our analysis revealed a gradual increase in hospitalizations with age for both genders, reaching a hospitalization rate for the population over 80 years old of 51.2 × 100,000 for males and 52.8 × 100,000 for females. The average hospitalization rate for HZ-related conditions during the years 2008-2016 was 7.7 per 100,000 population. Postherpetic neuralgia was diagnosed in 8.2% of hospitalizations, with no difference between the genders. The estimated overall cost of HZ-related conditions was approximately €2.7 million a year.

CONCLUSIONS

This study suggests that the burden of HZ and its impact on quality of life are of critical relevance to public health decision-making.

LTBI among migrants by Mediterranean Sea: assessing prevalence and its variations according with different thresholds and diagnostic tools. A 10-month on-field experience

BACKGROUND

In 2016, 362 753 migrants reached Europe by sea. Most of migrants come from high tuberculosis (TB) burden countries and travel in conditions that increase the risk for communicable diseases. The goal of WHO End TB Strategy is to end global epidemic by 2035. Management of latent TB infection (LTBI) in low TB incidence countries is thus essential. Nevertheless, a lack of uniformity in policies and procedures for LTBI screening in Europe is perceived. The aim of this study was to estimate the LTBI prevalence in migrants by Mediterranean Sea.

METHODS

A cross-sectional study was conducted, involving 1038 migrants. Since a gold standard method is not available, LTBI prevalence was assessed in four alternative scenarios with different thresholds and diagnostic tools: (i) TST ≥ 5 mm; (ii) TST ≥ 10 mm; (iii) TST ≥ 5 mm plus IGRA; and (iv) TST ≥ 10 mm plus IGRA. TST = tuberculin skin test; IGRA = interferon-gamma release assay.

RESULTS

The four scenarios returned the following prevalence: (i) TST ≥ 5 mm: 40%; (ii) TST ≥ 10 mm: 33%; (iii) TST ≥ 5 mm plus IGRA: 27%; and (iv) TST ≥ 10 mm plus IGRA: 25%. Moreover, a positive association was found between the proportion of IGRA positive patients and the size of TST induration site. No patient who reported TST ≥ 18 mm tested IGRA negative.

CONCLUSIONS

Prevalence varied substantially in the investigated scenarios. Significant differences were noted according with the nationality of migrants, probably attributable to different Bacillus Calmette-Guérin vaccination coverage rates in the countries of origin or different exposition to non-tuberculous mycobacteria infection. Data about the nationality can suggest the need of a tailored approach according to migrants' area of origin.

The new pandemic influenza A/(H1N1)pdm09 virus: is it really "new"?

In June 2009, the World Health Organization (WHO) issued a pandemic alert concerning the spread of an influenza A (H1N1) virus that showed distinctive genetic characteristics vis-à-vis both seasonal influenza strains and vaccine strains. The main mutation occurred in the gene coding for hemagglutinin (HA). Mathematical models were developed to calculate the transmissibility of the virus; the results indicated a significant overlap with the transmissibility of previous pandemic strains and seasonal strains. The remarkable feature of A/(H1N1)pdm09, compared with seasonal strains, is its high fatality rate and its higher incidence among younger people. Data provided by the WHO on the number of deaths caused by A/(H1N1)pdm09 only include laboratory-confirmed cases. Some authors suggest that these data could underestimate the magnitude of the event, as laboratory confirmation is not obtained in all cases. It is important to bear in mind that the A/(H1N1)pdm09 virus is still circulating in the population. It is therefore essential to maintain its epidemiological and virological surveillance.