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The present comment deals with the much-debated issue of the denial of foreign States’ jurisdictional immunity for acta iure imperii resulting in serious violations of human rights. This question came to the fore in Italy in the early 2000s and has since led to a stark contrast between the International Court of Justice, on the one hand, and Italian courts, in particular the Constitutional Court, on the other. Against this backdrop, these pages are aimed at analysing Order No. 39391/2021 of the Italian Corte di Cassazione, which concerns a proceeding for the enforcement of a US judgment condemning Iran to pay damages to the victims of the 9/11 terrorist attacks. Based on the reasoning of the decision, this comment argues that Italian courts, while praiseworthy for attempting to protect fundamental human rights, seem to have renounced speaking the language of international law.

Sporidesmin A is the most important mycotoxin produced by the fungus Pithomyces chartarum that grows on pasture litter during late summer and autumn. This fungi produces several variants of sporidesmin (from A to J), with sporidesmin A accounting for 80-90% of congeners. Sporidesmins affect the hepatobiliary system of ruminants and lead to the retention of phytoporphyrin which, reacting with light in peripheral tissues, causes the photosensitivity reaction known as "facial eczema". The disease produces losses in animal production and serious animal welfare problems in farmed ruminants in New Zealand and in warm temperate regions of the world. Zinc in several forms and with high dose rates is used as a control measure for facial eczema, but it poses safety issues. Other additives for sporidesmins control in feeds have not been evaluated. The use of adsorbing agents to reduce the exposure to mycotoxins by decreasing their bioavailability is a valuable strategy to cope with mycotoxins. To this scope, this study examines the ability of a clay based agent in sequestering sporidesmins from liquid mediums at physiological pH values (2.5-6.5). The adsorption behaviour of the clay for sporidesmins was studied by equilibrium isotherms as a function of pH, clay dosage, initial toxin concentration, equilibrium time, and temperature. Physico-chemical, kinetic and thermodynamic parameters related to the adsorption process were calculated, including the adsorbent dosage to achieve a 50 (C50) and 100% (C100) of toxin adsorption, the maximum adsorption capacity (Bmax) and the affinity (KL), the rate constants, and the ?G°, ?H°, ?S° parameters. The results showed that the clay exhibited high affinity for sporidesmins at ruminal pH (6.5), while its adsorption capacity slightly decreased with increasing pH from 2.5 to 6.5. In particular, the values of C50 and C100, expressed as mg of clay/µg of sporidesmin A, were 10 and 64 mg/µg at pH 2.5 and 14 and 51 mg/µg at pH 6.5. Bmax values (ng of sporidesmin A adsorbed/mg of clay) calculated at pH 2.5 and 6.5, were 54 and 26 ng/mg, respectively. KL values (L/mg of sporidesmin A) were 16 and 7*102 L/mg at pH 2.5 and 6.5. Kinetic studies suggested that sporidesmin A was adsorbed in less than 60 min following the pseudo second order model. Considering that ruminants are susceptible to sporidesmin A contaminated feed on a µg/kg basis, the results of this study suggest that the clay is promising for use as an effective adsorbent for sporidesmin decontamination.

In addition to the immunomodulatory and antimicrobial properties, yeast cell walls (YCWs) are widely used as feed additives for mycotoxin control. YCW are known to adsorb ZEA, while data on other toxins are conflicting. In this study, a new YCW product was developed to sequester a large spectrum of mycotoxins (AFB1, ZEA, OTA and FB1), and its efficacy was assessed first in vitro by the isotherm approach, and then in vivo with rats. The product at 0.5% w/v dosage adsorbed simultaneously up to 80% ZEA, 65% OTA, 40% FB1 and 10% AFB1 from multi-mycotoxins buffers containing 1 µg/mL of each toxin. The adsorption isotherm approach allowed us to study the adsorption mechanism and to determine the parameters affecting mycotoxin uptake, i.e., type and toxin concentration, pH of the medium and adsorbent concentration. For the study with rats (0.3 kg initial BW), each mycotoxin was administered singularly by a single oral intragastric bolus containing the mycotoxin +/- the product. Two groups of rats were used for each mycotoxin: the control groups received the mycotoxins at the dose of 12, 1, 0.5 and 0.12 mg/kg BW for FB1, ZEA, OTA or AFB1, respectively; while the treated groups received the same dose of mycotoxins with the YCW (0.5% w/w of feed consumption). Feed intake was 100 g feed/kg BW. After toxin administration, rats were housed individually in metabolic cages to collect urine at different time points (4-72h for AFB1, ZEA and FB1; 4-320 h for OTA). The mycotoxin biomarkers (AFM1, ZEA and its metabolites of phase I biotransformation i.e., ?-ZOL, ?-ZOL and ?-ZAL, OTA and FB1) were determined in urine by in-house validated HPLC/UHPLC methods. Mycotoxin content in urine was normalized to the respective creatinine concentration. Toxicokinetic parameters, i.e., area under the curve over 72/320h (AUC0->t) and maximal urine concentration (Cmax) were calculated for target mycotoxins/metabolites and were used to compare control and treatment groups. The YCW reduced the urinary excretion of ZEA, FB1 and OTA, but it was ineffective for AFB1. In particular, AUC was significantly reduced by -50% for OTA (p=0.014) and -42% for FB1 (p=0.048), while Cmax value was reduced by -79% (p

Yeast cell wall (YCW) products are used worldwide as alternatives to antibiotics growth promoters for health and performances improvement in livestock. The success of yeast and YCW products as feed additives in farm animals' nutrition relies on their capacity to bind enteropathogenic bacteria and on their immunomodulatory activity. In vivo studies report their anti-infectious activity on Gram-positive pathogens like clostridia. However, the in vitro antimicrobial activity of YCW products seems to be limited to some Gram-negative enteropathogens, and literature lacks in vitro evidences for antimicrobial effect of YCW products against Clostridium perfringens. This study aims to measure the antimicrobial activity of YCW products on C. perfringens. Five different YCW products were assayed for their capacity to inhibit the growth of C. perfringens, by analyzing the growth kinetics of the pathogen. All YCW products inhibited the growth of the pathogen, by reducing the growth rate and the maximum growth value and extending the lag phase duration. The effect on the growth parameters was product and dosage dependent. The most effective YCW (namely YCW2), at the minimum effective concentration of 1.25 mg/mL, increased the lag phase duration by 3.6 h, reduced the maximum growth rate by >50%, and reduced the final cell count by 10(2) colony-forming unit per milliliter in 24 h, with respect to the control. YCW products did not show a strain-dependent impact on C. perfringens growth when tested on different strains of the bacterium.

The removal of mycotoxins from contaminated feed using lactic acid bacteria (LAB) has been proposed as an inexpensive, safe, and promising mycotoxin decontamination strategy. In this study, viable and heat-inactivated L. acidophilus CIP 76.13T and L. delbrueckii subsp. bulgaricus CIP 101027T cells were investigated for their ability to remove aflatoxin B1 (AFB1), ochratoxin A (OTA), zearalenone (ZEA), and deoxynivalenol (DON) from MRS medium and PBS buffer over a 24 h period at 37 °C. LAB decontamination activity was also assessed in a ZEA-contaminated liquid feed (LF). Residual mycotoxin concentrations were determined by UHPLC-FLD/DAD analysis. In PBS, viable L. acidophilus CIP 76.13T and L. delbrueckii subsp. bulgaricus CIP 101027T cells removed up to 57% and 30% of ZEA and DON, respectively, while AFB1 and OTA reductions were lower than 15%. In MRS, 28% and 33% of ZEA and AFB1 were removed, respectively, OTA and DON reductions were small (≤15%). Regardless of the medium, heat-inactivated cells produced significantly lower mycotoxin reductions than those obtained with viable cells. An adsorption mechanism was suggested to explain the reductions in AFB1 and OTA, while biodegradation could be responsible for the removal of ZEA and DON. Both viable LAB strains reduced ZEA by 23% in contaminated LF after 48 h of incubation. These findings suggest that LAB strains of L. acidophilus CIP 76.13T and L. delbrueckii subsp. bulgaricus CIP 101027T may be applied in the feed industry to reduce mycotoxin contamination.

Background Community participatory interventions mobilizing women of childbearing age are an effective strategy to promote maternal and child health. In 2017, we implemented this strategy in Gulu Northern Uganda. This study explored the perceived impact of this approach on women's capability. Methods We conducted a qualitative study based on three data collection methods: 14 in-depth individual interviews with participating women of childbearing age, five focus group discussions with female facilitators, and document analysis. We used the Sen capability approach as a conceptual framework and undertook a thematic analysis. Results Women adopted safe and healthy behaviors for themselves and their children. They were also able to respond to some of their family's financial needs. They reported a reduction in domestic violence and in mistreatment towards their children. The facilitators perceived improved communication skills, networking, self-confidence, and an increase in their social status. Nevertheless, the women still faced unfreedoms that deprived them of living the life they wanted to lead. These unfreedoms are related to their lack of access to economic opportunities and socio-cultural norms underlying gender inequalities. Conclusion To expand women's freedoms, we need more collective political actions to tackle gender inequalities and need to question the values underlying women's social status.

Background South Sudan has one of the highest maternal mortality ratios in the world, at 789 deaths per 100,000 live births. The majority of these deaths are due to complications during labor and delivery. Institutional delivery under the care of skilled attendants is a proven, effective intervention to avert some deaths. The aim was to determine the prevalence and explore the factors that affect utilization of health facilities for routine delivery and postnatal care in Torit County, South Sudan. Methods A convergent parallel mixed method design combined a community survey among women who had delivered in the previous 12 months selected through a multistage sampling technique (n = 418) with an exploratory descriptive qualitative study. Interviews (n = 19) were conducted with policymakers, staff from non-governmental organizations and health workers. Focus group discussions (n = 12) were conducted among men and women within the communities. Bivariate and multivariate logistic regression were conducted to determine independent factors associated with institutional delivery. Thematic analysis was undertaken for the qualitative data. Results Of 418 participants who had delivered in the previous 12 months, 27.7% had institutional deliveries and 22.5% attended postnatal care at least once within 42 days following delivery. Four or more antenatal care visits increased institutional delivery 5 times (p p = 0.021). Women were more likely to plan and prepare for home delivery than for institutional delivery and sought institutional delivery when complications arose. Perceived poor quality of care due to absence of health staff and lack of supplies was reported as a major barrier to institutional delivery. Women emphasized fear of discrimination based on social and economic status. Unofficial payments such as soap and sweets were reported as routine expectations and another major barrier to institutional delivery. Conclusion Interventions to stop unofficial payments and discrimination based on socio-economic status and to increase access to ANC, delivery services and PNC are needed.

ObjectivesThis study examines health facility utilization for pregnancy and delivery care and the health system challenges, in the light of renewed conflict in 2016, in Torit County, South Sudan. We collected monthly facility data retrospectively on total Antenatal Care (ANC) visits, institutional deliveries, major obstetric, and neonatal complications treated from January 2015 to December 2016. We compared 2015 data with that of 2016 when conflict re-started. We also conducted a descriptive qualitative study based on key informant interviews and Focus Group Discussions (FGDs) to explore the health system challenges. We used a thematic approach to analyse qualitative data. Results ANC visits declined by 21% between 2015 and 2016. The proportion of expected births that occurred in facilities declined from 23.6% in 2015 to 16.7% in 2016 (p< 0.001) while the proportion of obstetric complications treated in facilities declined from 58.9% in 2015 to 43.9% in 2016 (p

Mycotoxins are known worldwide as fungus-produced toxins that adulterate a wide heterogeneity of raw feed ingredients and final products. Consumption of mycotoxins-contaminated feed causes a plethora of harmful responses from acute toxicity to many persistent health disorders with lethal outcomes; such as mycotoxicosis when ingested by animals. Therefore, the main task for feed producers is to minimize the concentration of mycotoxin by applying different strategies aimed at minimizing the risk of mycotoxin effects on animals and human health. Once mycotoxins enter the production chain it is hard to eliminate or inactivate them. This paper examines the most recent findings on different processes and strategies for the reduction of toxicity of mycotoxins in animals. The review gives detailed information about the decontamination approaches to mitigate mycotoxin contamination of feedstuffs and compound feed, which could be implemented in practice.

Since 2013, bentonite in the form of dioctahedral smectite is an additive authorised in the EU as a substance for the reduction of the contamination of feed by aflatoxins. Several studies indicate a big difference in the effectiveness of smectites in sequestering aflatoxins. A clear correlation between mineralogical and physico-chemical properties of smectites and aflatoxin adsorption has not been well established. In the effort to identify the most critical mineralogical, chemical, and physical properties that affect aflatoxin adsorption by smectites, 29 samples of bentonites obtained from different sources around the world were evaluated. “As received” samples were divided into two main groups, i.e. hydrothermal (n=14) and sedimentary (n=15) bentonites depending on their geological origin. The characterization studies showed that all samples contained dioctahedral smectite as major mineral; a moderate CEC value (60-116 cmol/kg); the presence of iron; a small organic matter content; a near-neutral pH; and a fine and uniform particle size (in vitroadsorption studies showed that they also differed in a significant manner in adsorbing aflatoxin B1(AFB1). A correlation between geological origin and AFB1adsorption capacity was found (p1adsorption by all samples was negatively and linearly correlated to the extent of desorption, and sedimentary smectites were significantly more effective than hydrothermal smectites in keeping bound the adsorbed fraction of the toxin (p 1adsorption by smectites correlated positively with sodium content and swell index, but negatively with d001-value, magnesium and calcium contents. In conclusion, it seems that the geological origin of smectite is a useful guide for the selection of bentonites for AFB1detoxification. Sedimentary bentonites containing sodium/swelling-smectite should be preferred to hydrothermal samples as potential aflatoxin binders. Taking into account the geographical origin of our samples, this approach should be applicable to bentonites worldwide.

Yeast cell wall (YCW) products are currently used as substitutes to antibiotic growth promoters, to improve animal performances, and to reduce the incidence of infectious diseases in livestock. They are claimed to bind enteropathogens, thus interfering with their colonization in the intestinal mucosa. Although the anti-infectious activity of YCW products on Gram-positive pathogens like Clostridium perfringens has been reported in vivo, in vitro evidences on the adsorption of C. perfringens by YCW fractions are not yet available. Preliminary results showed that purified YCW products exert antimicrobial activity toward C. perfringens. Using the adsorption isotherm approach, we measured the ability of YCW products in adsorbing C. perfringens, thus reducing its viability. Dosages of YCW products >1 mg/mL adsorbed 4 Log colony-forming unit (CFU)/mL of C. perfringens in buffered solution. The maximum adsorption of the bacterium was reached in 3 h, whereas only one product of four YCW products retained the adsorption up to 6 h. The analysis of equilibrium isotherms and adsorption kinetics revealed that all products adsorb C. perfringens in a dose- and time-dependent manner, with high affinity and capacity, sequestering up to 4 Log CFU/mg of product. The determination of adsorption parameters allows to differentiate among adsorbents and select the most efficient product. This approach discriminated among YCW products more efficiently than the antimicrobial assay. In conclusion, this study suggests that the ability of YCW products in reducing C. perfringens viability can be the result of an adsorption mechanism.

Herpes zoster (HZ) is an acute viral illness characterized by a vesicular rash with unilateral distribution, which can also result in severe complications such as post-herpetic neuralgia (PHN), ophthalmic zoster, stroke or other neurological complications. The estimate incidence in Europe ranges between 2.0 and 4.6 cases per 1,000 person-years, with a sharp increase in >50 year-old subjects. Currently, treatment options for HZ are only partially effective in limiting the acute phase, while the management of complications is complex and often unsatisfactory. The total burden of the disease and the high costs related to its diagnostic and therapeutic management led researchers to develop a new preventive approach through a live attenuated virus vaccine. The currently available vaccine, with a high antigen content, is safe, well tolerated and reduces the incidence of HZ, PHN and the burden of illness. Several countries have introduced this vaccination, albeit with different recommendations and methods of financing. Taking into account the barriers to this immunization registered in some areas (difficulty of vaccine distribution, lack of physician recommendations, the cost of vaccine for patients, etc.), this group of Italian experts advocate that a common strategy able to guarantee a good compliance with this vaccination should be implemented. The same group addresses some practical questions concerning the use of zoster vaccine.

Rosin acids (RA) from coniferous trees are used in folk medicine for healing various skin infections. Despite the antimicrobial potential of RA, their poor solubility in aqueous media may limit their use. In this work RA-loaded polyethylene glycol-poly(lactic-co-glycolic acid) nanoparticles (RA-NPs) with enhanced antimicrobial properties against foodborne bacterial pathogens were produced. RA-NPs were prepared by solvent displacement technique and characterized for relevant colloidal features by dynamic light scattering, laser Doppler anemometry and transmission electron microscopy. Association of RA to NPs occurred with high yields (86% w/w). RA and RA-NPs (~130 nm) were strongly active against antibiotic-sensitive Gram + pathogens, i.e. Clostridium perfringens, Listeria monocytogenes and antibiotic-resistant Staphylococcus aureus. However, both failed in inhibiting the growth of Gram – pathogens (Campylobacter jejuni, Campylobacter coli, Escherichia coli and Salmonella enterica). Association to NPs enhanced the antimicrobial activity of RA. MIC, IC 50 , IC 90 , and MBC values of RA-NPs were ten-times lower than RA. RA-NPs did not change the intrinsic toxicity potential of RA. This is the first study on the enhancement of the antimicrobial activity of RA when associated to nanocarriers. This approach may be an effective strategy to produce aqueous-based RA solutions with enhanced antimicrobial activity against antibiotic-sensitive and antibiotic-resistant Gram + pathogens. The authors thank Prof. Filip Van Immerseel for providing the C. perfringens CP56 strains and ADRIA d_eveloppement for providing the strains indicated with the letters AD in this study. The authors also thank NFT S.r.l. for providing purified rosinic acids, and the i3S Scientific Platform Biointerfaces and Nanotechnology (BN) for assistance in DLS/LDAmeasurements.

Epidemics and pandemics are natural events recurring over the time: their impact can be appropriately minimised but most countries only rely on emergency response. The European Decision 1082/2013 on serious cross-border threats to health is innovative in recognising risk communication as an essential tool in coping with public health emergencies of international concern (PHEIC). The Decision serves as proper context for the EU-funded ASSET (Action plan in Science in Society in Epidemics and Total pandemics) research project that aims to create the blueprint for a better response to PHEIC, through improved forms of dialogue and better cooperation at different levels on Science-in-Society (SiS) issues (governance, engagement, ethics, gender, science education, open access). A Mobilization and Mutual Learning (MML) approach was developed through the ASSET Strategic and Action Plans toward different targets and relevant stakeholders. An integrated participatory approach needs to be recognized into the national plans for preparedness and response.

Enteroviruses (EVs) cause severe outbreaks of respiratory and neurological disease as illustrated by EV-D68 and EV-A71 outbreaks, respectively. We have mapped European laboratory capacity for identification and characterisation of non-polio EVs to improve preparedness to respond to (re)-emerging EVs linked to severe disease. An online questionnaire on non-polio EV surveillance and laboratory detection was submitted to all 30 European Union (EU)/European Economic Area (EEA) countries. Twenty-nine countries responded; 26 conducted laboratory-based non-polio EV surveillance, and 24 included neurological infections in their surveillance. Eleven countries have established specific surveillance for EV-D68 via sentinel influenza surveillance (n = 7), typing EV-positive respiratory samples (n = 10) and/or acute flaccid paralysis surveillance (n = 5). Of 26 countries performing non-polio EV characterisation/typing, 10 further characterised culture-positive EV isolates, whereas the remainder typed PCR-positive but culture-negative samples. Although 19 countries have introduced sequence-based EV typing, seven still rely entirely on virus isolation. Based on 2015 data, six countries typed over 300 specimens mostly by sequencing, whereas 11 countries characterised under 50 EV-positive samples. EV surveillance activity varied between EU/EEA countries, and did not always specifically target patients with neurological and/or respiratory infections. Introduction of sequence-based typing methods is needed throughout the EU/EEA to enhance laboratory capacity for the detection of EVs.

In the 1990s, an epidemic of cholera caused by Vibrio cholerae 01 El Tor has spread from northern Pakistan to the Mediterranean. In 1993 sporadic cases of cholera, and epidemic foci, were recorded in many countries of the southern part of Eastern Europe.

Although vaccination is one of the most cost-effective health care interventions, under-vaccination and variation in coverage rates lower than policy targets is rising in developed countries, partly due to concerns about vaccination value and benefits. By merging various antigens into a single product, combination vaccines represent a valuable tool to mitigate the burden associated with the numerous injections needed to protect against vaccine preventable infectious diseases and increase coverage rate, possibly through various behavioral mechanisms which have yet to be fully explored. Beyond their cost-effectiveness in protecting against more diseases with fewer injections, combination vaccines also have several other benefits, for children, their parents/carers, as well as for the health system and the population as a whole. The objectives of this review are to identify and illustrate the value of combination vaccines for childhood immunization. Evidence was classified into 2 groups: benefits for society and benefits for public health and healthcare systems. This article also highlights the value of innovation and challenges of combination vaccine development as well as the need for an increased number of suppliers to mitigate the impact of any potential vaccine shortage. Increasing public confidence in vaccines and combination vaccines is also critical to fully exploit their benefits.

Population aging is the demographic phenomenon characterizing all countries in the world, and it is challenging the national infrastructures, in particular health systems. However, aging itself is not associated with increased medical spending, but disability and comorbidity that affect older individuals are the actual drivers for health expenditures. Therefore, if people age in better health, medical spending may be significantly reduced. Preventative interventions proved to be effective in reducing/preventing disease and disability and often found to be cost effective, include diet and exercise interventions, medications, routine disease screenings, and immunizations. Vaccination can protect older citizens against life-threatening diseases, such as influenza, pneumococcal infections, tetanus, and against diseases which adversely impact their quality of life, such as herpes zoster (HZ). Including HZ vaccination in its citizens' lifetime immunization calendar can reinforce Europe's commitment toward active, healthy aging. This paper outlines the consensus statement of a group of Italian experts on HZ.

Herpes Zoster (HZ) is a viral disease with painful neuro-dermatologic manifestations. Incidence increases with age. In Italy, the estimated incidence is 6.3 cases/1000 person/year; hospital admissions are less than 2%, 69% in patients aged over 65 years. The most frequent complication of HZ is Post-Herpetic Neuralgia (PHN) characterized by metameric pain, allodynia, and hyperalgesia. In Italy 20.6% and 9.2% of HZ patients experience PHN after 3 and 6 months, respectively. Available antiviral and analgesic treatments are relatively unsatisfactory in reducing pain and length of the disease. Prevention has recently become possible with the live attenuated vaccine Oka/Merck. Clinical studies show a reduction of 51% in the incidence of the disease, 61% of its burden and 67% of PHN in vaccinees. Protection seems to be long lasting and vaccine safety matches registration requirements. Available evidence suggests that the costs for QALY (less than € 20 000) and avoided cases is favorable. Due to the heavy burden of disease, it is time to offer this vaccination to elderly population.

Objective: During the last decade, a worldwide growing interest in evaluating performance of health services through ‘outcome studies’ took place. This study started in early 2002 and represents the first National Health System (NHS) experience to evaluate adjusted performance indicators at national level. The aim of this study was to compare 30 days mortality after coronary artery bypass graft (CABG) between cardiac surgery centres, adjusting by confounding risk factors. Methods: All patients, aged 15—99 years, undergoing a CABG intervention after 1st January 2002 in 82 participating centres were eligible for this observational longitudinal study. For each patient, data on severity and risk factors were collected (type of procedure, haemodynamic condition, co-morbidities, recent myocardial infarction and unstable angina, ventricular function, emergency condition, vital status at 30 days). Using a multiple logistic regression analysis the best predictive model was developed for risk-adjustment; a cross-validation procedure was applied; specific risk adjusted mortality rates (RAMR) were estimated. The overall study population was used as reference standard. Results: 34,310 isolated CABG were performed in 64 of the 82 participating centres. Thirty days mortality resulted 2.61%, ranging from 0.33 to 7.63%; eight centres presented a RAMR significantly lower and seven significantly higher than the reference. Conclusions: The study provides valid measures of the heterogeneity between outcomes of the Italian cardiac surgery centres, to support decision-makingbyNHS management and individualpatients. Althoughnotstatisticallysignificant, RAMRdroppedfromyear 2002 to 2004 (2.8—2.4%) suggesting that this comparative outcome assessment can contribute to the improvement of performances in cardiac surgery. # 2005 Elsevier B.V. All rights reserved.

From August 2000 through January 2001, a large epidemic of Ebola hemorrhagic fever occurred in Uganda, with 425 cases and 224 deaths. Starting from three laboratoryconfirmed cases, we traced the chains of transmission for three generations, until we reached the primary casepatients (i.e., persons with an unidentified source of infection). We then prospectively identified the other contacts in whom the disease had developed. To identify the risk factors associated with transmission, we interviewed both healthy and ill contacts (or their proxies) who had been reported by the case-patients (or their proxies) and who met the criteria set for contact tracing during surveillance. The patterns of exposure of 24 case-patients and 65 healthy contacts were defined, and crude and adjusted prevalence proportion ratios (PPR) were estimated for different types of exposure. Contact with the patient’s body fluids (PPR = 4.61%, 95% confidence interval 1.73 to 12.29) was the strongest risk factor, although transmission through fomites also seems possible.

An outbreak of tuberculosis (TB) in Italy involved 19 schoolchildren with active TB and 43 with latent infection. The source of the outbreak was a school assistant born in Italy who had a family history of TB. This outbreak highlights the need for maintaining clinical and public health expertise in countries with low TB incidence.

Supported by a specific act of the Italian Parliament.The committees and members of the Italian StudyGroup for the Di Bella Multitherapy Trials are asfollows. Research Coordinating Center: D. Greco,R. Raschetti, B. Caffari, F. Chiarotti, R. Da Cas, B.De Mei, G. Di Giovambattista, M. Maggini, F. Men-niti-Ippolito, S. Modigliani, P. Popoli, P. Ruggeri, S.Spila-Alegiani, C. Tomino, G. Traversa, P. Bruzzi, T.Gamucci. Steering Committee: G. Benagiano, D.Amadori, P. Bruzzi, E. Buiatti, E. Ciranni, F. Cog-netti, G. Colucci, P.F. Conte, G. Di Bella*, D. Greco,S. Iacobelli, F. Mandelli, E. Marubini, M. Massotti,S. Monfardini, F. Oleari, R. Raschetti, G. L. San-nazzari, L. Tomatis, U. Veronesi. (*Dr. G. Di Bella,the son of Dr. L. Di Bella, only participated in thefirst two meetings of the Steering Committee. Onmany occasions, he strongly disagreed with theperformance and results of the trials. No part ofthe current article has been discussed with orendorsed by Dr. G. Di Bella.) International ReviewBoard: P. Calabresi (Rhode Island), F. Cavalli (Bell-inzona, Switzerland), P. Kleihues (Lyon Cedex,France), J.G. Mc Vie (London, UK), H. Pinedo (Am-sterdam, The Netherlands), K. Sikora (Lyon Cedex,France), T. Tursz (Villejuif Cedex, France). Indepen-dent Endpoint Evaluation Committee: A. R. Bianco,R. Labianca, P. L. Rossi Ferrini, G. Simonetti, A.Sobrero. Investigators: Ancona—R. Cellerino, S.Antognoli, R. Berardi, R. Bracci, P. Lippe, F. Pulita;Aosta—F. Di Vito, D. Martinod, M. Musi; Avi-ano—A. Veronesi, R. Lazzarini; Bari—G. Colucci(Principal Investigator [PI]), V. Attolico, F. Giotta, M.Longo, E. Maiello; Bologna—S. Tura, F. Gherlin-zoni, M. Tani; Bolzano—H. Amor, P. Borona, F.Girardi, C. Graiff; Cagliari—G. Broccia, M. G. Co-rona, A. Desogus, V. Mascia, S. Pasqualucci; Ca-tania—G. Failla, M. R. Aiello, S. Cordio, P. Finoc-chiaro. Chieti—S. Iacobelli (PI), E. Melena, M. DeTursi, M. T. Scognamiglio, N. Tinari; Forli`—D.Amadori (PI), M. Maltoni, O. Nanni, F. Scardovi, P.Serra; Genoa—R. Rosso, F. Boccardo, A. Barp, T.Coli, M. Grimaldi; Milan—N. Cascinelli, L. Ascani,E. Bajetta, P. Bidoli, A. Cassata, D. De Candis, W.Giannessi, G. Procopio; Milan—S. Di Donato, A.Boiardi, D. Cerri, M. Eoli, A. Silvani; Milan—U.Veronesi (PI), M. Colleoni, N. Rotmensz; Na-ples—S. Monfardini (PI), G. Comella, A. De Mat-teis, A. Gravina, C. Gridelli, F. Perrone, M. R.Salzano, C. Sandomenico; Naples—C. Battista, G.Iodice, R. Fico, A. Nicchia; Padua—M. Lise, G. L.De Salvo, E. Di Lenardo, G. Iadicicco; Palermo—B.Agostara, I. Cafarelli; Perugia—M. Tonato, F.Radicchi, S. Sorbolini, O. Taschini; Pisa—P. F.Conte (PI), A. Carmignani, L. Del Mastro, A. Gen-nari, C. Orlandini; Potenza—L. Manzione, A. Di-nota, G. Lombardi; Reggio Calabria—G. Gasparini,M. G. Arena, M. Fanelli, F. Modafferi, A. Morabito;Rome—F. Mandelli (PI), P. Fazi, F. Mauro, M.Martelli, C. Ricci, M. Vignetti; Rome—F. Cognetti(PI), A. D’Alessio, S. De Marco, V. Ferraresi, T.Gamucci, D. Giannarelli, E. Magnani, P. Rellecati,E. M. Ruggeri, M. Zeuli; Turin—G. L. Sannazzari(PI), M. Borgognone, R. Chio`, A. Gasco, R. Ragona,M. Sacco, R. Soffietti, R. Verna, M. Tessa;Turin—A. Pileri; Trento—E. Galligioni, A. Lucenti,F. Moltrer, F. Paolazzi.The authors thank the Stabilimento ChimicoFarmaceutico Militare, Florence, Italy (Colonel G.Muzzi, Director), for the production of the melato-nin tablets and retinoid solution and the Group forthe supervision and control of custom-made drugsof the Istituto Superiore di Sanita`, Roma (E. Cir-anni, Director; R. Alimenti, S. Alimonti, G. Cavaz-zutti, L. Gagliardi, B. Gallinella, G. Incarnato, F. LaTorre, A. Mosca, G. Multari, L. Turchetto, L. Valvo).Address for reprints: Giuseppe Traversa, M.D., De-partment of Epidemiology and Biostatistics, IstitutoSuperiore di Sanita`, Viale Regina Elena 299, 00161Rome, Italy.Received April 26, 1999; revision received July 22,1999; accepted July 29, 1999.

Titers of serum antibody and cell-mediated immunity (CMI) to Bordetella pertussis antigens were assessed in a cohort of Italian military school students for whom the coverage of pertussis vaccination was low. The overall prevalence of IgG antibody above the minimum level of detection (MLD) was 71.6% for pertussis toxin (PT), 81% for pertactin (PRN), and 99% for filamentous hemagglutinin (FHA). Levels of IgA antibody to PT above the MLD were detected in 15.9% of the study participants. CMI to FHA, PRN, and PT was positive in 97%, 100%, and 82% of tested individuals, respectively. Only 9.7% of the participants had neither antibody nor CMI specific to B. pertussis antigens. In the 5-month clinical, microbiological, and serological follow-up conducted during a high-risk period of pertussis, no cases of pertussis were detected. These data, in particular CMI, demonstrate that most Italian young adults are specifically primed against B. pertussis, which should be taken into consideration when future policy on pertussis vaccination is being made in Italy.

After >10 years without detection of any cases of wild virus-associated poliomyelitis, a large outbreak of poliomyelitis occurred in Albania in 1996. A total of 138 paralytic cases occurred, of which 16 (12%) were fatal. The outbreak was due to wild poliovirus type 1, isolated from 69 cases. An attack rate of 10 per 100,000 population was observed among adults aged 19-25 years who were born during a time of declining wild poliovirus circulation and had been vaccinated with two doses of monovalent oral poliovirus vaccines (OPVs) that may have been exposed to ambient temperatures for prolonged periods. Control of the epidemic was achieved by two rounds of mass vaccination with trivalent oral poliovirus vaccine targeted to persons aged 0-50 years. This outbreak underscores the ongoing threat of importation of wild poliovirus into European countries, the importance of delivering potent vaccine through an adequate cold chain, and the effectiveness of national OPV mass vaccination campaigns for outbreak control.

We present magneto-photoluminescence experiments on a multi-quantum-barrier structure consisting of 31 period of wide (58 nm) quaternary wells of InGaAsP with the same lattice parameter as InP separated by thin (8 nm) InP barriers. The anomalous diamagnetic shift and the asymmetric broadening of the luminescence spectra evidence strong band filling in the tail of the density of states of the quaternary alloy, suggesting that tunneling transport through the InP barrier is anisotropic along the growth axis, due to different band lineups for the direct (InGaAsP-on-InP) and inverse (InP-on-InGaAsP) interfaces. This finding is supported by high resolution X-ray patterns, yielding evidence that the direct and inverse interfaces are smooth and display different chemical compositions.

Grape pomace (pulp and skins) was investigated as a new biosorbent for removing mycotoxins from liquid media. In vitro adsorption experiments showed that the pomace obtained from Primitivo grapes is able to sequester rapidly and simultaneously different mycotoxins. Aflatoxin B-1 (AFB(1)) was the most adsorbed mycotoxin followed by zearalenone (ZEA), ochratoxin A (OTA), and fumonisin B-1 (FB1), whereas the adsorption of deoxynivalenol (DON) was negligible. AFB(1) and ZEA adsorptions were not affected by changing pH values in the pH 3-8 range, whereas OTA and FB1 adsorptions were significantly affected by pH. Equilibrium adsorption isotherms obtained at different temperatures (5-70 degrees C) and pH values (3 and 7) were modeled and evaluated using the Freundlich, Langmuir, Sips, and Hill models. The goodness of the fits and the parameters involved in the adsorption mechanism were calculated by the nonlinear regression analysis method. The best-fitting models to describe AFB(1), ZEA, and OTA adsorption by grape pomace were the Sips, Langmuir, and Freundlich models, respectively. The Langmuir and Sips models were the best models for FB1 adsorption at pH 7 and 3, respectively. The theoretical maximum adsorption capacities (mmol/kg dried pomace) calculated at pH 7 and 3 decreased in the following order: AFB(1) (15.0 and 15.1) > ZEA (8.6 and 8.3) > OTA (6.3-6.9) > FB1 (2.2 and 0.4). Single- and multi-mycotoxin adsorption isotherms showed that toxin adsorption is not affected by the simultaneous presence of different mycotoxins in the liquid medium. The profiles of adsorption isotherms obtained at different temperatures and pH and the thermodynamic parameters (Delta G degrees, Delta H degrees, Delta S degrees) suggest that mycotoxin adsorption is an exothermic and spontaneous process, which involves physisorption weak associations. Hydrophobic interactions may be associated with AFB(1) and ZEA adsorption, whereas polar noncovalent interactions may be associated with OTA and FB1 adsorption. In conclusion, this study suggests that biosorption of mycotoxins onto grape pomace may be a reasonably low-cost decontamination method.

Background The signal of an association between vaccination in the second year of life with a hexavalent vaccine and sudden unexpected deaths (SUD) in the two days following vaccination was reported in Germany in 2003. A study to establish whether the immunisation with hexavalent vaccines increased the short term risk of SUD in infants was conducted in Italy. Methodology/Principal Findings The reference population comprises around 3 million infants vaccinated in Italy in the study period 1999–2004 (1.5 million received hexavalent vaccines). Events of SUD in infants aged 1–23 months were identified through the death certificates. Vaccination history was retrieved from immunisation registries. Association between immunisation and death was assessed adopting a case series design focusing on the risk periods 0–1, 0–7, and 0–14 days after immunisation. Among the 604 infants who died of SUD, 244 (40%) had received at least one vaccination. Four deaths occurred within two days from vaccination with the hexavalent vaccines (RR = 1.5; 95% CI 0.6 to 4.2). The RRs for the risk periods 0–7 and 0–14 were 2.0 (95% CI 1.2 to 3.5) and 1.5 (95% CI 0.9 to 2.4). The increased risk was limited to the first dose (RR = 2.2; 95% CI 1.1 to 4.4), whereas no increase was observed for the second and third doses combined. Conclusions The RRs of SUD for any vaccines and any risk periods, even when greater than 1, were almost an order of magnitude lower than the estimates in Germany. The limited increase in RRs found in Italy appears confined to the first dose and may be partly explained by a residual uncontrolled confounding effect of age.

A sample of 393 Albanian refugees, including both children and adults, was tested for serological HAV, HBV, HDV and HCV markers. A high prevalence of infection with both the hepatitis A and B viruses was found, while HDV and HCV infections were uncommon. The overall prevalence of anti-HAV was 96%; it was very high in children 0-10 years, suggesting that HAV infection is largely acquired during childhood and that poor ambiental conditions influence the spreading of this viral infection. One or more serological markers of HBV infection were found in 295 Albanians (75%), confirming the endemic nature of this virus in the Albanian community. The overall prevalence of HBsAg was 19%, and the carrier rate was higher in males than in females. The high HBsAg prevalence among children suggests that HBV infection is usually acquired in early childhood. The serological data obtained in the Albanian sample examined clearly indicate the urgent need for measures to reduce the incidence of HAV and HBV infections and to avoid the further spread of HDV and HCV infections. Finally, the high prevalence of type B hepatitis indicates the necessity of vaccination against HBV for all risk groups and for all children at birth.

The significance of the binomial "ethics" and "public health" is firstly described. Several definitions are given. A few characteristics making bioethics (concerning mainly individuals) different from ethics in public health (concerning populations) are described. The authors point out how bioethics has been investigated more deeply than public health ethics. Synergy between the two is desirable and efforts should be made in order to promote integration. The importance of research and training in public health ethics and of data exchange with other branches of learning are underlined. A list of national and international institutions dealing with public health ethics is given.

In late May 1994, following reports of an outbreak of group A beta-haemolytic streptococcus (GAS) in the United Kingdom, the Istituto Superiore di Sanità (ISS) set up a surveillance system for systemic invasive GAS disease. The surveillance system was als

An outbreak of diarrhoea in a hotel affected 25 time keepers attending the 1997 Mediterranean Games. Epidemiological investigation implicated a ‘pasta al ragu’ consumed at the hotel's restaurant and Clostridium perfringens food poisoning was identified by direct detection of C. perfringens enterotoxin in patients' stools. This report confirms that a careful evaluation of epidemiological features, together with the availability of direct and rapid laboratory methods, may lead to a prompt identification of C. perfringens food poisioning.

Between April and November 1996, a large outbreak of polio occurred in Albania, which had reported to be free of polio since 1985. Although Albania had not reported polio in that interval, the risk of introduction and circulation of wild poliovirus had in

A prospective, multicenter, open study of fluconazole prophylaxis was performed in AIDS patients to evaluate the efficacy and toxicity of the drug in preventing relapses of esophageal candidiasis. To this aim, 99 AIDS patients who presented a first episode of clinically and microbiologically confirmed esophageal candidiasis were enrolled in eleven clinical centers scattered throughout the Italian territory. After resolution of this initial esophagitis, all subjects were given fluconazole, 100 mg/die, and followed up for a 6 month period. Only 7 out of the 99 patients enrolled had a relapse of Candida esophagitis, during a mean follow-up period of 138.5 days. All relapsing patients had CD4+ cell number < 100/microliters at baseline. Mild side effects were reported in only eight patients. However, 14 of the 27 subjects from whom serial serum samples were available became (12) or remained (2) antigenemic during fluconazole prophylaxis, independently from relapse, suggesting the persistence of tissue-invasive, proliferating Candida cells. Overall, the data of this study suggest a beneficial effect of prophylactic maintenance therapy with fluconazole against Candida esophagitis, particularly in the population with > 100 CD4+/microliters. However, the data on Candida antigenemia in these patients invite the consideration of a relative inefficiency of the drug to eradicate the microrganism from the esophageal tissue