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Objectives: To collect and summarise all current data from observational studies, generating evidence of the association between health literacy (HL) and the dietary intake of sugar, salt and fat, to analyse intervention studies on the promotion of an appropriate dietary intake of the above-mentioned nutrients and to ascertain whether HL moderates the efficacy of such intervention. Design: A systematic literature search of analytical observational studies on the association between HL and dietary intake of sugar, salt and fat was performed in Medline and Scopus databases. Intervention studies on the promotion of healthy nutrition that concerned the intake of sugar, salt and fat were also assessed. Results: Of the eight observational studies included in this review, five investigated dietary intake of sugar, one focused on salt, one assessed sugar and salt and one analysed the fat intake. The results of the five studies assessing sugar were mixed: three found an association between low levels of HL and a high sugar intake, one found this association only for boys and two found no evidence of any association. The two studies assessing salt and the one assessing fat found no evidence of any association with HL. One intervention study on the sugar intake concluded that HL was not a significant moderator of the intervention’s effectiveness. Conclusion: No evidence of any association between HL and salt and fat intake emerged, while for sugar, the results are mixed. More work is needed to better understand the moderating effects of HL on the outcomes of health promotion interventions.

Objectives: The study aimed to analyze and update the impact of pertussis on the Italian population by evaluating pertussis-related hospital admissions in the period 2001–2014. Design or methods: Hospital Discharge Records (HDR) were provided by the National Archive of HDR data of the Ministry of Health. Only hospitalizations included in the primary diagnosis were evaluated. Significant trends over the considered years were assessed as average annual percent changes (AAPC) applying the Joinpoint model. Results: A total of 7,102 hospital admissions for pertussis (main diagnosis) were registered; the trend of hospitalizations progressively decreased from >1/100,000 inhabitants in the years 2001-2004 to 0.64/100,000 inhabitants in 2014. A great part of hospitalizations (63.6%) involved subjects

The aim of our study was to ascertain the prevalence of SARS-CoV-2 infection in the general population during a period of moderate risk, just before Italy started to implement its vaccination campaign. A third-generation antigenic nasal swab sample was collected by a healthcare provider, and all individuals testing positive subsequently had a nasopharyngeal swab for molecular testing, the result was used to calculate the positive predictive value. The population consisted of 4467 asymptomatic adults with a mean age of 46.8 ± 16.00 years. The 62.2% tested for the first time, while 37.8% had previously undergone a mean 2.2 tests for SARS-CoV-2. With 77 of our overall sample reporting they had previously tested positive for COVID-19 and 14 found positive on our screening test, the overall estimated prevalence of the infection was 0.31%. Nine of the 14 cases were confirmed on molecular testing with a PPV of 64.3%. The mean age of the individuals testing positive was 38.1 ± 17.4. Based on the timing of symptom onset, six of the above cases were classified as false negatives, and the adjusted estimated prevalence was 0.34%. Describing levels of infection in a general population seems to be very difficult to achieve, and the universal screening proved hugely expensive particularly in a low-prevalence situation. Anyway, it is only thanks to mass screening efforts that epidemiological data have been collected. This would support the idea that routine screening may have an impact on mitigating the spread of the virus in higher-risk environments, where people come into contact more frequently, as in the workplace.

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.

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.

BackgroundHealthcare factors have strongly influenced the propagation of COVID-19. The present study aims to examine whether excess mortality during the first phase of the COVID-19 outbreak in Italy was associated with health, healthcare, demographic, and socioeconomic indicators measured at a provincial level.MethodsThe present ecological study concerns the raw number of deaths from Jan. 1 to Apr. 30, 2020 and the mean number of deaths in the same months of 2015 to 2019, per province. Information on socioeconomic factors and healthcare settings were extracted from the most recently updated databases on the ISTAT website. Two multilevel, multivariate models were constructed to test whether excess mortality was associated with the indicators across 107 provinces in Italy.ResultsOn linear multilevel, multivariate analysis, AIDS mortality rate (p-value ConclusionSome health and healthcare variables are strongly associated with excess mortality caused by COVID-19 in Italy and should be considered to implement mitigation policies and increase healthcare resilience.

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 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.

Background: A few years after the introduction in Italy of a four-component anti-meningococcal B vaccine (4CMenB), we evaluated the effectiveness and impact of vaccination in two regions using different schedules (2, 4, 6, 12 months in Tuscany vs. 7, 9, 15 months in Veneto) through an observational retrospective study. Methods: Vaccination started in 2014 in Tuscany and in 2015 in Veneto, the data collected referred to the period 2006&ndash, 2018 for Tuscany and 2007&ndash, 2018 for Veneto. Cases of invasive meningococcal disease due to N. Meningitidis B were identified by culture and/or real-time PCR. Results: In Tuscany, pre-vaccine incidence was 1.96 (95% CL 1.52, 2.40) and dropped to 0.62 (95% CL 0.60, 0.64) in the post-4CMenB era. Evaluating only vaccinated children, post-4CMenB incidence was 0.12 (95% CL 0.08, 0.15). In Veneto pre-vaccine incidence was 1.94 (95% CL 1.92, 1.96) and dropped to 1.34 (95% CL 1.31, 1.38) in the post-4CMenB era. In the vaccinated population, MenB incidence was 0.53 (95% CL 0.50, 0.56). Vaccine effectiveness was 93.6% (95% CL 55.4, 99.1) in Tuscany and 91.0% (95% CL 59.9, 97.9) in Veneto, with mean vaccine coverages of 83.9% and 81.7%, respectively. The overall impact (evaluating both vaccinated and unvaccinated children) was 0.68 (95% CL 0.10, 0.89) in Tuscany and 0.31 (95% CL &minus, 0.56, 0.69) in Veneto, the total impact (evaluating only vaccinated children) was 0.94 (95% CL 0.56, 0.99) and 0.90 (95% CL 0.57, 0.97), respectively. The relative case reduction (RCR) was 65% in Tuscany and 31% in Veneto. Considering the vaccinated population, the RCR was equal to 91% and 80%, respectively. Conclusion: In conclusion, 4CMenB appears to have a very high effectiveness in Italy, the impact of vaccination appears greater where the immunization program is started early.

Background: Since the beginning of SARS-CoV-2 outbreak, a large number of infections have been reported among healthcare workers (HCWs). The aim of this study was to investigate the occurrence of SARS-CoV-2 infection among HCWs involved in the first management of infected patients and to describe the measures adopted to prevent the transmission in the hospital. Methods: This prospective observational study was conducted between February 21 and April 16, 2020, in the Padua University Hospital (north-east Italy). The infection control policy adopted consisted of the following: the creation of the &ldquo, Advanced Triage&rdquo, area for the evaluation of SARS-CoV-2 cases, and the implementation of an integrated infection control surveillance system directed to all the healthcare personnel involved in the Advance Triage area. HCWs were regularly tested with nasopharyngeal swabs for SARS-CoV-2, body temperature and suggestive symptoms were evaluated at each duty. Demographic and clinical data of both patients and HCWs were collected and analyzed, HCWs&rsquo, personal protective equipment (PPE) consumption was also recorded. The efficiency of the control strategy among HCWs was evaluated identifying symptomatic infection (primary endpoint) and asymptomatic infection (secondary endpoint) with confirmed detection of SARS-CoV-2. Results: 7595 patients were evaluated in the Advanced Triage area: 5.2% resulted positive and 72.4% was symptomatic. The HCW team was composed of 60 members. A total of 361 nasopharyngeal swabs were performed on HCWs. All the swabs resulted negative and none of the HCWs reached the primary or the secondary endpoint. Conclusions: An integrated hospital infection control strategy, consisting of dedicated areas for infected patients, strict measures for PPE use and mass surveillance, is successful to prevent infection among HCWs.

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., Graphical abstract Unlabelled Image, Highlights • Wastewater-based epidemiology is a promising tool for COVID-19 environmental surveillance. • An experimental WBE sampling site network was tested for public health purposes. • SARS-CoV-2 RNA was detected by RT-qPCR in untreated and treated wastewaters. • Detection power is estimated at least equal to 1 case out of 388 to 822 inhabitants. • Persistence of viral RNA after 24 h in refrigerated samples was also confirmed.

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 &plusmn, 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&ndash, 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 &lt, 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&ndash, 0.66). A prior flu vaccination also had a protective role (adj OR: 0.752 (95% CI: 0.70&ndash, 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&ndash, 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.

Childhood vaccination has been a milestone in the control of infectious diseases. However, even in countries offering equal access to vaccination, a number of vaccine-preventable diseases have re-emerged. Suboptimal vaccination coverage has been called into question. The aim was to explore socioeconomic inequalities in vaccine hesitancy and outright refusal. Families with at least one child aged between 3 months and 7 years were involved through an online survey. Families were classified as provaccine, hesitant, or antivaccine. The association between socioeconomic determinants and hesitancy/refusal was investigated with a logistic-regression model. A total of 3865 questionnaires were collected: 64.0% of families were provaccine, 32.4% hesitant, and 3.6% antivaccine. Rising levels of perceived economic hardship were associated with hesitancy (adjusted odds ratio (AOR) from 1.34 to 1.59), and lower parental education was significantly associated with refusal (AOR from 1.89 to 3.39). Family economic hardship and parental education did not move in parallel. Economic hardship was a determinant of hesitancy. Lower education was a predictor of outright refusal without affecting hesitancy. These findings may serve as warnings, and further explanations of socioeconomic inequities are needed even in universal healthcare systems. Insight into these factors is necessary to improve convenience and remove potential access issues.

On the 21st of February 2020 a resident of the municipality of Vo’, a small town near Padua, died of pneumonia due to SARS-CoV-2 infection1. This was the first COVID-19 death detected in Italy since the emergence of SARS-CoV-2 in the Chinese city of Wuhan, Hubei province2. In response, the regional authorities imposed the lockdown of the whole municipality for 14 days3. We collected information on the demography, clinical presentation, hospitalization, contact network and presence of SARS-CoV-2 infection in nasopharyngeal swabs for 85.9% and 71.5% of the population of Vo’ at two consecutive time points. On the first survey, which was conducted around the time the town lockdown started, we found a prevalence of infection of 2.6% (95% confidence interval (CI) 2.1-3.3%). On the second survey, which was conducted at the end of the lockdown, we found a prevalence of 1.2% (95% CI 0.8-1.8%). Notably, 43.2% (95% CI 32.2-54.7%) of the confirmed SARS-CoV-2 infections detected across the two surveys were asymptomatic. The mean serial interval was 6.9 days (95% CI 2.6-13.4). We found no statistically significant difference in the viral load (as measured by genome equivalents inferred from cycle threshold data) of symptomatic versus asymptomatic infections (p-values 0.6 and 0.2 for E and RdRp genes, respectively, Exact Wilcoxon-Mann-Whitney test). Contact tracing of the newly infected cases and transmission chain reconstruction revealed that most new infections in the second survey were infected in the community before the lockdown or from asymptomatic infections living in the same household. This study sheds new light on the frequency of asymptomatic SARS-CoV-2 infection and their infectivity (as measured by the viral load) and provides new insights into its transmission dynamics, the duration of viral load detectability and the efficacy of the implemented control measures.

Herpes zoster (HZ) infection is widespread in the general population - especially in the elderly - and can be associated with major sequelae such as post-herpetic neuralgia. Live attenuated zoster vaccine was licensed in Europe in May 2006 and in Italy in 2010; since March 2014, it has been commercially available in Italy. In Italy, vaccination against HZV is recommended in all subjects at risk - for example, those with diabetes, cardiovascular disease, chronic obstructive pulmonary disease or patients on immunosuppressive agents - from the age of 50 years onwards and for all persons aged >64 years. This paper summarizes the virtuous experiences on the effectiveness of the HZ vaccine in the elderly, with a focus on the Italian scenario. Considering the current barriers to this immunization registered in some areas (difficulties of vaccine distribution, lack of physician recommendations, costs), proper educational and communication efforts should be pursued to guarantee a good coverage of HZ vaccination.

Background: The importance of health literacy (HL) in health promotion is increasingly clear and acknowledged globally, especially when addressing noncommunicable diseases. This paper aimed to collect and summarize all current data from observational studies generating evidence of the association between HL and physical activity (PA) and to analyze intervention studies on the promotion of PA to ascertain whether HL moderates the efficacy of such intervention. Methods: A comprehensive systematic literature search of observational studies investigating the association between HL and PA was performed. Intervention studies on the promotion of PA that also measured the HL levels of participants and its effect on the outcome of the intervention were also identified. Results: Of the 22 studies included in this review, 18 found a significant positive association between high HL and high levels of PA. The only intervention study among them indicated that HL was not a significant moderator of the intervention’s effectiveness. Conclusion: HL can enable individuals to make deliberate choices about their PA and thus contribute to preventing many chronic noncommunicable diseases. That said, low levels of HL do not seem to influence the efficacy of health promotion interventions.

Herpes zoster (HZ) has a relevant impact on the population in terms of incidence and complications. The aim of this study was to estimate the HZ-related hospitalization rates in Italy in the period 2001–2013, and to evaluate the trend of hospitalizations in the course of time pointing out any differences between regions that have or have not introduced universal childhood varicella immunization (UVI). A retrospective analysis was conducted on hospital discharge records contained in the national database of the Ministry of Health for the period January 2001–December 2013. The comparison of hospitalization rates of "pilot" versus "not pilot" regions was performed taking into account as "pilot" regions the three that first introduced UVI (Sicily, Veneto, and Apulia). The average annual percentage change in hospitalization rates was used to highlight any significant change in time trends. In the period 2001–2013, 93,808 HZ-related hospitalizations were registered altogether. Complicated HZ was diagnosed in 53.2% of cases; a relevant part (32.5%) of hospitalizations involved subjects with at least one co-morbidity. In the three Italian "pilot" regions, a greater decrease of HZ-related hospitalization rates occurred in comparison to other regions. A good understanding of the epidemiology of HZ disease is required to assess the overall impact of the varicella immunization programs and to establish the most appropriate health strategies against HZ. The data obtained confirm the epidemiological impact of HZ and its complications and the need of a preventive approach.

Background Human papillomavirus (HPV) is one of the most common sexually transmitted pathogens. This observational study was conducted to estimate the trend of hospitalization for genital warts (GWs) in the Veneto region (Italy) from 2004 to 2015. Methods All patients with GWs were identified in the hospital discharge records of all public and accredited private hospitals that related to Veneto residents and contained the ICD9-CM code 078.11 associated with a genital surgical procedure (vulval/vaginal warts, penile warts and 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 An annual rate of 11.8 per 100,000 population (8.6 per 100,000 males, and 14.8 per 100,000 females) was found, corresponding to 6076 hospitalizations for condyloma (53.3% vulval/vaginal, 35.8% anal, 8.3% penile, and 2.6% both penile or vulval/vaginal and anal). Among females, the rate of overall GWs remained stable to 2007 (19.1 per 100,000), then dropped significantly, reaching a rate of 11.3 per 100,000 in 2015 (average annual percent changes [AAPC]: -6.1%; 95% CI: -8.4; −3.7). For males, the overall rate increased over the study period (from 6.4 per 100,000 in 2004 to 10.8 per 100,000 in 2015; AAPC: 3.8%; 95% CI: 1.2; 6.4). Among the potentially vaccinated females (12- to 20-year-olds) there was a 62.1% decrease in the number of vulval/vaginal warts from the years 2010-2012 to the years 2013-2015 due to an increase in the HPV coverage rate. A similar reduction among males was observed in the same period and the same age group for penile warts (−68.2%). Conclusion GWs have an important impact on the health services and data suggest that GW-related hospitalization rates rapidly decline in a population with a high HPV vaccination coverage (about 75%). Further efforts should be made to better clarify the epidemiological picture regarding HPV-related diseases, with particular regard to sexual behavior.

Background COVID-19 rapidly escalated into a pandemic, threatening 213 countries, areas, and territories the world over. We aimed to identify potential province-level socioeconomic determinants of the virus’s dissemination, and explain between-province differences in the speed of its spread, based on data from 36 provinces of Northern Italy. Methods This is an ecological study. We included all confirmed cases of SARS-CoV-2 reported between February 24th and March 30th, 2020. For each province, we calculated the trend of contagion as the relative increase in the number of individuals infected between two time endpoints, assuming an exponential growth. Pearson’s test was used to correlate the trend of contagion with a set of healthcare-associated, economic, and demographic parameters by province. The virus’s spread was input as a dependent variable in a stepwise OLS regression model to test the association between rate of spread and province-level indicators. Results Multivariate analysis showed that the spread of COVID-19 was correlated negatively with aging index (p-value = 0.003), and positively with public transportation per capita (p-value = 0.012), the % of private long-term care hospital beds and, to a lesser extent (p-value = 0.070), the % of private acute care hospital beds (p-value = 0.006). Conclusion Demographic and socioeconomic factors, and healthcare organization variables were found associated with a significant difference in the rate of COVID-19 spread in 36 provinces of Northern Italy. An aging population seemed to naturally contain social contacts. The availability of healthcare resources and their coordination could play an important part in spreading infection.

Background Seasonal influenza epidemics yearly affects 5–15% of the world’s population, resulting in 3–5 million serious cases and up to 650,000 deaths. According to the 2017–2019 Italian National Immunisation Plan, free immunisation is offered to the categories at increased risk of experience the complications of the infection (over 65 years old subjects, pregnant women and individuals with underlying conditions, including chronic heart diseases). Rising evidence suggests that influenza can trigger adverse cardiovascular events therefore the vaccination is recommended for secondary prevention of cardiovascular diseases. Despite this, the influenza coverage rate in subjects with chronic heart disease is underestimated. Methods The study investigated the coverage rate in four consecutive influenza seasons (from 2011/2012 to 2014/2015) in subjects that benefit from exemption from paying healthcare costs for chronic heart disease living in Local Health Unit (LHU) of Ferrara (Italy), comparing the databases of exemptions and immunisations. Results The levels of influenza vaccine uptake were unstable, reaching the 50.3% in 2011/2012 immunisation season and falling to 42.2% in the following year. Coverage rates increased with increasing age, without achieving the 75% target, neither in over 65 years old subjects. The logistic regression analysis showed that influenza coverage rates were statistically significant different (p Conclusions The recommendation of influenza immunisation was weakly followed in individuals with chronic heart diseases. A collaboration between cardiologists, GPs, scientific societies and patient associations could successfully support influenza vaccine uptake.

Background Four percent of the world’s population suffers from depression, which is a major public health issue. Medical students are at risk, as their depressive symptoms (DS) prevalence is reported to be approximately 27% worldwide. Since few data on Italian medical students exist, this study aimed to estimate their DS prevalence and assess risk and protective factors. Methods The PRIMES was a multicentre cross-sectional study performed in 12 Italian medical schools. Questionnaires were self-reported and included 30 sociodemographic items and the Beck Depression Inventory-II (BDI-II). The primary outcome was the presence of DS (BDI-II score≥14). The main analyses were chi-squared tests and multivariable logistic regressions with a p-value

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.

Background Pulmonary diseases are a common and costly cause of 30-day readmissions. Few studies have focused on the difference in risk for rehospitalization between men and women in older patients. In this study we analyzed the association between sex and the risk of readmission in a cohort of patients admitted to the hospital for chronic obstructive pulmonary disease (COPD) exacerbation and other major pulmonary diseases. Methods This was a retrospective cohort study based on administrative data collected in the Veneto Region in 2016. We included 14,869 hospital admissions among residents aged ≥65 years for diagnosis related groups (DRGs) of the most common disorders of the respiratory system: bronchitis and asthma, pneumonia, pulmonary edema, respiratory failure, and COPD. Multilevel logistic regressions were performed to test the association between 30-day hospital readmission and sex, adjusting for confounding factors. Results For bronchitis and asthma, male patients had significantly higher odds of 30-day readmission than female patients (adjusted odds ratio (aOR), 2.07; 95% confidence interval (CI), 1.11–3.87). The odds of readmission for men were also significantly higher for pneumonia (aOR, 1.40; 95% CI, 1.13–1.72), for pulmonary edema and respiratory failure (aOR, 1.28; 95% CI, 1.05–1.55), and for COPD (aOR, 1.34; 95% CI, 1.00–1.81). Conclusions This study found that male sex is a major risk factors for readmission in patients aged more than 65 years with a primary pulmonary diagnosis. More studies are needed to understand the underlying determinants of this phenomena and to provide targets for future interventions.

Background: research in the health sector is an activity associated with an uncertain return on investment. This study aims to outline a multidimensional framework for assessing the imact of research funded by public (or mixed public and private) sponsors. Methods: a focus group representing different stakeholders was created to develop a sense of purpose that would be shared by the intended beneficiaries of the research assessment process, and others with a direct or indirect interest in a program’s implementation. Results: a framework was designed that takes a holistic approach to the impact of research in which not only technical, but also economic, social and political dimensions are interrelated with the results achieved for the population and health services. Conclusions: the framework reflected the views of different stakeholders, favoring the development of the positive, proactive relationships essential to orienting the process of transforming the evidence emerging from research into action for health.

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.

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.

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.

Primary biliary cholangitis (PBC) is often associated with other autoimmune diseases, but little is known about the influence of thyroid disease (TD) on the natural history of PBC. Our aim is to analyze the association between PBC and TD, and the latter's impact on the natural history of PBC at two European centers.The study involved 921 PBC patients enrolled between 1975 and 2015 in Padova (376 patients) and Barcelona (545 patients), with a mean follow-up of 126.9±91.7 months. Data were recorded on patients' histological stage at diagnosis, biochemical data, associated extrahepatic autoimmune conditions, and clinical events, including hepatic decompensation.A total of 150 patients (16.3%) had TD, including 94 patients (10.2%) with Hashimoto's thyroiditis; 15 (1.6%) with Graves' disease; 22 (2.4%) with multinodular goiter; 7 (0.8%) with thyroid cancer; and 12 (1.3%) with other thyroid conditions. The prevalence of different types of TD was similar in Padova and Barcelona, except for Graves' disease and thyroid cancer, which were more frequent in the Padova cohort (15.7 vs. 5.0%, and 8.6 vs. 1.3%, respectively, P0.05). Overall, there were no differences between PBC patients with and without TD in terms of their histological stage at diagnosis, hepatic decompensation events, occurrence of HCC, or liver transplantation rate. The presence of associated TD was not associated with lower survival for PBC patients in either cohort.TDs, and autoimmune TD like Hashimoto's thyroiditis in particular, are often associated with PBC, but the presence of TD does not influence the rate of hepatic complications or the natural history of PBC.

Summary Background More than 10 years have elapsed since human papillomavirus (HPV) vaccination was implemented. We did a systematic review and meta-analysis of the population-level impact of vaccinating girls and women against human papillomavirus on HPV infections, anogenital wart diagnoses, and cervical intraepithelial neoplasia grade 2+ (CIN2+) to summarise the most recent evidence about the effectiveness of HPV vaccines in real-world settings and to quantify the impact of multiple age-cohort vaccination. Methods In this updated systematic review and meta-analysis, we used the same search strategy as in our previous paper. We searched MEDLINE and Embase for studies published between Feb 1, 2014, and Oct 11, 2018. Studies were eligible if they compared the frequency (prevalence or incidence) of at least one HPV-related endpoint (genital HPV infections, anogenital wart diagnoses, or histologically confirmed CIN2+) between pre-vaccination and post-vaccination periods among the general population and if they used the same population sources and recruitment methods before and after vaccination. Our primary assessment was the relative risk (RR) comparing the frequency (prevalence or incidence) of HPV-related endpoints between the pre-vaccination and post-vaccination periods. We stratified all analyses by sex, age, and years since introduction of HPV vaccination. We used random-effects models to estimate pooled relative risks. Findings We identified 1702 potentially eligible articles for this systematic review and meta-analysis, and included 65 articles in 14 high-income countries: 23 for HPV infection, 29 for anogenital warts, and 13 for CIN2+. After 5–8 years of vaccination, the prevalence of HPV 16 and 18 decreased significantly by 83% (RR 0·17, 95% CI 0·11–0·25) among girls aged 13–19 years, and decreased significantly by 66% (RR 0·34, 95% CI 0·23–0·49) among women aged 20–24 years. The prevalence of HPV 31, 33, and 45 decreased significantly by 54% (RR 0·46, 95% CI 0·33–0·66) among girls aged 13–19 years. Anogenital wart diagnoses decreased significantly by 67% (RR 0·33, 95% CI 0·24–0·46) among girls aged 15–19 years, decreased significantly by 54% (RR 0·46, 95% CI 0.36–0.60) among women aged 20–24 years, and decreased significantly by 31% (RR 0·69, 95% CI 0·53–0·89) among women aged 25–29 years. Among boys aged 15–19 years anogenital wart diagnoses decreased significantly by 48% (RR 0·52, 95% CI 0·37–0·75) and among men aged 20–24 years they decreased significantly by 32% (RR 0·68, 95% CI 0·47–0·98). After 5–9 years of vaccination, CIN2+ decreased significantly by 51% (RR 0·49, 95% CI 0·42–0·58) among screened girls aged 15–19 years and decreased significantly by 31% (RR 0·69, 95% CI 0·57–0·84) among women aged 20–24 years. Interpretation This updated systematic review and meta-analysis includes data from 60 million individuals and up to 8 years of post-vaccination follow-up. Our results show compelling evidence of the substantial impact of HPV vaccination programmes on HPV infections and CIN2+ among girls and women, and on anogenital warts diagnoses among girls, women, boys, and men. Additionally, programmes with multi-cohort vaccination and high vaccination coverage had a greater direct impact and herd effects. Funding WHO, Canadian Institutes of Health Research, Fonds de recherche du Quebec – Sante.

Vaccine hesitancy is a growing concern in many European countries, including Italy, as instanced by alarming results from Eurobarometer 488 dated April 2019. In the view of the current magnitude of the phenomenon, our aim was to investigate its determinants among parents, with a specific view on those working as health professional. In 2017, parents of children aged 3-84 months were recruited online. Based on self-reported vaccine status and timeliness of vaccinations, parents were classified as pro-, hesitant, or anti-vaccine. The association between baseline characteristics and hesitancy was investigated with logistic regression adjusting for child’s and parents’ age, prematurity, presence of older children, previous vaccine adverse reaction in the child at issue, parents’ nationality, education and employment status, health profession of at least one parent, single parenting, vegetarian lifestyle and perceived economic security. A total of 3,865 questionnaires were collected (64% pro-, 32% hesitant, 4% anti-vaccine). Families with at least one health professional as parent were 20% of the sample. Vegetarian lifestyle (aOR 3.0; 95%CI 2.20-4.08), unsatisfactory (aOR 1.67 95%CI 1.08-2.58) and partially satisfactory perceived economic security (aOR 1.40; 95%CI 1.09-1.78) and previous vaccine adverse reactions (aOR 1.25; 95%CI 1.05-1.48) were associated with vaccine hesitancy, while having older children resulted as a protective factor (aOR 0.82; 95%CI 0.69-0.98). No significant association was found with other abovementioned variables, including parent employed as health professional (aOR 0.99; 95%CI 0.81-1.22). Vaccine hesitancy seems to be part of a lifestyle choice and, to a smaller extent, associated with previous vaccine adverse reactions and lower socioeconomic status. Interestingly, parents’ level of education and employment in healthcare do not affect vaccine acceptance. The latter poses a challenge, given their crucial role in promoting vaccination. 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.

HPV vaccination is a milestone in primary prevention. However in Italy, vaccine coverage is still nowhere near the target of 95%. We investigated drivers of vaccine uptake among university students, as they are likely to have just assumed a central role in their healthcare decision-making and potential barriers may differ from parents. 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 drivers of vaccine uptake. 9,988 questionnaires were included; awareness of HPV and vaccine was 83.3% and 69.9%, respectively. Awareness (adjOR: 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 (adjOR 1.6 95%CI 1.4-1.9) and family members (adjOR 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 (adjOR 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 uptake; only 50% of individuals not interested in receiving vaccine were aware of it; males are much less aware (adjOR 0.09 95%CI 0.07-0.11). Moreover, this study spotlights some misconceptions and may provide suitable evidence in tailoring more efficacious communication strategies. 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.

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.

Patient satisfaction is considered an important indicator of the quality of care in psychiatric services. Its importance has been widely studied, but the literature identifies methodological problems deriving from samples with low response rates and exclusion criteria which would seem to imply a kind of exclusion in the evaluations of less compliant patients. The aim of this study is to test a methodology to assess patient satisfaction with the quality of care received at an acute psychiatric ward in terms of its application in daily routine. In this cross sectional survey inpatients were given the Rome Opinion Questionnaire (ROQ). Our patients, involuntary patients included, with a 92.3% participation rate (47 patients out of 51), returned a mean general satisfaction score of 7.7/9. This response rate is higher than that reported in most previously published studies, which shows that a good level of both voluntary and involuntary patient participation may be achieved when an appropriate methodological approach is adopted. Not acknowledging patient satisfaction reduces the possibility of more effective caring actions. Measuring patient satisfaction, through use of short questionnaires, should become a routine in daily practice.

Background Genital warts are one of the most common forms of sexually-transmitted disease, but their epidemiology has yet to be thoroughly elucidated. The present study was designed to shed light on the prevalence of clinically-confirmed, self-reported genital warts (GWs) in a representative sample of the university population. Methods In 2015, a cross-sectional survey was conducted on 11,096 individuals approached at the Students Information Bureau where they came to enroll for a university degree course. Participants completed an anonymous, self-administered questionnaire providing information on their sociodemographic characteristics, sexual behavior, and any history of clinically-diagnosed genital warts. Multivariate logistic regression was then used to identify any factors associated with the disease. Results Our analysis was conducted on 9259 questionnaires (83.4%). Participants were a mean 21.8 ± 4.8 years of age, and 59.6% were female. Overall, 124 individuals (1.3%, 95%CI: 1.0–1.6) reported having been diagnosed with genital warts: 48 men (1.3%, 95%CI: 0.9–1.6), and 76 women (1.4% 95%CI: 1.1–1.7). Overall, 22.5% of the sample were vaccinated (1.3% of the males and 36.8% of the females). The group of respondents aged 30 years or more had the highest incidence of genital warts (males: 5.6%, 95%CI: 2.5–8.6; females: 6.9%, 95%CI: 3.4–10.4). The independent risk factors associated with a history of disease were (for both genders) a history of other sexually-transmitted diseases, and ≥2 sex partners in the previous 24 months. A protective role emerged for routine condom use. Additional risk factors associated with genital warts in males concerned men who have sex with men, bisexuality vis-à-vis heterosexuality, and smoking. Conclusions The findings emerging from our study help to further clarify the epidemiology of genital warts in young people, and may be useful to public health decision-makers. This study showed that genital warts occur in men as well as women, and suggests that both genders should be monitored for this disease to ascertain the effects of the free HPV vaccination offered to all girls in the Veneto in their 12th year of life since 2008, and to all boys of the same age since 2015.

To assess the burden of herpes zoster (HZ) by analyzing HZ-related hospital admissions. 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. 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. This study suggests that the burden of HZ and its impact on quality of life are of critical relevance to public health decision-making.

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-Guerin 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.

Background Streptococcus pneumoniae (SP) is a major cause of morbidity and mortality worldwide in all age groups. Serious diseases often caused by pneumococci include pneumonia, meningitis and bacteremia. Objective The aim of this work was to estimate the hospitalization rate for SP in the Veneto region by investigating pneumococcal-related discharges. Material and methods This was a retrospective study based on hospital discharge data collected from 2008 to 2012 in the Veneto Region (north-east Italy). All hospitalizations for diseases potentially associated with SP were identified by searching the hospital discharge records, then the proportions of hospital admissions for pneumonia, meningitis and septicemia attributable to the infection were calculated. Comorbidities were also graded according to the Charlson Comorbidity Index (CCI). Data were analyzed using the chi square test and Student's t-test for unpaired data, as appropriate. Significant trends over the years considered were examined in terms of average annual percent changes (AAPC). A p value, Highlights • Estimated hospitalization rate was higher in children and the elderly • Overall fatality rate was 11.0%. • Economic burden of SP-HA was around €14.8 million a year in Veneto Region.

HPV (human papillomavirus) is the virus most often responsible for sexually transmitted infections. The burden of HPV-related diseases on hospital resources represents a major public health problem. The aim of this study was to assess the economic burden of HPV-related diseases (anal cancer, genital cancer, genital warts, oropharyngeal cancer) on hospital resources in two Italian regions. A retrospective, non-randomized, observational study was developed in the Marche and Veneto Regions, based on patients receiving hospitalization between 2008 and 2011. All hospitalizations were identified through administrative archives, according to the International Classification of Diseases (ICD-9 CM) to which a defined tariff was assigned. We identified 5299 hospitalized patients in Veneto and 1735 in the Marche Region. The mean annual hospitalization rate was 49.44 per 100,000 individuals in Veneto and 48.41 in Marche. The total mean annual cost attributable to HPV-related diseases was €5.78 (SD 0.80) million in Veneto and €2.24 (SD 0.17) million in Marche. Costs associated with genital cancer amounted to €1.61 million in Veneto and €1.06 million in Marche (28% and 47% of the total mean annual cost, respectively). Oropharyngeal cancer accounted for 36% in Veneto (€2.08 million) and 28% in Marche (€632,645). Hospitalization costs related to anal cancer were €882,567 in Veneto and €377,719 in Marche; genital warts accounted for €1.19 million in Veneto and €171,406 in Marche. Finally, the mean cost per patient was €4364 in Veneto and €5176 in Marche. The present work estimated the cost of HPV-related diseases for hospitalized patients in two Italian regions. The considerable estimated annual economic burden is a powerful driver for the governance of the public health sector.

Background Epidemiology of Neisseria meningitidis has been changing since the introduction of universal vaccination programmes against meningococcal serogroup C (MenC) and meningococcal serogroup B (MenB) has now become dominant. This study aimed to analyse the cases reported in institutional data recording systems to estimate the burden of invasive meningococcal diseases (IMDs) and assess the effectiveness of surveillance in Veneto region (Italy). Methods Analysis was performed from 2007 to 2014 on data recorded in different systems: Mandatory Notification System, National Surveillance of Invasive Bacterial Diseases System and Laboratories Surveillance System (LSS), which were pooled into a combined surveillance system (CSS) and hospital discharge records (HDRs). A capture-recapture method was used and completeness of each source estimated. Number of cases with IMD by source of information and year, incidence of IMD by age group, case fatality rate (CFR) and distribution of meningococcal serogroups by year were also analysed. Results Combining the four data systems enabled the identification of 179 confirmed cases with IMD, achieving an overall sensitivity of 94.7% (95% CI: 90.8% to 98.8%), while it was 76.7% (95% CI: 73.6% to 80.1%) for CSS and 77.2% (95% CI: 74.1% to 80.6%) for HDRs. Typing of isolates was done in 80% of cases, and 95.2% of the typed cases were provided by LSS. Serogroup B was confirmed in 50.3% of cases. The estimated IMD notification rate (cases with IMD diagnosed and reported to the surveillance systems) was 0.48/100 000 population, and incidence peaked at 6.2/100 000 in children aged

A survey about history of non-fatal suicidal behaviour was performed on 1,171 subjects in the waiting room of general practitioners’ practices in the territory of Rovigo (Northern Italy). The mean age of interviewed subjects was 52.9 ± 17.0, with a majority of female individuals. Two and two percent admitted previous experience of non-suicidal self-injury, 4.7 % admitted having had serious suicidal thoughts/plans, and 1.8 % reported at least one suicide attempt. Compared to the rest of the sample, people with history of suicidal behaviours resulted to be of younger age (p < .05), whilst their level of well-being was poorer (p < .001). When compared to the results of the Italian arm of the European Study of the Epidemiology of Mental Disorders, carried out on general population samples, the present study produces higher rates of suicidality, despite the much higher mean age of the interviewed subjects compared to the general population.

Background Community-acquired pneumonia (CAP) is an important cause of illness and death worldwide, particularly among the elderly. Previous studies on the factors associated with mortality in patients hospitalized for CAP revealed a direct association between the type of microorganism involved, the characteristics of the patient and mortality. Vaccination status against pneumococcal disease was not considered. We conducted a retrospective analysis on the mortality rates after a first hospitalization for CAP in north-east Italy with a view to examining especially the role of anti-pneumococcal vaccination as a factor associated with pneumonia-related mortality at one year. Method Between 2012–2013, patients aged 65+ hospitalized with a primary diagnosis of CAP, identified based on International Classification of Diseases, Ninth Revision, Clinical Modification codes 481–486, were enrolled in the study only once. Patients were divided into three groups by pneumococcal vaccination status: 1) 13-valent pneumococcal conjugate vaccine (PCV13) prior to their hospitalization; 2) 23-valent pneumococcal polysaccharide vaccine (PPV23) within 5 years before hospitalization and 3) unvaccinated or PPV23 more than 5 years prior to admission. Gender, age, length of hospital stay and influenza vaccination were considered. Comorbidities were ascertained by means of a properly coded diagnosis. Every patient was followed up for 1 year and the outcome investigated was mortality for any cause and for pneumonia. Results A total of 4,030 patient were included in the study; mean age at the time of admission to hospital was 84.3±7.7; 50.9% were female. 74.2% of subjects had at least one comorbidity; 73.7% has been vaccinated against influenza. Regard to pneumococcal vaccine, 80.4% of patients were not vaccinated, 14.5% vaccinated with PPV23 and 5.1% with PCV13. The 1-year survival rates after hospitalization for pneumonia were 83.6%, 85.9% and 89.3% in the unvaccinated, PPV23 and PCV13 groups, respectively. Regression analysis indicated that the risk of death due to pneumonia increased significantly with age (adjusted OR: 1.073; 1.061–1.085), shorter hospital stay (adjusted OR: 0.981; 0.971–0.990), and male gender (adjusted OR: 1.372; 1.165–1.616). The model also confirmed the pneumococcal 13-valent conjugated vaccine as an independent protective factor for mortality-related pneumonia (adjusted OR: 0.599; 0.390–0.921). Conclusion The main finding of our observational cohort study is a high mortality rate among elderly patients admitted to hospital for pneumonia. The present study suggests a protective role for PCV13 vaccination.

In Italy, the introduction of Universal Varicella Vaccination (UVV) has been decided but postponed, as a national programme, until 2015, when data from Regions which have already implemented it will be available. Starting from 2003, eight Italian Regions (Basilicata, Calabria, Friuli Venezia Giulia, Apulia, Sardinia, Sicily, Tuscany and Veneto) have progressively introduced UVV, in their immunization programme, with different schedules in children aged 13-15 months and 5-6 years, currently a two-dose schedule is adopted by all Regions. In June 2013, an Interregional Group on Varicella Vaccination (IGVV) has been established in order to assess the effectiveness of varicella vaccination with standardized and shared tools. The aim of this study was to evaluate the impact of varicella vaccination on the incidence and hospitalizations due to varicella and its complications in the period 2003-2012 in order to support the Italian decision makers on the future national adoption. Preliminary data showed that a general reduction of incidence and hospitalization rates was observed in the study period, resulting in relevant savings for the National Health Service. Immunization coverage with first dose at 24 months of age was high in all Regions (84%-95%) in 2012. Adverse events due to varicella vaccines were rare and without permanent sequelae. Underreporting of varicella cases and delays in the administration of the first dose of varicella vaccines were the main critical issues. In conclusion, solid evidences in support of universal UVV arise from the experiences available today in Italy.

To monitor the results of ultrasound (US)-guided percutaneous treatment of calcific tendinopathy of the shoulder at 12 months (T12) after treatment (T0). To verify the possible relations between some pre- and post-procedural variables with the clinical outcome at T12. Forty-seven patients (26 female and 21 male) were enrolled in the study. Patients' approval and written informed consent were obtained. Symptoms were assessed by Constant Shoulder Score (CSS) at T0 and T12. Thirty of these also underwent a CSS control at 3 months (T3). The treatment efficacy was statistically tested for relation with location and type of calcification, characteristics of the tendon and subdeltoid bursa, impingement, and rehabilitation treatments. There was a significant increase in the average CSS value between T0 and T12 (40.7 vs. 75.3). The variables analysed did not show a statistically significant effect on the outcome at T12. A link was noticed only between patients' increasing age and score improvement, particularly among female subjects. US-guided treatment of calcific tendonitis is a viable therapeutic option. No pre- or intra-procedural parameters emerged which might help in predicting the outcome, apart from patients' needs in everyday life. • US-guided tcreatment of shoulder calcific tendinopathy is an excellent therapeutic option • Long-term results seem greatly affected by patients’ features and needs in everyday life • No proven pre- or intra-procedural parameters emerged that might predict the outcome

Background Human papillomavirus (HPV) is one of the most common sexually-transmitted pathogens. A number of studies in the literature have estimated the burden of HPV-related diseases by collecting data at primary care level, while a comprehensive assessment of the global burden of HPV-related diseases on hospital resources is still lacking. Methods This was a retrospective cohort study based on hospital discharge data collected from 2000 to 2010 in the Veneto Region (north-east Italy). All hospitalizations for diseases potentially associated with HPV were identified by searching the hospital discharge records, then the proportion of these hospitalizations relating to diseases attributable to the HPV infection was calculated. Results Overall, the annual hospitalization rate for HPV-related diseases was 21.3 per 100,000 individuals in the general population, 15.8 per 100,000 males, and 27.6 per 100,000 females. Hospitalizations were due mainly to genital warts, and peak among 15- to 44-year-olds in both genders. Taking both sexes together, the hospitalizations attributable to HPV dropped from 24.5/100,000 in 2000 to 17.5/100,000 in 2011, showing a significant decline during this period, with an average annual percent change (AAPC) of −1.9% (CI 95%: -2.8, -0.9;). On the other hand, the hospitalization rate for genital warts tended to increase significantly (AAPC 3.0% [CI 95%: 1.4;4.7]), whilst there was a significantly declining trend in the hospitalization rate for anal cancer (AAPC - 5.0% [CI 95%: -7.7;-2.2]), genital cancer (AAPC −6.2% [CI 95%: -7.8;-4.6]) and oropharyngeal cancer (AAPC −4.3% [CI 95%: -4.8;-3,8]). Conclusion Data derived from the hospital records indicate that HPV-related diseases are an important public health issue.

Aim The aim of this observational study was to assess mortality of patients with type 2 diabetes by type of healthcare delivery system, i.e. through specialist centers or generalist doctors, or integrated care. Methods The study was conducted at the “Vicentino Ovest” Local Health District in the Veneto Region (north-eastern Italy) from January 1, 2008 to December 31, 2010. Patients with diabetes (≥20 years old) were identified using different public health databases. They were grouped as: patients followed up by specialists at diabetes clinics (DS); patients seen only by their own general practitioner (GP); and patients receiving integrated care (DS-GP). Cox's regression analysis was used to estimate adjusted hazard ratios for available potential predictors of death by level of care. Results The crude mortality rate was highest in the GP group (26.1 per 1000 person-years), the difference being minimal when compared with the DS group (21.7 per 1000 person-years) and more marked when compared with the DS-GP group (8.8 per 1000 person-years). Patients followed up by their GPs had a 2.7 adjusted RR for mortality by comparison with the DS-GP group. Conclusions The findings of the present study could demonstrate that it is safe and cost-effective, after a first specialist assessment at a diabetes service, for low-risk diabetic patients to be managed by family physicians as part of a coordinated care approach, based on the specialist's clinical recommendations; GPs can subsequently refer patients to a specialist whenever warranted by their clinical condition.

The widespread use of poliovirus vaccination schemes has led to a marked decline in the incidence of paralytic poliomyelitis worldwide, but wild poliovirus is still endemic in some developing countries, and in 2009 a total of 23 countries reported at least 1 case of poliomyelitis caused by wild-strain polio viruses. A serological survey was thus conducted on the immunological status against polioviruses of 318 young adults, classified by their country of origin. Immunity to poliomyelitis was assessed by neutralizing antibody titration in tissues cultured on microplates. The rate of seronegativity (≤1:8) in the study population was 26.7% for poliovirus type 1, 7.2% for type 2, and 22.6% for type 3. In our sample of 318 individuals, 219 (68.9%) were Italian and 99 (31.1%) were from outside the European Union (EU). The proportion of cases found seropositive to polioviruses 1 and 3 decreased significantly with older age; this age-related decrease was more evident in the Italian group than among the non-EU subjects. Any risk of the wild virus recurring and causing paralytic poliomyelitis must be prevented, keeping Europe polio free by means of appropriate immunological protection, until polio has been conclusively eradicated all over the world. Judging from our findings, it may be worth considering administering a fifth dose of polio vaccine to adolescents.

CANCER INVADING THE SUBMUCOSAL LAYER: IS IT TIME TO CHANGE SURGICAL INDICATIONS FOR SCREENING COLONOSCOPIES? E. Rosa-Rizzotto ∗ ,1, M. Lo Mele2, D. Caroli 3 , E. Guido1, F. Ancona1, L. Peraro1, R. Cappellesso2 , S. Cocchio4 , V. Baldo4, M. Rugge2, F. De Lazzari 1 1Dpt of Medicine, Gastroenterology Unit, St Anthony Hospital, Padova, Italy; 2Department of Diagnostic, Medical Sciences and Special Therapies, Surgical Pathology and Cytopathology Unit, University of Padua, Padua, Padova, Italy; 3Dpt of Medicine, Chioggia Hospital, Venice, Italy; 4Dpt of Molecular Medicine, Laboratory of Public Health and Population Studies, University of Padua, Padova, Italy