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Vulnerability during the coronavirus disease 2019 (COVID-19) pandemic is an emotional state that affects all of us globally. The Italian experience shows that our general practitioners (GPs) seem to have a higher rate of death due to COVID-19 infection than other physicians. This article discusses clinical ethics questions related to the vulnerability of GPs and the community during the pandemic in Italy: the total lack of, or the inadequate protection of personal protective equipment, the increased use of virtual medicine, and the value of a solid synergy between hospitals and territorial systems. We provide a few examples of experiences in other affected countries and populations (Indigenous communities in Brazil, Australia and Germany). In conclusion, we offer some reflections on the crucial role of communication in dealing with vulnerability issues during this COVID-19 pandemic period.

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.

The world was never so close to reach the polio eradication: only 37 cases notified in 2016 in only three countries, but the game is not yet at the end. The risk of polio outbreaks in the EU is smaller than it has ever been in the past, but it is not so small that we can ignore it. The EU MS must remain alert and plan and prepare for managing polio events or outbreaks because of the possible dire consequences. The IPV only vaccination schedule universally applied in EU has achieved satisfactory coverage, but constantly leaving small accumulating pockets of susceptible individuals. Moreover the IPV only schedule is not an absolute barrier against poliovirus silent transmission as demonstrated in the recent Israel outbreak. The availability of annually revised S.O.P. from WHO GPEI on the identification and response of a polio event, without local poliovirus transmission or a polio outbreak with sustained transmission, helps and challenge EU countries to update their polio national preparedness plans. The EU/EEA area, in fact, is a peculiar area regarding the polio risk both for its vaccination policy, the large polio vaccines manufactures and the constant immigration from areas at polio high risk, but also EU include cultural and financial potentials crucial to sustain the polio end game strategy and reach the benefit of a world without polio risk. Poliovirus eradication will continue to be challenged as long as there is the worldwide presence of polioviruses in laboratories and vaccine production plants. Most of the world's OPV vaccines are produced in the EU and many laboratories and research centers store and handle polio viruses. EU Member States are engaged actively in implementing the poliovirus biocontainment plans that are part of the polio eradication strategy and to certify the destruction of poliovirus strains and potentially contaminated biological materials.

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.

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.

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.

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.

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.

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.

OBJECTIVE To describe the epidemiology of AIDS-associated Kaposi's sarcoma (KS) in Italy between January 1982 and September 1991. DESIGN To make this study comparable with previous research from other countries, statistical analysis of data from the Italian AIDS surveillance system was performed. METHODS Odds ratios (OR) and 95% confidence intervals (CI) were used to examine the association between several characteristics of AIDS cases and the presence of KS as the presenting clinical manifestation of AIDS. Trends in the frequency of AIDS-associated KS were also estimated. RESULTS Of the 10,584 Italian AIDS cases reported up to September 1991, 720 (6.8%) had KS as the presenting clinical manifestation. In comparison with intravenous drug users (IVDU), of whom 2.6% had KS, homosexual or bisexual men had a nearly 10-fold higher risk of KS (OR, 10.2; 95% CI, 8.2-12.8), homosexual men who were also IVDU a nearly fourfold increased risk (OR, 4.4; 95% CI, 3.0-6.6) and heterosexuals a 2.6-fold risk (95% CI, 1.7-3.7). Men were more likely to have KS than women. The percentage of new AIDS cases with KS recorded each year in Italy declined from 12.0% in 1982-1986 to 5.8% in 1990-1991, a significant relative decrease of 19.0% per year (95% CI, 14.1-23.6%). The decline was observed among both IVDU (20% per year) and homosexual or bisexual men (11.4% per year). The frequency of KS was similar across age groups within each transmission category, whereas geographical differences emerged in the prevalence of AIDS-associated KS, especially among IVDU. CONCLUSIONS Our data on the epidemiology of AIDS-associated KS in Italy are similar to reports from North America and Europe, which show that KS is more common among individuals who acquired HIV infection by sexual transmission rather than parenterally, and that the incidence of this neoplasm is declining over time. The still poorly understood aetiology of AIDS-associated KS needs to be investigated further.

The immunity against poliomyelitis in a representative sample of the Albanian population recently immigrant to Italy was evaluated. A significant number of the subjects examined lacked protective antibodies against one or more polioviruses. The most prevalent seronegativity related to poliovirus type 3 (41.3%), followed by poliovirus type 1 (21.5%). This result was more consistent in the younger age groups. Our data suggest the hypothesis that this problem arises from the use of a vaccine of discontinuous efficacy caused by defective preservation. A poliovaccine booster dose for all emigree subjects aged less than 15 years is suggested.

To assess the magnitude of the AIDS epidemic in the Italian adolescent (13-19 years) and young adult (20-24 years) age groups, data on AIDS cases notified to the AIDS Operational Centre as of 31 March 1990 were used. Of the 6068 reported AIDS cases, 0.7% occurred among adolescents and 15.7% among young adults. Among adolescents most cases were haemophiliacs (45.4%), while among young adults, drug use was the most frequently reported mode of transmission (87.5%). Females were more likely than males to contract the disease through the heterosexual contact in both the adolescent (20.0% vs 0%) and in young adult (15.1% vs 0.7%) age groups. Among young adults a geographical trend was present with a decrease in case rates from north to south, while for adolescents the rates were higher in northern and southern than in central Italy. If the incidence of AIDS is to be reduced in Italy, further efforts should be made to target the adolescent age group, since many of the young adult cases are likely to have resulted from HIV infection during adolescence.

An influenza pandemic is expected to occur and will require timely countermeasures. Based on analysis of past influenza epidemics, a deterministic model was developed to estimate the expected number of cases (over 12 million), medical consultations (over 5 million), hospital admissions (over 220,000) and deaths (over 43,000) in the absence of public health interventions. The adoption of available measures would reduce the number of cases by about 22%, hospitalizations by 20%, and deaths by 28%.

Recurrence of adverse events, the effect of site of injection, and concurrent administration of oral polio vaccine (OPV) and hepatitis B vaccine (HBV) on reactogenicity were assessed in recipients of two acellular pertussis vaccines given in combination with diphtheria and tetanus toxoids (DTaP), one whole-cell DTP vaccine (DTPwc) and one DT vaccine during a double blind, randomized, controlled clinical trial. Local and systemic side reactions were more likely to recur after the administration of DTaP and DT compared with DTPwc. In all vaccine groups, injection in the buttock was associated with a lower rate of common adverse events compared with injection in the thigh, while simultaneous administration of OPV and/or HBV did not increase the risk of onset of side reactions.

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.

Italian cardiac surgery units have changed in their characteristics over time. These changes have to be monitored. At the moment, there are no regular monitoring systems that could be used to support the processes of evaluation of performance. The Italian Institute of Health has recently started a national prospective study on the short-term outcomes (within 30 days mortality) of coronary artery bypass graft procedures. This study has been preceded by a cross-sectional investigation on the general activities of the Italian cardiac surgery centers.A complete Italian cardiac surgery center directory has been assembled. A questionnaire on hospital characteristics, number of beds, number of yearly coronary artery bypass graft procedures, department computer systems and methods for surgery risk assessment has been sent to the person responsible for each cardiac surgery center.In Italy there are 86 non-pediatric cardiac surgery centers (65% public centers, 31% accountable private and 4% not yet accountable private). Sixty-eight centers answered the questionnaire. Each cardiac surgery center has, on the average, availability of 26 beds and carries out about 400 coronary artery bypass graft procedures per year; 81% of cardiac surgery centers follow their patients until day 30 after the intervention, but only 64% of them report the cause of death when the patient dies; 75% of cardiac surgery centers regularly use surgery risk assessment systems.These data indicate that a project on cardiac surgery outcome assessment can be conducted in Italy. This project will help defining standardized methodologies that will represent essential instruments for each cardiac surgery center and for regional offices in order to improve and optimize their activity.

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.

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

Researchers gathered data from the National Registry of AIDS in Italy to examine the effect breast feeding has on the incubation time for AIDS in 117 vertically infected children. 36 children received breast milk and 64 were bottle fed. No perinatal feeding data existed in the registry for the remaining 17 children. There was a significant difference between the median incubation periods for the 36 breast fed (19 months) and 64 bottle fed (9.7 months) children (p=.003). An overlap in the incubation curves took place shortly before 60 months however. Further the breast fed children had a longer survival rate than the bottle fed children (Breslow p=.01; Mantel-Cox p=.003). From 198 when the 1st case occurred to 1986 breast feeding and bottle feeding patterns remained stable but beginning in 1987 the frequency of breast feeding declined significantly (p

Sexually Transmitted Diseases (STD) surveillance has caught the attention of the Italian public health authorities during the past decades. The spread of HIV infection increased the awareness of the need for a better STD surveillance system. This paper reports a retrospective survey of STD clinics in Italy, intended to form an epidemiological base for further development of STD surveillance. The data for 1986-87 and 1988 on a predefined set of diseases, all of them sexually transmitted, were collected from 85 of 127 centres contacted. The data obtained offer the first national figures for some STD not included in the statutory notification list, such as chlamydial infection, herpes and genital warts, as well as HIV infections. Those data show an increase in time frequencies. For gonorrhoea and syphilis, it was possible to compare our data with statutory notifications, showing a large gap between notified and reported cases. This gap is not stable in time (increasing in time) or in geographical area (increasing from north to south).

A person to person outbreak of hepatitis A is described: 90 cases of hepatitis A occurred in a small town in Calabria, southern Italy; all cases were under 18 years of age with the highest age-specific incidence rate in the 6-10 year age group. Transmission was identified by tracing close contacts with other incubating or active cases; only eight out of 90 cases were not identified as having a very probable or possible contact with an infecting case. Transmission was high between family members leading to a secondary family attack rate of 51% in children under 16. An enteric disease educational campaign was carried out together with IgG and no cases of hepatitis A were reported in the two years following the investigation.

In 1983 a national prevalence survey was conducted in Italy to discover the general distribution of infection among patients in public hospitals. Thirty-four thousand, five hundred and seventy-seven acute patients were surveyed in 130 hospitals spread throughout the country: 6668 patients (19·3%) had an active infection at the time of the survey; the infection was hospital-acquired in 2361 (6·8%) and community-acquired in 4307 (12·5%). The urinary tract was the site most frequently involved in hospital infection (30·2% of patients with hospital-acquired infection). The respiratory tract was the site most often involved in community infections (35·7% for the lower tract and 9·1% for the upper). Hospital-acquired infections were more frequent in intensive care units (12·4%) and in geriatric (11·6%), orthopaedic (8·2%) and surgical wards (7·6%). The prevalence of urinary tract infection was 10·4% among the 9·4% of patients who were catheterized compared with a prevalence of 2·6% in the uncatheterized. Thirty-five point five per cent of patients were receiving an antimicrobial on the day of the survey.

From August through October, 1973, 278 cases of bacteriologically confirmed cholera were reported to the Italian Ministry of Health. Epidemiological investigation of the three epidemic foci—the coastal regions of Campania and Puglia, and the province of Cagliari in Sardinia— revealed that the cases occurred in explosive outbreaks. Mussels were probably vehicles of Vibrio cholerae infection in Campania, and other bivalves probably transmitted cholera in Sardinia. Other types of raw seafood were probably vehicles of infection in Puglia. Most of the scattered cases reported from other parts of Italy were associated with travel in Campania or Puglia shortly before the onset of illness. Almost all cases were in adults, with a preponderance of men. In Campania and Puglia a history of gastric surgery was significantly more common among patients interviewed than among members of their households or paired controls.

From Oct. 30 to Nov. 7, 1979, 10 people in the Sardinian province of Cagliari had onset of bacteriologically confirmed cholera. Two symptom-free excretors of Vibrio cholerœ O:1 were detected in household contacts of the patients. There were no deaths. All but 1 of the 12 people with V. cholerœ O:1 infection gave a history of recent consumption of marine bivalves known locally as arselle (pelecypods). Triplicate matched neighbourhood controls for each of the first 7 cases identified were also interviewed; none had recently eaten arselle. V. cholerœ O:1 was also recovered from samples of water and bivalves obtained from a lagoon on the outskirts of the city of Cagliari. Arselle had also been implicated as the vehicle of transmission in 1973 in the last outbreak of cholera in Sardinia. It seems unlikely that cholera transmission had persisted locally in the interim.

A questionnaire was mailed to 1073 Italian public hospitals in an attempt to find out if infection control programmes existed, the type of programme used and available resources. After two attempts a total of 54·9 per cent of the hospitals responded to the request and of these 16·1 per cent claimed to have an infection control programme. Sixty-six per cent of the hospitals who have a control programme also have a system of continuous surveillance whilst the remainder investigated epidemics only. Infection control programmes were encountered most frequently in paediatrics, obstetrics and surgical departments. The organisms most often surveyed were the salmonellas, other types of enterobacteria, staphylococci and streptococci.

Outbreaks of febrile illness consistent with legionellosis occurred in successive groups of vacationers at an Adriatic resort in 1980. Illness was associated with one of two hotels used by the groups. A cohort study of guests of the suspect hotel revealed 23 cases of febrile illness with pulmonary symptoms, significant antibody titers to Legionella pneumophila, or both, among 291 persons at risk. Two patients died. Attack rates ranged from 0-19% in the nine cohorts of vacationers and were highest among the most elderly. Febrile illness in the last two cohorts of the season was associated with an antibody titer greater than or equal to 128. L. pneumophila was isolated from shower heads in the suspect hotel, but no association was found between showering and illness or seropositivity. Bacteria identified as L. pneumophila by direct immunofluorescence were also found in water from an adjacent hotel and from the outflow from a common well. No cases were associated with the adjacent hotel.

SummaryThe susceptibility to antimicrobial agents of 569 salmonella isolates collected in 1977–8 from patients in hospitals in Rome was tested. Fifty-nine per cent of all isolates were resistant to one or more antimicrobials. Resistance was most common to sulphathiazole, tetracycline, streptomycin, whereas colistin, gentamicin, tobramycin, trimethoprim-sulphamethoxazole and nalidixic acid were the most activein vitro.Multiple resistance was most frequently found in strains ofSalmonella wienandS. typhimurium(94% and 38% respectively).A significant change in the resistance pattern ofS. wienwas observed between 1977 and 1978, with a significant increase of susceptibility to some antimicrobials in 1978.Twenty-one R-plasmids transmissible toE. coliK12 were derived from 46 resistant strains ofS. typhimurum.

We analyzed peripheral blood mononuclear cells from 19 asymptomatic seropositive pregnant women from the district of Gulu in northern Uganda. A 700-bp fragment of the human immunodeficiency virus type 1 (HIV-1) env gene, including the V3-V5 region, was successfully amplified by PCR from 10 samples (52.6%) and was subsequently subjected to both a heteroduplex mobility assay for genetic screening and subtyping and DNA sequence analysis (approximately 300 bp) for nucleotide comparison and phylogenetic studies. The results show the presence of HIV-1 A and D subtypes (or clades) in this rural area, with the prevalence of the A subtype (8 of 10) being greater than that of the D (2 of 10) subtype, which is unlike what was previously reported for Uganda. By pairwise comparison analysis, the percentage of sequence divergence among samples within each subtype is low (the average intrasubtype divergence is 15.8%), but it is significantly higher between the two subtypes (the average intersubtype divergence is 23%). At the amino acid level, the two HIV-1 subtypes show distinct tetramers at the apex of the V3 loop and, in particular, GPGQ in clade A and GPGR in clade D. In addition, 10 of the 19 viral samples (52.6%) have been isolated in vitro. Nine of the samples have been classified as rapid/high, which reflects a high in vitro replication capacity for the HIV-1 field isolates from this country, even for those obtained from seropositive asymptomatic individuals. These observations, despite being made on the basis of a limited sample size, show a modest degree of genetic divergence among samples isolated in the last 4 years in this country by comparison with those based on the 1990 data on HIV-1 isolates from Kampala. The results reported here are, therefore, extremely relevant for Uganda, which is one of the selected World Health Organization field sites for future HIV-1 vaccine evaluation programs.

Because of the variety of problems connected with the AIDS epidemic, there is an urgent need for qualified information and counselling. In June 1987, The Italian Ministry of Health established a hot-line, acting within the National AIDS Operational Centre. Through the analysis of more than 39,000 calls received during the first year of activity, a clear outline has been obtained of the emotional impact of the disease on Italian public opinion, and of the problems raised. 67% of callers belong to 20–39 age group; the male/female ratio is 2:1. Interesting correlations have been found between the content of the questions and the sex, age, and type of caller. The vast majority of questions concerning basic concepts and notions about HIV infections are asked by no-risk-related subjects. During the first year, the percentage of questions asked by subjects actually at risk increased, and the questions themselves have become more specific.