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In September 2018 in Brescia province, northern Italy, an outbreak of Legionnaires' disease (LD) caused by Legionella pneumophila serogroup 2 ( Lp2 ) occurred. The 33 cases (two fatal) resided in seven municipalities along the Chiese river. All cases were negative by urinary antigen test (UAT) and most were diagnosed by real-time PCR and serology. In only three cases, respiratory sample cultures were positive, and Lp2 was identified and typed as sequence type (ST)1455. In another three cases, nested sequence-based typing was directly applied to respiratory samples, which provided allelic profiles highly similar to ST1455. An environmental investigation was undertaken immediately and water samples were collected from private homes, municipal water systems, cooling towers and the river. Overall, 533 environmental water samples were analysed and 34 were positive for Lp . Of these, only three samples, all collected from the Chiese river, were Lp2 ST1455. If and how the river water could have been aerosolised causing the LD cases remains unexplained. This outbreak, the first to our knowledge caused by Lp2 , highlights the limits of UAT for LD diagnosis, underlining the importance of adopting multiple tests to ensure that serogroups other than serogroup 1, as well as other Legionella species, are identified.

Many African countries, representing the origin of the majority of refugees, asylum-seekers, and other migrants, toward regions bordering on the Mediterranean area, are experiencing sustained local transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Sicily is one of the main entry gates of migrants crossing into Europe. We conducted a pilot study, based on the full-genome sequencing of SARS-CoV-2 strains isolated from migrants coming to Sicily by crossing the Mediterranean Sea, with the aim to investigate the viral genome polymorphism and to describe their genetic variations and the phylogenetic relationships. On June 21, a nongovernmental organization vessel rescued 210 migrants crossing the Mediterranean Sea from Libya to Sicily. Of them, 13.4% tested positive for SARS-CoV-2. Eighteen whole genome sequences were obtained to explore viral genetic variability. All but one of the sequences clustered with other viral African strains within the lineage A, whereas only one intermixed among B.1 lineage genomes. Our findings documented that most of the investigated migrants acquired SARS-CoV-2 infection before landing in Sicily. However, SARS-CoV-2 transmission during travel or in overcrowded Libyan immigrant camps and/or illegal transport boats could not be ruled out. SARS-CoV-2 molecular surveillance on migrants arriving in Europe through the Sicilian gate may improve the knowledge of global SARS-CoV-2 transmission dynamic also in light of the emergence of new variants., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Tramuto, Reale, Lo Presti, Vitale, Pulvirenti, Rezza, Vitale, Purpari, Maida, Zichichi, Scibetta, Mazzucco and Stefanelli.)

Objectives: A seroprevalence study of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was conducted in a high-incidence area located in northeastern Italy., Methods: All citizens above 10 years of age resident in five municipalities of the Autonomous Province of Trento, with the highest incidence of coronavirus disease 2019 (COVID-19) cases, were invited to participate in the study. Among 6098 participants, 6075 sera and a standardized questionnaire administered face-to-face were collected between 5 May and 15 May 2020 and examined. Symptomatic individuals and their family contacts were tested by RT-PCR. Anti-SARS-CoV-2 antibodies were detected using an Abbott SARS-CoV-2 IgG assay, which was performed on the Abbott Architect i2000SR automated analyser. Seroprevalence was calculated as the proportion of positive results among the total number tested. A multivariable logistic regression model was performed to assess the relationship between seropositive versus seronegative individuals for a set of explanatory variables., Results: A total of 1402 participants were positive for IgG antibodies against SARS-CoV-2, with a prevalence of 23.1% (1402/6075). The highest prevalence was found in the age class 40-49 years. Overall, 34.4% (2096/6098) of the participants reported at least one symptom. The ratio between reported cases identified by molecular test and those with seropositive results was 1:3, with a maximum ratio of about 1:7 in the age group <20 years and a minimum around 1:1 in those >70 years old. The infection fatality rate was 2.5% (35/1402). Among the symptoms, anosmia and ageusia were strongly associated with seropositivity., Conclusions: The estimated seroprevalence of 23% was three-fold higher than the number of cases reported in the COVID-19 Integrated Surveillance data in the study area. This may be explained in part by a relatively high number of individuals presenting mild or no illness, especially those of younger age, and people who did not seek medical care or testing, but who may contribute to virus transmission in the community., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Pandemic coronavirus disease 2019 (COVID-19) disease represents a challenge for healthcare structures. The molecular confirmation of samples from infected individuals is crucial and therefore guides public health decision making. Clusters and possibly increased diffuse transmission could occur in the context of the next influenza season. For this reason, a diagnostic test able to discriminate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from influenza viruses is urgently needed., Methods: A multiplex real-time reverse-transcription polymerase chain reaction (PCR) assay was assessed using 1 laboratory protocol with different real-time PCR instruments. Overall, 1000 clinical samples (600 from samples SARS-CoV-2-infected patients, 200 samples from influenza-infected patients, and 200 negative samples) were analyzed., Results: The assay developed was able to detect and discriminate each virus target and to intercept coinfections. The limit of quantification of each assay ranged between 5 and 10 genomic copy numbers, with a cutoff value of 37.7 and 37.8 for influenza and SARS-CoV-2 viruses, respectively. Only 2 influenza coinfections were detected in COVID-19 samples., Conclusions: This study suggests that multiplex assay is a rapid, valid, and accurate method for the detection of SARS-CoV-2 and influenza viruses in clinical samples. The test may be an important diagnostic tool for both diagnostic and surveillance purposes during the seasonal influenza activity period., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America.)

Introduction. In May-June 2018, an outbreak of campylobacteriosis involved students and school staff from kindergartens and primary schools in Pescara, southern Italy. Aim. We present details of the epidemiological and microbiological investigation, and the findings of the analytical study, as well as the implemented control measures. Methodology. To identify possible risk factors associated with the observed outbreak, a case control study was conducted using a questionnaire to collect information on the date of symptoms onset, type and duration of symptoms, type of healthcare contact, school attendance, and food items consumed at school lunches during the presumed days of exposure. Attack rates were calculated for each date and school. Logistic regression models were used to estimate the odds ratios of being a case and the odds of illness by food items consumed, respectively. Moreover, we carried out a comparative genomic analysis using whole genome multilocus sequence typing (wgMLST) of Campylobacter jejuni strains isolated during the outbreak investigation to identify the source of the outbreak. Results. Overall, 222 probable cases from 21 schools were identified, and C. jejuni was successfully isolated from 60 patients. The meals in the schools involved were provided by two cooking centres managed by a joint venture between two food companies. Environmental and food sampling, epidemiological and microbiological analyses, as well as a case control study with 176 cases and 62 controls from the same schools were performed to identify the source of the outbreak. The highest attack rate was recorded among those having lunch at school on 29 May (7.8 %), and the most likely exposure was 'caciotta' cheese (odds ratio 2.40, 95 % confidence interval 1.10-5.26, P =0.028). C. jejuni was isolated from the cheese, and wgMLST showed that the human and cheese isolates belonged to the same genomic cluster, confirming that the cheese was the vehicle of the infection. Conclusion. It is plausible that a failure of the pasteurization process contributed to the contamination of the cheese batches. Timely suspension of the catering service and summer closure of the schools prevented further spread.

Background: International literature suggests that disadvantaged groups are at higher risk of morbidity and mortality from SARS-CoV-2 infection due to poorer living/working conditions and barriers to healthcare access. Yet, to date, there is no evidence of this disproportionate impact on non-national individuals, including economic migrants, short-term travellers and refugees., Methods: We analyzed data from the Italian surveillance system of all COVID-19 laboratory-confirmed cases tested positive from the beginning of the outbreak (20th of February) to the 19th of July 2020. We used multilevel negative-binomial regression models to compare the case fatality and the rate of admission to hospital and intensive care unit (ICU) between Italian and non-Italian nationals. The analysis was adjusted for differences in demographic characteristics, pre-existing comorbidities, and period of diagnosis., Results: We analyzed 213 180 COVID-19 cases, including 15 974 (7.5%) non-Italian nationals. We found that, compared to Italian cases, non-Italian cases were diagnosed at a later date and were more likely to be hospitalized {[adjusted rate ratio (ARR)=1.39, 95% confidence interval (CI): 1.33-1.44]} and admitted to ICU (ARR=1.19, 95% CI: 1.07-1.32), with differences being more pronounced in those coming from countries with lower human development index (HDI). We also observed an increased risk of death in non-Italian cases from low-HDI countries (ARR=1.32, 95% CI: 1.01-1.75)., Conclusions: A delayed diagnosis in non-Italian cases could explain their worse outcomes compared to Italian cases. Ensuring early access to diagnosis and treatment to non-Italians could facilitate the control of SARS-CoV-2 transmission and improve health outcomes in all people living in Italy, regardless of nationality., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Public Health Association.)

Objectives: To evaluate whether the increase of temperature can influence the environmental endurance of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)., Methods: Virus was inoculated on a plastic surface and harvested at predefined time-points in parallel at 20°C-25°C (room temperature; RT) and at 28°C (June temperature; JT). Samples were tested by TCID 50 titres on Vero cells., Results: Our results confirm that fomite transmission of the emerging SARS-CoV-2 is possible: the virus reserved its ability to infect cells for up to 84 hours at both RT and JT on a plastic surface, with TCID 50 viral titres of 0.67 and 0.25 log 10 , respectively. At RT, an important reduction in the viral titre, from 4 log 10 to 3 log 10 TCID 50 , was observed during the first 24-36 hours. At JT, the same decay was observed more rapidly (between 8 and 12 hours), The rate of viral inactivation by D-value was 24.74 hours at RT and 12.21 hours at JT., Conclusions: This remarkable difference between the two temperatures suggests that virus vitality can be influenced by the environmental temperature and that the hot season could reduce the probability of COVID-19 transmission., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

After the national lockdown imposed on March 11, 2020, the Italian government has gradually resumed the suspended economic and social activities since May 4, while maintaining the closure of schools until September 14. We use a model of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission to estimate the health impact of different exit strategies. The strategy adopted in Italy kept the reproduction number R t at values close to one until the end of September, with marginal regional differences. Based on the estimated postlockdown transmissibility, reopening of workplaces in selected industrial activities might have had a minor impact on the transmissibility. Reopening educational levels in May up to secondary schools might have influenced SARS-CoV-2 transmissibility only marginally; however, including high schools might have resulted in a marked increase of the disease burden. Earlier reopening would have resulted in disproportionately higher hospitalization incidence. Given community contacts in September, we project a large second wave associated with school reopening in the fall., Competing Interests: Competing interest statement: M.A. has received research funding from Seqirus. The funding is not related to COVID-19. All other authors declare no competing interest., (Copyright © 2021 the Author(s). Published by PNAS.)

Background: On 11 March 2020, the World Health Organisation (WHO) declared the coronavirus disease 2019 (COVID-19) outbreak to be a pandemic. As the mosquito season progressed, the understandable concern that mosquitoes could transmit the virus began to increase among the general public and public health organisations. We have investigated the vector competence of Culex pipiens and Aedes albopictus, the two most common species of vector mosquitoes in Europe, for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Due to the very unusual feeding behaviour of Ae. albopictus, we also evaluated the role of this mosquito in a potential mechanical transmission of the virus., Methods: For the vector competence study, mosquitoes were allowed to take several infectious blood meals. The mosquitoes were then collected and analysed at 0, 3, 7 and 10 days post-feeding. For the mechanical transmission test, Ae. albopictus females were allowed to feed for a short time on a feeder containing infectious blood and then on a feeder containing virus-free blood. Both mosquitoes and blood were tested for viral presence., Results: Culex pipiens and Ae. albopictus were found not be competent vectors for SARS-CoV-2, and Ae. albopictus was unable to mechanically transmit the virus., Conclusions: This is the first study to show that the most common species of vector mosquitoes in Europe do not transmit SARS-CoV-2 and that Ae. albopictus is unable to mechanically transmit the virus from a positive host to a healthy host through host-feeding.

On March 11, 2020, Italy imposed a national lockdown to curtail the spread of severe acute respiratory syndrome coronavirus 2. We estimate that, 14 days after lockdown, the net reproduction number had dropped below 1 and remained stable at »0.76 (95% CI 0.67-0.85) in all regions for >3 of the following weeks.

BackgroundOn 20 February 2020, a locally acquired coronavirus disease (COVID-19) case was detected in Lombardy, Italy. This was the first signal of ongoing transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the country. The number of cases in Italy increased rapidly and the country became the first in Europe to experience a SARS-CoV-2 outbreak.AimOur aim was to describe the epidemiology and transmission dynamics of the first COVID-19 cases in Italy amid ongoing control measures.MethodsWe analysed all RT-PCR-confirmed COVID-19 cases reported to the national integrated surveillance system until 31 March 2020. We provide a descriptive epidemiological summary and estimate the basic and net reproductive numbers by region.ResultsOf the 98,716 cases of COVID-19 analysed, 9,512 were healthcare workers. Of the 10,943 reported COVID-19-associated deaths (crude case fatality ratio: 11.1%) 49.5% occurred in cases older than 80 years. Male sex and age were independent risk factors for COVID-19 death. Estimates of R 0 varied between 2.50 (95% confidence interval (CI): 2.18-2.83) in Tuscany and 3.00 (95% CI: 2.68-3.33) in Lazio. The net reproduction number R t in northern regions started decreasing immediately after the first detection.ConclusionThe COVID-19 outbreak in Italy showed a clustering onset similar to the one in Wuhan, China. R 0 at 2.96 in Lombardy combined with delayed detection explains the high case load and rapid geographical spread. Overall, R t in Italian regions showed early signs of decrease, with large diversity in incidence, supporting the importance of combined non-pharmacological control measures.

This study aimed at the identification of the settings linked to SARS-CoV-2 transmission through the analysis of clusters and small outbreaks detected by the Lombardy Region surveillance system during the second epidemic wave. Comparing the data before and after the introduction of restrictive measures (night curfew, partial closure of schools and businesses, smaart working), we observed a significant decrease of infections in workplaces, social gatherings, coffee shops, restaurants, and sports centers; contagion in schools decreased from 9.2% to 3.4%, in hospitals environments and nursing homes from 5% to 2%; domestic infections increased instead from 73.5% to 92.7%. These results suggest that containment measures have been effective in controlling virus circulation in the community but not at the household level and might inform future interventions, including the establishment of structures (Covid Hotels) for the isolation infected people. At the same time, they raise awareness on the risk of transmission among family members and during households social gatherings.

Introduction: Hyperinvasive strains of Neisseria meningitidis serogroup C have caused outbreaks of severe disease in Italy. Here, we report the analysis of the migration patterns of C:P1.5-1,10-8:F3-6:ST-11(cc11) meningococcal strains from different Italian regions collected between 2012 and 2017., Methods: N. meningitidis genomes were sequenced through the whole genome sequencing (WGS) method and were analyzed using the BIGSdb Genome Comparator tool. The phylogeography was performed using BEAST. The gene flows in Italy were tested by using MacClade., Results: The C:P1.5-1,10-8:F3-6:ST-11(cc11) hyperinvasive meningococcal strain, for the data available at the time of the analysis, from UK reached at first Emilia Romagna region, and then, in 2012, was detected in the outbreak occurred in the port of Livorno. The "Tuscany-outbreak strain" was likely introduced in Italy between 2013 and 2014. Most of the observed gene flow events occurred from the Center to Northern part of Italy., Discussion: The phylogeographic analysis allowed to track the dissemination of C:P1.5-1,10-8:F3-6:ST-11(cc11) strains in the country.

Background: Neisseria meningitidis can cause sporadic cases and outbreaks of invasive disease, including meningitis and sepsis. The meningococcal serogroup C (MenC) is the second most common serogroup in Italy after MenB. In this study we have estimated the reproductive numbers and the demographic reconstruction on the genomes of invasive N. meningitidis C:P1.5-1,10-8:F3-6:ST-11(cc11) strains isolated in Italy in 2012 - 2017, a period that includes the outbreak in Tuscany., Methods: The genomes of N. meningitidis were sequenced using the Illumina MiSeq platform, through the whole genome sequencing (WGS) method and were analyzed by the core genome MLST (cgMLST) approach, using the BIGSdb Genome Comparator tool implemented on the PubMLST website. A Bayesian method was applied to study population dynamics across the entire N. meningitidis dataset. The basic reproduction number R 0, which indicates the average number of secondary cases generated by a single primary case, was calculated using a Bayesian method, on the dataset and on the two subsets. The effective reproduction number R(t), defined as the average number of secondary cases per infectious case in a population, made up of susceptible and non-susceptible hosts was studied on the Tuscany dataset, with a Bayesian method., Results: An increase in the effective number of the N. meningitidis infections was observed between 2013 and 2016. The estimated R 0 parameter was 1.31 (95% HPD: 1.03 - 1.64), 1.22 (95% HPD: 0.90 - 1.64) and 1.4 (95% HPD: 0.91 - 1.9) for the entire dataset, first and second subset, respectively. The BDSKY estimated an initial R(t) of about 2.0 (95% HPD: 0.04 - 5.0), which showed a growing trend at the end of 2014, reaching an average value of 3.22 in 2015, and then declining below 1 from the year 2016., Conclusion: Monitoring the effective reproduction number can help to inform future vaccination strategies. The increase in the reproductive number for the Tuscany dataset, was consistent with the amplification event that led to the Tuscany outbreak. Subsequently, the intervention that led to the decline of the cases was followed, suggesting a high effectiveness of the vaccination campaign., Competing Interests: Declaration of Competing Interest The authors do not have any disclosures to report., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: To describe the epidemiological and clinical characteristics of coronavirus disease (COVID-19) pediatric patients aged <18 years in Italy., Methods: Data from the national case-based surveillance system of confirmed COVID-19 infections until May 8, 2020, were analyzed. Demographic and clinical characteristics of subjects were summarized by age groups (0-1, 2-6, 7-12, 13-18 years), and risk factors for disease severity were evaluated by using a multilevel (clustered by region) multivariable logistic regression model. Furthermore, a comparison among children, adults, and elderly was performed., Results: Pediatric patients (3836) accounted for 1.8% of total infections (216 305); the median age was 11 years, 51.4% were male, 13.3% were hospitalized, and 5.4% presented underlying medical conditions. The disease was mild in 32.4% of cases and severe in 4.3%, particularly in children ≤6 years old (10.8%); among 511 hospitalized patients, 3.5% were admitted in ICU, and 4 deaths occurred. Lower risk of disease severity was associated with increasing age and calendar time, whereas a higher risk was associated with preexisting underlying medical conditions (odds ratio = 2.80, 95% confidence interval = 1.74-4.48). Hospitalization rate, admission in ICU, disease severity, and days from symptoms onset to recovery significantly increased with age among children, adults and elderly., Conclusions: Data suggest that pediatric cases of COVID-19 are less severe than adults; however, age ≤1 year and the presence of underlying conditions represent severity risk factors. A better understanding of the infection in children may give important insights into disease pathogenesis, health care practices, and public health policies., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Background: Aim of the present study is to describe characteristics of COVID-19-related deaths and to compare the clinical phenotype and course of COVID-19-related deaths occurring in adults (<65 years) and older adults (≥65 years)., Method: Medical charts of 3,032 patients dying with COVID-19 in Italy (368 aged < 65 years and 2,664 aged ≥65 years) were revised to extract information on demographics, preexisting comorbidities, and in-hospital complications leading to death., Results: Older adults (≥65 years) presented with a higher number of comorbidities compared to those aged <65 years (3.3 ± 1.9 vs 2.5 ± 1.8, p < .001). Prevalence of ischemic heart disease, atrial fibrillation, heart failure, stroke, hypertension, dementia, COPD, and chronic renal failure was higher in older patients (≥65 years), while obesity, chronic liver disease, and HIV infection were more common in younger adults (<65 years); 10.9% of younger patients (<65 years) had no comorbidities, compared to 3.2% of older patients (≥65 years). The younger adults had a higher rate of non-respiratory complications than older patients, including acute renal failure (30.0% vs 20.6%), acute cardiac injury (13.5% vs 10.3%), and superinfections (30.9% vs 9.8%)., Conclusions: Individuals dying with COVID-19 present with high levels of comorbidities, irrespective of age group, but a small proportion of deaths occur in healthy adults with no preexisting conditions. Non-respiratory complications are common, suggesting that the treatment of respiratory conditions needs to be combined with strategies to prevent and mitigate the effects of non-respiratory complications., (© The Author(s) 2020. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: to assess the temporal variation in excess total mortality and the portion of excess explained by COVID-19 deaths by geographical area, gender, and age during the COVID-19 epidemic., Design: descriptive analysis of temporal variations of total excess deaths and COVID-19 deaths in the phase 1 and phase 2 of the epidemic in Italy., Setting and Participants: 12 Northern cities and 20 Central-Southern cities from December 2019 to June 2020: daily mortality from the National Surveillance System of Daily Mortality (SiSMG) and COVID-19 deaths from the integrated COVID-19 surveillance system., Main Outcome Measures: total mortality excess and COVID-19 deaths, defined as deaths in microbiologically confirmed cases of SARS-CoV-2, by gender and age groups., Results: the largest excess mortality was observed in the North and during the first phase of the epidemic. The portion of excess mortality explained by COVID-19 decreases with age, decreasing to 51% among the very old (>=85 years). In phase 2 (until June 2020), the impact was more contained and totally attributable to COVID-19 deaths and this suggests an effectiveness of social distancing measures., Conclusions: mortality surveillance is a sensible information basis for the monitoring of health impact of the different phases of the epidemic and supporting decision making at the local and national level on containment measures to put in place in coming months.

Background: An outbreak of a febrile respiratory illness due to the newly discovered Coronavirus, SARS-CoV-2, was initially detected in mid-December 2019 in the city of Wuhan, Hubei province (China). The virus then spread to most countries in the world. As an RNA virus, SARS-CoV-2 may acquire mutations that may be fixed. The aim of this study was to evaluate the selective pressure acting on SARS-CoV-2 protein coding genes., Methods: Mutations and glycosylation site prediction were analyzed in SARS-CoV-2 genomes (from 464 to 477 sequences)., Results: Selective pressure on surface glycoprotein (S) revealed one positively selected site (AA 943), located outside the receptor binding domain (RBD). Mutation analysis identified five residues on the surface glycoprotein, with variations (AA positions 367, 458, 477, 483, 491) located inside the RDB. Positive selective pressure was identified in nsp2 , nsp3, nsp4, nsp6, nsp12 , helicase , ORF3a , ORF8 , and N sub-sets. A total of 22 predicted N-glycosylation positions were found in the SARS-CoV-2 surface glycoprotein; one of them, 343N, was located within the RBD. One predicted N-glycosylation site was found in the M protein and 4 potential O-glycosylation sites in specific protein 3a sequences., Conclusion: Overall, the data showed positive pressure and mutations acting on specific protein coding genes. These findings may provide useful information on: i) markers for vaccine design, ii) new therapeutic approach, iii) information to implement mutagenesis experiments to inhibit SARS-CoV-2 cell entry. The negative selection identified in SARS-CoV-2 protein coding genes may help the identification of highly conserved regions useful to implement new future diagnostic protocols., (© 2020 Published by Elsevier Ltd.)

An amendment to this paper has been published and can be accessed via the original article.

Background: Standardized mortality surveillance data, capable of detecting variations in total mortality at population level and not only among the infected, provide an unbiased insight into the impact of epidemics, like COVID-19 (Coronavirus disease). We analysed the temporal trend in total excess mortality and deaths among positive cases of SARS-CoV-2 by geographical area (north and centre-south), age and sex, taking into account the deficit in mortality in previous months., Methods: Data from the Italian rapid mortality surveillance system was used to quantify excess deaths during the epidemic, to estimate the mortality deficit during the previous months and to compare total excess mortality with deaths among positive cases of SARS-CoV-2. Data were stratified by geographical area (north vs centre and south), age and sex., Results: COVID-19 had a greater impact in northern Italian cities among subjects aged 75-84 and 85+ years. COVID-19 deaths accounted for half of total excess mortality in both areas, with differences by age: almost all excess deaths were from COVID-19 among adults, while among the elderly only one third of the excess was coded as COVID-19. When taking into account the mortality deficit in the pre-pandemic period, different trends were observed by area: all excess mortality during COVID-19 was explained by deficit mortality in the centre and south, while only a 16% overlap was estimated in northern cities, with quotas decreasing by age, from 67% in the 15-64 years old to 1% only among subjects 85+ years old., Conclusions: An underestimation of COVID-19 deaths is particularly evident among the elderly. When quantifying the burden in mortality related to COVID-19, it is important to consider seasonal dynamics in mortality. Surveillance data provides an impartial indicator for monitoring the following phases of the epidemic, and may help in the evaluation of mitigation measures adopted.

An amendment to this paper has been published and can be accessed via the original article.

Background: The European region achieved interruption of malaria transmission during the 1970s. Since then, malaria control programs were replaced by surveillance systems in order to prevent possible re-emergence of this disease. Sporadic cases of non-imported malaria were recorded in several European countries in the past decade and locally transmitted outbreaks of Plasmodium vivax, most probably supported by Anopheles sacharovi, have been repeatedly reported from Greece since 2009. The possibility of locally-transmitted malaria has been extensively studied in Italy where the former malaria vector An. labranchiae survived the control campaign which led to malaria elimination. In this study, we present paradigmatic cases that occurred during a 2017 unusual cluster, which caused strong concern in public opinion and were carefully investigated after the implementation of the updated malaria surveillance system., Methods: For suspected locally-transmitted malaria cases, alerts to Ministry of Health (MoH) and the National Institute of Health (ISS) were mandated by the Local Health Services (LHS). Epidemiological investigations on the transmission modes and the identification of possible infection's source were carried out by LHS, MoH and ISS. Entomological investigations were implemented locally for all suspected locally-transmitted cases that occurred in periods suitable to anopheline activity. Molecular diagnosis by nested-PCR for the five human Plasmodium species was performed to support microscopic diagnosis. In addition, genotyping of P. falciparum isolate was carried out to investigate putative sources of infection and transmission modalities., Results: In 2017, a cluster of seven non-imported cases was recorded from August through October. Among them, P. ovale curtisi was responsible of one case whereas six cases were caused by P. falciparum. Two cases were proved to be nosocomial while the other five were recorded as cryptic at the end of epidemiological investigations., Conclusions: The epidemiological evidence shows that the locally acquired events are sporadic, often remain unresolved and classified as cryptic ones despite investigative efforts. The "cluster" of seven non-imported cases that occurred in 2017 in different regions of Italy therefore represents a conscious alert that should lead us to maintain a constant level of surveillance in a former malaria endemic country.

Background: After Action Reviews (AAR) with a One Health perspective were performed in Slovenia, Italy, Serbia and Greece following a severe West Nile virus (WNV) transmission season in 2018. A protocol combining traditional techniques and organizational process analysis was developed and then implemented in each country., Results: In 2018, response to the unusually intense transmission season of WNV in Slovenia, Italy, Serbia and Greece took place through routine response mechanisms. None of the four countries declared a national or subnational emergency. We found a very strong consensus on the strengths identified in responding to this event. All countries indicated the availability of One Health Plans for surveillance and response; very high laboratory diagnostic capacity in the human, veterinary and entomology sectors and strong inter-sectoral collaboration with strong commitment of engaged institutions as critical in the management of the event. Finally, countries implementing One Health surveillance for WNV (in terms of early warning and early activation of prevention measures) consistently reported a positive impact on their activities, in particular when combining mosquito and bird surveillance with surveillance of cases in humans and equids. Recurring priority areas for improvement included: increasing knowledge on vector-control measures, ensuring the sustainability of vector monitoring and surveillance, and improving capacity to manage media pressure., Conclusions: The AARs presented here demonstrate the benefit of cross-sectoral and cross-disciplinary approaches to preparedness for West Nile virus outbreaks in Europe. In the coming years, priorities include fostering and strengthening arrangements that: enable coordinated One Health surveillance and response during WNV transmission seasons; ensure adequate laboratory capacities; strengthen risk communication; and fund longer-term research to address the knowledge gaps identified in this study.

Since the identification of chikungunya virus (CHIKV), sporadic cases and outbreaks were reported in several African countries, on the Indian subcontinent, and in south-east Asia. In the last 20 years, there is a growing number of reports of CHIKV infections from African countries, but the overall picture of its circulation at the continent level remains ill-characterized because of under-diagnosis and under-reporting. Moreover, the public health impact of the infection in Africa is generally poorly understood, especially during outbreak situations. Our work has the aim to review available data on CHIKV circulation in Africa to facilitate the understanding of underlying reasons of its increased detection in the African continent.

Whole genome sequences of SARS-CoV-2 obtained from two patients, a Chinese tourist visiting Rome and an Italian, were compared with sequences from Europe and elsewhere. In a phylogenetic tree, the Italian patient's sequence clustered with sequences from Germany while the tourist's sequence clustered with other European sequences. Some additional European sequences in the tree segregated outside the two clusters containing the patients' sequences. This suggests multiple SARS-CoV-2 introductions in Europe or virus evolution during circulation.

Background: In Italy, out of 60 millions of inhabitants, 3000 (2700-4000) new HIV infections are estimated each year. As combined antiretroviral therapy (ART) prolongs life for HIV sufferers, the prevalence of HIV-infection is likely to increase over time. Few studies have assessed factors associated with being HIV positive in people accessing public outpatient clinics and, in particular, the influence of socio-economic circumstances on HIV prevalence. This study aims to evaluate the association between subjects' serostatus and socio-economic determinants measured at the individual and neighbourhood levels., Methods: Data from a large anonymous survey performed in 2012-2014 on more than 10 000 individuals 18-59 years old who underwent 21 public ambulatories in Rome were analysed. Subjects' socio-demographic characteristics, sexual orientation, number of sexual partners, HIV risk behaviour and HIV testing uptake were collected by a self-administered questionnaire. Level of area deprivation was measured at the postal code level by the index of social disadvantage (ISD). Multilevel Poisson regressions were carried out to take heterogeneity between clusters (post code and clinics) into account., Results: Self-reported HIV-prevalence was 2.0% among subjects ever been tested (13.7% for the homosexual/lesbians 7.0% for the bisexual and 1.3% for the heterosexual). About 1% of subjects self-identified as low risk was HIV infected. This prevalence increased up to 2% in the age group 18-34 and up to 5% in the non-heterosexuals (i.e. self- identified homosexuals/lesbians and bisexuals). At the individual level, HIV-prevalence decreased linearly from lowest to highest levels of education. Living in a deprived neighbourhood was not associated with HIV-infection., Conclusions: Our study confirms high HIV prevalences among homosexuals/lesbians. Some infections occur in subjects who do not report high risk behaviours for HIV transmission.

Background: It is estimated that, in Italy, 12 000-18 000 (11-13% of 130 000) HIV-infected subjects are not aware of their serostatus. People in this condition may visit the healthcare system multiple times without being diagnosed. If tested on one of these occasions, they could modify their high-risk behaviours and benefit from treatment, factors that reduce HIV transmission. In Italy, no data on HIV testing in the general population are available so far and little is known on the relationship between socioeconomic determinants (at individual and neighbourhood levels) and testing uptake., Methods: A large anonymous survey was performed in 2012-2014 on more than 10 000 individuals 18-59 years old who underwent 21 public ambulatories in Rome to determine the proportion of subjects tested for HIV and factors related to testing uptake. Subjects' socio-demographic characteristics, sexual orientation, number of sexual partners, HIV risk behaviour, HIV testing uptake were collected by a self-administered questionnaire. Level of area deprivation was measured at the postal code level by the index of social disadvantage (ISD). Multilevel Poisson regressions were carried out to take heterogeneity between clusters (post code and clinics) into account., Results: Among people participating in the study, 58.1% of subjects self-reported to have been tested at least once for HIV. Those who had one high risk behaviour for HIV-infection were 11% more likely to test than those not reporting any, and subjects who had had a STI (sexually-transmitted-infection) in the past were 12% more likely to test than those who had not had a STI. However only 44% (54% among subjects aged 18-35 years) of those with self-reported risks of contracting HIV had been tested at least once in life. This percentage increases, as expected, with the level of education, but, even so, about 40% of university educated subjects self-reporting risks of contracting HIV had never undergone an HIV test., Conclusions: This study highlights that, while the percentage of subjects tested is even higher than observed in other western nations, only 44% of subjects, self-reporting risks of contracting HIV, had tested at least once in life and about 40% of university educated subjects self reporting risks of contracting HIV had never tested.

Neisseria meningitidis is one of the few commensal bacteria that can even cause large epidemics of invasive meningococcal disease (IMD). N. meningitis serogroup C belonging to the hypervirulent clonal complex 11 (cc11) represents an important public health threat worldwide. We reconstructed the dispersal patterns of hypervirulent meningococcal strains of serogroup C:cc11 by phylogenomic time trees. In particular, we focused the attention on the epidemic dynamics of C:P1.5.1,10-8:F3-6;ST-11(cc11) meningococci causing outbreaks, as occurred in the Tuscany region, Italy, in 2015 to 2016. A phylogeographic analysis was performed through a Bayesian method on 103 Italian and 208 foreign meningococcal genomes. The C:P1.5.1,10-8:F3-6;ST-11(cc11) genotype dated back to 1995 (1992 to 1998) in the United Kingdom. Two main clades of the hypervirulent genotype were identified in Italy. The Tuscany outbreak isolates were included in different clusters in a specific subclade which originated in the United Kingdom around 2011 and was introduced in Tuscany in 2013 to 2014. In this work, phylogeographic analysis allowed the identification of multiple introductions of these strains in several European countries and connections with extra-European areas. Whole-genome sequencing (WGS) combined with phylogeography enables us to track the dissemination of meningococci and their transmission. The C:P1.5.1,10-8:F3-6;ST-11(cc11) genotype analysis revealed how a hypervirulent strain may be introduced in previously naïve areas, causing a large and long-lasting outbreak., (Copyright © 2019 Lo Presti et al.)

In 2017, a chikungunya outbreak in central Italy later evolved into a secondary cluster in southern Italy, providing evidence of disease emergence in new areas. Officials have taken action to raise awareness among clinicians and the general population, increase timely case detection, reduce mosquito breeding sites, and promote mosquito bite prevention.

Climate changes affect social and environmental health determinants such as clean air, ecosystems health, safe drinking water and safe sufficient food. Globally, people at greatest risk of adverse health effects associated with climate change include children, the elderly and other vulnerable groups. Temperature-related death and illness, extreme events, polluted or stressed ecosystems represent relevant issues raising concern for both health and economic consequences. The aim of the Symposium "Health and Climate Change" (Istituto Superiore di Sanità, Rome 3-5 December 2018) was to promote an inter-sectoral and multidisciplinary approach to estimate and prevent climate change-related events as well as to call the authorities to put in place measures to reduce adverse health effects. At the end of the Symposium the Rome International Charter on Health and Climate Change was presented. It includes a series of actions and recommendations, discussed and shared by all the participants, intended to inform policy makers and all the stakeholders involved in the management of climate changes.

Maintaining high vaccination coverage is important in order to protect the individual and the community. Mandatory vaccination is an option in case of declining coverage. Widely used in the USA, it is considered a rather controversial issue in Europe. In Italy, after a decrease of vaccination coverage for the hexavalent and the MPR vaccine under the optimal threshold, a new law, which extended the number of mandatory vaccines from 4 to 10 and reinforced coercive measures, was introduced in July 2017. After 2 years, vaccination coverage increased for all mandatory vaccines and for the other two recommended vaccines (anti-pneumococcal and anti-meningococcal C). Although it is not possible to disentangle the role of other factors contributing to the positive outcome, consistently with the results of studies conducted in the USA, vaccine mandates appeared to be successful in increasing vaccination coverage in Italy. The long-term sustainability of the effect of mandatory vaccination and the potential negative drawbacks of the coercive measures need to be evaluated to generate scientific evidence in public health.

The emergence of Zika virus in the Americas has caused an increase of babies born with microcephaly or other neurological malformations. The differential diagnosis of Zika infection, particularly serological diagnosis, is an important but complex issue. In this study, we describe clinical manifestations of 94 suspected cases of congenital Zika from Bahia state, Brazil, and the results of serological tests performed on children and/or their mothers at an average of 71 days after birth. Anti-Zika immunoglobulin M (IgM) antibodies were detected in 44.4% and in 7.1% of samples from mothers and children, respectively. Nearly all the IgM, and 92% of immunoglobulin G positive results were confirmed by neutralization test. Zika specific neutralizing antibodies were detected in as much as 90.4% of the cases. Moreover, dengue specific neutralizing antibodies were detected in 79.0% of Zika seropositive mothers. In conclusion, Zika IgM negative results should be considered with caution, due to a possible rapid loss of sensitivity after birth, while the NS1-based Zika IgM enzyme-linked immunosorbent assay test we have used has demonstrated to be highly specific. In a high percentage of cases, Zika specific neutralizing antibodies were detected, which are indicative of a past Zika infection, probably occurred during pregnancy in this population., (© 2019 The Authors. Journal of Medical Virology Published by Wiley Periodicals, Inc.)

Background: Data on Streptococcus pneumoniae carriage in adults with co-morbidities are limited. In this study we estimated the pneumococcal carriage among adults with co-morbidities and evaluated socio-demographic and clinical risk factors. The potential coverage of the current pneumococcal vaccines recommended for adults (PCV13 and PPV23) was also investigated., Methods: A cross-sectional study on S. pneumoniae carriage among unvaccinated adults ≥50 years with co-morbidities, presenting with or without acute respiratory symptoms at general practitioners in Rome, Italy, between October 2015 and July 2016 was conducted. Pneumococcal carriage was investigated by both cultural and molecular methods. Socio-demographic variables and co-morbidities were evaluated by logistic models as possible risk factors for pneumococcal carriage., Results: Out of 248 patients (median age: 73 yrs; IQR: 65-79), 12 (4.8%) and 83 (33.5%) individuals were found colonized using cultural or molecular methods, respectively. Potential risk factors for pneumococcal colonization as ascertained by molecular methods were: low level of education (adjusted OR = 3.71, 95% CI: 1.62-9.40), winter months (December-March vs other months, adjusted OR = 2.56, 95% CI: 1.29-5.14), and presence of chronic lung diseases (adjusted OR = 2.18, 95% CI: 1.15-4.16). The combination of serotype-specific multiplex RT-PCR and conventional PCR allowed to identify 22 serotypes/group of serotypes, of which the most common were: 24F/24A/24B, 12F/12A/12B/44/46, 6A/6B, 14, 15B/15C, and 22F/22A. Prevalence of pneumococcal carriage due to PCV13 serotypes and non-PCV13 serotypes was 23.6% and 67.3%, respectively. Prevalence of colonization due to PPV23 serotypes was estimated to be 54.6%., Conclusions: A high prevalence of S. pneumoniae carriage was observed among adults with co-morbidities, especially among individuals affected by chronic lung diseases. These results support vaccine strategies based on the sequential administration of PCV13 and PPV23 to control potentially invasive pneumococcal strains in adults, especially in subjects with co-morbidities., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Italy introduced a national law extending the number of compulsory vaccines from four to 10 in July 2017. The implementation placed a further burden on immunisation centres as they were required to cover the increased demand of vaccination by the parents of unvaccinated children. Vaccine coverage (VC) estimated 6 months and 1 year later, at 24 and 30 months (same birth cohort), had increased for all vaccines. At 24 months of age, measles VC increased from 87.3% in 2016 to 91.8% in 2017 and 94.1% at 30 months of age as at June 2018. In six of 21 regions and autonomous provinces, VC for measles was >95%. Despite the implementation of this law, vaccine hesitancy is still a problem in Italy and the political and social debate on mandatory vaccination is ongoing. Regardless of the policy to be adopted in the future, strategies to maintain high vaccination rates and the related herd immunity should be considered, including adequate communication to the population and the implementation of electronic immunisation registries.

Italy is a low-incidence country for tuberculosis (TB). We describe a TB outbreak in a primary school in north-eastern Italy, involving 10 cases of active pulmonary disease and 42 cases of latent infection. The index case was detected in March 2019, while the primary case, an Italian-born schoolteacher, was likely infectious since January 2018. Administration of a pre-employment health questionnaire to school staff with sustained contact with children should be considered in low-incidence countries.

Background: People living in poverty (PLP) are highly vulnerable to hepatitis B virus (HBV) infection. This study aimed to investigate the epidemiology of HBV infection in PLP in the metropolitan region of Goiânia, Goiás State, in the Central-West Region of Brazil., Methods: A cross-sectional study was conducted from August to December 2016 in adults aged ≥12 years living in poverty. The following serological markers for HBV were investigated: hepatitis B surface antigen (HBsAg), antibody to HBV core antigen (total anti-HBc), IgM anti-HBc, and hepatitis B surface antibody (anti-HBs), which were detected by enzyme-linked immunosorbent assay (ELISA). Poisson regression analysis with robust variance was performed to verify the factors associated with HBV exposure., Results: The study included 378 participants. The overall prevalence rate of HBV (any viral marker) was 9.8% (95% confidence interval [CI], 7.2-13.2). The prevalence rate of HBsAg in combination with total anti-HBc was 0.8% (95% CI, 0.3-2.4), total anti-HBc in combination with anti-HBs was 7.7% (95% CI, 5.4-10.9), and total anti-HBc alone was 1.3% (95% CI, 0.5-3.0) in the population. Furthermore, isolated positivity for anti-HBs was identified in only 25.4% (95% CI, 21.3-30.0) of the participants. Multiple regression analysis revealed that age (adjusted prevalence ratio [APR], 1.04; 95% CI, 1.01-1.07), female sex (APR, 2.18; 95% CI, 1.01-4.73), sexual intercourse under the influence of alcohol (APR, 2.49; 95% CI, 1.36-7.06), and exposure to Treponema pallidum (APR, 3.10; 95% CI, 1.36-7.06) were associated with HBV exposure., Conclusion: There was a high prevalence of HBV exposure in PLP in the Central-West Region of Brazil, indicating significant viral spread of the infection. Additionally, there was low serological evidence of immunisation against hepatitis B, indicating that a large proportion of the participants in this study are susceptible to the infection. The results support the need for public health policies that facilitate access to the existing healthcare services in hard-to-reach groups with special regard to immunisation programmes against hepatitis B.

Herpes zoster (HZ) is a painful cutaneous rash with vesicular lesions, lasting up to 3 weeks, and caused by reactivation of the latent varicella zoster virus (VZV). It may be associated with complications, the most feared being post-herpetic neuralgia. Effective vaccines are available to prevent HZ, but uptake remains low. We report here the conclusions of an expert focus group convened by the European Interdisciplinary Council on Ageing (EICA). The group discussed how existing recommendations regarding HZ vaccination could be better implemented, and how compliance and coverage with HZ vaccination could be enhanced. This report proposes strategies to increase awareness of HZ and its vaccine, enhance vaccine uptake, and educate regarding the role of prevention, including immunization, as a means to "age well". A key strategy that could rapidly and easily be implemented at low cost is co-administration of HZ vaccine with other vaccines scheduled in the target age group. The scientific evidence surrounding the safety and efficacy of co-administration is discussed. Other strategies, such as active calls, publicity campaigns and national vaccine registries are also outlined. There is a compelling need for a full consensus document that carries weight across all the healthcare professions involved in vaccination, to issue simple and basic recommendations for all healthcare providers.

Chikungunya fever (CHIKF) is an emerging infectious disease caused by an alphavirus transmitted by Aedes spp. mosquitoes. Because mosquito control programs are not highly efficient for outbreak containment, vaccines are essential to reduce the burden of disease. Although no licensed vaccine against CHIKF is yet available, many highly promising candidates are undergoing preclinical studies, and a few of them have been tested in human trials of phase 1 or 2. Here, we review recent findings regarding the need for a CHIKF vaccine and provide an update on vaccines nearing or having entered clinical trials. We also address needs to tackle bottlenecks to vaccine development-including scientific and financial barriers-and to accelerate the development of vaccines; several actions should be taken: (i) design efficacy trials to be conducted during the course of outbreaks; (ii) evaluate the opportunity for adopting the "animal rule"for demonstration of efficacy for regulatory purposes; (iii) strengthen the collective commitment of nations, international organizations, potential donors and industry; (iv) stimulate public and/or private partnerships to invest in vaccine development and licensure; and (v) identify potential markets for an effective and safe CHIKF vaccine., Competing Interests: I have read the journal's policy, and the authors of this manuscript have the following competing interests: SCW holds patents for alphavirus attenuation that are licensed for vaccine development.

Background: During 2015-2016 an outbreak of invasive meningococcal disease due to N. meningitidis serogroup C ST-11 (cc11) occurred in Tuscany, Italy. The outbreak affected mainly the age group 20-30 years, men who have sex with men, and the area located between the cities of Firenze, Prato and Empoli, with discos and gay-venues associated-clusters. A cross-sectional-survey was conducted to assess the prevalence and risk factors for meningococcal-carriage, in order to address public health interventions., Methods: A convenience sample of people aged 11-45 years provided oropharyngeal swab specimens and completed questionnaires on risk factors for meningococcal carriage during a 3 months study-period, conducted either in the outbreak-area and in a control-area not affected by the outbreak (cities of Grosseto and Siena). Isolates were tested by culture plus polymerase chain reaction. Serogroup C meningococcal isolates were further characterized using multilocus sequence typing. Univariate and multivariate analyses were performed to estimate adjusted odds ratios (AORs) for meningococcal carriage., Results: A total of 2285 oropharyngeal samples were collected. Overall, meningococcal carriage prevalence was 4.8% (n = 110), with nonencapsulated meningococci most prevalent (2.3%; n = 52). Among encapsulated meningococci, serogroup B was the most prevalent (1.8%; n = 41), followed by serogroup Y (0.5%; n = 11) and serogroup C (0.2%; n = 4); one carrier of serogroup E and one of serogroup Z, were also found (0.04%). Three individuals from the city of Empoli were found to carry the outbreak strain, C:ST-11 (cc11); this city also had the highest serogroup C carriage prevalence (0.5%). At the multivariate analyses, risk factors for meningococcal carriage were: illicit-drugs consumption (AOR 6.30; p < 0.01), active smoking (AOR 2.78; p = 0.01), disco/clubs/parties attendance (AOR 2.06; p = 0.04), being aged 20-30 years (AOR 3.08; p < 0.01), and have had same-sex intercourses (AOR 6.69; p < 0.01)., Conclusions: A low prevalence of meningococcal serogroup C carriage in an area affected by an outbreak due to the hypervirulent N. meningitidis serogroup C ST-11 (cc11) strain was found. The city of Empoli had the highest attack-rate during the outbreak and also the highest meningococcal serogroup C carriage-prevalence due to the outbreak-strain. Multivariate analyses underlined a convergence of risk factors, which partially confirmed those observed among meningococcal outbreak-cases, and that should be considered in targeted immunization campaigns.

Background: Vaccine-preventable invasive bacterial diseases (IBDs) caused by Neisseria meningitidis (Nm), Streptococcus pneumoniae (Sp), and Haemophilus influenzae (Hi) have been notified in Italy since 2007 without assessing reporting completeness., Methods: Our study compared the number of cases of IBDs identified from the Italian Hospital Discharge Records (HDRs), using specific diagnostic ICD-9-CM codes, with those notified to the National Surveillance System (NSS) from 2007 to 2016. A multinomial logistic regression model was used to impute the aetiology of all discharges with a diagnosis of unspecified bacterial meningitis., Results: Over a 10-year period, 14,243 hospital discharges with diagnosis of IBD were estimated in Italy (12,671 with specified aetiology and 1,572 with imputed aetiology). Among those, 2,513 (17.6%) were caused by Nm, 10,441 (73.3%) by Sp, and 1289 (9.1%) by Hi. Most invasive meningococcal diseases were coded as meningitis (72.3%), while Hi and Sp were more frequently coded as septicaemia (51.6% and 60.4%, respectively). The highest mean annual incidence rate was found for IBD caused by Sp (1.74 per 100,000), followed by Nm (0.42 per 100,000) and by Hi (0.21 per 100,000). Comparing NSS with HDR data, we found an initially high underreporting of all IBDs, and particularly for Hi. Data from the two systems overlapped in more recent years, due to an improved reporting completeness. The increasing IBD incidence observed in NSS data was not confirmed by HDR data trends, although with pathogen-related differences with Hi cases rising in both data sources, suggesting that is mainly due to an improved disease notification rather than to a true incidence increase., Conclusions: Comparing surveillance data with other data sources is useful to better interpret observed trends of notifiable diseases., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

To determine the seroprevalence of antibodies against dengue virus (DENV) and West Nile virus (WNV) in the human population of the Bolivian Chaco, we tested 256 inhabitants of two rural communities. The seroprevalence, confirmed by plaque reduction neutralization test, was 7.8% and 2.7% for DENV and WNV, respectively., (© 2018 Wiley Periodicals, Inc.)

In Sierra Leone, the Ebola virus disease (EVD) outbreak occurred with substantial differences between districts with someone even not affected. To monitor the epidemic, a community event-based surveillance system was set up, collecting data into the Viral Haemorrhagic Fever (VHF) database. We analysed the VHF database of Tonkolili district to describe the epidemiology of the EVD outbreak during July 2014-June 2015 (data availability). Multivariable analysis was used to identify risk factors for EVD, fatal EVD and barriers to healthcare access, by comparing EVD-positive vs. EVD-negative cases. Key-performance indicators for EVD response were also measured. Overall, 454 EVD-positive cases were reported. At multivariable analysis, the odds of EVD was higher among those reporting contacts with an EVD-positive/suspected case (odds ratio (OR) 2.47; 95% confidence interval (CI) 2.44-2.50; P &lt; 0.01) and those attending funeral (OR 1.02; 95% CI 1.01-1.04; P &lt; 0.01). EVD cases from Kunike chiefdom had a lower odds of death (OR 0.22; 95% CI 0.08-0.44; P &lt; 0.01) and were also more likely to be hospitalised (OR 2.34; 95% CI 1.23-4.57; P &lt; 0.05). Only 25.1% of alerts were generated within 1 day from symptom onset. EVD preparedness and response plans for Tonkolili should include social-mobilisation activities targeting Ebola/knowledge-attitudes-practice during funeral attendance, to avoid contact with suspected cases and to increase awareness on EVD symptoms, in order to reduce delays between symptom onset to alert generation and consequently improve the outbreak-response promptness.

Objectives: The aim was to investigate an outbreak of invasive meningococcal disease (IMD) in Southern Sardinia., Methods: Epidemiological and microbiological investigations were performed. The latter included antimicrobial susceptibility testing and whole-genome sequencing (WGS)., Results: Seven individuals with severe IMD were found to be infected with serogroup B (MenB) Neisseria meningitidis in the first quarter of 2018. Five of the seven cases (five males; mean age 19 years; range 18-21 years; CFR 40%) were due to a unique strain B:P1.5-1,10-8:F3-6:ST-11(cc11), probably switched from the hypervirulent C-cc11, as confirmed by WGS. All five patients had attended the same nightclub in the 2 weeks prior to symptom onset. Public health measures, including chemoprophylaxis of contacts and active immunization against MenB, were implemented., Conclusions: We observed five IMD cases due to the same switched MenB strain. The hypervirulent B:P1.5-1,10-8:F3-6:ST-11(cc11) strain, probably switched from C-cc11, is of concern due to the observed high virulence and case fatality rates. All the patients shared the same place of probable exposure. The molecular characterization of the invasive strain allowed the outbreak to be confirmed, which was then controlled through timely public health action., (Copyright © 2018 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

The Mediterranean spotted fever (MSF) rickettsiosis is the predominant rickettsial disease among the spotted fever group (SFG) rickettsiae in the Mediterranean countries and North Africa. Its causative agent is Rickettsia conorii, although, SFG rickettsiosis - cases due to Rickettsia monacensis, Rickettsia massiliae and Rickettsia aeschlimannii were also described. A retrospective study based on hospital discharge records with a diagnosis of SFG rickettsiosis was carried out to describe the spatial pattern, the trend of the disease, and the epidemiological characteristics of persons hospitalized in the period 2001-2015. Standardized hospitalization ratios were calculated at municipal level using the European population. Smoothed maps were produced using a localised smoothing Poisson model. The mean annual standardized hospitalization rate was 1.36/100,000 person years (95%CI: 1.34; 1.39). Rates showed strong summer seasonality and tended to decrease over time. During the study period, 28.89% of municipalities had smoothed standardized hospitalization ratios greater than 1 and 14.01% above 20. Higher standardized hospitalization ratios were found in areas along the Tyrrhenian coast, especially in the south of Calabria and in the islands of Sardinia and Sicily, where the disease is of public health relevance., (Copyright © 2018 Elsevier GmbH. All rights reserved.)