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Background To understand the impact of the COVID-19 pandemic on mortality, this study investigates overall, sex- and age-specific excess all-cause mortality in 20 countries, during 2020. Methods Total, sex- and age-specific weekly all-cause mortality for 2015–2020 was collected from national vital statistics databases. Excess mortality for 2020 was calculated by comparing weekly 2020 observed mortality against expected mortality, estimated from historical data (2015–2019) accounting for seasonality, long- and short-term trends. Crude and age-standardized rates were analysed for total and sex-specific mortality. Results Austria, Brazil, Cyprus, England and Wales, France, Georgia, Israel, Italy, Northern Ireland, Peru, Scotland, Slovenia, Sweden, and the USA displayed substantial excess age-standardized mortality of varying duration during 2020, while Australia, Denmark, Estonia, Mauritius, Norway, and Ukraine did not. In sex-specific analyses, excess mortality was higher in males than females, except for Slovenia (higher in females) and Cyprus (similar in both sexes). Lastly, for most countries substantial excess mortality was only detectable (Austria, Cyprus, Israel, and Slovenia) or was higher (Brazil, England and Wales, France, Georgia, Italy, Northern Ireland, Sweden, Peru and the USA) in the oldest age group investigated. Peru demonstrated substantial excess mortality even in the Conclusions This study highlights that excess all-cause mortality during 2020 is context dependent, with specific countries, sex- and age-groups being most affected. As the pandemic continues, tracking excess mortality is important to accurately estimate the true toll of COVID-19, while at the same time investigating the effects of changing contexts, different variants, testing, quarantine, and vaccination strategies.

This work was supported by the University of Nicosia Medical School (internal funding)., Achilleos S, Quattrocchi A, Gabel J, Heraclides A, Kolokotroni O, Constantinou C, Pagola Ugarte M, Nicolaou N, Rodriguez-Llanes JM, Bennett CM, Bogatyreva E, Schernhammer E, Zimmermann C, Costa AJL, Lobato JCP, Fernandes NM, Semedo-Aguiar AP, Jaramillo Ramirez GI, Martin Garzon OD, Mortensen LH, Critchley JA, Goldsmith LP, Denissov G, Rüütel K, Le Meur N, Kandelaki L, Tsiklauri S, O'Donnell J, Oza A, Kaufman Z, Zucker I, Ambrosio G, Stracci F, Hagen TP, Erzen I, Klepac P, Arcos González P, Fernández Camporro Á, Burström B, Pidmurniak N, Verstiuk O, Huang Q, Mehta NK, Polemitis A, Charalambous A, Demetriou CA.

Objectives We explored the effectiveness of COVID-19 vaccines in preventing reinfection in the Republic of Cyprus. Study design Matched case-control study (1:2). Methods Cases were adults with a first episode of SARS-CoV-2 infection in 2020 and a second episode (i.e., reinfection) between June-August 2021. Controls were adults with only one infection episode in 2020 (i.e., not reinfected). Matching was performed by age, gender, and week of diagnosis for first episode. The reinfection date of a case was applied to the matched controls for estimating full or partial vaccination status. Cases and controls were classified as unvaccinated, partially vaccinated (i.e., vaccination series not completed or final dose received ≤14 days before the reinfection date) or fully vaccinated (i.e., final dose received >14 days before the reinfection date). Conditional logistic regression was performed to calculate odds ratios (ORs) and 95% confidence intervals (CI) for full or partial vaccination, against no vaccination, between controls and cases. Results This study showed that controls were more likely to be vaccinated (OR for full vaccination: 5.51, 95% CI: 2.43-12.49) than cases. Conclusions This finding answers a pressing question of the public and supports the offer of vaccination to people with previous SARS-CoV-2 infection.

Coronavirus disease 2019 (COVID-19) has significantly affected the well-being of individuals worldwide. We herein describe the epidemiology of COVID-19 in the Republic of Cyprus during the first epidemic wave (9 March&ndash, 3 May 2020). We analyzed surveillance data from laboratory-confirmed cases, including targeted testing and population screening. Statistical analyses included logistic regression. During the surveillance period, 64,136 tests (7322.3 per 100,000) were performed, 873 COVID-19 cases were diagnosed, and 20 deaths were reported (2.3%). Health-care workers (HCWs) represented 21.4% of cases. Overall, 19.1% of cases received hospital care and 3.7% required admission to Intensive Care Units. Male sex (adjusted Odds Ratio (aOR): 3.04, 95% Confidence Interval (CI): 1.97&ndash, 4.69), increasing age (aOR: 1.56, 95%CI: 1.36&ndash, 1.79), symptoms at diagnosis (aOR: 6.05, 95%CI: 3.18&ndash, 11.50), and underlying health conditions (aOR: 2.08, 95%CI: 1.31&ndash, 3.31) were associated with hospitalization. For recovered cases, the median time from first to last second negative test was 21 days. Overall, 119 primary cases reported 616 close contacts, yielding a pooled secondary attack rate of 12% (95%CI: 9.6&ndash, 14.8%). Three population-based screening projects, and two projects targeting employees and HCWs, involving 25,496 people, revealed 60 positive individuals (0.2%). Early implementation of interventions with targeted and expanded testing facilitated prompt outbreak control on the island.

Infections caused by parasites affect millions of people around the world and cause human death worldwide. Most of the protozoan exists as free-living species in different aquatic environments as well as some of the species living in association with host organisms and can infect the host. The aim of this narrative review is to provide an overview of the available information concerning infectious parasitic diseases in Cyprus. Data on protozoan parasitic infections/carriage prevalence in Cyprus is limited, possibly due to the unknown levels of pathogens contamination in the water supplies and in the ecosystem, which could relate to tourism on the island—a major pillar in the Cypriot economy. Tourists and immigrants represent a melting pot of many human activities that brings many people from all over the world together and potentially serves as a source for contamination that can cause endemic infectious diseases on the island.

Background This study aimed to explore socioeconomic factors associated with obesity in the Republic of Cyprus. Methods We interviewed 3021 Greek-Cypriots aged 25-64 years through a multistage survey. We collected self-reported information on demographics, health behaviours (physical activity, smoking, alcohol consumption and dietary intake), socio-economic characteristics (educational attainment, household income and occupational social class) and anthropometric measurements. Obesity was defined as body mass index ≥30 kg/m2. For the association between obesity and each socio-economic indicator, we conducted sex-specific Poisson's regression with robust variance, adjusting for all demographics and health-related behaviours, reporting adjusted prevalence ratios (aPR) and 95% confidence intervals (CI). Results The prevalence of obesity was 22% and 17% among men and women, respectively. There was a significant trend of higher obesity prevalence with increasing age as well as with being widowed in both genders and being a refugee in men. Obesity prevalence decreased with increasing educational attainment (postgraduate vs. none/gymnasium: a PRmen=0.45; 95%CI=0.25-0.82; a PRwomen=0.41; 95%CI=0.18-0.95; p-trends€4000/month vs. ≤€1000/month: a PRmen=0.45; 95%CI=0.26-0.81; a PRwomen=0.45; 95%CI=0.22-0.92; p-trends Conclusions The current study highlights striking social inequalities in obesity among Cypriot men and women, characterised by a linear decrease in obesity prevalence each step up the socioeconomic hierarchy. We recommend that comprehensive and multifaceted public health interventions are considered to address income and education-related barriers resulting in higher obesity rates among specific population sub-groups. Key messages Among Greek Cypriot adults, obesity affects almost one in five whilst obesity prevalence shows gender-specific social inequalities. When investigating social inequalities in health, the choice of socioeconomic indicators should reflect the context of the population and gender-specific differences.

Background A national breast cancer (BC) screening programme, targeting women 50-69 years old, was introduced in Cyprus in 2007. This study aims to assess rural/urban differences in BC incidence, tumour stage at diagnosis (TSD) and mortality, since 2004 and since the introduction of the screening programme. Methods Data were obtained for 6589 new cases of BC (diagnosis 2004-2016) from a national population-based cancer registry (1998-today) in Cyprus. TSD was recorded according to the Surveillance, Epidemiology, and End Results categories. We defined late TSD as regional or distant stage. Unknown stages were excluded. We linked cases to the population census data and place of residence (rural/urban) and calculated incidence and mortality rate ratios (RR) by place of residence. We conducted logistic regression to measure the association between place of residence and TSD or mortality, adjusting for sex, age, ethnicity, smoking and marital status. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) are reported. Results Since 2004, 54.7% of BC cases were diagnosed at localised stage, 40.6% at regional stage and 4.7% at distant stage. Incidence, but not mortality, rate for all BC was higher in urban than in rural areas (RRincidece=1.22;95%CI=1.51-1.28 and RRmortality=1.10;95%CI=0.97-1.24). Rural place of residence was associated with higher odds of late TSD (aOR=1.34; 95%CI=1.15-1.58) and death (aOR=1.36; 95%CI=1.11-1.68). After the introduction of the screening programme, for the targeted age group, rural place of residence was still associated with higher odds of late TSD (aOR=1.31; 95%C= 1.03-1.67), but not with death (p > 0.05). Conclusions Even though BC incidence is higher in urban than in rural areas, women residing in rural areas had higher odds of late TSD and death. The introduction of the national BC screening programme only slightly reduced geographical inequalities in TSD. Further studies are needed to understand and reduce the role of inequalities in TSD. Key messages Rural/Urban inequalities in TSD are evident among BC cases in Cyprus, diagnosed between 2004 and 2016. The introduction of the national BC screening programme reduced but did not overcome geographical inequalities in TSD.

Background Despite widespread adoption of lockdown by governments in the COVID-19 response, research on how it affects the individual pillars of Lifestyle Medicine is limited. We aimed to explore the effects of COVID-19 lockdown on healthy eating, physical activity, sleep, stress, social support and use of risky substances. Methods This was a cross-sectional study on a convenient sample of adults who resided in Cyprus during the lockdown. An anonymous questionnaire was completed online in Greek or English comprised of five validated tools in relation to their behaviours before and during the lockdown. We compared median values for each variable/tool before and during lockdown, using Wilcoxon Signed Rank test, and performed stratified analyses for sociodemographic characteristics. Results Out of 745 respondents, 74% were female and median age was 39. Overall scores showed significantly increased sleep quality difficulty (4 v 5, p Conclusions Many aspects of lifestyle were adversely affected by lockdown in Cyprus. As people return to their pre-lockdown routines, the outcomes described provide data to inform the design of lifestyle interventions that support changing or maintaining lifestyle habits. Such interventions can then help decrease people's risk for future poor health outcomes, including the risk for COVID-19 infection. Key messages This study describes aspects of lifestyle affected by the Cyprus COVID-19 lockdown, significant when considering future lockdowns and pre-, during or post-lockdown healthful lifestyle interventions. The outcomes provide data to inform the design of lifestyle interventions to support changing or maintaining healthy lifestyle habits.

During the first quarter of 2020 the world is experiencing a pandemic of Severe Acute Respiratory Syndrome‑Coronavirus‑2 (SARS‑CoV‑2), a novel beta coronavirus that is responsible for the 2019 novel coronavirus disease (COVID‐19). The COVID‐19 pandemic revealed that healthcare systems around the world were not prepared to deal with either the direct effects of the pandemic or with the indirect effects that are imposed on the health of patients with chronic disorders such as cancer patients. Some challenges and dilemmas currently faced during the pandemic include the management of cancer patients during the treatment and follow‐up phases, the assessment of the safety of treatments currently used for the management of SARS‑CoV‑2 for use in cancer patients, the development of psychoeducation and emotional support for cancer patients and the safe conduct of clinical trials involving participation of cancer patients. Evidence from the literature supports the need for the urgent development of a holistic contingency plan which will include clear guidelines for the protection and comprehensive care of cancer patients. The implementation of such a plan is expected to have many beneficial effects by mainly minimizing the increased morbidity and mortality of cancer patients that could result as an adverse consequence of the COVID‐19 or future pandemics., The COVID‐19 pandemic has revealed that health care systems around the world were not prepared to deal with either the direct effects of the pandemic or with the indirect effects that are imposed on the health of cancer patients. The evidence from the literature supports that the development of a contingency plan is as urgent as ever to minimise the increased morbidity and mortality of cancer patients that could result as a consequence of the current COVID‐19 pandemic or any other future pandemics.

There is an ongoing need for solid evidence about the effects of healthy behaviors, and particularly diet, on the quality of life (QoL) among breast cancer survivors. We first conducted a cross-sectional study on 68 Italian stage I-III breast cancer survivors, to investigate the association of adherence to the Mediterranean diet (MD), physical activity and weight status with QoL. Adherence to MD and physical activity was assessed using structured questionnaires. QoL was assessed using the European Organization for the Research and Treatment of Cancer Quality-of-Life tools. We showed that low consumption of red meat and carbonated beverages, daily consumption of wine and high consumption of dishes seasoned with sofrito had beneficial effects on several QoL subscales. By contrast, using olive oil as the main culinary fat, low consumption of commercial sweets and high consumption of nuts were associated with negative effects. Overall, these findings resulted in a null effect of adherence to MD on QoL. Furthermore, we observed better QoL sub-scores among women who performed moderate physical activity (i.e., diarrhea) and those who were underweight/normal weight (i.e., physical functioning and dyspnea) if compared with their counterparts (p-values &le, 0.003 after correction for multiple comparison). Next, we performed a systematic review of nine experimental studies to summarize whether dietary interventions might improve QoL among breast cancer patients. All the studies demonstrated significant improvements in overall QoL and/or its subscales after the interventions. However, differences in study design, interventions and tools used for QoL assessment did not allow us to provide an overall estimate. Moreover, only a single-arm trial evaluated the effect of an exclusive dietary-based intervention, while others combined dietary recommendations with physical activity and weight loss programs. For these reasons, our study encourages more efforts to improve the robustness of current evidence, through more homogenous tools, larger population-based studies and further randomized controlled trials.

Background Antimicrobial resistance (AMR) is one of the ten threats identified by the WHO in 2019. In order to face this issue and in the framework of the National Action Plan on Antimicrobial Resistance (PNCAR) 2017-2020, the Sicilian Health Authority has implemented a surveillance system of antibiotic consumption in the hospital sector and in the community and of antibiotic resistance in the Sicilian hospitals. The aim of the present work is to report the results of three-year surveillance. Methods From 2015 to 2017, data on antibiotic consumption have been collected from pharmacies of participating hospitals. AMR data on seven bacterial pathogens isolated in blood and cerebrospinal fluid have been collected from hospital laboratories, using routine clinical antimicrobial susceptibility tests. Antibiotic consumption was expressed as Defined Daily Dose (DDD) per 100 patient-days. Antibiotic resistance rates (RRs) were calculated as the number of non-susceptible isolates divided by the total number of isolates multiplied by 100. Results The most commonly consumed antibiotics in participating hospitals were fluoroquinolones in 2015, penicillins in 2016, and beta-lactams in 2017, respectively. RRs of Klebsiella pneumoniae significantly increased for all antimicrobial classes (p < 0.001), but carbapenems. By contrast, RRs of Escherichia coli resistant to third-generation cephalosporins and carbapenems showed significant decreasing trends (p < 0.001). Conclusions The implementation of the Sicilian surveillance system provides Sicilian reference data to monitor trends and target interventions and policies for reducing the threat of AMR. Recently, using toolkits of the ECDC-EAAD initiative adapted with regional surveillance data, an educational campaign “Obiettivo Antibiotico” - https://www.obiettivoantibiotico.it/ - was designed and launched to raise awareness of prudent use of antibiotics in the general public and in healthcare professionals in Sicily. Key messages Inappropriate antimicrobial consumption observed in Sicilian hospitals contributes to the emergence and selection of AMR. Surveillance system of antimicrobial consumption and AMR can help identify strategies for preventing spread of multi-drug resistant microorganisms.

Bioactive food compounds have different effects on global DNA methylation, an epigenetic mechanism associated with chromosomal stability and genome function. Since the diet is characterized by a mixture of foods, we aimed to identify dietary patterns in women, and to evaluate their association with long interspersed nuclear elements (LINE-1) methylation, a surrogate marker of global DNA methylation. We conducted an observational cross-sectional study of 349 women from Southern Italy, with no history of severe diseases. Dietary patterns were derived by food frequency questionnaire and principal component analysis. LINE-1 methylation of leukocyte DNA was assessed by pyrosequencing. We observed that intake of wholemeal bread, cereals, fish, fruit, raw and cooked vegetables, legumes, soup, potatoes, fries, rice, and pizza positively correlated with LINE-1 methylation levels. By contrast, vegetable oil negatively correlated with LINE-1 methylation levels. Next, we demonstrated that adherence to a prudent dietary pattern&mdash, characterized by high intake of potatoes, cooked and raw vegetables, legumes, soup and fish&mdash, was positively associated with LINE-1 methylation. In particular, women in the 3rd tertile exhibited higher LINE-1 methylation level than those in the 1st tertile (median = 66.7 %5mC, IQR = 4.67 %5mC vs. median = 63.1 %5mC, IQR = 12.3 %5mC, p &lt, 0.001). Linear regression confirmed that women in the 3rd tertile had higher LINE-1 methylation than those in the 1st tertile (&beta, = 0.022, SE = 0.003, 0.001), after adjusting for age, educational level, employment status, smoking status, use of folic acid supplement, total energy intake and body mass index. By contrast, no differences in LINE-1 methylation across tertiles of adherence to the Western dietary pattern were evident. Interestingly, women who exclusively adhered to the prudent dietary pattern had a higher average LINE-1 methylation level than those who exclusively or preferably adhered to the Western dietary pattern (&beta, = 0.030, SE = 0.004, 0.001, &beta, = 0.023, respectively), or those with no preference for a specific dietary pattern (&beta, = 0.013, p = 0.002). Our study suggested a remarkable link between diet and DNA methylation, however, further mechanistic studies should be encouraged to understand the causal relationship between dietary intake and DNA methylation.

Background Until recently, trivalent influenza vaccines (TIV) have contained one influenza B virus, recommended annually by the WHO vaccine selection committee. Quadrivalent Influenza Vaccines (QIV) add protection against a second B lineage; preventing the threat of a vaccine mismatched season, which often occurs in the Northern Hemisphere, leading to reduced vaccine effectiveness (VE) and increased influenza morbidity and mortality. Young children have one of the highest clinical burdens in Ireland, with the highest age-specific rate for influenza cases admitted to critical care units generally in children aged 0–4 years. Additionally, school-aged children are a major source of community transmission. Aim To assess the benefit of a QIV in the Irish paediatric population. Methods A literature review was conducted comparing QIV to TIV, focusing on VE and cost-effectiveness (CE). The VE of live-attenuated influenza vaccine (LAIV) compared to inactivated influenza vaccine (IIV) in children was also studied. The Cochrane database of systematic reviews, the Cochrane Central Register of Controlled Trials, PubMed, the Lancet, and publications from the European projects I-MOVE/I-MOVE+ and VENICE were searched for publications between 2009–2018. Results Recent influenza seasons suggest a higher VE of QIV compared to TIV. Studies have shown that QIV is as effective as TIV for the strains included in both; however QIV has superior immunogenicity for the additional B strain when there is a mismatch season. These results are also reflected in pre-licensing studies of the immunogenicity of QIVs that are now approved. LAIV has been recommended due to higher VE against influenza B strains and the ease and acceptability of the intranasal vaccination compared to the injectable IIV. QIV are more expensive than TIV, however CE analyses indicate that QIV delivers substantial savings in terms of preventing direct healthcare costs through reductions in infection numbers, hospitalisations and deaths; resulting in quality-adjusted life years gained. There are also substantial societal benefits through indirect savings in productivity (preventing employee/caregiver absences). Rolling out QIV to children was the most cost-effective vaccination strategy in the UK (aged 2–11 years) and in European countries (4–16 years) partaking in the I-MOVE+ project, with the exception of Portugal. Conclusion QIV would stabilise the VE across influenza seasons; eliminating the uncertainty of predicting the influenza B lineage, ultimately increasing public confidence in the vaccine, resulting in increased vaccine uptake. Broader protection in the paediatric population would directly reduce influenza transmission and indirectly protect vulnerable populations in the community.

In Ireland seasonal influenza and pertussis vaccination during pregnancy is recommended and every year national campaigns are organised to raise awareness and improve uptake. We estimated influenza and pertussis vaccine uptake and identified factors associated with vaccination status in pregnant women in 2017/18. We conducted a face-to-face omnibus survey, with quota sampling, among women aged 18–55 years and collected socio-demographic characteristics, self-reported vaccination status, awareness of vaccine campaigns, and attitudes towards vaccination. Sample was weighted to ensure representativeness with the target population. We performed univariate and multivariable logistic regression analyses on survey data. Overall, 241 pregnant women were enrolled. Influenza and pertussis vaccine uptake was 61.7% and 49.9%, respectively. Awareness of vaccine campaign and socio-economic status (SES) were associated with both influenza and pertussis vaccine uptake. The association between SES and uptake of vaccines differed by awareness. Women aware of the influenza vaccine campaign and with mid and low SES were less likely to be vaccinated, compared to those with high SES (aOR = 0.46; 95%CI: 0.22–0.97; aOR = 0.27; 95%CI: 0.12–0.60, respectively); women not aware of the pertussis vaccine campaign and with mid and low SES were less likely to be vaccinated, compared to those aware and with high SES (aOR = 0.15; 95%CI: 0.04–0.48; aOR = 0.05; 95%CI: 0.01–0.24, respectively). General practitioner (GP) recommendation was the main reason for receiving influenza vaccine (39.2%), and 71.8% of women were recommended pertussis vaccination from their GPs. The survey reports moderate uptake of vaccines among pregnant women, inequalities in uptake by SES and identifies GPs as primary source for vaccine recommendation. We recommend multifaceted campaigns, by engaging GPs, to target all socio-economic groups.

Antimicrobial resistance (AMR) is one of the biggest issues facing global public health. In 2017, Italy adopted its first National Action Plan on Antimicrobial Resistance 2017&ndash, 2020, which works through the synergy between national, regional, and local levels. In the framework of a Regional Action Plan on healthcare-associated infections and AMR prevention, the Sicilian Health Authority of the Sicilian Region, Southern Italy, has implemented a surveillance system of antibiotic consumption in hospitals, in the community, and of resistance rates (RRs) in hospital settings. Data on antibiotic consumption and on antibiotic RRs have been collected from 2015 to 2017 from pharmacies and laboratories of participating hospitals and from community, respectively. Data on antibiotic consumption showed that the most consumed antibiotics in hospitals were fluoroquinolones in 2015, penicillin in 2016, and beta-lactams in 2017. From 2015 to 2017, data on Klebsiella pneumoniae showed significant increasing RRs to all antibiotic classes, except to carbapenems. RRs of third-generation cephalosporins and carbapenems Escherichia coli showed significant decreasing trends. RRs of the other microorganisms did not change significantly during the study period. The results from the present study show that in Sicily, the use of antibiotics and RRs for selected microorganisms are at a high level. Immediate strategies are needed to decrease the inappropriate usage of antibiotics and control the spread of AMR.

Burden of AMR Collaborative Group:National Institute of Health Dr Ricardo Jorge, Lisbon, Portugal (Prof M Caniça PhD, Vera Manageiro PhD) Free PMC Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6300481/ Background: Infections due to antibiotic-resistant bacteria are threatening modern health care. However, estimating their incidence, complications, and attributable mortality is challenging. We aimed to estimate the burden of infections caused by antibiotic-resistant bacteria of public health concern in countries of the EU and European Economic Area (EEA) in 2015, measured in number of cases, attributable deaths, and disability-adjusted life-years (DALYs). Methods: We estimated the incidence of infections with 16 antibiotic resistance–bacterium combinations from European Antimicrobial Resistance Surveillance Network (EARS-Net) 2015 data that was country-corrected for population coverage. We multiplied the number of bloodstream infections (BSIs) by a conversion factor derived from the European Centre for Disease Prevention and Control point prevalence survey of health-care-associated infections in European acute care hospitals in 2011–12 to estimate the number of non-BSIs. We developed disease outcome models for five types of infection on the basis of systematic reviews of the literature. Findings: From EARS-Net data collected between Jan 1, 2015, and Dec 31, 2015, we estimated 671 689 (95% uncertainty interval [UI] 583 148–763 966) infections with antibiotic-resistant bacteria, of which 63·5% (426 277 of 671 689) were associated with health care. These infections accounted for an estimated 33 110 (28 480–38 430) attributable deaths and 874 541 (768 837–989 068) DALYs. The burden for the EU and EEA was highest in infants (aged

The issue of antimicrobial resistance (AMR) is a focus of the World Health Organization, which proposes educational interventions targeting the public and healthcare professionals. Here, we present the first attempt at a regionwide multicomponent campaign in Sicily (Italy), called &ldquo, Obiettivo Antibiotico&rdquo, which aims to raise the awareness of prudent use of antibiotics in the public and in healthcare professionals. The campaign was designed by an interdisciplinary academic team, and an interactive website was populated with different materials, including key messages, letters, slogans, posters, factsheets, leaflets, and videos. The campaign was launched in November 2018 and, as of 21 December 2018, the website had a total of 1159 unique visitors, of which 190 became champions by pledging to take simple actions to support the fight against AMR. Data from social media showed that the audience was between 18 and 54 years of age, with a high proportion of female participants (64%). Interestingly, the LinkedIn page received more than 1200 followers, and Facebook 685 followers. The number of actions taken (pledges) by the audience was 458, evenly divided between experts (53%) and the general public (47%). Additional efforts are needed to reach more people, thus future efforts should focus on further promotion within the Sicilian region to sustain the engagement with the campaign.

The aims of the present study were to: (1) assess surgical site infection (SSI) incidence in a cohort of surgical patients and (2) estimate the compliance with national guidelines for perioperative antibiotic prophylaxis (PAP). SSIs, among the most common health care–associated infections, are an important target for surveillance and an official priority in several European countries. SSI commonly complicates surgical procedures in older people and is associated with substantial attributable mortality and costs. The implementation of PAP guidelines is difficult among surgeons, and failure to comply with the standard of care has been widely reported. A 12-month prospective survey was performed in accordance with the methods, protocols, and definitions of the Hospital in Europe Link for Infection Control through Surveillance (HELICS) protocol. The compliance of the current PAP practices with the published national guidelines was assessed. A total of 249 patients were enrolled. The cumulative SSI incidence was 3.2 per 100 operative procedures. Cumulative compliance for PAP was 12.4%. Overall, only infection risk index ≥1 was confirmed as a significant risk factor for SSI (odds ratio, 6.65; 95% confidence interval, 1.04–42.59; P = 0.045). When only older patients (age >65 years) were considered, no significant risk factors for SSI were identified. Our study indicates an overall inadequate compliance with PAP recommendations, thus highlighting the need to develop multimodal and targeted intervention programs to improve compliance with PAP guidelines.

Healthcare system quality improvements depend both on the availability of innovative technologies and on proper investments to transfer experimental policies into daily practices that could be easily adopted in all hospitals. Unfortunately, funds are generally not enough to cover all the addressable issues and the policy makers are faced with the difficult problem to decide where to allocate the money to produce the most relevant positive outcomes. To support this decision process, data gathering, and analysis play a key role. In this contribution we propose a simplified pipeline that starting from observational data to achieve statistical conclusions as valid as in designed randomized studies. After detailing the proposed analytic method, its soundness is proved using an important case study: the problem of the reduction of Healthcare-Associated Infections, and especially those acquired in Intensive Care Units. In particular, we show how to estimate the preventable proportion of Intubation-Associated Pneumonia in ICUs. In our study, using G-Computation based approach, we found out that the preventable proportion for IAP is of 44%. Interestingly, when bundle compliance is added in the statistical model, the preventable proportion for IAP is of 40%.

Specific foods and nutrients help prevent the progression of persistent high-risk human papillomavirus (hrHPV) infection to cervical cancer (CC). The aim of this study was to investigate dietary patterns which may be associated with hrHPV status and the risk of high-grade cervical intraepithelial neoplasia (CIN2+). Overall, 539 eligible women, including 127 with CIN2+, were enrolled in a cross-sectional study, and tested for hrHPV infection. Food intake was estimated using a food frequency questionnaire. Logistic regression models were applied. Using the Mediterranean Diet Score, we demonstrated that, among 252 women with a normal cervical epithelium, medium adherence to the Mediterranean diet decreased the odds of hrHPV infection when compared to low adherence (adjOR = 0.40, 95%CI = 0.22–0.73). Using the principal component analysis, we also identified two dietary patterns which explained 14.31% of the variance in food groups intake. Women in the third and fourth quartiles of the “Western pattern” had higher odds of hrHPV infection when compared with first quartile (adjOR = 1.77, 95% CI = 1.04–3.54 and adjOR = 1.97, 95%CI = 1.14–4.18, respectively). Adjusting for hrHPV status and age, women in the third quartile of the “prudent pattern” had lower odds of CIN2+ when compared with those in the first quartile (OR = 0.50, 95%CI = 0.26–0.98). Our study is the first to demonstrate the association of dietary patterns with hrHPV infection and CC and discourages unhealthy habits in favour of a Mediterranean-like diet.

ObjectivesThe aim of this cross-sectional study was to identify key factors associated with patient delay (PD), health system delay (HSD) and total delay (TOTD) in patients with tuberculosis (TB) to inform control programmes.SettingThe study was conducted in four Italian regions in 2014–2016. Data were obtained using a questionnaire including: sociodemographic and lifestyle data, TB comorbidities, patient knowledge and attitudes towards TB, stigma, access to TB care and health-seeking behaviours.ParticipantsPatients’ inclusion criteria were being diagnosed as a new smear positive pulmonary TB case and living in one of the participating Italian regions. Overall, 344 patients from 30 healthcare centres were invited to participate and 253 patients were included in the analysis (26.5% non-response rate); 63.6% were males and 55.7% were non-Italian born.Outcome measuresRisk factors for PD, HSD and TOTD in patients with TB were assessed by multivariable analysis. Adjusted ORs (aOR) and 95% CIs were calculated.ResultsMedian PD, HSD and TOTD were 30, 11 and 45 days, respectively. Factors associated with longer PD were: stigma (aOR 2.30; 95% CI 1.06 to 4.98), chest pain (aOR 2.67; 95% CI 1.24 to 6.49), weight loss (aOR 4.66; 95% CI 2.16 to 10.05), paying for transportation (aOR 2.66; 95% CI 1.24 to 5.74) and distance to the health centre (aOR 2.46; 95% CI 1.05 to 5.74) (the latter three were also associated with TOTD). Shorter HSD was associated with foreign-born and female status (aOR 0.50; 95% CI 0.27 to 0.91; aOR 0.28; 95% CI 0.15 to 0.53, respectively), dizziness (aOR 0.18, 95% CI 0.04 to 0.78) and seeking care at hospital (aOR 0.35; 95% CI 0.18 to 0.66). Prior unspecific treatment was associated with longer HSD (aOR 2.25; 95% CI 1.19 to 4.25) and TOTD (aOR 2.55; 95% CI 1.18 to 5.82). Haemoptysis (aOR 0.12; 95% CI 0.03 to 0.43) and repeated visits with the same provider (aOR 0.29; 95% CI 0.11 to 0.76) showed shorter TOTD.ConclusionsThis study identifies several determinants of delays associated with patient’s behaviours and healthcare qualities. Tackling TB effectively requires addressing key risk factors that make individuals more vulnerable by the means of public health policy, cooperation and advocacy to ensure that all patients have easy access to care and receive high-quality healthcare.

Several studies showed that altered expression of the miRNA-ome in maternal circulation or in placental tissue may reflect not only gestational disorders, such as preeclampsia, spontaneous abortion, preterm birth, low birth weight, or macrosomia, but also prenatal exposure to environmental pollutants. Generally, the relationships between environmental exposure, changes in miRNA expression, and gestational disorders are explored separately, producing conflicting findings. However, validation of tissue-accessible biomarkers for the monitoring of adverse pregnancy outcomes needs a systematic methodological approach that takes also into account early-life environmental exposure. To achieve this goal, exposure to xenochemicals, endogenous agents, and diet should be assessed. This study has the aim to provide a comprehensive review on the role of miRNAs as potential biomarkers for adverse pregnancy outcomes and prenatal environmental exposure.

Background Long Interspersed Nuclear Elements-1 (LINEs-1) methylation from white blood cells (WBCs) DNA has been proposed as biomarker associated with different types of cancer. The aim of the present study was to investigate the degree of WBCs LINE-1 methylation, according to high-risk Human Papilloma Virus (hrHPV) status in a healthy population, and the association with high-grade Cervical Intraepithelial Neoplasia (CIN2+) in hrHPV positive women. Methods Women with abnormal cervical cells were enrolled and classified by histological diagnosis and hrHPV infection. A structured questionnaire was used to obtain information on socio-demographic variables and lifestyle factors. LINE-1 methylation level in WBCs was measured by pyrosequencing-based methylation analysis after bisulfite conversion. Results Among 252 women diagnosed with normal cervical epithelium, with regard to LINE-1 methylation level no significant difference was observed between hrHPV positive and hrHPV negative women, also adjusting for known risk factors of infection. The association between WBCs LINE-1 methylation and CIN2+ status was analyzed in hrHPV positive women. The median value of LINE-1 methylation levels was higher in cases (CIN2+) than in controls (75.00% versus 73.17%; p = 0.002). For a one-unit increase in LINE-1 methylation level, the odds of being diagnosed with CIN2+ increased by 10%, adjusting for known factors related to LINE-1 methylation (adjOR: 1.10; 95% CI:1.01–1.20; p = 0.032). The Receiver-Operating Characteristic (ROC) curve analysis identified the cut-off value of 73.8% as the best threshold to separate cases from controls (sensitivity: 63.4% and specificity: 61.8%). Conclusions LINE-1 methylation status in WBCs DNA may represent a cost-effective and tissue-accessible biomarker for high-grade CIN in hrHPV positive women. However, LINE-1 hypermethylation cannot be considered specific for cervical cancer (CC) and a model based solely on LINE-1 methylation levels has limited performance. Further investigations are necessary to propose and validate a novel methylation biomarker panel, based on LINE-1 methylation and other differentially methylated regions, for the screening of women at risk of CC.

Summary Background Infections caused by multidrug-resistant (MDR) Acinetobacter baumannii have become an important healthcare-associated problem, particularly in intensive care units (ICUs). Aim To investigate the emergence of carbapenem- and colistin-resistant A. baumannii infections in two Sicilian hospitals. Methods From October 2008 to May 2011, a period which included two Italian Nosocomial Infections Surveillance in ICUs network (SPIN-UTI) project surveys, all carbapenem-resistant A. baumannii isolates from the ICUs of two hospitals in Catania, Italy, were prospectively collected. Minimum inhibitory concentrations (MICs) were measured by agar dilution, and phenotypic testing for metallo-β-lactamase (MBL) production was performed. Carbapenem resistance genes and their genetic elements were identified by polymerase chain reaction and sequencing. Genotypic relatedness was assessed by pulsed-field gel electrophoresis (PFGE) and multi-locus sequence typing. Patient-based surveillance was conducted using the SPIN-UTI protocol and previous antibiotic consumption was recorded. Findings Twenty-six carbapenem-resistant A. baumannii were identified. Imipenem and meropenem MICs ranged from 4 to >32 mg/L, and 15 isolates exhibited high-level colistin resistance (MICs >32 mg/L). PFGE demonstrated that all isolates belonged to a unique clonal type and were assigned to ST2 of the international clone II. They harboured an intrinsic bla OxA-51-like carbapenemase gene, bla OxA-82 , which was flanked upstream by IS Aba1. Conclusions The dissemination of clonally related isolates of carbapenem-resistant A. baumannii in two hospitals is described. Simultaneous resistance to colistin in more than half of the isolates is a problem for effective antibiotic treatment. Prior carbapenem and colistin consumption may have acted as triggering factors.

Background/Aims: An important public health issue is monitoring folate inadequacy in women of childbearing potential. The aim of the present study was to investigate associations between folate intake, red blood cell (RBC) folate, total homocysteine (tHcy) and the MTHFR 677T allele. Methods: A total of 204 women were enrolled in a cross-sectional study. Folate intake was assessed by a food frequency questionnaire, and RBC folate, tHcy and MTHFR C677T genotype were determined. Results: About half of the women had a decreased RBC folate level (Conclusions: Our study revealed significant folate deficiency in our Mediterranean population and higher than ideal Hcy concentrations, thus emphasizing that in these groups an improvement in the folate status is needed via a food-based approach or supplement. Consequently, public health policy strategies aiming at improved supplementation are required.

tuberculosis, health-care system, diagnosis

Objective: The aim of the present study was to estimate the preventable proportion of Intubation-Associated Pneumonia (IAP) in the Intensive Care Units (ICUs) participating in the Italian Nosocomial Infections Surveillance in ICUs (SPIN-UTI) network, taking into account differences in intrinsic patients’ risk factors, and additionally considering the compliance with the European bundle for IAP prevention. Methods: A prospective patient-based survey was conducted and all patients staying in ICU for more than 2 days were enrolled in the surveillance. Compliance with the bundle was assessed using a questionnaire for each intubated patient. A twofold analysis by the parametric g-formula was used to compute the number of infections to be expected if the infection incidence in all ICUs could be reduced to that one of the top-tenth-percentile-ranked ICUs and to that one of the ICU with the highest compliance to all five bundle components. Results: A total of 1,840 patients and of 17 ICUs were included in the first analysis showing a preventable proportion of 44% of IAP. In a second analysis on a subset of data, considering compliance with the European bundle, a preventable proportion of 40% of IAP was shown. A significant negative trend of IAP incidences was observed with increasing number of bundle components performed (p Conclusions: The g-formula controlled for time-varying factors is a valuable approach for estimating the preventable proportion of IAP and the impact of interventions, based entirely on an observed population in a real-world setting. However, both the study design that cannot definitively prove a causative relationship between bundle compliance and IAP risk, and the small number of patients included in the care bundle compliance analysis, may represent limits of the study and further and larger studies should be conducted.

Objectives: In order to assess the prevalence of surgical site infections (SSIs) before and after the implementation of a multimodal infection control programme including the realization of a campaign to increase compliance with guidelines for antimicrobial prophylaxis, we designed and conducted the present study involving all 20 of the surgical departments of a large teaching hospital in Catania, Italy. Patients and methods: SSI definitions of the Hospital in Europe Link for Infection Control through Surveillance (HELICS) protocol were used in four 1 day point-prevalence surveys. After the first survey, an infection control programme was implemented involving the active commitment of surgeons and infection control staff. Results: Overall, a total of 600 surgical patients were enrolled. A significant decreasing trend in the SSI rate (from 16.4 to 8.2 per 100 surgical patients, P¼0.018) was shown. After multivariate analysis, significant risk factors for SSI were identified: age .31 years, kidney insufficiency and infection at admission. Taking into account the indication and the timing of administration of antibiotic prophylaxis, in the four surveys prophylaxis was administered inappropriately in 55.3% of surgical procedures. Conclusions: The approach used in this study remains a feasible method of evaluating the burden of SSIs using repeated prevalence surveys. The results provide evidence of a significant decreasing trend in the SSI rate following the infection control intervention. Furthermore, our study underlines the need to develop evidencebased guidelines in collaboration with surgeons, to achieve consensus before implementation in order to improve compliance with antimicrobial prophylaxis and, finally, decrease SSI rates.