[ESCULAPIO: A project to elaborate strategies and actions of multi-purpose health communication on vaccine preventable infectious diseases in order to increase vaccination coverage in the population]. / Progetto ESCULAPIO: Elaborazione di Strategie e di interventi di Comunicazione sanitaria mUlti-obiettivo sulle maLAttie infettive Prevenibili e sulle vaccInazioni come mezzo per aumentare le cOperture vaccinali nella popolazione.

ESCULAPIO Project, funded by the Centre for Disease Prevention and Control (CCM) of the Italian Ministry of Health, for the program 2013, aims at increasing awareness on vaccine preventable infectious diseases (VPID) and vaccination in different targets of population and at spreading the culture of prevention by the development of information/training interventions on VPID. In Tuscany Region (Central Italy), educational courses on VPID in high schools were organized and students were stimulated to prepare informative materials on VPID for lower grade school pupils. Educational games for school pupils were realized in Liguria Region (Northern Italy) with the aim to increase awareness and knowledge of vaccination among primary school children, their families, and teachers. The Sicilian Operative Unit (OU) developed and validated a questionnaire to collect data on the main factors influencing vaccine uptake in a population from Southern Italy and spreading information on vaccines to the general population. Aim of the activities performed in Apulia Region (Southern Italy) was to collect, directly from the public, a set of issues to which people were more "sensitive," in order to perceive the dimension of informative needs and the misinformation in the field of vaccinations. A toll-free telephone line to answer questions on VPID was also the aim of the Apulian activities. The objective of the OU of Sardinia (Southern Italy) was to increase knowledge on VPID and adherence to immunization campaigns in health care workers (HCW) by realizing traditional and e-learning training courses and initiatives of health promotion in healthcare and hospital setting. Interventions to promote vaccinations in maternal and child health services and outreach interventions in case of parental non-compliance with vaccination schedules were performed in the Veneto Region (Northern Italy), with the aim to reach a particular subgroup of the general population: new or future parents. The activities of Veneto Region aimed also at realizing individual interviews with parents and/or home visit, if considered useful, for families not respondents to the active ordinary call.

Sexual behaviour and risk factors for the acquisition of human papillomavirus infections in young people in Italy: suggestions for future vaccination policies.

BACKGROUND: Human Papillomavirus (HPV) is the most common sexually transmitted infection. The main risk factors correlated with HPV infection are: early sexual debut, the number of partners, frequency and type of sexual contact and partner's sexual histories.We surveyed sexual habits among young people in order to provide information that might orient decision-makers in adopting HPV multi-cohort vaccination policies. METHODS: We administered a questionnaire to students (14-24 years old) in five Italian cities. RESULTS: 7298 questionnaires were analyzed (4962 females and 2336 males); 55.3% of females (95% CI 53.9-56.7) and 52.5% of males (95% CI 50.5-54.5) reported regular sexual activity. The mean age at sexual debut was 15.7 ± 1.6 and 15.6 ± 1.6 for females and males, respectively, and the median age was 16 for both sexes.With regard to contraceptive use during the last year, 63.6% of males and 62.8% of females responded affirmatively; 42.6% of males and 42.8% of females used condoms. CONCLUSION: The results reveal precocious sexual activity among respondents, with the mean age at first intercourse declining as age decreases. Condom use proved to be scant. Considering lifestyle-related risk factors, males appear to have a higher probability of acquiring HPV infection than females.These data support the importance of promoting multi-cohort HPV vaccination strategies for females up to 25 years of age. It is essential to improve vaccination coverage through different broad-spectrum strategies, including campaigns to increase awareness of sexually transmitted diseases and their prevention.

Progress towards measles and rubella elimination in Tuscany, Italy: the role of population seroepidemiological profile.

BACKGROUND: As a part of the National Plan for Measles and Congenital Rubella Elimination, a catch-up campaign targeting children aged 7-14 years with Measles-Mumps-Rubella (MMR) vaccine was conducted during 2004-05 in Tuscany, Central Italy. METHODS: To assess the profile of measles and rubella susceptibility, immunoglobulin G antibodies against measles (945 subjects) and rubella (1110 subjects) were detected using two commercial enzyme-linked immunosorbent assay tests in sera from a population aged 1-49 years. RESULTS: Overall immunity towards measles increased in the last years, but the WHO-Euro recommended threshold of susceptibility for elimination was attained only in 2- to 4-year-olds. All fertile women up to 29 years had rates of susceptibility clearly higher than those required by WHO-Euro (5%) to eliminate congenital rubella. Despite the reduction of susceptibility among subjects targeted by the catch-up campaign, continuous efforts to increase immunization coverage are needed to eliminate measles and rubella circulation. Our results are predictive of a high chance of measles and rubella outbreaks because of the accumulation of susceptible individuals. CONCLUSION: Additional catch-up vaccination strategies targeting the adult population (particularly fertile women) are strongly needed to eliminate the risk of measles and congenital rubella syndrome for future generations.

An overview on the implementation of HPV vaccination in Europe.

The discovery that the Human PapillomaVirus (HPV) is the necessary cause of cervical cancer has led to the development of prophylactic vaccines. Cervical cancer is the second most common cause of death from cancer among young women in Europe: mortality is still high, despite its important reduction due to screening programs for early detection. Besides cervical cancer, HPV is responsible for a significant proportion of other anogenital cancers and an increasing number of oropharyngeal cancers, representing together an at least equal burden compared to cervical cancer. HPV is also responsible for conditions such as condyloma acuminata (genital warts) and recurrent respiratory papillomatosis. Organized vaccination programs against HPV have the potential to prevent about 70% of cervical cancers and the vast majority of the other HPV-related conditions. Recommendations for HPV vaccination of at least one cohort of females have been issued in nearly all western European countries, and national/regional publicly funded vaccination programs have been introduced in most of them. Different approaches have been chosen for the implementation of HPV vaccination, based on the organization of each country's health care system. A brief outline of these programs in Europe is presented. As for all preventive public health interventions, high coverage of the target population with HPV vaccines pre-exposure is essential to achieve maximum reduction of cases: therefore, in order to obtain the maximum and most equitable coverage and future benefit, programs targeting adolescents before exposure to HPV should be preferred and population-based. Catch-up programs should also be implemented wherever possible, in order to deliver more and even earlier benefits, and effective communication strategies need to be adopted.

Safety and tolerability of bivalent HPV vaccine: an Italian post-licensure study.

One of the most important scientific discoveries of the last century was that persistent infection by some types of HPV is a precondition for the development of cervical cancer. The oncogenic types of HPV are also associated with other tumours (vaginal, vulvar and anal carcinomas, tumours of the head and neck, urethra and penis). Two preventive vaccines are currently available (Cervarix and Gardasil). Both have shown very good efficacy, safety and tolerability profiles. Nonetheless, extensive vaccination requires long-term monitoring of safety and tolerability. The aim of our study was to evaluate the safety and tolerability of the bivalent vaccine Cervarix in Italy. Every participant in the study completed a questionnaire after each dose of vaccine received, with a view to recording adverse events during the first 7 days after vaccination. We registered local (pain, redness, swelling) and systemic symptoms (fever, headache, myalgia, fatigue, arthralgia, itching, gastrointestinal disorders, rash and urticaria). A total of 4,643 subjects were recruited. In all, 7,107 questionnaires were collected: 3,064 after the first dose, 2,367 after the second and 1,676 after the third. No serious adverse events were observed. The most frequent local symptom was pain at the injection site, while fatigue, headache and myalgia were the most common systemic reactions. Pain was reported more frequently after the first dose than after the others, while all the other local and general symptoms were reported most frequently after the third dose. Almost all of the local and general reactions proved to be of negligible intensity and duration and required no medical intervention. Our results show better tolerability of the vaccine in comparison with the data from some controlled clinical studies and from other surveillance programmes conducted internationally. That tolerability proved to be better than in clinical studies could be explained by the absence of the typical apprehension felt by subjects involved in clinical experimentation.

A Study of Varicella Seroprevalence in a Pediatric and Adolescent Population in Florence (Italy). Natural Infection and Vaccination-Acquired Immunization.

Background: Varicella is a well-known infectious disease that can have severe complications, also in young children. The Universal Varicella Vaccination (UVV) program was introduced in Tuscany (Italy) in 2003, with a two-dose vaccine schedule given to children between their 13th and 15th month, and at 5-6 years old, as a monovalent for varicella (V) or tetravalent (measles, mumps, rubella and varicella (MMRV)) formulation. Although varicella notifications have dramatically fallen in the last two decades, varicella disease underreporting remains a challenge. Methods: A qualitative immunoenzymatic test (ELISA) was used to measure the presence of anti-varicella antibodies in 165 sera of subjects aged 1-18 years residing in the province of Florence (Italy). Information regarding the anamnestic and vaccination status (including disease notification) was also collected. Results: Our study showed an overall varicella seropositivity of 75.8% (reaching the maximum at 96.3% in the 15-18 years age group). We found that varicella disease notification had been recorded for only 7/165 subjects; however, since 42/165 recalled having had the disease, we can hypothesize that some of them must have been underreported. Furthermore, our study showed that the presence of antibodies after the varicella vaccination remained over time, lasting up to 12 years. Conclusions: Although varicella seroprevalence is <95% in almost all our age groups (except for the 15-18 years age group), our data are encouraging and reflect the success of the introduction of the UVV program and the vaccination campaigns promoted in the Tuscany region.

Need to take special care of non-responders to hepatitis B vaccination among health-care workers, students and chronic patients.

Both our research and that published by Sticchi et al. on immunological memory against hepatitis B virus (HBV) in health-care workers (HCWs) vaccinated as infants or adolescents confirm that in those testing negative after the primary course, one additional (fourth) booster dose is able to elicit an anti-HBs response in >85% subjects. The fifth and the sixth doses further contribute substantially to a high overall response rate. The rate of subjects showing an anamnestic response after the booster dose was almost six-fold higher in HCWs compared to chronic patients. Since universal vaccination in Italy resulted in a significant decrease in HBV infections, special attention and testing should be addressed to those affected by chronic diseases.

A Study of Hepatitis A Seroprevalence in a Paediatric and Adolescent Population of the Province of Florence (Italy) in the Period 2017-2018 Confirms Tuscany a Low Endemic Area.

Background: Italy is considered an area with very low HAV (hepatitis A virus) endemicity. Currently in Italy the anti-HAV vaccine is recommended only for specific risk groups and there is no universal vaccination program. The aim of this study was to assess the level of immunity against hepatitis A in a sample of children and adolescents from the province of Florence. Methods: A total of 165 sera were collected from subjects aged 1 to 18 years, proportionally selected according to the general population size and stratified by age and sex. A qualitative evaluation of anti-HAV antibodies was performed using the enzyme-linked immunosorbent assay (ELISA). Anamnestic and vaccination status data were also collected. Results: Our study showed a hepatitis A seroprevalence of 9.1% in the enrolled population. A statistically significant difference in the prevalence of anti-HAV was found between Italian and non-Italian subjects. About half of the population having anti-HAV antibodies was reported to be vaccinated, and no cases of hepatitis A were found. Conclusions: The data from our study confirmed Tuscany as an area with low HAV endemicity and showed that hepatitis A seroprevalence is significantly higher in foreign children and adolescents. The presence of more seropositive subjects than those vaccinated was probably due to a natural immunization achieved through a subclinical infection and/or to underreporting of the surveillance systems.

Hepatitis B Seroprevalence in the Pediatric and Adolescent Population of Florence (Italy): An Update 27 Years after the Implementation of Universal Vaccination.

BACKGROUND: Hepatitis B still represents a health concern, although safe and effectivevaccines have been available since 1982. Italy introduced a program of universal vaccination againsthepatitis B in 1991. The aim of this study was to assess the immunity levels towards hepatitis B in asample of sera from the pediatric and adolescent population in the province of Florence, CentralItaly, twenty-seven years after the implementation of universal vaccination. METHODS: A total of 165sera samples were collected from the resident population of Florence aged 1-18 years. The anti-HBsand anti-HBc enzyme-linked immunosorbent Assay (ELISA) tests were performed on all samples.The anamnestic and vaccination status data were also collected. RESULTS: Seroprevalence of anti-HBswas approximately 60%, with children aged 1-5 years having the highest positivity rate (81.6%),and decreasing trends in the older age groups. The zero prevalence of anti-HBc shows that thedetected protective immunity is mainly due to vaccination, and natural infection was not reportedin the studied population. CONCLUSIONS: The seroprevalence of anti-HBs and the lack of anti-HBc inthis study highlights that immunity levels have been derived mainly from immunization. Thisconfirms how vaccination dramatically reduced circulation of the hepatitis B virus in Italy in thepediatric and adolescent population twenty-seven years after implementation of the mandatoryuniversal program.

High chance to overcome the non-responder status to hepatitis B vaccine after a further full vaccination course: results from the extended study on healthcare students and workers in Florence, Italy.

Healthcare workers (HCWs) are considered high-risk subjects for Hepatitis B Virus (HBV) infection due to occupational exposure to blood and body fluids. Vaccination represents the core strategy for HBV infection prevention. Following our previous publication on this topic, we aimed to assess the effectiveness of booster vaccine doses in eliciting the immunological response in seronegative (<10 mIU/mL) HCWs and students of Careggi Teaching Hospital, Florence (Italy). All subjects received primary vaccination course, and they were tested for serum anti-HBs antibodies. In seronegative subjects, a challenge dose of vaccine was administered and the test was repeated 1 month later. Six hundred and ninety-eight (87.8%) of 795 HCWs and students tested responded to the challenge dose. After this challenge dose, males more often had negative anti-HBs titer compared with females (15.9% vs 10.2%; p < .05). The completion of the second vaccination course was offered to subjects with persistently negative anti-HBs titer. 76.2% (32) of those who accepted the fifth dose, and 3 of the 5 who accepted the sixth dose seroconverted. This report shows the importance to convey a strong message to negative subjects at the initial anti-HBs dosage: accepting all the three additional vaccine doses allows the vast majority of them to obtain protection.

Increasing Measles Seroprevalence in a Sample of Pediatric and Adolescent Population of Tuscany (Italy): A Vaccination Campaign Success.

Background: Despite the National Plan for the Elimination of Measles and congenital Rubella (NPEMcR), in 2017, a measles outbreak occurred in Italy, due to sub-optimal vaccination coverage (<95%) for many years. Since that year, the anti-measles vaccination became compulsory in minors (0-16 years) for school attendance. The aim of our study was to assess the immunity/susceptibility against measles in a representative sample of pediatric and adolescent (1-18 years) residents of the province of Florence (Tuscany, Italy), and to compare these results with two previous surveys (2003 and 2005-2006). Methods: The enzyme-linked immunosorbent assay (ELISA) was applied for a qualitative measurement of anti-measles antibodies on 165 sera. The anamnestic and vaccination status was also collected. Results: No measles notification was reported. The overall seropositivity was 88.5%; mostly in the 5-9 years old subjects (97.9%). Among the 152 vaccinated, 92.1% were positive. The seropositivity persisted after many years since the last dose of vaccine and tended to be more long-lasting in those who had received two or three doses. The susceptibility towards measles decreased over time, reaching a lower value in the current survey (8.5%) than in 2003 (30.8%) and in 2005-2006 (25.5%). Conclusions: This study confirmed the anti-measles vaccination campaign success, which allowed for the increase in vaccination coverage and immunity levels against measles in the Florentine pediatric and adolescent population following the NPEMcR implementation.

Rubella Seroprevalence Boost in the Pediatric and Adolescent Population of Florence (Italy) as a Preventive Strategy for Congenital Rubella Syndrome (CRS).

BACKGROUND: Despite the availability of an effective vaccine since the 1970s, rubella disease and, importantly, congenital rubella syndrome (CRS) remain a public health concern. The aim of this study was to analyze the rubella seroprevalence in the children population of the province of Florence and compare the obtained results to a previous survey conducted in 2005-2006. METHODS: A qualitative measurement of anti-rubella antibodies was performed on 165 sera using the enzyme-linked immunosorbent Assay (ELISA). The anamnestic and vaccination status was also collected. RESULTS: Our study highlighted a very high rubella seroprevalence (85-100%) in our enrolled population. In the vaccinated group (153/165), 98.7% of them were positive to rubella antibodies. CONCLUSIONS: Our study showed the highest seroprevalence rate reached in the province of Florence for rubella in the last 15 years, thanks to the several successful vaccination campaigns promoted in the Tuscany region. Our findings in pediatric and adolescent subjects are a key factor in preventing CRS in adult life, specifically in childbearing women. Thus, the set goal will be to keep the awareness about the vaccination for this preventable disease high.

Focusing on the implementation of 21st century vaccines for adults.

Adult immunization is a priority for public health, particularly in countries where an aging population has become increasingly more numerous. Protection against diseases which typically affect adults (like flu, pneumococcal diseases and Herpes zoster), the shift of age of infections which originally affected children (like measles), the decreasing protection with time for infections which need periodical booster doses of vaccines (Tdap), the availability of vaccines which can also impact on adult health (HPV) are only some examples of the importance of implementing targeted vaccination strategies. The possibility to reach high coverage with immunizations that can guarantee a fundamental improvement of health for adults and the elderly can only be achieved through a coordinated effort where all stakeholders, under the coordination of public health, contribute to issue recommendations; create a functioning database for vaccine coverage registration; promote formative courses for healthcare workers and continuous information for the public; increase vaccines uptake among healthcare workers, who need to give the first testimony on the relevance of immunization.

Is hepatitis B vaccination performed at infant and adolescent age able to provide long-term immunological memory? An observational study on healthcare students and workers in Florence, Italy.

Universal vaccination programmes against Hepatitis B Virus (HBV) have significantly reduced the burden of the disease; nevertheless, HBV infection remains a relevant issue for high-risk subjects, such as healthcare workers (HCWs), who may potentially be exposed to blood or body fluids. Our study evaluates the long-term duration of the immunological memory of HBV vaccination 11-23 years after primary immunization by examining the response to booster doses in HCWs and students of health disciplines at Careggi Teaching Hospital in Florence (Italy). All participants (n = 2,203) had received a complete HBV immunization course in infancy or adolescence. Blood samples were collected to measure antibody levels against the HBV surface antigen (anti-HBs); an anti-HBs titre <10 mIU/mL was considered as negative. The administration of the vaccination course during infancy induced lower long-term anti-HBs titres compared to those in case of vaccination performed during adolescence (titre <10 mIU/mL: 51.1% and 12.2% respectively; p < 0.001), also considering that an equal number of years has elapsed since vaccination. A booster dose administered to subjects vaccinated in infancy is able to induce anamnestic immunological response in a higher percentage of vaccinated people (p < 0.001). Few subjects (n. = 4) accepted a fifth dose of vaccine in the case of persistent anti-HBs negative titres; this aspect requires further investigation. The total absence of acute hepatitis B among vaccinated subjects suggests that the long incubation period of the disease allows the activation of immunologic memory mechanisms, which is also true in case of low anti-HBs level. In conclusion HCWs still represent a high-risk category; it is therefore, necessary to increase efforts to protect and vaccinate these subjects.

Is Italian population protected from Poliovirus? Results of a seroprevalence survey in Florence, Italy.

OBJECTIVES: Periodical assessments of population susceptibility to polioviruses (PV) is essential for evaluating population protection and planning appropriate vaccination strategies. The aim of the current work was to assess serological protective titers against all three polioviruses in the general population of Florence. METHODS: A convenience sample of 328 sera, collected in 2009 in Florence (Central Italy) was analyzed. Samples were considered protective if neutralizing antibodies were detected at dilutions ≥1:8, according to the WHO protocols. RESULTS: The immune coverage was 75.3%, 69.2% and 46% for PV1, PV2 and PV3, respectively. The protective titers of neutralizing antibodies were generally higher in children up to 14 years of age, with 74.4% (PV1), 75.6% (PV2) and 56.7% (PV3) of seroprevalence. From the age of 11 years, most of the study subjects were seronegative for PV3. CONCLUSIONS: In a polio-free country with strong migration pressures, such as Italy, our results bring clear support to the recent recommendation of Italian health authorities to introduce a fifth dose of IPV vaccine in adolescence all over the country.

Clinical and economic impact of herpes zoster vaccination in elderly in Italy.

Herpes zoster (HZ) is a very relevant pathology among elderly people (≥ 60 years of age), with a considerable disease burden and loss of quality of life. In the last years a new vaccine against HZ became available in Italy. Therefore, the Italian decision makers are now confronted with the decision whether that vaccination should be implemented. Pharmaco-economic analyses represent useful tools to value the feasibility of new immunization programs and their sustainability. To this aim, an ad hoc population model was developed in order to value the clinical and economic impact of HZ vaccination program for the elderly in Italy. Particularly, different immunization scenarios were modeled: vaccination of 60 years-old subjects (single cohort strategy), simultaneous vaccination of people aged 60 and 65 years (double cohort strategy) and, lastly, immunization of people aged 60, 65 and 70 years (triple cohort strategy), thus leading to the vaccination of 5, 10 and 15 cohorts during the first 5 years of the program. The mathematical model valued the clinical impact of vaccination on the number of HZ, post-herpetic neuralgia (PHN) and ophthalmic HZ. The results of the analysis show that, in Italy, a cohort-based HZ vaccination program in elderly could have a relevant impact on the reduction of clinical cases and a favorable economic profile for the National Health Service (NHS), as already foreseen in other countries. In addition, further benefits could be obtained when extending the study period beyond the 5-year horizon of our analysis.

Strategies and actions of multi-purpose health communication on vaccine preventable infectious diseases in order to increase vaccination coverage in the population: The ESCULAPIO project.

The ESCULAPIO Project aims at increasing awareness on vaccine preventable infectious diseases (VPID) and vaccinations in different target populations and to spread the culture of prevention. Information/training interventions on VPID have been developed and health promotion activities for the general population, students and their parents, teachers and health care workers (HCWs) were set up. In Tuscany, educational courses on VPID in high schools were organized and students were stimulated to prepare informative materials on VPID for lower grade school pupils. In Liguria, an educational card game (named 'Vaccine at the Fair') was presented to children of primary schools. Stands in shopping centers were used in Palermo to distribute the regional vaccination schedule and gadgets, also providing indications on reliable websites where to find correct information on vaccinations. A music video played by health care workers (HCWs) was created and used in the University Hospital of Cagliari to promote the anti-flu vaccination campaign in HCWs. In Apulia, meetings with the general population were organized to collect controversial issues about vaccinations and a national call center was launched to create a direct line from the general population to experts in vaccines and vaccination strategies. In Veneto, meetings in the birth centers and home visits for subjects refusing vaccination have been organized. All activities are useful and effective tools to increase knowledge about VPID and confidence in vaccination, which are crucial aspects in order to increase vaccine uptake. The project was funded by the Italian Ministry of Health, Center for Disease Prevention and Control (CCM) in 2013.

Alkylphenol polyethoxylate removal in a pilot-scale reed bed and phenotypic characterization of the aerobic heterotrophic community.

The removal of the non-ionic surfactant Triton X-100, dosed at 30 and 300 mg/L in a pilot-scale subsurface horizontal flow reed bed, and the aerobic heterotrophic cultivable community associated with the roots and with the substrate gravel in both absence and presence of Triton X-100 were investigated. t-Octylphenol (OP) and its mono-, di- and tri-ethoxyl derivatives, among others, were found in the outlet. A mass balance allowed us to calculate that approximately 40% of the Triton X-100 metabolites OP and octylphenol polyethoxylate derivatives flowed out of the reed bed during the dosage and postdosage experiments. More aerobic heterotrophic microorganisms adhered to the roots than to the gravel. The appearance of new strains (Aeromonas, Flavobacterium, and Aquaspirillum) and the increased presence of others (Pseudomonas) during the dosage of Triton may be linked to the capacity of these bacteria to adapt to the presence of the surfactant or to use it as a nourishment.

The burden of disease of Herpes Zoster in Tuscany.

Herpes zoster (HZ) is a disease caused by the reactivation of the latent α-herpes virus varicella zoster virus (VZV), for which, in Italy, a specific surveillance system does not exist, but around 200 000 cases are estimated each year. In older patients, who are at increased risk of developing HZ, symptoms are more severe and the chances to develop postherpetic neuralgia (PHN), the most severe complication, are substantially higher. A vaccine against HZ with demonstrated efficacy and an acceptable safety profile is now available and is recommended in Europe for adults >50 years.   In anticipation of the possible introduction of an immunization programme for the elderly in Tuscany, the burden of disease caused by HZ and its complications was assessed through a retrospective analysis of the hospital discharge records between 2002 and 2012, using the ICD-9-CM 053 code. In the period 2002-2012, 4475 hospital admissions were registered with annual means of 368 hospitalizations and 39 day-hospital admissions. Most of the hospitalizations (68%) involved subjects > 65 years; the mean length of stay was 9.5 days. Slightly more than half (51.2%) of total hospital admissions were complicated cases. The most frequent were neurological complications (24.2% of total admissions), followed by ophthalmic complications (16.5%). Cases with neurological complications were those with the higher average length of stay and higher average costs for case. This study confirmed the epidemiological impact of HZ and its complications and the positive impact on morbidity that the introduction of the HZ vaccination could have in older age groups.

A retrospective analysis of hospital discharge records for S. pneumoniae diseases in the elderly population of Florence, Italy, 2010-2012.

Invasive pneumococcal diseases (IPD) and community acquired pneumonia (CAP) represent two of the major causes of out-patient visits, hospital admissions and deaths in the elderly. In Tuscany (Italy), in the Local Health Unit of Florence, a project aimed at implementing an active surveillance of pneumococcal diseases in the hospitalized elderly population started in 2013. The aim of this study is to show the results of the retrospective analysis (2010-2012) on hospital discharge records (HDRs) related to diseases potentially due to S. pneumoniae, using a selection of ICD9-CM codes. All ordinary hospitalizations (primary and secondary diagnoses) of the elderly population were included (11 245 HDRs). Among a population of about 200 000 inhabitants ≥65 y, the hospitalization rate (HR) increased with increasing age and was higher in males in all age groups. Almost all hospitalizations (95%) were due to CAP, only 5% were invasive diseases. Only few cases of CAP were specified as related to S. pneumoniae, the percentage was higher in case of meningitis (100%) or septicemia (22%). In-hospital deaths over the three-year period were 1703 (case fatality rate: 15%). The risk of dying, being hospitalized for a disease potentially attributable to pneumococcus (as primary diagnosis) increased significantly with age (P < 0.001), the odds ratio (OR) per increasing age year was 1.06 (95% CI 1.05-1.07) and was higher in patients with co-existing medical conditions with respect to patients without comorbidities. Currently, an active surveillance system on S. pneumoniae diseases with the inclusion of bio-molecular tests (RT-PCR), is a key step to assess the effectiveness of the PCV13 vaccine (13-valent pneumococcal conjugate vaccine) in the elderly population after implementation of vaccination policies. The results of this study will provide the comparator baseline data for the evaluation of a possible immunization programme involving one or more cohorts of the elderly in Tuscany.