Trends in influenza coverage rates in five consecutive immunisation seasons in the Local Health Unit of Ferrara (North Italy).

Seasonal influenza epidemics yearly affects 5-15% of the world's population, resulting in 3-5 million serious cases and up to 650,000 deaths. Elderly, pregnant women and individuals with underlying conditions are at increased risk of complications. According to the Italian National Immunisation Prevention Plan 2017-2019, these categories benefit from free vaccination but coverage rate in Italy are below desirable levels. The study considered the coverage rate in five consecutive influenza seasons (2010/2011-2014/2015) in Local Health Unit (LHU) of Ferrara (Italy). The amount of delivered vaccinations was not constant, with a decreasing trend. Coverage rose with increasing age, but the 75% target of over-65 years old individuals immunised was never achieved. In addition to age, coverage rates varied also according to District (the area of residence within the LHU). The District with the lowest vaccination coverage was the Western District. Higher levels of immunisation were observed in South-Eastern District in the pediatric age and in North-Central District in adult age group with a statistically significant difference. In the considered timespan, the percentage of immunisations delivered by the General Practitioners (GPs) increased. The trend in the LHU of Ferrara was similar to regional and national data, conditioned in the 2014/2015 season by the spreading of worrying news, although unfounded, on the safety of the vaccine. The GPs were essential in ensuring vaccine uptake, growing the percentage of delivered doses and achieving as much as possible effective elderly immunisation.

Predictors of severe or lethal COVID-19, including Angiotensin Converting Enzyme inhibitors and Angiotensin II Receptor Blockers, in a sample of infected Italian citizens.

AIMS: This retrospective case-control study was aimed at identifying potential independent predictors of severe/lethal COVID-19, including the treatment with Angiotensin-Converting Enzyme inhibitors (ACEi) and/or Angiotensin II Receptor Blockers (ARBs). METHODS AND RESULTS: All adults with SARS-CoV-2 infection in two Italian provinces were followed for a median of 24 days. ARBs and/or ACEi treatments, and hypertension, diabetes, cancer, COPD, renal and major cardiovascular diseases (CVD) were extracted from clinical charts and electronic health records, up to two years before infection. The sample consisted of 1603 subjects (mean age 58.0y; 47.3% males): 454 (28.3%) had severe symptoms, 192 (12.0%) very severe or lethal disease (154 deaths; mean age 79.3 years; 70.8% hypertensive, 42.2% with CVD). The youngest deceased person aged 44 years. Among hypertensive subjects (n = 543), the proportion of those treated with ARBs or ACEi were 88.4%, 78.7% and 80.6% among patients with mild, severe and very severe/lethal disease, respectively. At multivariate analysis, no association was observed between therapy and disease severity (Adjusted OR for very severe/lethal COVID-19: 0.87; 95% CI: 0.50-1.49). Significant predictors of severe disease were older age (with AORs largely increasing after 70 years of age), male gender (AOR: 1.76; 1.40-2.23), diabetes (AOR: 1.52; 1.05-2.18), CVD (AOR: 1.88; 1.32-2.70) and COPD (AOR: 1.88; 1.11-3.20). Only gender, age and diabetes also predicted very severe/lethal disease. CONCLUSION: No association was found between COVID-19 severity and treatment with ARBs and/or ACEi, supporting the recommendation to continue medication for all patients unless otherwise advised by their physicians.

Association Between Short-Term Exposure to PM2.5 and PM10 and Mortality in Susceptible Subgroups: A Multisite Case-Crossover Analysis of Individual Effect Modifiers.

We performed a multisite study to evaluate demographic and clinical conditions as potential modifiers of the particulate matter (PM)-mortality association. We selected 228,619 natural deaths of elderly persons (ages ≥65 years) that occurred in 12 Italian cities during the period 2006-2010. Individual data on causes of death, age, sex, location of death, and preexisting chronic and acute conditions from the previous 5 years' hospitalizations were collected. City-specific conditional logistic regression models were applied within the case-crossover "time-stratified" framework, followed by random-effects meta-analysis. Particulate matter less than or equal to 2.5 µm in aerodynamic diameter (PM2.5) and particulate matter less than or equal to 10 µm in aerodynamic diameter (PM10) were positively associated with natural mortality (1.05% and 0.74% increases in mortality risk for increments of 10 µg/m3 and 14.4 µg/m3, respectively), with greater effects being seen among older people, those dying out-of-hospital or during the warm season, and those affected by 2 or more chronic diseases. Limited associations were found among persons with no previous hospital admissions. Diabetes (1.98%, 95% confidence interval (CI): 0.54, 3.44) and cardiac arrhythmia (1.65%, 95% CI: 0.37, 2.95) increased risk of PM2.5-related mortality, while heart conduction disorders increased risk of mortality related to both PM2.5 (4.22%, 95% CI: 0.15, 8.46) and PM10 (4.19%, 95% CI: 0.38, 8.14). Among acute conditions, recent hospital discharge for heart failure modified the PM10-mortality association. The study found increases in natural mortality from PM exposure among people with chronic morbidity; diabetes and cardiac disorders were the main susceptibility factors.

Asthmatic symptoms and air pollution: a panel study on children living in the Italian Po Valley.

The Po Valley (Northern Italy) has elevated levels of air-pollution due to various sources of pollution and adverse weather conditions. This study evaluates the short-term effects of exposure to particulate matter with a diameter of 10 microns or less (PM10) on asthma symptoms in school-aged children. An initial cross-sectional survey was conducted in the area to estimate asthma prevalence in children. Out of a total of 250 asthmatic children identified by the study, 69 agreed to participate in a panel study. The PM10 exposure assessment was based on a combination of geographic and environmental measurements leading to a focus on three different areas, each characterised by its own daily PM10 level. Participants were monitored daily for respiratory symptoms for eight weeks (January-March 2006). We assessed the relationship between daily PM10 exposure and occurrence of asthma symptoms with a generalised linear model based on a total of 3864 person-days of observation. Exposure to PM10 per m³ was found to be particularly associated with cough (OR=1.03, CI 95% 0.99; 1.08) and phlegm (OR=1.05, CI 95% 1.00; 1.10). In the most polluted area, exposure to PM10 was also associated with wheezing (OR=1.18, CI 95% 1.02; 1.37).

[Meta-analysis or pooled analysis? A comparison based on time-series used for the analysis of short-term effects of air pollution on human health]. / Metanalisi o analisi pooled? Un confronto basato su serie storiche per l'analisi degli effetti a breve termine dell'inquinamento atmosferico sulla salute umana.

OBJECTIVES: to compare the meta-analysis and the pooled analysis approach to study short-term effects of air pollution on human health in Emilia-Romagna Region (Central Italy) cities, characterised by strong homogeneity of environmental and sociodemographic features. METHODS: application of fixed-effects meta-analysis and fixed-effects pooled analysis on time-series data of seven cities in Emilia-Romagna in the period 2006-2010. The relationship among adverse health events (deaths due to natural causes, cardiovascular disease, cerebrovascular disease and respiratory disease) and concentrations of PM10, PM2.5 and NO2 was investigated by means of GAM models, using the EpiAir protocol. RESULTS: the pooled analysis application entailed a gain in terms of precision of effect estimates in respect to meta-analysis approach. The interval widths of pooled analysis are lower than those of meta-analytic estimates, with percentage reductions between 7% and 43%. This power increase led to a major number of statistically significant pooled analysis estimates. It has been a generally good correspondence between the two methods in terms of direction and strength of the association among health outcomes and the various pollutants. An exception is the PM10 effect estimate on respiratory mortality, where the meta-analytic estimate was significantly higher and not in line with literature data. CONCLUSIONS: the study highlighted the increase in accuracy and stability of effect estimates obtained from a pooled analysis compared to a meta-analysis in a regional context such as the Emilia-Romagna Region, characterised by the absence of heterogeneity in exposure to pollutants and other confounders. In this context, the pooled approach is to be considered preferable to meta-analysis.

Cohort study of residents of a district with soil and groundwater industrial waste contamination.

INTRODUCTION: A neighbourhood of the city of Ferrara (Italy) was built over an area polluted with chlorinated organic compounds. A residential cohort study was performed to assess the health profile of the population living in the polluted area. METHODS: The residential history of 3475 subjects who had lived in the East quadrant neighbourhood in the period 1994-2010 was constructed. Mortality for the period 1994- 2010 and cancer incidence for the years 1994-2007 were studied. Standardised mortality ratios (SMR) for 2632 subjects and standardised incidence ratios (SIR) for 2578 subjects who had lived for at least 5 years in the area under study were calculated. Indicators were calculated for males and females combined, using the population of Ferrara as reference population. RESULTS: The health profile of the population of the East quadrant neighbourhood, defined using mortality indicators for major groups of causes, is essentially similar to that of the city of Ferrara. Increased mortality rates for lung cancer (SMR 131, 90% CI 94-178) and incidence rates for some cancer sites, including liver (SIR 135, 90% CI 67-243) were observed, albeit on the basis of few cases and with wide confidence intervals. DISCUSSION: The likelihood of observing significant increases in risk is reduced by the sizes of the cohorts and the short follow-up period, but some findings nonetheless suggest that, as a precautionary measure, the cohort study should be continued in parallel with measures for the reclamation of the site and that this study should take the form of epidemiological surveillance.

[Air pollution and urgent hospital admissions in 25 Italian cities: results from the EpiAir2 project]. / Inquinamento atmosferico e ricoveri ospedalieri urgenti in 25 città italiane: risultati del progetto EpiAir2.

OBJECTIVE: to evaluate the relationship between air pollution and hospital admissions in 25 Italian cities that took part in the EpiAir (Epidemiological surveillance of air pollution effects among Italian cities) project. DESIGN: study of time series with case-crossover methodology, with adjustment for meteorological and time-dependent variables. The association air pollution hospitalisation was analyzed in each of the 25 cities involved in the study; the overall estimates of effect were obtained subsequently by means of a meta-analysis. The pollutants considered were PM10, PM2.5 (in 13 cities only), NO2 and ozone (O3); this last pollutant restricted to the summer season (April-September). SETTING AND PARTICIPANTS: the study has analyzed 2,246,448 urgent hospital admissions for non-accidental diseases in 25 Italian cities during the period 2006- 2010; 10 out of 25 cities took part also in the first phase of the project (2001-2005). MAIN OUTCOME MEASURES: urgent hospital admissions for cardiac, cerebrovascular and respiratory diseases, for all age groups, were considered. The respiratory hospital admissions were analysed also for the 0-14-year subgroup. Percentage increases risk of hospitalization associated with increments of 10 µg/m(3) and interquartile range (IQR) of the concentration of each pollutant were calculated. RESULTS: reported results were related to an increment of 10 µg/m(3) of air pollutant. The percent increase for PM10 for cardiac causes was 0.34% at lag 0 (95%CI 0.04-0.63), for respiratory causes 0.75% at lag 0-5 (95%CI 0.25-1.25). For PM2.5, the percent increase for respiratory causes was 1.23% at lag 0- 5 (95%CI 0.58-1.88). For NO2, the percent increase for cardiac causes was 0.57% at lag 0 (95%CI 0.13-1.02); 1.29% at lag 0-5 (95%CI 0.52-2.06) for respiratory causes. Ozone (O3) did not turned out to be positively associated neither with cardiac nor with respiratory causes as noted in the previous period (2001-2005). CONCLUSION: the results of the study confirm an association between PM10, PM2.5, and NO2 on hospital admissions among 25 Italian cities. No positive associations for ozone was noted in this period.

[From research to medical advice: prescription of physical activity to 1,005 subjects with type 2 diabetes mellitus by 48 family doctors. Results]. / Dalla ricerca alla pratica medica: prescrizione di attività motoria a 1.005 soggetti con diabete mellito di tipo 2 da parte di 48 medici di famiglia. Risultati.

OBJECTIVES: to involve a group of general practitioners (GPs) in a programme for prescribing physical activity (PhA) for patients with type 2 diabetes; to document, for each patient, the amount of physical activity carried out and the modifications in biomedical variables and in the medical expenses possibly occurring after the PhA programme. SETTING AND PARTICIPANTS: 48 GPs joined the project. The beneficial effects of regular PhA on diabetes were presented to each patient enrolled. Walking daily for at least 15 minutes was suggested. A booklet with specific instructions and a step meter were given to each patient. Diet programmes were not modified. MAIN OUTCOME MEASURES: average daily PhA; values of Body Mass Index (BMI), waist circumference, systolic and diastolic blood pressure, blood glucose and HbA1c, blood cholesterol (total, LDL, HDL) and triglycerides determined before and at the end of the programme; pharmaceutical expenses attributed to the enrolled patients in 2008 (the year preceding the PhA programme) and in 2010 (the year of end of the PhA programme). RESULTS: of the 1,005 patients enrolled, 766 indicated their daily PhA. In all patients, and especially in those who presented values outside the norm in the variables considered at the start of the programme, improvements up to normalization were observed. A reduction in pharmaceutical expenses proportional to the PhA carried out was documented in the more active group of patients, who walked 1 km or more daily. CONCLUSIONS: the domiciliary PhA recommended by 48 GPs for 1,005 patients with type 2 diabetes enrolled in the programme was carried out by 766 subjects. The biomedical improvements and the reduction in pharmaceutical expenses, proportional to the PhA carried out, are in keeping with other reports in the literature. The major finding of this project is that GPs can effectively prescribe PhA to their patients who suffer form sport-sensitive diseases, such as type 2 diabetes.

Screening patterns within organized programs and survival of Italian women with invasive cervical cancer.

OBJECTIVES: To evaluate screening patterns within organized cervical screening programs (OCSPs) and survival of women with invasive cervical cancer (ICC). METHODS: A population-based study was conducted in Italian areas covered by cancer registries and OCSPs. The study included all women aged 25-65 years diagnosed with ICC between 1995 and 2008, and their screening histories within OCSPs were retrieved. Hazard ratios (HR) of death and 95% confidence intervals (CI) were computed according to screening pattern, using Cox models adjusted for age, ICC stage, and major confounders. RESULTS: Among 3268 women with ICC, 20% were never-invited to OCSP, 36% were never-compliant with OCSP's invitation, 33% were compliant and had a screen-detected ICC within OCSP (i.e., after a positive cytology), and 11% were compliant but had a non-screen-detected ICC. Screen-detected ICCs were more frequently micro-invasive (42%) compared to non-screen-detected ones (14%). Compared to women with screen-detected ICC, the adjusted HRs of death were 1.9 (95% CI 1.5-2.4) for those never-invited, 2.0 (95% CI 1.6-2.5) for never-compliant, and 1.7 (95% CI 1.3-2.4) for compliant women having non-screen-detected ICC. CONCLUSION: Prolonged survival, beyond down-staging, of women with ICC detected within OCSPs in Italy, further calls for improvements of OCSPs' invitational coverage and participation.

Assessing paediatric asthma occurrence through dispensed prescription data and questionnaires.

BACKGROUND: The prevalence of asthma, a common disorder in childhood, is often estimated by cross-sectional studies based on questionnaires, with the drawback that estimates are limited to certain age groups and areas. The use of electronic health data is increasingly allowing researchers to overcome these limitations. This study is aimed at assessing asthma occurrence of a school-aged population in Northeast Italy using two different data sources. METHODS: In 2004, a population-based survey using a standardized questionnaire was conducted to estimate asthma occurrence among a resident population of children aged 6-7 years and adolescents aged 13 years. A selection of dispensed asthma medications was extracted from electronic databases for a 4-year period prior to questionnaire completion (2000-03). Asthma prevalence was estimated by commonly used questionnaire classifications and compared with use of inhaled bronchodilators (alone or in combination) in various time periods. Correlations between the two approaches were calculated. RESULTS: A total of 10 252 subjects were eligible for analysis (85% of the resident population). A total of 4747 subjects (38% of the resident population) were registered in the drug database during 2000-03. Asthma prevalence was higher in males and in children. Congruence between the two enquiry methods varied according to criteria applied and improved with the protraction of the observation period. CONCLUSION: A longer period for the capture of medication data yielded higher congruence. A degree of mismatch was observed between the two methods most likely related to factors of drug use and questionnaire reliability. Nonetheless, the benefits of using easily accessible population data prevail, and further studies are warranted.

Epidemiological, clinical and laboratory features of chronic hepatitis B infection in a cohort of immigrant and Italian patients from Ferrara, Italy.

BACKGROUND: Italy has recently become a land of immigration. Two hundred and fifty thousand carriers are immigrants and chronic HBV infection is the prevalent form. Considering the elevated number of foreigners resident in our province and the potential risk of transmission to local people, we retrospectively investigated the patterns of chronic hepatitis B (CHB) in 154 patients (76 foreigners, 78 Italians) observed in our Institution, with regard to demographic and clinical/laboratory characteristics. RESULTS: The immigrants were younger (mean age 31 years) compared to Italians (51.5) and mainly came from East Europe. Regarding exposure to HBV, the intra-familial risk factor was most frequently observed in foreigners, compared to Italians (p = 0.03). Foreigners also showed a higher prevalence of HBeAg positive forms, HDV co-infection (7.9%) and abnormal ALT and/or HBV-DNA values, compared to Italians. HBeAg positivity was more associated with increased ALT (OR = 36.6, p = 0.001) than with elevated HBV viremia (OR = 6.5, p = 0.049); age was a protective factor (OR = 0.1; p = 0.014). No significant association was found between increased ALT and foreign nationality. The simultaneous presence of increased ALT and viremia was more frequent among foreigners, (OR = 7.6, p = 0,014) and increased with age (OR = 1.06, p = 0.013). Antiviral therapy was given in 7.8% of foreign citizens. CONCLUSION: Immigrants constitute a vulnerable population subgroup that would benefit from a more active approach regarding doctor patient relationship for early recognition of HBV and treatment programmes.

Type 1 diabetes (T1DM) in children and adolescents of immigrated families in Emilia-Romagna (Italy).

BACKGROUND AND AIM OF THE WORK: The etiology and natural history of T1DM are still unknown but certainly both genetics and environmental factors contribute to the development of the disease. Migration studies are an important tool to better understand the role of the environment. The aim of this study was to investigate some variables in diabetic children of immigrant families living in Emilia-Romagna compared with Italian diabetic children living in the same region. METHODS: We recruited 73 diabetic children from immigrant families and 707 Italian diabetic children. All children were cared by Pediatric Diabetes Units of Emilia-Romagna (10 centers). The investigated variables were: gender, current age, place of birth, parents' country of origin, age at diagnosis, HbA1c and insulin regimen. RESULTS: No significant difference with reference to gender neither among the two ethnic groups, nor in the current mean age was observed. Mean age at diagnosis in the Italian children was lower than in immigrant patients born outside Italy--group A- (7.4 vs. 9.6, p < 0.000) and higher compared to those born in Italy--group B- (7.4 vs. 5.7 p < 0.003; A vs. B p < 0.000). The immigrant patients showed higher mean HbA1c than Italian patients (8.8 vs. 8.2, p < 0.009). CONCLUSIONS: A younger age at diagnosis of T1DM in immigrant children, born in Italy compared with those born in the country of origin, and with Italian patients, suggests the existence of some environmental determinants acquired with a more westernised lifestyle. Immigrant children have significantly poorer metabolic control compared with western patients. (www.actabiomedica.it)

Poor control increases the economic cost of asthma. A multicentre population-based study.

BACKGROUND/AIMS: Up to now, few cost-of-illness (COI) studies have estimated the cost of adult asthma at an individual level on general population samples. We sought to evaluate the cost of current asthma from the societal perspective in young Italian adults and the determinants of cost variation. METHODS: In 2000, a COI study was carried out in the frame of the Italian Study on Asthma in Young Adults on 527 current asthmatics (20-44 years) screened out of 15,591 subjects from the general population in seven centres. Detailed information about direct medical expenditures (DMEs) and indirect costs due to asthma was collected at an individual level over the past 12 months. RESULTS: The mean annual cost per patient was EUR 741 (95% CI: 599-884). DMEs represented 42.8% of the total cost, whereas the remaining 57.2% was indirect costs. The largest component of DMEs was medication costs (47.3%; 23.0% was due to hospitalization). The mean annual cost per patient ranged from EUR 379 (95% CI: 216-541)for well-controlled asthmatics to EUR 1,341 (95% CI: 978-1,706) for poorly controlled cases that accounted for 46.2% of the total cost. Poor control, coexisting chronic cough and phlegm, and low socio-economic status were significantly associated with high DMEs and indirect costs. CONCLUSIONS: In Italy, asthma-related costs were substantial even in unselected patients and were largely driven by indirect costs. Since about half of the total cost was due to a limited proportion of poorly controlled asthmatics, interventions aimed at these high-cost patients could reduce the economic burden of the disease.

Are the asthma guideline goals achieved in daily practice? A population-based study on treatment adequacy and the control of asthma.

BACKGROUND: The guidelines for asthma recommend that the use of anti-inflammatory therapy should be adapted to the severity of the disease. However, few data are available to assess the adequacy of the use of drugs and its influence on the control of asthma in 'real life'. METHODS: The adequacy of the current use of anti-asthmatic medication according to the Global Initiative for Asthma (GINA) guidelines was assessed in a random sample of 400 asthmatics identified in the frame of the Italian Study on Asthma in Young Adults. Asthma severity was assessed using the GINA criteria; accordingly, a patient was classified as receiving inadequate treatment if his/her current use of drugs was lower than that suggested by the guidelines for the corresponding severity level. The absence of asthma attacks in the last 3 months was used as an indicator of the disease control. RESULTS: Fifty-five percent of the patients had persistent asthma. Overall, 48% (95% CI 41.2-54.8) of persistent asthmatics were receiving inadequate treatment, and 66% (95% CI 59.5-72.4) had not used their medication daily over the past 3 months. Persistent asthmatics who were inadequately treated had a significantly greater frequency of asthma attacks (geometric mean ratio 3.7; 95% CI 2.1-6.6) than those using an adequate dose of medication. Mild and moderate persistent asthmatics using an adequate medication regimen reported a low number of asthma attacks (median 0). At the multivariate analysis, a good control of the disease was positively associated with an adequate dose of anti-inflammatory medication (OR = 2.2; 95% CI 1.1-4.5) and was negatively associated with a later onset of asthma (OR = 0.96; 95% CI 0.93-0.99) and severe asthma (OR = 0.37; 95% CI 0.17-0.81). CONCLUSIONS: Despite the increase in the use of inhaled corticosteroids, half of the persistent asthmatics from the general population are using a medication regimen below their severity level. When the use of drugs follows the GINA guideline recommendations, a good control of asthma is also achievable in the daily management of the disease, particularly in the case of mild and moderate asthmatics.