Perception and Awareness about Monkeypox and Vaccination Acceptance in an At-Risk Population in Brescia, Italy: An Investigative Survey.

Before 2022, monkeypox virus (Mpox) infection in humans was seldom reported outside Africa. During the May 2022 outbreak, most cases were detected among men who have sex with men (MSM). Since Mpox is largely unknown to the general population, through a self-completion questionnaire, we investigated the behaviours and knowledge of our at-risk population belonging to the sexually transmitted infection (STI) outpatient clinic of the Infectious Diseases Unit of the ASST Spedali Civili of Brescia, Italy, between August and October 2022. Most patients that took part in the compilation are HIV positive MSM. The other participants were HIV-seronegative patients with other STIs. Overall, 144 questionnaires were compiled. Most of the participants were Italians (130;90%) and males (139;96.5%) between 30 and 60 years (118;82%). Almost all (136;94%) reported having heard about Mpox and more than half (80;56%) received information about the transmission. Twenty-four respondents (16%) received information from health professionals and 14 (10%) believed that the information received was complete. Although 41% of respondents thought they were at risk of getting the infection and 62% were afraid to get it, the majority (56%) did not increase the precautions taken. When asked if they would accept a vaccine to prevent the disease, more than a third (32%) of respondents expressed hesitation or complete refusal to be vaccinated. Based on our results, what emerges is that there is still a lack of knowledge and awareness about Mpox. To address this issue, targeted health promotion and education strategies that provide the necessary resources to reduce risk behaviours and enhance connections with healthcare professionals are needed.

Knowledge and Attitudes towards HIV and HCV among the Population Attending the Fast-Track Cities Mobile Unit in Brescia, Italy.

The Infectious and Tropical Diseases Department of the University of Brescia organized free rapid screening tests for HIV and HCV as part of the Fast-Track City commitment. A cross-sectional study was conducted, consisting of an anonymous multiple-choice questionnaire that was administered to individuals who underwent the screening or consultation. The study aimed to compare knowledge and attitudes towards HIV and HCV between age groups (18-40 vs. >40) and sexual orientations (heterosexual vs. LGBTQ+). Overall, 333 questionnaires were completed. Overall, only 107 (32%) of respondents knew how HIV is transmitted. Major differences were shown between different age groups, where people under the age of 40 had a significantly higher correct response rate than people over 40 (n = 101; 39% versus n = 6; 7.8%, p < 0.00001). Similarly, almost half of LGBTQI+ people (n = 28; 44.4%) gave the correct answer, versus 30% (n = 79) of heterosexuals (p = 0.0359). Only 9.6% of the population demonstrated high levels of knowledge for both HIV and HCV. Our study highlights that misconceptions about HIV and HCV should be addressed in prevention and education programs, whose target should also be specific populations.

Screening for Tuberculosis Infection among Migrants: A Cost-Effectiveness Analysis in the Italian Context.

BACKGROUND: Screening of tuberculosis infection (TBI) among migrants from high-incidence countries is a cornerstone of tuberculosis control in low-incidence countries. However, the optimal screening strategy has not been defined yet. METHODS: A quasi-experimental study involving migrants residing in the province of Brescia was carried out that aimed at assessing the completion rate, time to completion, preventive treatment initiation rate, and cost-effectiveness of two strategies for TBI screening. They underwent TBI screening with the IGRA-only strategy (arm 1) or with the sequential strategy (tuberculin skin test, TST, followed by IGRA in case of a positive result-arm 2). The two strategies were compared in terms of screening completion, time to complete the screening process, therapy initiation, and cost-effectiveness. RESULTS: Between May 2019 and May 2022, 657 migrants were evaluated, and 599 subjects were included in the study, with 358 assigned to arm 1 and 237 to arm 2. Screening strategy was the only factor associated with screening completion in a multivariable analysis, with the subjects assigned to the IGRA-only strategy more likely to complete the screening cascade (n = 328, 91.6% vs. n = 202, 85.2%, IRR 1.08, 95% CI (1.01-1.14), p = 0.019). The time to complete the screening process was significantly longer for patients assigned to the sequential strategy arm (74 days vs. 46 days, p = 0.002). Therapy initiation did not significantly differ between the two arms, and cost-effectiveness was higher for the sequential strategy. CONCLUSION: Sequential strategy implementation for TBI screening among migrants may be justified by its higher cost-effectiveness in spite of the lower completion of the screening cascade.

Fragmentation of Healthcare Services as a Possible Determinant of the Low Completion for the Tuberculosis Cascade of Prevention among Asylum Seekers: Results from a Prospective Study with Historical Comparison.

Background: Effective screening for tuberculosis infection (TBI) among asylum seekers (AS) is crucial for tuberculosis (TB) elimination in low incidence countries. Methods: We assessed the proportion of completion of the screening for TBI among asylum seekers with a centralized delivery method compared to the decentralized model previously adopted in the study area (historical control). In the historical model (January 2017 to May 2018) screening of AS was performed at the arrival offering TBI testing (TST followed by IGRA among those positive), radiological investigation, treatment initiation and hospital referral, if needed, at three sites: migrant health clinic, pneumology clinic and infectious diseases department for active disease (decentralized model). In the study model (June 2018, centralized) all steps of screening were performed at a single site, at a minimum of 6 months after arrival. Multivariable Poisson regression analysis, with robust variance, was used to assess variables associated with the completion of screening for infection. Multivariable logistic regression was used to identify factors associated with the diagnosis of TB infection. Results: The intervention approach was offered to 144 AS with an overall 98.6% proportion of completion (98.7% for those with a positive TST). In the historical screening model, 1192 AS were candidates for screening, which was completed by 74.5% of those who started it (44.7% for those resulted TST positive). Major losses (55%) were detected in the TST/CXR-IGRA sequential step, followed by the execution of TST test (25%). The ratio of screening completion was significantly higher in the intervention period (aIRR 1.78, 95% CI 1.68-1.88) and for AS coming from high incidence TB countries (aIRR 1.14, 95% CI 1.04-1.25). Screening after 6 months from arrival and age were associated with TB infection (2.09, 95% CI 1.36-3.2 and 1.14, 95% CI 1.01-1.29). Conclusions: Screening for TBI can be improved by a centralized approach. Higher prevalence of TBI 6 months after arrival could reflect recent (either during travel or in Italy) acquisition of the infection.

"Immuni" and the National Health System: Lessons Learnt from the COVID-19 Digital Contact Tracing in Italy.

Since the early stage of the current pandemic, digital contact tracing (DCT) through mobile phone apps, called "Immuni", has been introduced to complement manual contact tracing in Italy. Until 31 December 2021, Immuni identified 44,880 COVID-19 cases, which corresponds to less than 1% of total COVID-19 cases reported in Italy in the same period (5,886,411). Overall, Immuni generated 143,956 notifications. Although the initial download of the Immuni app represented an early interest in the new tool, Immuni has had little adoption across the Italian population, and the recent increase in its download is likely to be related to the mandatory Green Pass certification for conducting most daily activities that can be obtained via the application. Therefore, Immuni failed as a support tool for the contact tracing system. Other European experiences seem to show similar limitations in the use of DTC, leaving open questions about its effectiveness, although in theory, contact tracing could allow useful means of "proximity tracking".

The impact of COVID-19 on communicable and non-communicable diseases in Africa: a narrative review.

The global pandemic of coronavirus disease 2019 (COVID-19) has disproportionately impacted global human health, economy, and security. Because of weaker health-care systems, existing comorbidities burden (HIV, malaria, tuberculosis, and non-communicable conditions), and poor socioeconomic determinants, initial predictive models had forecast a disastrous impact of COVID-19 in Africa in terms of transmission, severity, and deaths. Nonetheless, current epidemiological data seem not to have matched expectations, showing lower SARS-CoV-2 infection and fatality rates compared to Europe, the Americas and Asia. However, only few studies were conducted in low- and middle-income African settings where high poverty and limited access to health services worsen underlying health conditions, including endemic chronic infectious diseases such as HIV and tuberculosis. Furthermore, limited, and heterogeneous research was conducted to evaluate the indirect impact of the pandemic on general health services and on major diseases across African countries. International mitigation measures, such as resource reallocation, lockdowns, social restrictions, and fear from the population have had multi-sectoral impacts on various aspects of everyday life, that shaped the general health response. Despite the vast heterogeneity of data across African countries, available evidence suggests that the COVID-19 pandemic has severely impacted the control and prevention programs, the diagnosis capacity and the adherence to treatment of major infectious diseases (HIV, TB, and Malaria) - including neglected diseases - and non-communicable diseases. Future research and efforts are essential to deeply assess the medium- and long-term impact of the pandemic, and to implement tailored interventions to mitigate the standstill on decades of improvement on public health programs.

Tuberculosis trend among native and foreign-born people over a 17 year period (2004-2020) in a large province in Northern Italy.

Tuberculosis (TB) incidence should decline by 20% in the Europe in 2015-2020, in line with End-TB milestones. We retrospectively evaluated TB notifications in the province of Brescia from 2004 to 2020. Cases were classified per patient origin and entitlement to Health Assistance for foreign born people: Italians (ITA), Foreigners permanently entitled (PEF) or Temporarily Entitled (TEF) to Health Regional Assistance. Poisson regression analysis was performed to assess associations between incidence and age, sex, continent of origin and year of notification. Overall 2279 TB cases were notified: 1290 (56.6%) in PEF, 700 (30.7%) in ITA and 289 (12.7%) in TEF. Notifications declined from 15.2/100,000 in 2004 to 6.9/100,000 in 2020 (54.6% reduction, temporary increase in 2013-2018 for TEF). Age (Incidence Risk Ratio, IRR, 1.02, 1.019-1.024 95%CI), sex (IRR 1.22, 1.12-1.34 95%CI), and continent of origin were positively associated with notifications (IRR 34.8, 30.8-39.2 95%CI for Asiatic, and IRR 20.6, 18.1-23.4 95%CI for African origin), p < 0.001. Notification decline was sharper in 2020, especially among TEF. End-TB milestone for 2020 was reached, but foreigners continue to represent a high risk group for the disease. Discontinuation of services due to the COVID-19 pandemic was associated with a sharp decrease in TB notification in 2020.

Importance of mitigation measures for hospital transmission of SARS-CoV-2 at the onset of the epidemic: the experience of Brescia, Northern Italy.

PURPOSE: Since the first Italian case of SARS-CoV-2 was detected in Lombardy (Northern Italy)  Italy quickly became one of the worst-affected European countries, with a severe impact on health-care workers (HCWs). In the first epidemic, HCWs accounted for 12% of all national COVID-19 cases. We evaluated the burden of COVID-19 among HCWs and other non-health-care workers (nHCWs) in a large Italian hospital. METHODS: From March 1st to May 31st 2020, we performed a retrospective study at ASST Civil Hospital, in the Province of Brescia, Lombardy. The study population included all hospital personnel (n = 9265), categorized by professional status. RESULTS: A SARS-CoV-2 test was performed in 3572 workers (38.5%), with a positive result in 552 (5.9% of all hospital personnel). The temporal trend of SARS-CoV-2 cases in hospital staff broadly reflected that in the community, with a great majority of infections occurred during March 2020 (87.7%). From April onward, a steep decrease of positive cases was observed among hospital personnel, while in the community the decrease was much slower. Medical doctors (8.9%) and nurses (8.5%) were the most affected professional categories with a significantly higher risk of SARS-CoV-2 infection (OR 1.436 and OR 1.410, respectively p < 0.0001). HCWs in COVID-19 units presented a significantly higher risk of infection compared to HCWs in non-COVID units (p < 0.001). CONCLUSION: HCWs were severely affected by the COVID-19 epidemic, probably associated with an overwhelming burden of work and lack of preparedness in prevention of nosocomial transmission of the infection. The rapid decrease of COVID-19 spread in the hospital, registered before the one in the community, suggests that the adopted preventive measures were effective.

The Traffic Light Approach: Indicators and Algorithms to Identify Covid-19 Epidemic Risk Across Italian Regions.

With the beginning of the autumn-winter season, Italy experienced an increase of SARS-CoV-2 cases, requiring the Government to adopt new restrictive measures. The national surveillance system in place defines 21 key process and performance indicators addressing for each Region/Autonomous Province: (i) the monitoring capacity, (ii) the degree of diagnostic capability, investigation and contact tracing, and (iii) the characteristics of the transmission dynamics as well as the resilience of health services. Overall, the traffic light approach shows a collective effort by the Italian Government to define strategies to both contain the spread of COVID-19 and to minimize the economic and social impact of the epidemic. Nonetheless, on what principles color-labeled risk levels are assigned on a regional level, it remains rather unclear or difficult to track.

Face Masks for All and All for Face Masks in the COVID-19 Pandemic: Community Level Production to Face the Global Shortage and Shorten the Epidemic.

The current coronavirus disease 2019 (COVID-19) pandemic caused a global shortage of medical masks, leaving most exposed health personnel without appropriate protection.Since the beginning of the outbreak, the World Health Organization WHO) has revised several times the recommendations on general use of facemasks. Until recently, WHO recommended to limit the use of facemasks to symptomatic people and advised against off-standard solutions. Moreover, recommendations differ among and within countries, causing public confusion and individual initiative.There is wide consensus that universal appropriate use of masks may contribute both to contain the epidemic and to reduce the burden on national procurement, if a community production approach is followed. Especially in low-middle income countries, due to the scarce capacity of national industrial production or import, the use of masks produced at community level may become the only viable option. For the purpose ad hoc guidelines will be needed.Current knowledge and experience call for further and updated review of global and national guidelines to provide clear and consistent criteria to ensure the widest availability and appropriate use of facial protection, bearing in mind populations in socio-economic disadvantaged settings.

Consequences of the COVID-19 pandemic on the continuum of care in a cohort of people living with HIV followed in a single center of Northern Italy.

INTRODUCTION: During the COVID-19 pandemic, hospitals faced increasing pressure, where people living with HIV risked to either acquire SARS-CoV-2 and to interrupt the HIV continuum of care. METHODS: This is a retrospective, observational study. We compared the numbers of medical visits performed, antiretroviral drugs dispensed and the number of new HIV diagnosis and of hospitalizations in a cohort of people living with HIV (PLWH) followed by the Spedali Civili of Brescia between the bimester of the COVID-19 pandemic peak and the bimester of October-November 2019. Data were retrieved from administrative files and from paper and electronic clinical charts. Categorical variables were described using frequencies and percentages, while continuous variables were described using mean, median, and interquartile range (IQR) values. Means for continuous variables were compared using Student's t-tests and the Mann-Whitney test. Proportions for categorical variables were compared using the χ2 test. RESULTS: As of December 31st, 2019, a total of 3875 PLWH were followed in our clinic. Mean age was 51.4 ± 13 years old, where 28% were females and 18.8% non-Italian. Overall, 98.9% were on ART (n = 3834), 93% were viro-suppressed. A total of 1217 and 1162 patients had their visit scheduled at our out-patient HIV clinic during the two bimesters of 2019 and 2020, respectively. Comparing the two periods, we observed a raise of missed visits from 5 to 8% (p < 0.01), a reduction in the number of new HIV diagnosis from 6.4 in 2019 to 2.5 per month in 2020 (p = 0.01), a drop in ART dispensation and an increase of hospitalized HIV patients due to COVID-19. ART regimens including protease inhibitors (PIs) had a smaller average drop than ART not including PIs (16.6 vs 21.6%, p < 0.05). Whether this may be due to the perception of a possible efficacy of PIs on COVID19 is not known. CONCLUSIONS: Our experience highlights the importance of a resilient healthcare system and the need to implement new strategies in order to guarantee the continuum of HIV care even in the context of emergency.

Hazard Prevention, Death and Dignity During COVID-19 Pandemic in Italy.

On 9 March 2020, Italy passed the Prime Minister's Decree n. 648, establishing urgent measures to contain the transmission of COVID-19 and prevent biological hazards, including very restrictive interventions on public Holy Masses and funerals. Italy banned burial procedures based (i) on the recent acknowledgment about the virus environmental stability as well as (ii) its national civil contingency plan. Hence, only the cremation process is admitted for COVID-19 deaths. Viewing of the body is permitted only for mourners, which are allowed to perform the prayer at the closing of the coffin and the prayer at the tomb (cf. Rite of Succession, first part n. 3 and n. 5). The dead cannot be buried in their personal clothes; however, priests have been authorized to put the family clothes on top of the corpse, as if they were dressed. Burying personal items is also illegal. The dignity of the dead, their cultural and religious traditions, and their families should be always respected and protected. Among all the threats, COVID-19 epidemic in Italy revealed the fragility of human beings under enforced isolation and, for the first time, the painful deprivation of families to accompany their loved ones to the last farewell. Ethics poses new challenges in times of epidemics.