From Prioritization to Universal Treatment: Successes and Challenges of Hepatitis C Virus Elimination in Italy.

Italy has had the highest prevalence of hepatitis C virus (HCV) infection and mortality from HCV-related liver cancer in Europe. Although direct-acting antivirals (DAA) were initially restricted to persons with advanced fibrosis, their use has since been extended to all infected individuals; more than 244 000 persons have been treated to date. HCV liver-related mortality is expected to decline by 75% by 2030, achieving the World Health Organization target for mortality. However, Italy risks failing to meet the overall goal of eliminating HCV infection by 2030. In this light, €71.5 million have been allocated for screening initially specific target populations (persons who inject drugs, prison inmates, and the 1969-1989 birth cohort). Herein, we outline the challenges and recommendations for how to move Italy toward HCV elimination, including expanding screening programs in other populations, increasing awareness through strategic communication, sustaining DAA access, and tailoring care models to meet the needs of key populations.

An outbreak of chickenpox in an asylum seeker centre in Italy: outbreak investigation and validity of reported chickenpox history, December 2015-May 2016.

An outbreak of chickenpox occurred between December 2015 and May 2016 among asylum seekers in a reception centre in Latium, Italy. We describe the epidemiological and laboratory investigations, control measures and validity of reported history of chickenpox infection. Serological screening of all residents and incoming asylum seekers was performed, followed by vaccine offer to all susceptible individuals without contraindication. Forty-six cases were found and 41 were associated with the outbreak. No complications, hospitalisations or deaths occurred. Serological testing was performed in 1,278 individuals and 169 were found to be susceptible, with a seroprevalence of 86.8%. A questionnaire was administered to 336 individuals consecutively attending the CARA health post to collect their serological result. The sensitivity, specificity and the positive and negative predictive value (PPV and NPV) of the reported history of chickenpox were 45.0%, 76.1%, 88.3% and 25.6%, respectively. We observed an increasing trend for the PPV and decreasing trend for the NPV with increasing age. Our report confirms that, in the asylum seeker population, chickenpox history is not the optimal method to identify susceptible individuals. Our experience supports the need for additional prevention and control measures and highlights the importance of national and local surveillance systems for reception centres.

Percentage and determinants of missed HIV testing in pregnancy: a survey of women delivering in the Lazio region, Italy.

HIV testing is recommended as part of routine preconception and prenatal care but some cases of vertical transmission still occur because of missed HIV testing in pregnancy. We estimated the percentage of women missing HIV testing before delivery, and we evaluated factors related with it. An anonymous survey was distributed to women giving birth during a two-week period in the maternity units of hospitals in the Lazio region of Italy in 2011. Among the 1568 women who filled out the questionnaire, only 33.6% had an HIV test prior to conception, while 88.2% were tested during pregnancy; main reasons reported for missed testing were: not requested by the gynaecologist (57.0%), performed previously (20.7%), requested by the gynaecologist but not done (13.3%) and structural/organisational barriers (4.4%). The percentage of women who missed the HIV test as part of preconception care or during pregnancy was 9.1% (95% confidence interval, CI: 7.7-10.6). Multivariate analysis showed that those with missed test were younger (p = 0.05), of lower education level (p < 0.01), with a lower HIV-knowledge score (p < 0.01) and with fewer visits during pregnancy (p < 0.01). Around 10% of delivering women were not tested for HIV during pregnancy or as part of preconception care. Absence of a specific request by the gynaecologist was the most frequent reason given. The association of missed HIV testing with poor sociocultural level and limited maternal HIV knowledge emphasise the importance of promoting HIV information among women and prenatal care providers. Strategies to increase routine testing may include the adoption of an opt-out approach. Finally, availability of rapid HIV testing in the delivery room should be encouraged.

Healthy diet to prevent cardiovascular diseases and osteoporosis: the experience of the 'ProSa' project.

The ProSa (PROmozione e tutela della SAlute) Project ('Health Promotion Project') is a workplace programme geared to promote health among the Roman staff of the National Research Council of Italy. 789 employees of both genders (450 men, 339 women) have participated in the cardiovascular prevention programme (screening, computerized calculation of the risk level, dietary and pharmacological intervention) and 245 women have participated in the osteoporosis programme (calcaneal ultrasonometer test, dietary and pharmacological intervention). Menopause increases the risk of cardiovascular diseases and osteoporosis. In order to lower dietary fat content, dietary intake of calcium and vitamin D could be reduced. However, supplementation of both may not be necessary if we follow an integrated dietary approach. Therefore, for women in menopause with mixed hyperlipidaemia (hypercholesterolaemia and/or hypertriglyceridaemia) and/or overweight/obesity, dietary intervention was aimed at promoting the choice of foods low in fats and rich in calcium based on a list of recommended products distributed to all the participants. The dietary intervention was accompanied by a programme of regular physical activity with adequate exposure to sunlight. By following a balanced diet it is possible to improve the prognosis not only for hyperlipidaemic patients, but also for patients with signs of osteopaenia or osteoporosis.

Survey of determinants and effects of timing of referral to a nephrologist: the patient's point of view.

INTRODUCTION: We conducted a survey interviewing end-stage renal disease (ESRD) patients just after they began chronic dialysis (CD) to describe characteristics and factors associated with early (ER) and late referral (LR), and to analyze the consequences of timing of referral to a nephrologist. METHODS: We interviewed 673 patients via telephone starting CD between 2004 and 2006 in Lazio, Italy, to collect information about the year before CD. Multiple logistic regression was performed to evaluate the factors associated with LR. RESULTS: We found that 22% of patients reported being LRs. A lower probability for LR was found for older age, family history of renal diseases, abnormal test for renal functions, presence of hypertension, married status and awareness of a nephrology outpatient center near home. LR patients had a lower frequency of hepatitis B virus (HBV) vaccination (14.9% vs. 41.7%), arteriovenous fistula (31.8% vs. 75.6%) and information about renal replacement therapy modalities (33.8% vs. 72.6%), and they more often started CD in an emergency (85.8% vs. 41.5%). CONCLUSIONS: The percentage of self-reported LR was lower than reported in other studies. However, many patients started CD in an emergency, with a catheter as first vascular access, without vaccination against HBV and without the possibility of choosing their dialysis modality. Individual conditions facilitating contact with medical care (older age and presence of comorbidities) seem to be associated with a lower probability of LR. These findings emphasize the importance of predialysis patient training, confirming the important role that information plays in health service access, to improve early and long-term dialysis outcomes.

[Feasibility of colorectal cancer screening with fecal occult blood test distributed by public pharmacies]. / Studio di fattibilità per lo screening del cancro del colon retto con sangue occulto fecale, mediante le farmacie comunali.

We conducted a colorectal cancer (CRC) screening program, in which public pharmacies provided the faecal occult blood test (FOBT), addressed to 50-70 years residents of 12th Municipality of Rome. A total of 5003 subjects were invited and 1103 (22.0%) performed the screening test, the adjusted compliance was 24.0%. Among 72 (6.5%) FOBT-positive subjects, 50 (69.5%) had colonoscopies; a CRC was detected in 5 subjects. Screening through the public pharmacies was feasible but the limited number of pharmacies enrolled have influenced compliance. A screening model that offers multiple providers (including private pharmacies) should be tested in order to improve screening compliance.

Epidemiology and costs of cervical cancer screening and cervical dysplasia in Italy.

BACKGROUND: We estimated the number of women undergoing cervical cancer screening annually in Italy, the rates of cervical abnormalities detected, and the costs of screening and management of abnormalities. METHODS: The annual number of screened women was estimated from National Health Interview data. Data from the Italian Group for Cervical Cancer Screening were used to estimate the number of positive, negative and unsatisfactory Pap smears. The incidence of CIN (cervical intra-epithelial neoplasia) was estimated from the Emilia Romagna Cancer Registry. Patterns of follow-up and treatment costs were estimated using a typical disease management approach based on national guidelines and data from the Italian Group for Cervical Cancer Screening. Treatment unit costs were obtained from Italian National Health Service and Hospital Information System of the Lazio Region. RESULTS: An estimated 6.4 million women aged 25-69 years undergo screening annually in Italy (1.2 million and 5.2 million through organized and opportunistic screening programs, respectively). Approximately 2.4% of tests have positive findings. There are approximately 21,000 cases of CIN1 and 7,000-17,000 cases of CIN2/3. Estimated costs to the healthcare service amount to 158.5 million euro for screening and 22.9 million euro for the management of cervical abnormalities. CONCLUSION: Although some cervical abnormalities might have been underestimated, the total annual cost of cervical cancer prevention in Italy is approximately 181.5 million euro, of which 87% is attributable to screening.

Ageing of patients on chronic dialysis: effects on mortality--a 12-year study.

BACKGROUND: During the last few decades the mean age of subjects on chronic dialysis (CD) significantly increased. The effects of these changes on mortality rates, causes of death, early and long-term predictors for mortality have not yet been clarified. We analysed this issue through a study performed over a period of 12 years. METHODS: We studied 8977 patients enrolled on the Lazio Dialysis Registry (Italy) in 1995-2006. We analysed annual mortality rates, causes of death, probability and determinants of the survival. RESULTS: The overall mortality rate was 14.6 deaths (95% CI: 14.2-14.9) per 100 person-years on CD, remaining essentially unchanged over the 12-year period, despite a 5-year increase in the median age. A reduction in mortality was found for patients >74 years from 29.8 (95% CI: 24.8-34.9) in 1995 to 22.5 (95% CI: 20.0-25.1) in 2006. No statistically significant differences were found over time in annual mortality rates by cause of death. The probability of survival was 0.86 1 year after starting dialysis and 0.33 after 12 years. We found a higher association between haematocrit levels, serum albumin, self-sufficiency and survival within 1 year of dialysis and between diabetes and survival after 1 year. CONCLUSIONS: The finding that the mortality rate of CD patients did not change over the last 12 years, despite concomitant and significant ageing of patients, supports the public health policy of providing CD to very old subjects. The identification of the clinical factors that predict survival underlines the role of clinicians in preventing and treating these conditions after the start of CD.

Can colorectal cancer mass-screening organization be evidence-based? Lessons from failures: the experimental and pilot phases of the Lazio program.

BACKGROUND: Screening programmes should be organized to translate theoretical efficacy into effectiveness. An evidence-based organizational model of colorectal cancer screening (CRCS) should assure feasibility and high compliance. METHODS: A multidisciplinary Working Group (WG), reviewed literature and guidelines to define evidence-based recommendations. The WG identified the need for further local studies: physicians' CRCS attitudes, the effect of test type and provider on compliance, and individual reasons for non-compliance. A survey of digestive endoscopy services was conducted. A feasibility study on a target population of 300.000 has begun. RESULTS: Based on the results of population trials and on literature review the screening strategy adopted was Faecal Occult Blood Test (FOBT) every two years for 50-74 year olds and, for positives, colonoscopy. The immunochemical test was chosen because it has 20% higher compliance than the Guaiac. GPs were chosen as the preferred provider also for higher compliance. Since we observed that distance is the major determinant of non-compliance, we choose GPs because they are the closest providers, both geographically and emotionally, to the public. The feasibility study showed several barriers: GP participation was low, there were administrative problems to involve GPs; opportunistic testing by the GPs; difficulties in access to Gastroenterology centres; difficulties in gathering colonoscopy results; little time given to screening activity by the gastroenterology centre. CONCLUSION: The feasibility study highlighted several limits of the model. Most of the barriers that emerged were consequences of organisational choices not supported by evidence. The principal limit was a lack of accountability by the participating centres.

Colorectal cancer screening: recommendations and guideline adherence by physicians from digestive endoscopy centers in the Lazio region, Italy.

INTRODUCTION: Endoscopy plays a key role in colorectal cancer screening; at the beginning of a mass screening campaign, it is important for public health officials to assess physicians' attitudes and adherence to guidelines regarding colorectal cancer screening. METHODS: In April 2004, a questionnaire was sent to all 80 digestive endoscopy centers in the Lazio region, identified by the annual census of the Italian Society of Digestive Endoscopy. The results were compared to those from a similar survey of general practitioners (GPs). RESULTS: Seventy-one centers (89%) returned the questionnaire. Only 3% of physicians said they did not recommend any colorectal cancer screening test. Colonoscopy was perceived as the most effective screening test and was the most recommended (80%). Fecal occult blood test was recommended by 61% of physicians and flexosigmoidoscopy by 11%. Endoscopy centers' physicians recommend screening more than GPs (96.9% vs. 78.3%), while they have a similar level of over-recommending (50.8% vs. 47.2%). Almost 95% of endoscopy physicians properly recommended colonoscopy after positive FOBT. CONCLUSIONS: Neither physicians at endoscopy centers nor GPs tend to follow screening guidelines. Screening programmes should not rely on a single medical specialist, but on interdisciplinary management of the disease to strengthen adherence to existing guidelines.