Risk of SARS-CoV-2 infection in migrants and ethnic minorities compared with the general population in the European WHO region during the first year of the pandemic: a systematic review.

BACKGROUND: Migrants and ethnic minorities have suffered a disproportionate impact of the COVID-19 pandemic compared to the general population from different perspectives. Our aim was to assess specifically their risk of infection in the 53 countries belonging to the World Health Organization European Region, during the first year of the pandemic. METHODS: We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO CRD42021247326). We searched multiple databases for peer-reviewed literature, published on Medline, Embase, Scisearch, Biosis and Esbiobase in 2020 and preprints from PubMed up to 29/03/2021. We included cross-sectional, case-control, cohort, intervention, case-series, prevalence or ecological studies, reporting the risk of SARS-CoV-2 infection among migrants, refugees, and ethnic minorities. RESULTS: Among the 1905 records screened, 25 met our inclusion criteria and were included in the final analysis. We found that migrants and ethnic minorities during the first wave of the pandemic were at increased exposure and risk of infection and were disproportionately represented among COVID-19 cases. However, the impact of COVID-19 on minorities does not seem homogeneous, since some ethnic groups seem to be more at risk than others. Risk factors include high-risk occupations, overcrowded accommodations, geographic distribution, social deprivation, barriers to access to information concerning preventive measures (due to the language barrier or to their marginality), together with biological and genetic susceptibilities. CONCLUSIONS: Although mixed methods studies will be required to fully understand the complex interplay between the various biological, social, and cultural factors underlying these findings, the impact of structural determinants of health is evident. Our findings corroborate the need to collect migration and ethnicity-disaggregated data and contribute to advocacy for inclusive policies and programmatic actions tailored to reach migrants and ethnic minorities.

Epidemiological characteristics of COVID-19 cases in non-Italian nationals notified to the Italian surveillance system.

BACKGROUND: International literature suggests that disadvantaged groups are at higher risk of morbidity and mortality from SARS-CoV-2 infection due to poorer living/working conditions and barriers to healthcare access. Yet, to date, there is no evidence of this disproportionate impact on non-national individuals, including economic migrants, short-term travellers and refugees. METHODS: We analyzed data from the Italian surveillance system of all COVID-19 laboratory-confirmed cases tested positive from the beginning of the outbreak (20th of February) to the 19th of July 2020. We used multilevel negative-binomial regression models to compare the case fatality and the rate of admission to hospital and intensive care unit (ICU) between Italian and non-Italian nationals. The analysis was adjusted for differences in demographic characteristics, pre-existing comorbidities, and period of diagnosis. RESULTS: We analyzed 213 180 COVID-19 cases, including 15 974 (7.5%) non-Italian nationals. We found that, compared to Italian cases, non-Italian cases were diagnosed at a later date and were more likely to be hospitalized {[adjusted rate ratio (ARR)=1.39, 95% confidence interval (CI): 1.33-1.44]} and admitted to ICU (ARR=1.19, 95% CI: 1.07-1.32), with differences being more pronounced in those coming from countries with lower human development index (HDI). We also observed an increased risk of death in non-Italian cases from low-HDI countries (ARR=1.32, 95% CI: 1.01-1.75). CONCLUSIONS: A delayed diagnosis in non-Italian cases could explain their worse outcomes compared to Italian cases. Ensuring early access to diagnosis and treatment to non-Italians could facilitate the control of SARS-CoV-2 transmission and improve health outcomes in all people living in Italy, regardless of nationality.

Underreporting of congenital rubella in Italy, 2010-2014.

In accordance with the goals of the World Health Organization Regional Committee for Europe, the Italian national Measles and Rubella Elimination Plan 2010-2015 aimed to reduce the incidence of congenital rubella cases to <1 case/100,000 live births by 2015. In Italy, a passive national surveillance system for congenital rubella and rubella in pregnancy is active since 2005. We estimated the degree of underreporting of congenital rubella, performing a capture-recapture analysis of cases detected through two independent sources: the national surveillance system and the national hospital discharge database, in the years 2010-2014. We found that 6 out of 11 cases tracked in the retrospective case-finding from hospital registries had not been notified to the surveillance system, and we estimated a degree of underreporting of 53% for the period 2010-2014. This approach showed to be simple to perform, repeatable, and effective. CONCLUSION: In order to reduce underreporting, some actions aimed at strengthening surveillance procedures are needed. The adoption on a routine basis of the review of hospital discharge registries for case-finding, monthly zero-reporting, and actions to train and sensitize all the specialists involved in the care of pregnant women and the newborns to notification procedures are recommended. What is Known • In Italy, the incidence of congenital rubella was below the WHO target of 1/100,000 live births in 2005-2015, except for two peaks in 2008 and 2012 (5 and 4/100,000, respectively). • Further efforts are required to improve congenital rubella surveillance so that it is more sensitive and specific. The WHO proposes retrospective case-finding from hospital records as an alternative approach to detect infants with congenital rubella. What is New • Underreporting of congenital rubella in Italy was 53% in 2010-2014. • Hospital discharge registries resulted to be an appropriate source to detect congenital rubella cases.

[Differences in influenza vaccination coverage among subgroups of adult immigrants residing in Italy at risk for complications (2012-2013)]. / Capitolo 7: Differenze nella copertura vaccinale antinfluenzale tra sottogruppi di immigrati adulti residenti in Italia a rischio di complicanze (2012-2013).

OBJECTIVES: to evaluate differences in influenza vaccination coverage (IVC) in immigrants at risk for influenza-related complications, according to their area of origin and length of stay in Italy. DESIGN: cross-sectional survey conducted on the sample of foreign citizens included in the survey on health conditions and use of health services of the Italian resident population (Italian national institute of statistics, 2012-2013). SETTING AND PARTICIPANTS: analysis conducted on 885 foreign adult citizens (≥18 years) at risk for influenza-related complications (elderly residents ≥65 years and residents with specific chronic diseases). MAIN OUTCOME MEASURES: vaccination coverage ratios (VCR) comparison between long-term immigrants (≥10 years) and recent immigrants (<10 years), and between non-African and African immigrants, adjusted by demographic and socioeconomic characteristics and level of health services utilization. RESULTS: IVC among immigrants was 15.6%, significantly higher in long-term immigrants (18.3%) compared to recent immigrants (10.2%) (VCR: 1.79; 95%CI 1.21-2.66), and in non-African immigrants (17.1%) compared to African immigrants (9.4%) (VCR: 1.82; 95%CI 1.04-3.17). After adjusting on the basis of demographic and socioeconomic characteristics and for level of health services utilization between the compared subgroups, the difference in IVC according to the length of stay was greatly reduced (VCR: 1.41; 95%CI 0.94- 2.10), while IVC difference reduction according to area of origin was less relevant (VCR: 1.66; 95%CI 0.95-2.91). CONCLUSIONS: demographic and socioeconomic characteristics and level of health services utilization explained part of the difference in IVC between the compared subgroups, particularly between long-term and recent immigrants. The difference in IVC between African immigrants and immigrants from other areas remained quite pronounced even after adjusting on the basis of these factors. This suggests that IVC, especially in African immigrants, is affected by other informal barriers, such as cultural and linguistic barriers, that need to be addressed when planning effective immunization access strategies.

Measles in Italy: Co-circulation of B3 variants during 2014.

In 2013, the majority of the WHO/EUR countries reported an annual incidence of >1 case per one million population indicating that the elimination target is far from being met. Thus, there is the urgent need to uncover and analyze chains of measles virus (MV) transmission with the objective to identify vulnerable groups and avoid possible routes of introduction of MV variants in the European population. The analysis of molecular epidemiology of MV B3 strains identified in 2014 has shown that four different variants co-circulated in Italy, including the strain that caused a cruise-line ship outbreak at the beginning of the year.

Risk of Zika virus transmission in the Euro-Mediterranean area and the added value of building preparedness to arboviral threats from a One Health perspective.

In the alarming context of risk of Zika virus (ZIKV) transmission in the Euro-Mediterranean area, there is a need to examine whether capacities to detect, diagnose and notify ZIKV infections in the region are in place and whether ongoing capacity-building initiatives are filling existing gaps.The MediLabSecure network, created in 2014, comprises 55 laboratories of virology and medical entomology and 19 public health institutions in 19 countries in the Balkans, North-Africa, the Middle-East and the Black Sea regions. It aims to set up awareness, risk assessment, monitoring and control of emerging and re-emerging vector-borne viruses. We here examine the actions and strategies that MediLabSecure has been implementing and how they will contribute to the prevention and control of the ZIKV threat in the Euro-Mediterranean area.Capacity-building for arbovirus diagnostics is a major objective of the project and follows a methodological rather than disease-driven approach. This enables the implementation of laboratory trainings on techniques that are common to several arboviruses, including ZIKV, and putting into action appropriate diagnostic tools in the target region.Moreover, by its One Health approach and the interaction of its four sub-networks in human virology, animal virology, medical entomology and public health, MediLabSecure is fostering intersectoral collaboration, expertise and sharing of information. The resulting exchanges (methodological, communication and operational) across disciplines and across countries, dedicated research on intersectoral collaboration and increasing diagnostic capacities are providing new paths and tools to public health professionals to face emerging viral threats such as a ZIKV epidemic in the Euro-Mediterranean region.

Extensive Nosocomial Transmission of Measles Originating in Cruise Ship Passenger, Sardinia, Italy, 2014.

We report a measles outbreak in Sardinia, Italy, that originated in a cruise ship passenger. The outbreak showed extensive nosocomial transmission (44 of 80 cases). To minimize nosocomial transmission, health care facilities should ensure that susceptible health care workers are vaccinated against measles and should implement effective infection control procedures.

Exploring reasons for non-vaccination against human papillomavirus in Italy.

BACKGROUND: In Italy, free-of-charge HPV vaccination is offered to 11-year-old girls since 2007. The National Immunization Plan established the target coverage at a minimum of 70%; it should increase to 95% within 3-year time frame. In 2012, four year after the introduction of HPV vaccination, coverage was stable at 69%. We conducted a national cross-sectional study to explore barriers to vaccination in Italy. METHODS: Vaccination services selected, through the immunization registries, a sample of unvaccinated girls born in 1997 or 1998 and posted to their families a 23-items questionnaire inquiring barriers to vaccination, HPV knowledge, source of information on HPV, perception of risk of contracting HPV, advice from consulted health professionals on HPV vaccination. RESULTS: We analysed 1,738 questionnaires. Main barriers were fear of adverse events (reported by 80% of families), lack of trust in a new vaccine (76%), discordant information received by health professionals (65%) and scarce information on HPV vaccination (54%). Overall, 54% of families replied correctly to more than half of 10 questions exploring knowledge on HPV vaccination. Families with a high knowledge score were more likely to live in Northern and Central Italy, be Italian, have a high educational level, include a mother who attended cervical screening regularly and consult more information sources. Although paediatricians/general practitioners and gynaecologists were considered the most trusted source of information by 79% and 61% of respondents, they were consulted only by 49% and 31%. Among parents who discussed vaccination with a physician, 28% received discordant advices and 31% received the recommendation of accepting vaccination. CONCLUSIONS: Fear of adverse events, discordance of information and advices from physicians, and scarce information were the more commonly reported barriers to HPV vaccination. Health professionals played a key role as information providers, thus they must be better trained to provide clear notions. Training needs to include the development of communication skills; transparent discussion about the pros and cons of vaccination may reduce fear of adverse events and increase trust in vaccination. The creation of a public health network around vaccination would allow sharing information and attitudes on vaccinations, so that homogeneous messages could reach the target population.

The Opportunity Provided by Vaccination Offer to Refugees from Ukraine in European Countries.

(1) The Russian invasion of Ukraine forced many people to leave their country and seek asylum in various European countries, with serious consequences from a health perspective. In this context, we describe the health measures undertaken by AcToVax4NAM Consortium Countries (Cyprus-Germany-Greece-Italy-Malta-Poland-Romania-Spain) to prevent Vaccine-Preventable Disease (VPD) outbreaks in the context of mass movements of populations that resulted from the crisis in Ukraine. (2) We collected information on the vaccinations offered to Ukrainians in the Consortium Countries. (3) All these countries have provided Temporary Protection (TP) status to refugees from Ukraine and have followed the recommendations of European and International Agencies to offer them vaccinations according to the National Immunisation Programmes. The COVID-19 vaccination is offered in all countries with regard to the general population. Most countries provide information on TP and access to health/vaccination services in the Ukrainian language. (4) The information collected shows a common effort to ensure the adequate planning of health and vaccination services for refugees from Ukraine and, very often, to include them in the national vaccination offer. It is important that this initial response towards people who have fled Ukraine will be continued following the emergency but, more importantly, that it serves as a best practice towards all migrants and refugees entering the EU.

Exploring COVID-19 Vaccination Willingness in Italy: A Focus on Resident Foreigners and Italians Using Data from PASSI and PASSI d'Argento Surveillance Systems.

(1) The COVID-19 pandemic exacerbated health disparities, both between foreign and autochthonous populations. Italy was one of the European countries that was the most affected by the COVID-19 pandemic; however, only limited data are available on vaccine willingness. This study aims to assess the propensity of foreign and autochthonous populations residing in Italy to be vaccinated and the relative associated factors. (2) Data were collected and analysed from the two Italian surveillance systems, PASSI and PASSI d'Argento, in the period of August 2020-December 2021. The data include those of the Italian resident adult population over 18 years old. A multinomial logistic regression model, stratified by citizenship, was used to assess the associations of sociodemographic, health, and COVID-19 experience variables with vaccination attitudes. (3) This study encompassed 19,681 eligible subjects. Considering the willingness to be vaccinated, foreign residents were significantly less certain to get vaccinated (49.4% vs. 60.7% among Italians). Sociodemographic characteristics, economic difficulties, and trust in local health units emerged as factors that were significantly associated with vaccine acceptance. Having received the seasonal flu vaccine was identified as a predictor of COVID-19 vaccine acceptance among foreign and Italian residents. (4) This study underscores the significance of tailoring interventions to address vaccine hesitancy based on the diverse characteristics of foreign and Italian residents. This research offers practical insights for public health strategies, highlighting the importance of tailored educational campaigns, improved communication, and nuanced interventions to enhance vaccine acceptance and uptake within both populations.

Assessing the Adoption of One Health Approaches in National Plans to Combat Health Threats: The Pilot of a One Health Conceptual Framework in Armenia.

Due to several factors, such as environmental and climate changes, the risk of health threats originating at the human-animal-environment interface, including vector-borne diseases (VBDs) and zoonoses, is increasing. Low-resource settings struggle to counter these multidimensional risks due to their already-strained health systems and are therefore disproportionally affected by the impact caused by these changes. Systemic approaches like One Health (OH) are sought to strengthen prevention and preparedness strategies by addressing the drivers of potential threats with a multidisciplinary and multisectoral approach, considering the whole system at the human-animal-environment interface. The integration of OH in national plans can be challenging due to the lack of effective coordination and collaboration among different sectors. To support the process of knowledge coproduction about the level of OH integration in prevention and preparedness strategies against health threats in Armenia, a situation analysis was performed on Crimean-Congo hemorrhagic fever/virus and anthrax (identified by local stakeholders as priorities to be addressed with the OH approach), and actions to strengthen the national OH system were identified with the support of a OH conceptual framework. The study highlighted that multidisciplinary and multisectoral efforts towards prevention and preparedness against VBDs and zoonoses threats need to be strengthened in Armenia, and priority actions to integrate the OH approach were identified.

A cross-sectional study to estimate high-risk human papillomavirus prevalence and type distribution in Italian women aged 18-26 years.

BACKGROUND: Pre-vaccination information on HPV type-specific prevalence in target populations is essential for designing and monitoring immunization strategies for cervical cancer (CC) prevention. Data on HPV prevalence in Italy are available for women over the age of 24 years, target of the population-based CC screening programmes; while data of HPV prevalence in younger ages are very limited. The present study enrolled Italian women aged 18-26 years in order to assess the prevalence and distribution of high-risk (HR) HPV types. Risk-factors correlated with HR-HPV positivity were also described. METHODS: A sample of 2,289 women was randomly selected from the resident population lists of ten Local Health Units (LHUs) located in six Italian Regions scattered across the country; both rural and urban LHUs were involved. Women aged between 18 and 26 years and living in the selected LHUs were included in the study; pregnant women and women who did not speak Italian were excluded. A total of 1,102 women met the inclusion criteria and agreed to participate. Participants were offered pap test and Hybrid-Capture 2 (HC2) test for HR-HPV types and genotyping was performed on positive smears. RESULTS: Out of 1,094 valid samples, 205 (18.7%) were HR-HPV positive. Women with 2-4 (ORadj = 4.15, 95%CI: 2.56-6.72) and ≥5 lifetime partners (ORadj = 10.63, 95%CI: 6.16-18.36) and women who have used any contraceptive in the last six months (ORadj = 1.67, 95%CI: 1.09-2.54) had a higher risk to be infected; women living with their partner had a lower risk (ORadj = 0.56, 95%CI: 0.34-0.92) to acquire infection than women living with parents/friends/alone. Among HC2 positive women, HPV16 was the most prevalent type (30.9%), followed by 31 (19.6%), 66 (12.9%), 51 (11.3%), 18 (8.8%), 56 (8.8%). Co-infections of HR-HC2 targeted types were found in 20.4% of positive samples. The HR-HPV prevalence in women with abnormal cytology (52.4%) was significantly higher than in women with normal cytology (14.6%); however 33.0% of HR-HPV infected women had an abnormal cytology. CONCLUSION: HR-HPV prevalence in Italian women aged 18-26 years was 19%, higher than what detected for older women, by other studies using the same molecular method and laboratory network; this result supports the choice of electing girls before the sexual debut as the primary target of HPV vaccination. The HPV type distribution found in this study may represent a baseline picture; an accurate post-vaccine surveillance is necessary to early detect a possible genotype replacement. The high prevalence of viral types other than vaccine-HPV types supports the necessity to guarantee the progression of CC screening programmes in vaccinated women.

One health adoption within prevention, preparedness and response to health threats: Highlights from a scoping review.

Introduction: As the COVID-19 pandemic has demonstrated, the complexity of factors involved in the emergence of health threats requires a holistic One Health (OH) approach to enhance the effectiveness of prevention, preparedness, and response (PPR) strategies. Therefore, we conducted a scoping review to explore how the OH approach has been adopted in the context of PPR strategies to health threats, and the challenges and benefits deriving from its integration. Methods: We defined the research questions and a strategy to guide the peer-reviewed and grey literature search to identify relevant articles and documents (identification). We assessed them for eligibility according to predefined criteria (screening) and finally included the ones that answered the research questions (inclusion). We performed a descriptive and thematic analysis of the results. Results: A total of 138 records were included in the review (57 from the peer-reviewed literature and 81 from the grey literature). The OH approach was mainly adopted in prevention strategies, particularly within the governance area. Human and animal health were the most integrated disciplines in the OH approach, while environmental and social sciences were the less integrated. The most targeted threats were antimicrobial resistance and zoonoses, with the African region being the most represented. Conducive factors for the adoption of OH PPR strategies were identified in resolutions and guidance emanating from international organisations. Discussion: The global governance of OH should utilise conducive factors, such as international resolutions and guidance, to enhance the adoption of multisectoral and multi-actor PPR strategies, that focus on national and international priorities and neglected threats, such as environmental hazards and pandemic risk. Integrated frameworks and metrics for the implementation and evaluation of OH PPR strategies need to be consolidated to contribute to the growing body of evidence supporting the adoption of the OH approach.

Access to Vaccination for Newly Arrived Migrants: Developing a General Conceptual Framework for Understanding How to Improve Vaccination Coverage in European Countries.

Objectives: Access to vaccination for newly arrived migrants (NAMs) is a relevant concern that requires urgent attention in EU/EEA countries. This study aimed to develop a General Conceptual Framework (GCF) for understanding how to improve vaccination coverage for NAMs, by characterizing and critically analyzing system barriers and possible strategies to increase vaccination. Methods: A theoretical conceptualization of the GCF was hypothesized based on conceptual hubs in the immunization process. Barriers and solutions were identified through a non-systematic desktop literature review and qualitative research. The GCF guided the activities and facilitated the integration of results, thereby enriching the GCF with content. Results: The study explores the vaccination of NAMs and proposes strategies to overcome barriers in their vaccination process. It introduces a framework called GCF, which consists of five interconnected steps: entitlement, reachability, adherence, achievement, and evaluation of vaccination. The study also presents barriers and solutions identified through literature review and qualitative research, along with strategies to enhance professionals' knowledge, improve reachability, promote adherence, achieve vaccination coverage, and evaluate interventions. The study concludes by recommending strategies such as proximity, provider training, a migrant-sensitive approach, and data collection to improve vaccination outcomes for NAMs. Conclusion: Ensuring equitable access to healthcare services, including vaccination, is crucial not only from a humanitarian perspective but also for the overall public health of these countries.

Risk of Covid-19 Severe Outcomes and Mortality in Migrants and Ethnic Minorities Compared to the General Population in the European WHO Region: a Systematic Review.

The Covid-19 pandemic has had a major impact on migrants and ethnic minorities (MEMs). Socio-economic factors and legal, administrative and language barriers are among the reasons for this increased susceptibility. The aim of the study is to investigate the impact of Covid-19 on MEMs compared to the general population in terms of serious outcomes. We conducted a systematic review collecting studies on the impact of Covid-19 on MEMs compared to the general population in the WHO European Region regarding hospitalisation, intensive care unit (ICU) admission and mortality, published between 01/01/2020 and 19/03/2021. Nine researchers were involved in selection, study quality assessment and data extraction. Of the 82 studies included, 15 of the 16 regarding hospitalisation for Covid-19 reported an increased risk for MEMs compared to the white and/or native population and 22 out of the 28 studies focusing on the ICU admission rates found an increased risk for MEMs. Among the 65 studies on mortality, 43 report a higher risk for MEMs. An increased risk of adverse outcomes was reported for MEMs. Social determinants of health are among the main factors involved in the genesis of health inequalities: a disadvantaged socio-economic status, a framework of structural racism and asymmetric access to healthcare are linked to increased susceptibility to the consequences of Covid-19. These findings underline the need for policymakers to consider the socio-economic barriers when designing prevention plans. Supplementary Information: The online version contains supplementary material available at 10.1007/s12134-023-01007-x.

Health assessment for migrants and asylum seekers upon arrival and while hosted in reception centres: Italian guidelines.

BACKGROUND: During 2016-17, national guidelines were developed in order to provide evidence-based recommendations on health assessments for migrants and asylum seekers upon their arrival in Italy. METHODS: Scientific literature published between 2005 and 2016 was searched in different databases. A free search was also performed on international organizations' websites in order to identify additional relevant documents. A multidisciplinary panel discussed the resulting evidence and formulated recommendations. RESULTS: Evidence-based recommendations were formulated: signs and symptoms of specific diseases should to be actively searched for active TB, malaria, STI, intestinal parasites, diabetes, anaemia. In case of other health conditions (latent TB, HIV, HBV, HCV, STI, strongyloides, schistosoma, diabetes), testing should be offered to asymptomatic subjects coming from endemic areas or exposed to risk factors. Mass screening is recommended for anaemia and hypertension; a pregnancy test should be considered, while inclusion in cervical cancer screening and vaccination programs is recommended. A modulated, progressive approach was developed, covering an initial evaluation during rescue operations, a full medical examination at first line reception stage and the referral to national health services during second line reception. CONCLUSIONS: It is important to produce and periodically update guidelines on these issues and local peculiarities should be taken into account in their design and implementation. Guidelines can not only support economic sustainability, but also counteract stigmatization dynamics.

Differences in Incidence of Acute Viral Hepatitis between Foreigners and Autochthonous Population in Italy.

BACKGROUND: In European countries, the prevalence of HBV and HCV in refugees and migrants tends to reflect the prevalence in their countries of origin. The aim of this study is to analyse acute viral hepatitis cases diagnosed in Italy among foreign citizens and to compare incidence rates in foreigners and Italians. METHODS: We analysed the cases of each viral hepatitis type among foreigners. Standardised incidence rates were compared between natives and foreigners. RESULTS: Between 2004 and 2019, 15,872 cases of acute viral hepatitis were notified by 10 Italian regions, 14.8% among foreign citizens. Until 2012, the percentage increased gradually, while a fluctuating trend set in from 2013 onwards; in 2019, 23.9% of cases were foreigners. Data from the SEIEVA surveillance show higher standardised incidence rates of hepatitis A and B among foreign citizens; no significant difference emerged between Italians and foreigners in terms of their hepatitis C incidence. CONCLUSIONS: foreign citizens have an increased incidence of hepatitis A and B. Regarding hepatitis A, vaccination is strongly recommended to foreigners travelling to their countries of origin. Screening tests for hepatitis B and C infection should be offered to newly arrived migrants from high prevalence countries, or having specific risk factors.