Data display format and hospital ward reports: effects of different presentations on data interpretation.

BACKGROUND: Graphs are often used in medical communication, both in clinical practice and health management. They can help the processing of quantitative information but may also contribute to drawing wrong conclusions. The aim of the survey is to study the graphical perception of the data at the management level and its possible effects, showing how some criteria of appraisal of a phenomenon are influenced by the graphical format. METHODS: One hundred and five medical doctors and health direction professionals of hospitals in Naples, Rome, Siena and Turin were interviewed. Four different graphs or table related to the same hypothetical data on average hospital stay in the period January 2000 to September 2003 were shown to participants, and their impressions were recorded. RESULTS: Less than one-fourth of the participants understood that the data set was the same for the different diagrams. The process of understanding is mostly correlated with being a director, having a degree in medicine and working in central-northern cities. The table seems easier for interpretation (98.1%), more suitable (84.8%), more used (92.4%) and more pleasant than other data presentation. On the other hand radar format had worse results in all questions. CONCLUSIONS: The choice of a graphical format may influence the understanding of data. Further research is needed in order to sustain the improvement of medical and health professionals' knowledge in the display data format.

[Health Technology Assessment to evaluate the economic advantage of offering of low-protein diet to pre-dialysis patients in Campania (Italy)]. / Un modello HTA a sostegno dell'offerta della dieta ipoproteica ai nefropatici della Campania.

A low-protein diet is well known to slow the progression of chronic renal failure, delay initiation of dialysis, while achieving significant economic benefits. In the context of a Health Technology Assessment (HTA), a budget impact analysis model was implemented to evaluate the economic advantage of offering of low-protein diet to nephropathic patients in Campania (Italy). The implemented model takes into account only the direct costs to the national healthcare system. In particular, costs related to supplying low-protein foods are compared to dialysis costs avoided, in a scenario that evaluates different indices of Numbers Needed to Treat and compliance to treatment. Results indicate that when compliance to treatment is at least 50% and NNT is £ 50, supplying a low-protein diet to all kidney disease patients in the pre-dialysis phase, namely with an estimated Glomerular filtration rate > 45, in Campania (which in the year 2009 were equal to 25,000 subjects), is economically advantageous. In this perspective, the authors argue that distribution of low-protein foods by local pharmacies could be an appropriate choice as it would allow the products to be offered at a discounted price and create a favorable setting for increasing adherence to treatment.

Tobacco use prevalence, knowledge and attitudes among Italian hospital healthcare professionals.

BACKGROUND: Healthcare professionals play a key role in tobacco use prevention because they are considered as model by patients. This multicenter study was aimed to evaluate smoking prevalence, knowledge and attitudes towards tobacco among Italian hospital professionals. METHODS: A cross-sectional study was carried out using a questionnaire administered to healthcare professionals in seven Italian hospitals, to investigate personal and occupational data, knowledge, attitudes, job setting, clinical activities, smoking habits and pattern for current smokers. Potential predictors of current smoking habits were evaluated using multiple logistic regressions. RESULTS: Sample population was comprised of 1082 health professionals (51.4% females; mean age was 37.3 years: 25.3% were nurses, 24.5% medical doctors, 17.1% students and 33.1% other healthcare workers). Smoking prevalence was 44%. Among responders, 67.7% considered healthcare professional as a model for citizens, 90.5% declared to see colleagues smoking cigarettes inside the hospital (47.4% in the dependents' toilets, 33.4% in the department kitchens and 4.7% in the patient room). Multivariate analysis showed that healthcare professionals working in Naples had a higher risk to be smokers in comparison to Rome [odds ratio (OR) = 2.29; 95% confidence interval (CI) 1.40-3.73]. Compared to medical doctors, post-graduate students (OR = 3.42; 95% CI: 1.81-6.44), nurses (OR = 2.48; 95% CI 1.51-4.08), nursing students (OR = 1.91; 95% CI 1.08-3.38) and auxiliary personnel (OR = 2.72; 95% CI 1.51-4.88), showed a higher likelihood of smoking. CONCLUSIONS: Among Italian hospital personnel there is a paradoxically large prevalence of smokers, higher than in the general population. Interventions aimed for the development of an adequate culture of health promotion, among these professionals, are urgently needed.

Compliance with herpes zoster vaccination in young and adult individuals in two regions of Italy.

BACKGROUND: The purpose of this work was to explore the knowledge and acceptance of Varicella Zoster Virus (VZV)-Herpes Zoster (HZ) vaccination in the general Italian population, where the HZ vaccine has not yet been distributed, using a prevalence study of subjects from two regions in Italy. METHODS: A group of 3,173 individuals were interviewed using a questionnaire. The youngest age group (or= 41 years) were interviewed by general practitioners in their office. RESULTS: In both regions, the majority of subjects had been infected with varicella, and only 165 (5.2%) subjects reported receiving the VZV vaccination. Regarding HZ, 2,749 (86.6%) individuals stated that they knew of the virus and 2,233 (70%) were willing to be vaccinated against HZ. The majority of people willing to be vaccinated were in the middle and older age groups (36.6% and 44.7%, respectively). CONCLUSION: Compliance versus vaccination results were satisfactory and probably, with the upcoming availability of the HZ vaccine in Italy, adults will be favourably disposed towards vaccination.

[A proposal of a triage model to control spreading diseases in public health]. / Proposta di un modello di triage per un controllo più efficace delle malattie infettive e diffusive in Sanità Pubblica.

Each case of infectious disease can be considered the consequence of an unexpected event which started an infection chain. Every infectious case is therefore a potential source of epidemic, resulting from the total of the epidemic potential of each individual variable involved in the pathology spreading process. This article identifies the main variables involved in the spreading of infectious diseases in communities, and it develops a method which gives importance to each one of them based on the main control measures available to Public Health operators. From this comes the proposition of valid instructions necessary to develop a triage method which controls infectious and spreading diseases, to identify the ones which need intervention priority within a continuous surveillance and control system.

Persistence of immunity 18-19 years after vaccination against hepatitis B in 2 cohorts of vaccinees primed as infants or as adolescents in Italy.

This study was aimed at assessing the anti-HBs persistence and immune memory 18-19 y after vaccination against hepatitis B in healthy individuals primed as infants or adolescents. We enrolled 405 teenagers (Group A) vaccinated as infants, and 409 young adults (Group B) vaccinated as adolescents. All vaccinees were tested for anti-HBs and anti-HBc antibodies; those found anti-HBc positive were further tested for HBsAg and HBV DNA. Eight individuals belonging to Group B were positive for anti-HBc alone, and were excluded from analysis. Individuals with anti-HBs concentration ≥ 10 mIU/ml were considered protected while those with anti-HBs concentration <10 mIU/ml were offered a booster dose and re-tested 2 weeks later. Overall, 67.9% individuals showed anti-HBs concentrations ≥ 10 mIU/ml (48.9% in Group A vs 87.0% in Group B, p < 0.001). The antibody geometric mean concentration (GMC) was higher in Group B than in Group A (102.5 mIU/ml vs 6.9 mIU/ml; p < 0.001). When boosted, 94.2% of vaccinees with anti-HBs <10 mIU/ml belonging to Group A and 94.7% to Group B showed an anamnestic response. Post-booster GMCs were similar in both groups (477.9 mIU/ml for Group A vs 710.0 mIU/ml for Group B, p = n.s.). Strong immunological memory persists for at least 18-19 y after immunization of infants or adolescents with a primary course of vaccination. Thus, booster doses are not needed at this time, but additional follow up is required to assess the long-life longevity of protection.

Long-term immunogenicity of hepatitis B vaccination and policy for booster: an Italian multicentre study.

BACKGROUND: Universal anti-hepatitis-B vaccination of infants and adolescents was implemented in Italy in 1991. We undertook a multicentre study in previously vaccinated individuals to assess the duration of immunity and need for booster, over 10 years after vaccination. METHODS: In 1212 children and 446 Italian Air Force recruits vaccinated as infants and adolescents, respectively, we measured the concentrations of antibodies to hepatitis-B surface antigen (anti-HBs) and the presence of antibodies to hepatitis-B core antigen (anti-HBc) at enrollment; postimmunisation values were not available. Individuals positive for anti-HBc were tested for hepatitis B surface antigen (HBsAg) and hepatitis B viral DNA. Individuals with anti-HBs concentrations at 10 IU/L or more were regarded as protected; those with antibody less than 10 IU/L were given a booster dose and retested 2 weeks later. Individuals showing postbooster anti-HBs concentrations of less than 10 IU/L were offered two additional vaccine doses and retested 1 month after the third dose. FINDINGS: Protective anti-HBs concentrations were retained in 779 (64%, 95% CI 61.6-67) children and 398 (89%, 86.4-92.1) recruits. We recorded antibody amounts of less than 10 IU/L in 433 children (36%, 33-38.4) and 48 (11%, 7.9-13.6) recruits. One child and four recruits were positive for anti-HBc, but negative for HBsAg and hepatitis B viral DNA. Antibody concentrations were higher in recruits than in children (geometric mean titre 234.8 IU/L vs 32.1 IU/L, p=0.0001). 332 (97%) of 342 children and 46 (96%) of 48 recruits who received a booster showed an anamnestic response, whereas ten (3%) children and two (4%) recruits remained negative for anti-HBs or had antibody concentrations of less than 10 IU/L. Prebooster and postbooster antibody titres were strongly correlated with each other in both groups. All individuals given two additional vaccine doses (eight children and two recruits) showed anti-HBs amounts of more than 10 IU/L at 1 month after vaccination. INTERPRETATION: Strong immunological memory persists more than 10 years after immunisation of infants and adolescents with a primary course of vaccination. Booster doses of vaccine do not seem necessary to ensure long-term protection.

[Tetanus in Italy and in the Campania region: retrospective analysis. The importance of vaccinations]. / Il tetano in Italia ed in regione Campania: analisi retrospettiva. L'importanza dei richiami vaccinali.

The authors intend to draw the attention on the issue of tetanus infections in adult patients whose history is often unknown or incomplete. For these people, current regulations (Presidential Decree 7th Nov 2001 no. 464) provides for more extended vaccination coverage. The input data were drawn by different sources (ISS; MS; National Statistics Institute; Campania Epidemiological Observatory) and allowed for the tetanus infections having occurred in Italy and Campania in the last ten years.

[Epidemic food outbreaks and activities of Department of Prevention: critic factors]. / Focolai epidemici di sospetta origine alimentare ed attività del Dipartimento di Prevenzione: elementi di criticità

The Authors critically review three food poisoning episodes occurred within the coverage area of ASL NA2, and the related epidemiological researches carried out by the Prevention Department. Events, methodology, results, strength points, and criticalities are singularly described for each episode. Among the main criticalities: timeliness, the missed recovery of food samples and the absence of a reference head laboratory. In conclusion, the Authors insist on the need to select a central referral facility, responsible for coordinating services between the Department and all the other facilities within the coverage area.

Adult immunization with 13-valent pneumococcal vaccine in Campania region, South Italy: an economic evaluation.

Pneumococcal pneumonia has a high clinical burden in terms of morbidity, mortality and hospitalization rate, with heavy implications for worldwide health systems. In particular, higher incidence and mortality rates of community-acquired pneumonia (CAP) cases, with related costs, are registered among elderly. This study aimed to an economic evaluation about the immunization with PCV13 in the adult population in Campania region, South Italy. For this purpose we performed, considering a period of 5 y, a budget impact analysis (BIA) and a cost-effectiveness analysis which considered 2 scenarios of immunization compared with lack of immunization for 2 targeted cohorts: first, the high risk subjects aged 50-79 y, and second the high risk individuals aged 50-64 y, together with all those aged 65 y. Regarding the first group, the decrease of pneumonia could give savings equal to €29,005,660, while the immunization of the second cohort could allow savings equal to €10,006,017. The economic evaluation of pneumococcal vaccine for adult groups represents an essential instrument to support health policies. This study showed that both hypothesized immunization strategies could produce savings. Obtained results support the use of pneumococcal conjugate vaccine for adults. This strategy could represent a sustainable and savings-producer health policy.

Priority persistent contaminants in people dwelling in critical areas of Campania Region, Italy (SEBIOREC biomonitoring study).

To investigate if protracted living in degraded environments of the Caserta and Naples provinces (Campania Region, Italy) had an impact on exposure of local people, highly toxic persistent contaminants were measured in blood, blood serum, and human milk of a large number of healthy donors. Sampling was carried out from 2008 to 2009. Blood was collected from over 850 20-64-year old donors; by pooling, 84 blood and 84 serum samples were obtained. Milk was donated by 52 mothers: specimens were pooled into six samples. Polychlorodibenzodioxins (PCDDs), polychlorodibenzofurans (PCDFs), and polychlorobiphenyls (PCBs, dioxin-like (DL) and non-dioxin-like (Σ6PCBs)), arsenic (As), cadmium (Cd), mercury (Hg), and lead (Pb) were measured in serum (organic biomarkers) and blood (metals); these chemicals and polybromobiphenyl ethers (Σ9PBDEs) were analyzed in milk. PCDD+PCDF, DL-PCB, TEQTOT, and Σ6PCB concentration ranges (medians) in serum were 6.26-23.1 (12.4), 3.42-31.7 (11.5), 10.0-52.8 (23.9) pgTEQ97/g fat, and 55.5-647 (219) ng/g fat, respectively, while in milk concentration ranges were 5.99-8.77, 4.02-6.15, 10.0-14.2 pgTEQ97/g fat, and 48.7-74.2 ng/g fat. Likewise, As, Cd, Hg, and Pb findings in blood spanned 2.34-13.4 (5.83), 0.180-0.930 (0.475), 1.09-7.60 (2.60), 10.2-55.9 (28.8) µg/L, respectively; only Pb could be measured in milk (2.78-5.99 µg/L). Σ9PBDE levels in milk samples were 0.965-6.05 ng/g fat. Biomarkers' concentrations were found to be compatible with their current values in European countries and in Italy, and consistent with an exposure primarily determined by consumption of commercial food from the large distribution system. Based on relatively higher biomarker values within the hematic biomonitoring database, the following municipalities were flagged as possibly deserving attention for health-oriented interventions: Brusciano and Caivano (As), Giugliano (Hg), Pianura (PCDDs+PCDFs), and Qualiano-Villaricca (As, Hg). The analysis of samples' qualitative variability indicated that biomarker composition was sensitive at municipality level, a feature that can potentially drive interventions for future local risk assessment and/or management measures.

Epidemiology of home injuries: a large observational study among adult mothers in Italy.

AIMS: The aims of the study were to describe the epidemiology of home injuries (HI) among Italian students' mothers and to identify the possible predictors of having HI. METHODS: An anonymous questionnaire was used in several Italian schools. In order to identify predictors of having HI, a multivariate analysis was performed. RESULTS: In our sample (3,610 women), the prevalence of HI was 18%; 6.2% of the interviewed had a severe HI. The multivariate analyses showed that increasing age, to spend more than 13 hours a day at home and to be housewife are risk factors for having HI. CONCLUSIONS: This study reports a high prevalence of HI, highlighting an urgent need for undertaking interventions to develop an adequate culture of safety and prevention.

Challenge with a hepatitis B vaccine in two cohorts of 4-7-year-old children primed with hexavalent vaccines: an open-label, randomised trial in Italy.

BACKGROUND AND AIMS: The anamnestic response to a challenge dose of vaccine can assess immune memory and protection against hepatitis B infection. This study investigated responses to a challenge dose of monovalent hepatitis B vaccine in children immunised with three doses of either Hexavac or Infanrix-Hexa during infancy. METHODS: This open-label, randomised, controlled, four-arm study enrolled 410 healthy children aged 4-7 years who had received either Hexavac (n=201) or Infanrix-Hexa (n=209) at 3, 5 and 11 months of life. Children received a single intramuscular challenge dose of either hepatitis B vaccine, HBVaxPro (Hexavac, n=34; Infanrix-Hexa, n=28) or Engerix-B (Hexavac, n=167; Infanrix-Hexa, n=181). Hepatitis B surface antibody (anti-HBs) concentrations were measured before and 1 month after the challenge vaccine dose. The analysis was descriptive and no formal hypothesis was tested. RESULTS: One month post-challenge, 91.2% of children in the Hexavac group (95% confidence interval [CI] 86.3, 94.8) and 98.0% (95% CI 94.9, 99.4) in the Infanrix-Hexa group had anti-HBs concentrations ≥10 mIU/ml (primary endpoint). In a post hoc analysis, most children with pre-challenge anti-HBs concentration <10 mIU/ml achieved anti-HBs concentrations ≥10 mIU/ml (Hexavac group, 85.3% [95% CI 77.6, 91.2]; Infanrix-Hexa group, 91.9% [95% CI 78.1, 98.3]). Both challenge vaccines were well tolerated. CONCLUSIONS: These data suggest that immune memory persists for long-term (5 years) after a primary vaccination in infancy with a hexavalent vaccine (Hexavac or Infanrix-Hexa).

Acceptance and safety of the intradermal influenza vaccine among the elderly in Italy: an on-field national study.

INTRODUCTION: An observational multicenter study was carried out in Italy, to evaluate the acceptability and safety of the new intradermal (ID) influenza vaccine (Intanza Sanofi Pasteur SA, Lyon, France) among subjects aged≥60 years, compared with that of other intramuscular (IM) influenza vaccines. Compliance with the use of the ID vaccine by healthcare professionals was also assessed. METHODS: A previously validated and self-administered questionnaire, Vaccinees' Perception of Injection (VAPI®), consisting of 21 questions, mainly focused on four dimensions (bother, arm movements, sleep, and acceptability), was administered to >1,600 individuals with spontaneous access to outpatient clinics, located in Northern, Central, and Southern Italy, to evaluate the acceptance of the vaccines. Occurrence of solicited and unsolicited side effects and of serious adverse events was assessed in a subset of subjects (n=500), using a clinical diary filled in by vaccinees following immunization. Compliance with the new ID vaccine by healthcare professionals was investigated using an ad-hoc questionnaire. RESULTS: A very favorable opinion concerning the acceptability of both the vaccines under survey, with the most positive answers ranging between 75.5% and 94.9%, was registered within the study population. Also the compliance by healthcare professionals (n=130) with the novel ID vaccine was favorable. No serious adverse event occurred during the 6-month follow-up period. The frequency of solicited systemic reactions was comparable between the two study groups, while solicited local reactions were significantly higher in the ID-vaccine group than in the IM-vaccine group, even if at values lower than those reported in phase 3 clinical trials (ranges=18.5-32.6% vs. 29.5-70.9%). These local events were mild and transient, thus without any clinical relevance. CONCLUSION: The novel ID influenza vaccine can be widely recommended in clinical practice, representing a useful tool to improve immunization coverage rates, and thus the control of influenza.

Role of beauty treatment in the spread of parenterally transmitted hepatitis viruses in Italy.

The aims of the study were to evaluate the role of beauty treatments in the spread of acute viral hepatitis B (HBV) and acute viral hepatitis C (HCV) in Italy. Data from the surveillance system for acute viral hepatitis (SEIEVA) during the period 1997-2002 were used. After exclusion of subjects <15 years or >55 years old and reporting intravenous drug use or blood transfusion, the association of acute HBV and HCV cases with beauty treatments (tattooing, piercing, manicure/chiropody, and barber shop shaving) was estimated comparing 2,964 hepatitis B and 598 hepatitis C cases with 7,221 hepatitis A cases, used as controls, by multiple logistic regression analysis. The population attributable risk (PAR) to beauty treatments was estimated according to Levin's formula. Beauty treatments were associated with acute HBV (OR = 1.8; CI 95% = 1.5-2.1) and acute HCV (OR = 1.7; CI 95% = 1.2-2.3). The strongest association was found with barber shop shaving for HBV (OR = 1.8; CI 95% = 1.5-2.2) and with tattooing for HCV cases (OR = 5.6; CI 95% = 2.8-11.0). The estimates of the population attributable risk (PAR) indicate that nearly 15% of all acute HBV (17.4% in males) and 11.5% of all acute HCV cases (16.4% in males) occurring in 15-55 year old subjects not exposed to intravenous drugs or blood transfusion in Italy are due to beauty treatments. It is concluded that certain beauty treatments play an important role in the spread of HBV and HCV infections in Italy.

Factors affecting the compliance of the antenatal hepatitis B screening programme in Italy.

The effectiveness in the prevention of perinatally transmitted HBV infection was assessed in 11858 pregnant women consecutively recruited in public and private hospitals in six Italian regions during a 2 months period in 2001. Of them 10881 (91.8%) attended HBsAg antenatal screening. The overall HBsAg prevalence was 1.7% (CI 95%: 1.4-1.9); it was 1.4% (CI 95%: 1.2-1.7) in pregnant women born in Italy but 5.9% (CI 95%: 4.1-8.1) in those born in Asia, Africa, central and south America, and eastern Europe. Results of multiple logistic regression analysis indicate that birth in foreign countries (OR 2.0; CI 95%: 1.3-3.0), family size with more than 4 members in the household (OR 3.5; CI 95%:2.7-4.6), and birth in a private hospital (OR 1.9; CI 95%: 1.3-2.8) were all independent predictors of lack of adherence to HBsAg screening. Out of the 182 new-borns of HBsAg positive mothers 172 (95.0%) were given active plus passive immunisation; this figure was 100% in new-borns of foreign mothers. These findings evidence a good effectiveness in the prevention of perinatally transmitted HBV in Italy. More efforts should be addressed to improve the effectiveness of the programme among foreign pregnant women who have high rate of HBsAg and more likely escape HBsAg screening than Italian pregnant women.