[Interrupting the chains of transmission of COVID-19 in Italy: survey among the Prevention Departments]. / Interrompere le catene di trasmissione di COVID-19 in Italia: indagine tra i Dipartimenti di prevenzione.

BACKGROUND: the ability to implement effective preventive and control measures is rooted in public health surveillance to promptly identify and isolate contagious patients. OBJECTIVES: to describe some organizational aspects and resources involved in the control of COVID-19 pandemic. DESIGN: observational cross sectional study. SETTING AND PARTICIPANTS: a survey of methods and tools adopted by the competent service (Prevention department) in the Local public health units (LHU) of the regional Health services has been performed in May 2020. The survey collected data related to activities carried out during the month of April 2020 on the surveillance system for collection of suspected cases, their virological ascertainment, the isolation procedures and contact-tracing activities by means of an online questionnaire filled in by the public health structure of the regional health system. A convenience sample of Prevention departments was recruited. RESULTS: in 44 Prevention departments of 14 Regions/Autonomous Provinces (caring for 40% of the population residing in Italy), different services were swiftly engaged in pandemic response. Reports of suspected cases were about 3 times the number of confirmed cases in the same month. Local reporting form was used in 46% of the LHUs while a regional form was available in 42% of the Departments (in 9/14 Regions). In one fourth the forms were not always used and 2% had no forms for the reporting of suspected cases. Data were recorded in 52% of LHUs on local databases, while in 20% a regional database (in 7 Regions) had been created. A proportion of 11% did not record the data for further elaboration. The virological assessment with nasopharyngeal swabs out of the hospital setting was carried out on the average in 7 points in each LHU (median 5) and the average daily capacity was 350 (71 per 100,000) swabs. The rate of subjects newly tested during the month of April was of 893 per 100,000 new people. Data collected at the swabbing were recorded on a regional platform in 17 LHUs (39%) of 8 Regions. In 7% LHUs only positive specimens were recorded electronically. Local files were used in 27% LHUs. The interview with confirmed cases was carried out with a local questionnaire in 52% LHUs, while 14% stated that a standardized form was not used. The data collected about cases were recorded on a regional IT platform in 30% Departments (in 8 Regions) and in 41% data were registered only locally. For each confirmed case in April, a median of 4 contacts were identified. Only 13 (30%) Departments in 9 Regions have registered contact data on a regional database. Ten Departments (23%) have only hard copies, while 56% recorded data on local databases. About 5 health professionals for 100,000 resident population were involved in each LHU in each of the following activities as receiving reports of suspected cases, swabs collection, interviews of cases and contact identifications. CONCLUSIONS: the pandemic required rapidly a great organizational effort and great flexibility to increase response capacity, which now must be strengthened and maintained. Several different tools (forms and electronic files) have been developed in each LHU and used for the same surveillance operational processes with a loss in local efficiency. The inhomogeneous data collection and recording is an obstacle for further analyses and risk identifications and is a missed opportunity for the advancement of our knowledge on pandemic epidemiology analysis. In Italy, updating the pandemic response plans is the priority, at national, regional and local level, and the occasion to fill the gaps and to improve surveillance systems to the interruption of COVID-19 transmission.

Migrant health in Italy: a better health status difficult to maintain-country of origin and assimilation effects studied from the Italian risk factor surveillance data.

BACKGROUND: Many studies on migrant health have focused on aspects of morbidity and mortality, but very few approach the relevant issues of migrants' health considering behavioral risk factors. Previous studies have often been limited methodologically because of sample size or lack of information on migrant country of origin. Information about risk factors is fundamental to direct any intervention, particularly with regard to non-communicable diseases that are leading causes of death and disease. Thus, the main focus of our analysis is the influence of country of origin and the assimilation process. METHOD: Utilizing a surveillance system that has been collecting over 30,000 interviews a year in Italy since 2008, we have studied migrants' attitudes and behaviors by country of origin and by length of stay. Given 6 years of observation, we have obtained and analyzed 228,201 interviews of which over 9000 were migrants. RESULTS: While migrants overall present similar conditions to native-born Italians, major differences appear when country of origin or length of stay is considered. Subgroups of migrants present substantially different behaviors, some much better than native-born Italians, some worse. However, integration processes generally produce a convergence towards the behavioral prevalence observed for native-born Italians. CONCLUSIONS: Health programs should consider the diversity of the growing migrant population: data and analyses are needed to support appropriate policies. Many migrants' subgroups arrive with healthier behaviors than those of their adopted country. However, they are likely to have a less favorable social position in their destination countries that could lead to a change towards less healthy behaviors. Interventions capable of identifying this tendency could produce significant better health for this important part of the future (multicultural) populations.

The perception of the relationship between environment and health according to data from Italian Behavioural Risk Factor Surveillance System (PASSI). / La percezione del rapporto ambiente-salute secondo i dati della sorveglianza Progressi delle aziende sanitarie per la salute in Italia (PASSI).

"OBJECTIVES: to identify groups of people in relation to the perception of environmental risk and to assess the main characteristics using data collected in the environmental module of the surveillance network Italian Behavioral Risk Factor Surveillance System (PASSI). METHODS: perceptive profiles were identified using a latent class analysis; later they were included as outcome in multinomial logistic regression models to assess the association between environmental risk perception and demographic, health, socio-economic and behavioural variables. RESULTS: the latent class analysis allowed to split the sample in "worried", "indifferent", and "positive" people. The multinomial logistic regression model showed that the "worried" profile typically includes people of Italian nationality, living in highly urbanized areas, with a high level of education, and with economic difficulties; they pay special attention to their own health and fitness, but they have a negative perception of their own psychophysical state. CONCLUSIONS: the application of advanced statistical analysis enable to appraise PASSI data in order to characterize the perception of environmental risk, making the planning of interventions related to risk communication possible. ".

Mortality in Italian veterans deployed in Bosnia-Herzegovina and Kosovo.

BACKGROUND AND AIMS: The possible increase of cancer risk in military personnel deployed in Balkans during and after the 1992-1999 wars, mainly related to the depleted uranium, was addressed by several studies on European veterans of those war theatres. This article reports on the results of the mortality study on the Italian cohort of Bosnia and Kosovo veterans (Balkan cohort). METHODS: Mortality rates for the Balkan cohort (71 144 persons) were compared with those of the Italian general population as well as to those of a comparable and unselected control cohort of not deployed military personnel (114 269 persons). Ascertainment of vital status during the period 1995-2008 of all the persons in the two cohorts has been carried out through deterministic record linkage with the national death records database, from information provided by the respective Armed Force General Staff, and through the civil registry offices of the veterans' residence or birth municipalities. RESULTS: The Balkan cohort experienced a mortality rates lower than both the general population (SMR = 0.56; 95% CI 0.51-0.62) and the control group (SMR = 0.88; 95% CI 0.79-0.97). Cancer mortality in the deployed cohort group was half of that from the general population mortality rates (SMR = 0.50; 95% CI 0.40-0.62) and slightly lower if compared with the control group cancer mortality rates (SMR = 0.95; 95% CI 0.77-1.18). CONCLUSION: Balkan veteran cohort did not show any increase in general mortality or in cancer mortality.

Cancer screening uptake: association with individual characteristics, geographic distribution, and time trends in Italy.

BACKGROUND: In Italy, organized screening programmes invite the vast majority of the population for cervical and breast cancer, and about one half of the population for colorectal cancer. Programme activity and quality are closely monitored. Nevertheless, there is a vast spontaneous activity, both public and private, for which information on service and coverage is missing. To estimate actual population coverage for the three types of screening the extent of spontaneous screening needs to be known. METHODS: PASSI is a national telephone-interview surveillance system that continuously collects information about behavioural health risk factors and the diffusion of preventive health interventions. From 2010 to 2013, more than 151,000 18- to 69-year-olds were interviewed. During 2013, 136 out of 147 Italian local health authorities participated in the survey. Information about screening includes: test uptake (Pap smear, HPV, mammography, faecal occult blood test, colonoscopy), date of the last test, provider of the last test (whether paid or for free, proxy of the organized screening programme), reason for not participating in screening, and screening promotion/recommendation received. Individual information on socio-economic characteristics is available. RESULTS: Seventy-seven percent of the 25-64 year-old women interviewed said they had undergone a Pap smear or HPV test in the three years before the interview, 40%within the screening programme, 37% spontaneously and paying. Seventy percent of the 50-69 year-old women interviewed reported having had a mammography in the two years before the interview, 51% within the screening programme, 19% spontaneously and paying. Thirty-eight percent of the 50-69 year olds interviewed reported having undergone colorectal screening in the two years before the interview, 31% within the screening programme, 7% spontaneously and paying. All three screening programmes showed a decreasing North-South trend in coverage. From 2010 to 2013, coverage increased for all types of screening; the trend was stronger in the South; the increase was mostly due to the tests performed within the organized programmes. People with low education, economic problems, and immigrants from high migration pressure countries had lower coverage levels. In regions with well-implemented organized screening programmes, test coverage was higher and differences for socio-economic factors were smaller than in regions with incomplete programme activation.

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.

[Human papillomavirus vaccine register]. / Il registro del vaccino anti-HPV.

INTRODUCTION: We carried out an active surveillance of common adverse events occurring among women (9 to 26 years old) receiving human papillomavirus vaccine (Gardasil® and Cervarix®) in 9 Italian Regions. METHODS: Common adverse events occurring in the two weeks following each dose administration were collected using a structured diary. RESULTS: From August 2008 to September 2011, 12,066 immunised women (9,084 receiving Cervarix® and 2,982 Gardasil®) were included in the surveillance for a total of 29,494 administered doses. 53% of women concluded the vaccination cycle (74% with Gardasil® and 47% with Cervarix®). 61% of women experienced an adverse event after the administration of the first dose. The high proportion of adverse events reported is mainly due to the design of the study, since women were requested to report all events occurring after the vaccination; however the majority of events were mild and transient. DISCUSSION: As for all vaccines, and in particular for newly marketed ones, the surveillance of adverse events represents an essential step in the evaluation of a vaccination programme.

Effect of duration of breastfeeding on neuropsychological development at 10 to 12 years of age in a cohort of healthy children.

AIM: The aim of this article was to explore the effect of duration of breastfeeding on neurocognitive development. METHOD: The long-term effect of breastfeeding on neurodevelopment was examined through a battery of neuropsychological tests in 1403 children (693 females, 710 males; mean age 11 y 9mo [SD 6mo], range: 10y 3mo-12y 8mo) who were originally recruited at 6 to 12 weeks of age for a clinical trial on acellular pertussis vaccines. An estimated IQ was obtained from scores of the vocabulary, similarities, block design, and coding tests. Breastfeeding data had been prospectively collected throughout the first year of life. Duration of exclusive breastfeeding was defined as the time during which children received breast milk without receiving any supplemental formula or food. Children were assessed at 10 to 12 years of age. We adjusted the analysis on test scores for multiple potential confounders. RESULTS: Multivariate analysis showed a significant association between exclusive breastfeeding duration and test scores in the vocabulary (odds ratio [OR] 0.05; confidence interval [CI] 0.00-0.10; p=0.04) and similarities (OR 0.06; CI 0.01-0.11; p=0.03) tests. These associations have a negligible effect size, however. Scores on one writing praxis test subcategory decreased with increasing duration of both exclusive breastfeeding (OR -0.06; CI -0.11 to -0.01; p=0.03) and breastfeeding irrespective of consumption of other foods (OR -0.06; CI -0.11 to -0.01; p=0.03). A negative association was also found between one subcategory of the California verbal learning test and breastfeeding duration longer than 6 months (OR -0.21; CI -0.42 to -0.01; p=0.04). INTERPRETATION: Breastfed healthy children may perform better on neuropsychological tests in the language domain at 10 to 12 years of age. However, the effect of breast milk on neuropsychological performance in healthy children may have a limited clinical relevance and is confounded by parental education.

[Health indicators in the time of crisis in Italy]. / Gli indicatori di salute ai tempi della crisi in Italia.

SCOPE: to estimate for the first time in Italy the consequences of the national current economic crisis on health and on social determinants of health, assessing its impact on a set of distal determinants (development and economic wellbeing, labour and environment) and of prossimal ones (material, psychosocial, professional, environmental and behavioural risk factors) on health care performance and on health outcomes normally related to economic trends, as self-perceived health, depression, number of suicides attempts, road traffic incidents and work injuries. The analysis is therefore aimed at identifying the most promising entry points in order to plan and implement either health care and other policies to tackle the negative effects of crisis on health. DESIGN: using the main international and national references on the measure of wellbeing and on the role of social determinants, this paper draws a conceptual framework of all the connections between recession and health. For each mechanism identified, it examines the value of the main available indicators before and during the crisis in order to measure its impact, adjusting if possible for the trend observed in the previous years. Indicators have been selected according to their availability in the main Italian national informative sources and, when not possible, circumscribing the analysis to the regional or local level. RESULTS: regarding the short term impact, results have shown an association between the recession and the raise of mental health related problems (measured in terms of number of suicides, depression and substance misuse), especially on the most disadvantaged groups because of their higher job and financial insecurity. A first ex-ante impact assessment on long term effects allows to attribute almost two hundred deaths a year due to the increase of unemployment rate. Regarding the budget cuts on public expenditure of the health care sector, significant reductions have been shown in specialist care and in drug prescriptions, associated with the increase of co-payment and with a stronger effect on the most vulnerable socioeconomic groups. Nevertheless the crisis does not seem to be associated with a reduction of indicators of quality, continuity and outcomes of the health care, at least in the considered clinical pathways (diabetes and maternal and child health). At the same time the crisis seems to be associated with the reduction in the rate of injuries in the workplace (although it has been observed an increase of the serious ones) and car crashes, probably explained by the reduction of industrial production and of household consumptions. CONCLUSIONS: the conceptual framework seems to be the appropriate tool to set an Italian surveillance system for assessing the short and medium term impact of crisis on health, in particular the health of the most disadvantaged groups, mainly focusing on unemployed which are the most vulnerable target.

Surveillance of perceptions, knowledge, attitudes and behaviors of the Italian adult population (18-69 years) during the 2009-2010 A/H1N1 influenza pandemic.

Monitoring perceptions, knowledge, attitudes and behaviors of populations during pandemic flu outbreaks is important as it allows communication strategies to be adjusted to meet emerging needs and assessment to be made of the effects of recommendations for prevention. The ongoing Italian Behavioral Risk Factor Surveillance System (PASSI) offered the setting for investigating people's opinions and behaviors regarding the A/H1N1 pandemic. PASSI surveillance is carried out in 126/148 Italian Local Health Units (LHU) through monthly telephone interviews administered by public health staff to a random sample of the resident population 18-69 years. In fall 2009 additional questions exploring issues related to the A/H1N1 flu were added to the standard questionnaire. The pandemic module was administered on a voluntary basis by the 70 participating LHUs from November 2nd, 2009 to February 7th, 2010; 4 047 interviews were collected. Overall 33% of respondents considered it likely that they would catch flu, 26% stated they were worried, 16% reported having limited some daily activities out of home and 22% said they would accept vaccination if offered. All these indicators showed a decreasing trend across the four-month period of observation. The most trusted sources of information were family doctors (81%). Willingness to be vaccinated was associated with worry about pandemic, age, sex, having a chronic disease and timing of the interview. The surveillance allowed us to gather relevant information, crucial for devising appropriate public health interventions. In future disease outbreaks, systems monitoring people's perceptions and behaviors should be included in the preparedness and response plans.

Features and initial assessment of the Italian Behavioral Risk Factor Surveillance System (PASSI), 2007-2008.

INTRODUCTION: Surveillance systems for health status and behaviors of populations are fundamental for planning, implementing, and monitoring preventive interventions. In 2006, the Italian Ministry of Health provided funding to the National Institute of Public Health to develop an ongoing surveillance system for adult behavioral risk factors. We describe the main features of the system (known as PASSI) and provide a preliminary assessment of its activity. METHODS: PASSI is conducted by participating local health units, which use a common questionnaire and methods. Each month, local health unit staff conduct telephone interviews of a random sample of resident adults aged 18 to 69 years. Data are transmitted to the national coordinating center, where they are cleaned, managed, and made available for local, regional, and national analysis. Training, data analysis, and communications are centrally supervised, and data quality is routinely monitored. RESULTS: In 2007 and 2008, nearly 60,000 interviews were completed. The demographic characteristics of survey participants closely corresponded to census data in the surveyed areas. The response rate was 82%; the refusal rate was 10% or less. Communications activities have been conducted to disseminate the results and encourage their use. CONCLUSION: PASSI is administered by the public health system with limited human and financial resources. In the first 2 years of activity, the data quality was good, and information collected was useful. The organizational model of PASSI may be of interest to countries that are developing surveillance systems as well as those with systems already in place.