SARS-CoV-2 spread and area economic disadvantage in the italian three-tier restrictions: a multilevel approach.

BACKGROUND: To face the second wave of COVID-19, Italy implemented a tiered restriction system with different limitation levels (yellow = medium; orange = medium-high, red = high) at the beginning of November 2020. The restrictions systematically reduced the transmission of SARS-CoV-2 with increasing strength for increasing tier. However, it is unknown whether the effect of limitations was equal between provinces with different socioeconomic levels. Therefore, we investigated the association between the province's socioeconomic level and SARS-CoV-2 infection daily reproduction number in each restriction level. METHODS: We measured the province's socioeconomic level as the percentage of individuals whose 2019 total yearly income was lower than 10,000€, using the measure as a proxy of economic disadvantage. We estimated the daily reproduction number (Rt) at the province level using the SARS-CoV-2 daily incidence data from November 2020 to May 2021. We then used multilevel linear regression models with random intercepts stratified by restriction level to estimate the association between economic disadvantage and Rt. We also adjusted the analyses for potential confounders of the association between the province's economic disadvantage and the Rt: the percentage of people with 0-5 years, the quartiles of population density, and the geographical repartition. RESULTS: Overall, we found increasing Rt in yellow (+ 0.004 p < 0.01, from Rt = 0.99 to 1.08 in three weeks) and containing effects for the orange (-0.005 p < 0.01, from Rt = 1.03 to 0.93) and the red tier (-0.014 p < 0.01, from Rt = 1.05 to 0.76). More economically disadvantaged provinces had higher Rt levels in every tier, although non-significantly in the yellow level (yellow = 0.001 p = 0.19; orange = 0.002 p = 0.02; red = 0.004 p < 0.01). The results showed that the association between economic disadvantage and Rt differed by level of restriction. The number of days into the restriction and the economic disadvantage had statistically significant interactions in every adjusted model. Compared to better off, more economically disadvantaged provinces had slower increasing trends in yellow and steeper Rt reductions in orange, but they showed slower Rt reductions in the highest tier. CONCLUSION: Lower tiers were more effective in more economically disadvantaged provinces, while the highest restriction level had milder effects. These results underline the importance of accounting for socioeconomic level when implementing public health measures.

[The impact of the COVID-19 pandemic on the Italian and foreign population in the various phases: the results of an interregional multicentre project]. / L'impatto della pandemia di COVID-19 nella popolazione italiana e straniera residente nelle diverse fasi: i risultati di un progetto multicentrico inter-regionale.

OBJECTIVES: to analyze the difference of the SARS-CoV-2 infection impact between Italian and foreigner subjects, evaluating the trend of infections and access to diagnostic tests (molecular or antigenic swabs for the detection of SARS- CoV-2) in the two different populations, inducing the detection of new positive cases in the population. DESIGN: retrospective population study for the period February 2020-June 2021. SETTING AND PARTICIPANTS: Italian and foreign resident population on 1st January of the years 2020 and 2021 in the Regions participating to the project: Piedmont, Lombardy, Veneto, Emilia-Romagna (Northern Italy), Tuscany, Lazio (Central Italy), and Sicily (Southern Italy). MAIN OUTCOME MEASURES: in the two populations, for every week and aggregated by macropandemic period were calculated: • the test rate (people tested on the population); • the swab positivity rate (positive subjects on those who are tested); • the new positives (positive subjects on study population); • the percentage of foreigners among the new positive cases. The ratio of the value of the indicators in the foreign and Italian populations (with 95% confidence interval) was calculated to evaluate the association between nationality (Italian vs not Italian) and outcome. The analyses were conducted at the regional level and at pool level. RESULTS: the trend of new positives by nationality (Italian vs not Italian) has a similar tendency in the different pandemic waves. However, the incidence of new positives during pandemic waves among foreigners is lower than in Italians, while it tends to increase during intermediate periods. Except for the summer periods, foreigners are less tested than Italians, but the percentage of new positives out of the total of new ones tested is higher among foreigners compared to Italians. The relative weight of new positives among foreigners tends to increase in periods with the greatest risk of inflow of SARS-CoV-2 for foreigners. CONCLUSIONS: the epidemic trends in the two populations are similar, although foreigners tend to show lower incidence values, probably in part because they are tested less frequently. Furthermore, in foreigners compared to Italians, there is a greater risk of contracting SARS-CoV-2 infection, especially in periods of relaxation of containment Coronavirus measures, reopening of national borders, production and commercial activities.

[Impact of COVID-19 on the immigrant population in the Veneto Region (Northern Italy), by geographical area of origin]. / Impatto del COVID-19 nella popolazione immigrata in Veneto, per area geografica di provenienza.

OBJECTIVES: to examine the differences in SARS-CoV-2 infection and hospitalization rates among migrant populations in Veneto Region (Northern Italy), according to the geographic area of origin. SETTING AND PARTICIPANTS: all residents in Veneto Region aged <65 years were included in the analyses. All subjects infected by SARS-CoV-2 and hospitalized for COVID-19 were identified by means of the regional biosurveillance system. MAIN OUTCOME MEASURES: age- and gender-specific infection and hospitalization rates were stratified by geographic area of origin and were estimated using the number of incident cases over the resident population in Veneto on 01.01.2021. Incidence rate ratios (IRR) for infection and hospitalization rates were estimated using a Poisson model, adjusted for age and gender, among migrants compared to Italians. RESULTS: compared to Italians, SARS-CoV-2 infection rates were significantly higher among migrants from Central and South America and Central and South Asia, lower among those from North Africa and High-Income Countries (HIC), and were approximately halved for those coming from Other Asian Countries (mainly represented by China). Hospitalization rates were significantly higher for all migrant populations when compared to Italians, with the exception of those coming from HIC. Neither age nor gender seemed to modify the association of the geographic area of origin with SARS-CoV-2 infection and hospitalization rates. IRR for SARS-CoV-2 infection of migrants compared to Italians showed how migrants from Other Asian Countries had the lowest infection rates (-53%), followed by people from HIC (-25%), North Africa (-21%), and Eastern Europe (-10%). Higher infection rates were present for Central and South America and Central and South Asia (+17% and +10, respectively). Hospitalization rates were especially high among migrants from Central and South Asia, Africa, and Central and South America, ranging from 1.84 to 3.14 times those observed for Italians. CONCLUSIONS: a significant heterogeneity in SARS-CoV-2 infection and hospitalization rates of migrant populations from different geographic areas of origin were observed. The significantly lower incidence rate ratio for infections, compared to that observed for hospitalizations, is suggestive of a possible under-diagnosis of SARS-CoV-2 infection among migrant populations. Public health efforts should be targeted at increasing support among migrants to contrast the spread of the pandemic by potentiating vaccination campaigns, contact tracing, and COVID-19 diagnostic tests.

Access to SARS-CoV-2 diagnostic tests: are there barriers for the immigrants in Italy?

OBJECTIVES: to describe the epidemiology of SARS-CoV-2 infection in relation with the use of nasal swabs in the immigrant population in Italy, using data from the COVID-19 national surveillance system and to verify if a difference is present comparing natives and immigrant. DESIGN: descriptive study based on longitudinal health-administrative data. SETTING AND PARTICIPANTS: general population of six Italian Regions (Piedmont, Lombardy, Veneto, Emilia-Romagna, Tuscany, Lazio) covering about 55% of the resident population and 72% of foreigners' population. MAIN OUTCOME MEASURES: regional rates of access to at least a nasal swab, separately by country of origin. RESULTS: across all the periods, a lower rate in the foreigners' group was observed, with the only exception of the period May-June 2021. Considering separately High Migratory Pressure Countries (HMPCs) and Highly Developed Countries (HDCs), a higher proportion of nasal swabs performed in people coming from HDC with respect to HMPCs and natives was noticed. This observation is consistent in males and females. CONCLUSIONS: during the first wave of the pandemic, Italians have had a higher proportion of nasal swabs compared to migrants across all Regions. This difference disappeared in the following periods, probably due to a major availability of diagnostic tests.

[SARS-CoV-2 epidemic among Italians e resident immigrant population: differential incidence from an interregional multicentre study]. / L'epidemia di SARS-CoV-2 nella popolazione italiana e straniera: differenze di incidenza che emergono da uno studio multicentrico interregionale.

OBJECTIVES: to describe differences in the incidence of SARS-CoV-2 infections between Italians and foreigners residing in seven Italian Regions during the different phases of the pandemic and by gender. DESIGN: retrospective observational study. SETTING AND PARTICIPANTS: all confirmed SARS-CoV-2 infections from 02.02. 2020 to 16.07.2021 in the seven Regions under study were included. Italian resident population calculated by the National Institute of Statistics as of 01.01.2020 was used to calculate the rates. The considered period is divided into 5 sub-periods (phases). MAIN OUTCOME MEASURES: number of confirmed SARS-CoV-2 infections in the five phases of the pandemic and crude rates by citizenship (Italian vs foreign). Distribution of infections by age group and by week. Crude and age-adjusted incidence rates ratios (IRR) were calculated, by Region, gender, and phase of the pandemic. RESULTS: an epidemic curve delay was observed in foreigners in the first phase of the epidemic, in particular in the northern Regions, the most affected in that phase. The first phase of the epidemic was characterized by a greater proportion of cases occurred in people aged over 60 years than the other phases, both in Italians and in foreigners. The incidence among foreigners is higher during the summer of 2020 (intermediate period: June-September 2020) and during the last period (May-July 2021) in all Regions. The overall figure shows a lower incidence among foreigners than Italians, except for males in Tuscany. CONCLUSIONS: the lower incidence rates among foreigners should be interpreted with caution as the available data suggest that it is at least partly attributable to less access to diagnostic tests. Regional differences found in the study deserve further research together with the effect of gender and country of origin.

[Hospital assistance for COVID-19: a comparison between non-Italian and Italian resident population in five Italian Regions since the beginning of the pandemic until June 2021]. / Un confronto tra italiani e stranieri residenti nell'assistenza ospedaliera per COVID-19 in cinque Regioni italiane da inizio pandemia a giugno 2021.

OBJECTIVES: to describe trends of overall and intensive care hospitalization for COVID-19 since the beginning of the pandemic in Italy until June 2021, and to compare the results between foreign and Italian population. DESIGN: retrospective observational study. SETTING AND PARTICIPANTS: hospital discharges of 28 million people living in Lombardy, Piedmont, Emilia-Romagna (Northern Italy), Toscana and Lazio (Central Italy) occurred between 22.02.2020 and 02.07.2021 in the hospitals located in each considered Region. MAIN OUTCOME MEASURES: two weekly outcomes were examined: 1. the overall number of COVID-19 hospitalizations; 2. the number of COVID-19 hospitalizations in intensive care units. RESULTS: a higher COVID-19 overall and intensive care unit hospitalization was found among the foreign population compared to Italians. The association emerged only after the adjustment for age, and it was consistent among all Regions, though less marked in Lombardy. The association varied across epidemic phases. CONCLUSIONS: the issue of vulnerability of migrants to the risk of severe COVID-19 calls for a diversity-sensitive approach in prevention. The specific country of origin and the prevalence of preventable co-morbidities that are often underestimated in the migrant populations, and related to COVID-19 complications, should be taken into consideration in future analyses.

[Mortality and impact of COVID-19 by citizenship in seven Italian Regions from the beginning of the pandemic to mid-July 2021]. / Mortalità per COVID-19 nella popolazione immigrata in sette Regioni italiane da inizio pandemia a metà luglio 2021.

OBJECTIVES: to quantify the variability of COVID-19 mortality from the beginning of the pandemic to mid-July 2021, in relation to the immigrant status and by Region and period. DESIGN: observational incidence study. SETTING AND PARTICIPANTS: the study population consists of the residents at the beginning of 2020 in seven Regions (Piedmont, Lombardy, Veneto, Emilia-Romagna, Tuscany, Lazio, Sicily) aged <=74 years. MAIN OUTCOME MEASURES: absolute frequency of deaths occurred in subjects who tested positive for SARS-CoV-2, crude and standardized rates (standard: Italian population at the beginning of 2020), and mortality rates ratios (obtained using Poisson models), by immigrant status and stratified by gender, Region of residence, and period. The study period was divided into 5 subperiods: 22.02.2020-25.05.2020, 26.05.2020-02.10.2020, 03.10.2020-26.02.2021, 27.02.2021-16.07.2021. RESULTS: the study includes more than one half of the Italian population and most of the immigrants residing in the country, who are younger than Italians and experienced fewer COVID-19 deaths. Deaths among those who tested positive varied greatly between Regions and periods; standardized rates showed considerable increases over time among immigrants. In terms of rate ratios, there were excesses among immigrant males in the third period (MRR: 1.46; 95%CI 1.30-1.65) and in the fourth period (MRR: 1.55; 95%CI 1, 34-1.81). Among immigrant females, there is an indication of lower risk in the third period (MRR: 0.79; 95%CI 0.65-0.97) and of greater risk in the fourth period (MRR: 1. 46; 95%CI 1.21-1.77). Finally, the effect is modified by the Region of residence, both in the third and in the fourth period for males and only in the fourth period for females. CONCLUSIONS: the risk of premature mortality due to COVID-19 is linked to immigrant status and with an intensity that varies by gender, Region, and period. More accessible tools for prevention, diagnosis and early healthcare can support immigrant communities in managing the risk factors linked to the spread of infections and, in particular, counteract their evolution into more severe disease outcomes.

Mortality differences between migrants and Italians residing in Rome before, during, and in the aftermath of the great recession. A longitudinal cohort study from 2001 to 2015.

BACKGROUND: In Europe, one of the most consistent findings is that of migrant mortality advantage in high-income countries. Furthermore, the literature shows that economic shocks, which bring worse health outcomes, can severely affect the most disadvantaged individuals. We analyse differences and changes in all-cause mortality between Italians and migrants residing in Rome before, during, and in the aftermath of the Great Recession (2001-2015) by birth-cohort. METHODS: The analysis is a longitudinal open cohort study. Mortality data come from the Register of the Causes of Death (58,637 deaths) and the population denominator (n = 2,454,410) comes from the Municipal Register of Rome. By comparing three time-periods (2001-2005, 2006-2010, and 2011-2015), we analyse all-cause mortality of Rome residents born, respectively, in the intervals 1937-1976, 1942-1981, 1947-1986 (aged 25-64 years at entry into observation). Computing birth-cohort-specific death rates and applying parametric survival models with age as the time-scale, we compare mortality differences between migrants and Italians by gender, area of origin, and time-period. RESULTS: Overall, we find a lower risk of dying for migrants than Italians regardless of gender (Women: HR = 0.61, 95% CI 0.56-0.66; Men: HR = 0.49, 95% CI 0.45-0.53), and a lower death risk over time for the total population. Nevertheless, such a pattern changes according to gender and migrants' area of origin. CONCLUSION: Given the relevance of international migrations in Europe, studying migrants' health has proved increasingly important. The deterioration in migrant health and the gradual weakening of migrants' mortality advantage is likely to become a public health issue with important consequences for the healthcare system of all European countries.

Avoidable hospitalisation for diabetes mellitus among immigrants and natives: Results from the Italian Network for Longitudinal Metropolitan Studies.

BACKGROUND AND AIMS: Italy has experienced a relevant increase in migration inflow over the last 20 years. Although the Italian Health Service is widely accessible, immigrants can face many barriers that limit their use of health services. Diabetes mellitus (DM) has a different prevalence across ethnic groups, but studies focusing on DM care among immigrants in Europe are scarce. This study aimed to compare the rates of avoidable hospitalisation (AH) between native and immigrant adults in Italy. METHODS AND RESULTS: A multi-centre open cohort study including all 18- to 64-year-old residents in Turin, Venice, Reggio-Emilia, Modena, Bologna and Rome between 01/01/2001 and 31/12/2013-14 was conducted. Italian citizens were compared with immigrants from high migratory pressure countries who were further divided by their area of origin. We calculated age-, sex- and calendar year-adjusted rate ratios (RRs) and 95% confidence intervals (95% CIs) of AH for DM by citizenship using negative binomial regression models. The RRs were summarized using a random effects meta-analysis. The results showed higher AH rates among immigrant males (RR: 1.63, 95% CI: 1.16-2.23), whereas no significant difference was found for females (RR: 1.14, 95% CI: 0.65-1.99). Immigrants from Asia and Africa showed a higher risk than Italians, whereas those from Central-Eastern Europe and Central-Southern America did not show any increased risk. CONCLUSION: Adult male immigrants were at higher risk of experiencing AH for DM than Italians, with differences by area of origin, suggesting that they may experience lower access to and lower quality of primary care for DM. These services should be improved to reduce disparities.

Disparities in emergency department use between Italians and migrants residing in Rome, Italy: the Rome Dynamic Longitudinal Study from 2005 to 2015.

BACKGROUND: The Emergency Department (ED) can be considered an indicator of accessibility and quality and can be influenced in period of economic downturns. In the last fifteen years, the number of migrants in Italy has doubled (from 2.4 million in 2005 to 5.2 in 2019, 4.1 and 8.7% of the total population, respectively). However, evidence about migrants' healthcare use is poor, and no studies focused on the ED utilisation rate during the Great Recession are available. This study aims to analyse trends in all-cause and cause-specific ED utilisation among migrants and Italians residing in Rome, Italy, before and after 2008. METHODS: Longitudinal study based on data from the Municipal Register of Rome linked to the Emergency Department Register from 2005 to 2015. We analysed 2,184,467 individuals, aged 25-64 in each year. We applied a Hurdle model to estimate the propensity to use the ED and to model how often individuals accessed the ED. RESULTS: Migrants were less likely to be ED users than Italians, except for Africans (RR = 1.46, 95%CI 1.40-1.52) and Latin Americans (RR = 1.04, 95%CI 1.00-1.08) who had higher all-cause utilisation rates than non-migrants. Compared to the pre-2008 period, in the post-2008 we found an increase in the likelihood of being an ED user (OR = 1.34, 95%CI 1.34-1.35), and a decrease in ED utilisation rates (RR = 0.96, 95%CI 0.96-0.97) for the whole population, with differences among migrant subgroups, regardless of cause. CONCLUSIONS: This study shows differences in the ED utilisation between migrants and Italians, and within the migrant population, during the Great Recession. The findings may reflect differentials in the health status, and barriers to access primary and secondary care among migrants. In this regard, health policies and cuts in health spending measures may have played a key role, and interventions to tackle health and access disparities should include policy measures addressing the underlying factors, adopting a Health in All Policies perspective. Further researches focusing on specific groups of migrants, and on the causes and diagnoses related to the ED utilisation, may help to explain the differences observed.

Potentially avoidable hospitalization for asthma in children and adolescents by migrant status: results from the Italian Network for Longitudinal Metropolitan Studies.

BACKGROUND: Global migration toward Europe is increasing. Providing health assistance to migrants is challenging because numerous barriers limit their accessibility to health services. Migrants may be at a greater risk of developing asthma and receiving lower quality healthcare assistance than non-migrants. We aim to investigate whether immigrants as children and adolescents have higher rates of potentially avoidable hospitalization (PAH) for asthma compared to Italians. METHODS: We performed a retrospective longitudinal study using six cohorts of 2-17-year-old residents in North and Central Italy from 01/01/2001 to 31/12/2014 (N = 1,256,826). We linked asthma hospital discharges to individuals using anonymized keys. We estimated cohort-specific age and calendar-year-adjusted asthma PAH rate ratios (HRRs) and 95% confidence intervals (95%CIs) among immigrants compared to Italians. We applied a two-stage random effect model to estimate asthma PAH meta-analytic rate ratios (MHRRs). We analyzed data by gender and geographical area of origin countries. RESULTS: Three thousand three hundred four and 471 discharges for asthma PAH occurred among Italians and immigrants, respectively. Compared to Italians, the asthma PAH cohort-specific rate was higher for immigrant males in Bologna (HRR:2.42; 95%CI:1.53-3.81) and Roma (1.22; 1.02-1.45), and for females in Torino (1.56; 1.10-2.20) and Roma (1.82; 1.50-2.20). Asthma PAH MHRRs were higher only among immigrant females (MHRRs:1.48; 95%CI:1.18-1.87). MHRRs by area of origin were 63 to 113% higher among immigrants, except for Central-Eastern Europeans (0.80; 0.65-0.98). CONCLUSION: The asthma PAH meta-analytic rate was higher among female children and adolescent immigrants compared to Italians, with heterogeneity among cohorts showing higher cohort-specific PAH also among males, with some differences by origin country. Access to primary care for children and adolescent immigrants should be improved and immigrants should be considered at risk of severe asthma outcomes and consequently targeted by clinicians.

[Urban health and inequalities in highly socially marginalised settings in Rome]. / Salute urbana e disuguaglianze a Roma in contesti a elevata marginalità sociale.

OBJECTIVES: to describe hospitalisation, access to emergency care, and mortality of people living in marginalized urban areas which include public housing buildings in the North-West suburb of Rome, and to compare the results with those observed among people living in the neighbouring area. DESIGN: cross sectional study. SETTING AND PARTICIPANTS: resident population in the XIII and XIV Municipality of Rome, subdivided into five urban areas, in 2011-2018. MAIN OUTCOME MEASURES: hospitalisation, access to emergency care, and mortality rates and rates ratios based on hospital discharges and emergency department visits derived from the Health Information Systems and from the Mortality Registry of Lazio Region (Central Italy), stratified by urban areas. RESULTS: the results show a higher use of hospital assistance and emergency care services as well a higher mortality among residents of urban areas characterized by marginalization and social disadvantage in the North-West suburb in Rome, compared to the surrounding area. The association is stronger for the residents of ex-Bastogi, a compound particularly marginalised and socially disadvantaged, where excesses in hospitalisation, emergency care admission, and mortality of +60%, +150%, and +140%, respectively, occurred. CONCLUSIONS: the excesses of hospital use, emergency care visits, and mortality observed among the residents of marginalized urban areas suggest the need to reorganize the preventive and primary care services considering the socioeconomic disadvantage in such housing contexts. The use of both qualitative and quantitative approaches allows to understand the complexity of such contexts.

[Evaluating health care of the immigrant population in Italy through indicators of a national monitoring system]. / Valutazione dell'assistenza sanitaria della popolazione immigrata in Italia attraverso alcuni indicatori di un sistema nazionale di monitoraggio.

OBJECTIVES: to evaluate maternal and child healthcare, avoidable hospitalisation, access to emergency services among immigrants in Italy. DESIGN: cross sectional study of some health and health care indicators among Italian and foreign population residing in Italy in 2016-2017. SETTING AND PARTICIPANTS: indicators based on the national monitoring system coordinated by the Italian National Institute for Health, Migration and Poverty (INMP) of Rome, calculated on perinatal care (CedAP), hospital discharge (SDO), emergency services (EMUR) archives for the years 2016-2017, by of the following regions: Piedmont, Trento, Bolzano, Emilia-Romagna, Tuscany, Umbria, Lazio, Basilicata, Sicily. MAIN OUTCOME MEASURES: number and timeliness of pregnancy visits, number of ultrasounds, invasive prenatal investigations; perinatal mortality rates, birth weight, Apgar score at 5 minutes, need for neonatal resuscitation; standardized rates of avoidable hospitalisation and access to emergency services by triage code. RESULTS: more often than Italians, immigrant women have during pregnancy: less than 5 gynaecological examination (16.3% vs 8.5%), first examination after the 12th week of gestational age (12.5% vs 3.8%), less than 2 ultrasounds (3.8% vs 1.0%). Higher perinatal mortality rates among immigrants compared to Italians (3.6 vs 2.3 x1,000). Higher standardized rates (x1,000) among immigrants compared to Italians of avoidable hospitalisation (men: 2.1 vs 1.4; women: 0.9 vs 0.7) and of white triage codes in emergency (men: 62.0 vs 32.7; women: 52.9 vs 31.4). CONCLUSIONS: study findings show differences in access and outcomes of healthcare between Italians and immigrants. National monitoring system of indicators, coordinated by INMP, represents a useful tool for healthcare intervention policies aimed to health equity.

[Immigrants' health and socioeconomic inequalities of overall population residing in Italy evaluated through the Italian network of Longitudinal Metropolitan Studies]. / Salute degli immigrati e disuguaglianze socioeconomiche nella popolazione residente in Italia valutate attraverso la rete degli Studi Longitudinali Metropolitani.

INTRODUCTION: Describing and monitoring socioeconomic inequalities in health are the prerequisite for planning equity policies. In Italy, some cities have integrated personal information from the municipal registries with Census data and with data from healthcare information systems to set up Longitudinal Metropolitan Studies (LMS). Under the coordination of the Italian National Institute for Health, Migration, and Poverty (NIHMP), six cities in the LMS network have contributed to the present monograph: Turin, Venice, Reggio Emilia, Modena, Bologna, and Rome. MORTALITY RESULTS. Significant socioeconomic differences by level of education were seen in all the participating centres. People who live alone or in single-parent households are more likely to die, as are those living in a substandard dwelling. Immigrants resident in the six cities included in the study showed lower all-cause mortality than Italians (males: MRR 0.83; 95%CI 0.78-0.90 - females: MRR 0.70; 95%CI 0.64-0.77). Sub-Saharan Africans experienced a significant higher mortality than Italians (males: MRR 1.33; 95%CI 1.12-1.59 - females: MMR 1.69; 95%CI 1.31-2.17). Immigrants had a neonatal and post-neonatal mortality risk about 1.5 times higher than Italians (neonatal: OR 1.71; 95%CI 1.22-2.39 - post-neonatal: OR 1.63; 95%CI 1.03-2.57). A difference between Italians and immigrants was also observed for mortality in children aged 1-4 years, though less marked (OR 1.24; 95%CI 0.73-2.11). Excesses concerned particularly immigrants from North Africa and from sub-Saharan Africa as well as those residing in Italy for >5 years. HOSPITALISATION RESULTS. Hospitalisation rates are lower for immigrants than for Italians, except when due to infectious diseases, blood disorders, and, among women, for reasons linked to pregnancy and childbirth. Avoidable hospitalisation rates of adults from low migratory pressure Countries are lower than or equal to those of Italians. On the contrary, adults from low migratory pressure Countries show higher avoidable hospitalisation rates compared to Italians in every cohort, with the exception of Rome (RR 0.81; 95%CI 0.78-0.85), with RR ranging from 1.08 (95%CI 0.96-1.22) in Venice to 1.64 (95%CI 1.47-1.83) in Modena. CONCLUSIONS: Maternal and child health is the most critical area of health for immigrant population. Considering the importance that the issue of health equity has taken on in the political agenda, the data presented in this volume are a great asset, particularly in light of the long recession and the social crisis that have impacted the Country.

Avoidable hospitalization among migrants and ethnic minority groups: a systematic review.

Background: The numbers of migrants living in Europe are growing rapidly, and has become essential to assess their access to primary health care (PHC). Avoidable Hospitalization (AH) rates can reflect differences across migrant and ethnic minority groups in the performance of PHC. We aimed to conduct a systematic review of all published studies on AH comparing separately migrants with natives or different racial/ethnic groups, in Europe and elsewhere. Methods: We ran a systematic search for original articles indexed in primary electronic databases on AH among migrants or ethnic minorities. Studies presenting AH rates and/or rate ratios between at least two different ethnic minority groups or between migrants and natives were included. Results: Of the 35 papers considered in the review, 28 (80%) were conducted in the United States, 4 in New Zealand, 2 in Australia, 1 in Singapore, and none in Europe. Most of the studies (91%) used a cross-sectional design. The exposure variable was defined in almost all articles by ethnicity, race, or a combination of the two; country of birth was only used in one Australian study. Most of the studies found significant differences in overall AH rates, with minorities (mainly Black and Hispanics) showing higher rates than non-Hispanic Whites. Conclusions: AH has been used, mostly in the US, to compare different racial/ethnic groups, while it has never been used in Europe to assess migrants' access to PHC. Studies comparing AH rates between migrants and natives in European settings can be helpful in filling this lack of evidence.

[Implementation of DNA-HPV primary screening in Italian cervical cancer screening programmes. Results of the MIDDIR Project]. / L'implementazione del DNA-HPV come test primario nei programmi italiani di screening del cervicocarcinoma. Risultati del Progetto MIDDIR.

OBJECTIVES: to obtain data on conversion paths to HPV testing as part of screening programmes and to harmonize the introduction of HPV testing in primary cervical cancer screening protocols of Italian programmes. DESIGN: survey by questionnaire on strategies adopted by screening programmes for transition to primary HPV testing; systematic review of the literature; discussion among experts. SETTING AND PARTICIPANT S: managers of Italian Regions' cervical cancer screening programmes. MAIN OUTCOME MEASURES: transition planning; activity volumes; modalities of centralization; criteria for dismissal; staff training; communication initiatives. RESULTS: nine cervical screening programmes responded to the survey. Most of them chose to schedule a transition of a few years to allow for adjustment of the volume of activity in the passage from the three-year screening interval to the five-year one. To select women to be given precedence, 7 programmes use the age, starting from the oldest. The liquid base is the choice by far preferred both for HPV test and for Pap test. The reading of HPV test "born" already centralized, but a centralization process is in place also for cytology. CONCLUSIONS: the survey on conversion strategies to primary HPV testing showed the opportunity to schedule a transition phase. For HPV test, cost, organization, and quality benefits of centralization are clear, thus the central organization should be preferred and managed immediately. Moreover, the need for a centralization of cytology is evident. The tariff scheme should be based on the whole process rather than on single performances. Dismissal strategies have to be tailored on peculiarities of single services, but some typologies can be outlined.

Differences in mortality by immigrant status in Italy. Results of the Italian Network of Longitudinal Metropolitan Studies.

Despite a rapid increase in immigration from low-income countries, studies on immigrants' mortality in Italy are scarce. We aimed to describe differences in all and cause-specific mortality among immigrants and Italians residing in Turin and Reggio Emilia (Northern Italy), two cities participating in the Italian Network of Longitudinal Metropolitan Studies (IN-LiMeS). We used individual data from the municipal population registers linked to the cause of death registers. All people aged 1-64 years residing between 2001 and 2010 were enrolled (open cohort) and followed up until 2013. The mortality of citizens from high migratory pressure countries (as a whole, and for each macro-area group) was compared with that of Italians; differences were estimated by Poisson regression adjusted by age and calendar year mortality rate ratios (MRRs), and by age-standardized mortality ratios for the analysis of cause-specific mortality. Compared with Italians, immigrants had lower overall mortality (MRR for men: 0.82, 95 % CI: 0.75-0.90; for women: 0.71, 95 % CI: 0.63-0.81). Sub-Saharan Africans experienced a significant higher mortality than Italians (MRR for men 1.29, 95 % CI: 1.03-1.61; for women: 1.70, 95 % CI: 1.22-2.36). Higher mortality for immigrants compared to Italians was observed for infectious diseases, congenital anomalies, some site-specific tumours and homicide mortality. Our study showed heterogeneity in mortality across the macro-areas of origin, and in particular Sub-Saharan Africans seemed to be a vulnerable population. The extension to other cohorts of IN-LiMeS will allow the health status of immigrants and vulnerable groups to be studied and monitored in more depth.

[Audit and feedback, and continuous quality improvement strategies to improve the quality of care for type 2 diabetes: a systematic review of literature]. / Audit e feedback e interventi di continuous quality improvement per il miglioramento della qualità delle cure nella gestione del diabete di tipo 2: una revisione sistematica della letteratura scientifica.

OBJECTIVES: we analysed evidence on effective interventions to improve the quality of care and management in patients with diabetes type 2. This review focuses particularly on audit and feedback intervention, targeted to healthcare providers, and continuous quality improvement (CQI) involving health professionals and health care systems, respectively. METHODS: we searched The Cochrane Library, PubMed, and EMBASE (search period: January 2005-December 2015) to identify systematic reviews (SR) and randomized controlled trials (RCTs) considering patients' outcomes and process measures as quality indicators in diabetes care. Selection of studies and data extraction were carried out independently by two reviewers. Methodological quality of individual studies was assessed using the checklist «Assessment of methodological quality of systematic review¼ (AMSTAR) and the Cochrane's tool, respectively. We produced summaries of results for each study design. RESULTS: the search process resulted in 810 citations. One SR and 7 RCTs that compared any intervention in which audit and feedback and CQI was a component vs. other interventions were selected. The SR found that audit and feedback activity was associated with improvements of glycaemic (mean difference: 0.26; 95%CI 0.08;0.44) and cholesterol control (mean difference: 0.03; 95%CI -0.04;0.10). CQI interventions were not associated with an improvement of quality of diabetes care. The RCTs considered in this review compared a broad range of interventions including feedback as unique activity or as part of more complex strategies. The methodological quality was generally poor in all the included trials. CONCLUSIONS: the available evidence suggests that audit and feedback and CQI improve quality of care in diabetic patients, although the effect is small and heterogeneous among process and outcomes indicators.

Access to SARS-CoV-2 vaccination in immigrants in Italy, by geographical area of origin.

OBJECTIVE: Immigrants are commonly considered disadvantaged and at high risk of not receiving appropriate care, including vaccination. This study aimed to evaluate the access to SARS-CoV-2 vaccination in immigrants, by geographical area of origin, compared with Italian citizens. We also evaluated sex differences in vaccine's coverage by geographical area of origin. METHODS: We performed a retrospective observational study in four Italian regions, including all resident subjects aged 5-69 years, and undergoing first dose SARS-CoV-2 vaccination in the period 28th December 2020- 3rd April 2022. We estimated cumulative coverage percentages, by age class and geographical area. To compare first-dose vaccine coverage by geographical area of origin, we estimated, through a Poisson analysis, Vaccine Coverage Ratios (VCR) with 95 % confidence intervals (95 %CI), adjusting for age and sex. RESULTS: We included 16,294,785 Italian citizens and 2,534,351 immigrants aged 5-69 years and resident in the four regions considered. Regarding the geographical area of origin, 40.7 % of immigrants came from Eastern Europe, 13.5 % from North Africa and 13.1 % from Western Asia. A great variability in the first dose vaccine coverage emerged. We documented substantial heterogeneity in the first-dose vaccine coverage within immigrant's population, expressed with Italy as a reference, ranging from 0,768 (95 %CI: 0,766-0,769) in Eastern Europe countries to 1,013 (95 %CI: 1,009 - 1,018) in Eastern Asia. The chance of being vaccinated was found higher in males compared with females for African countries (VCR 1.07, 95 %CI 1.06-1.08) and Western Asian countries (VCR 1.08, 95 %CI 1.07-1.09). CONCLUSION: We observed substantial heterogeneity in first-dose SARS-CoV-2 vaccination coverage in immigrants, suggesting a different propensity to vaccines according to the geographical area of origin. These data can help define appropriate and tailored strategies in order to improve vaccine coverage in some specific immigrant groups at the local health district level.

Covid-19 vaccination among migrants in Rome, Italy.

Migrants may be susceptible to vaccine barriers and hesitancy. We evaluated the association between migrant status, as measured by the citizenship from a High Migratory Pressure Country (HMPC), and COVID-19 vaccination uptake in the resident population in Rome, Italy. We also investigated sex differences. We followed participants for vaccination against COVID-19 in 2021. We calculated crude- and adjusted-vaccination rates and Cox hazard ratios of vaccination for migrants compared to Italians. Among migrants from HMPCs, we estimated HRs for females compared to males, stratifying by geographical area of origin. Models were adjusted for age and deprivation index and stratified by infection history. In 2021, among 1,731,832 18-64-year-olds, migrants were 55% less likely to uptake at least one COVID-19 vaccine dose than their Italian counterpart. Past SARS-CoV-2 infection reduced the difference between migrants and Italians to 27%. Among migrants from HMPCs, we observed a slight excess of vaccination uptake among females compared to males. Focusing on geographical areas, we observed that only females from central-western Asia were 9% less likely to uptake vaccination than males. Health communication strategies oriented to migrants and considering their different languages, cultures, and health literacy should be adopted for prevention before emergencies.