Is HCMV vaccine an unmet need? The state of art of vaccine development.

Congenital HCMV infection is the most frequent congenital infection, with an incidence of 0.2- 2.5 percent among all live births. About 11 percent of infected newborns show symptoms at birth, including hepato-splenomegaly, thrombocytopenia, neurologic involvement, hearing impairment and visual deficit. Moreover, 5-25 percent of the asymptomatic congenital HCMV-infected neonates will develop sequelae over months or even years. The relevant social burden, the economic costs of pre-natal screening, post-natal diagnosis, follow-up and possible therapy, although still limited, are the major factors to be considered. Several types of vaccines have been explored in order to develop an effective and safe HCMV vaccine: live attenuated, subunit, vectored, peptide, DNA, and subviral ones, but none are available for use. This review illustrates the different vaccine types studied to date, focusing on the possible vaccination strategy to be implemented once the HCMV vaccine is available, in terms of target population.

Epidemiological surveillance of West Nile neuroinvasive diseases in Italy, 2008 to 2011.

We describe the geographical and temporal distribution of West Nile neuroinvasive diseases (WNND) cases in Italy from 2008 to 2011. The increasing number of confirmed human cases from eight in 2008 to 18 in 2009 and the occurrence of the virus in a larger geographical area in 2009 (moving from east to west) prompted the Ministry of Health to publish, in spring 2010, a national programme for WNND human surveillance, comprising veterinary and vector surveillance. Subsequently, in 2011, a new national plan on integrated human surveillance of imported and autochthonous vector-borne diseases (chikungunya, dengue and West Nile disease) was issued. Between 2008 and 2011, 43 cases of WNND were reported from five regions in Italy with a case fatality rate of 16%. The incidence of WNND during the entire study period was 0.55 per 100,000 population (range: 0.06­0.23 per 100,000). During 2011, two new regions (Friuli-Venezia Giulia and Sardinia) reported confirmed cases in humans. Integrated human, entomological and animal surveillance for West Nile virus is a public health priority in Italy and will be maintained during 2012.

Response to the 2009 influenza A(H1N1) pandemic in Italy.

In Italy, the arrival of the 2009 pandemic influenza A(H1N1) virus triggered an integrated response that was mainly based on the 2006 National Pandemic Preparedness and Response Plan. In this article we analyse the main activities implemented for epidemiological surveillance, containment and mitigation of the pandemic influenza and the lesson learned from this experience. Overall, from week 31 (27 July ­ 2 August) of 2009 to week 17 (26 April ­ 2 May) of 2010, we estimate that there were approximately 5,600,000 cases of influenza-like illness (ILI) who received medical attention (with almost 2,000 laboratory-confirmed cases of pandemic influenza from May to October 2009). A total of 1,106 confirmed cases were admitted to hospital for serious conditions, of whom 532 were admitted to intensive care units. There were 260 reported deaths due to pandemic influenza. Approximately 870,000 first doses of the pandemic vaccine were administered, representing a vaccine coverage of 4% of the target population. One of the possible reasons for the low uptake of the pandemic vaccine in the target population could be the communication strategy adopted, for both the general population and healthcare workers, which turned out to be a major challenge. Active involvement of all health professionals (at local, regional and national level) in influenza pandemic preparedness and response should be encouraged in the future.

Differences in national influenza vaccination policies across the European Union, Norway and Iceland 2008-2009.

In 2009 the second cross-sectional web-based survey was undertaken by the Vaccine European New Integrated Collaboration Effort (VENICE) project across 27 European Union (EU) member states (MS), Norway and Iceland (n=29) to determine changes in official national seasonal influenza vaccination policies since a survey undertaken in 2008 and to compare the estimates of vaccination coverage between countries using data obtained from both surveys. Of 27 responding countries, all recommended vaccination against seasonal influenza to the older adult population. Six countries recommended vaccination of children aged between six months and <18 years old. Most countries recommended influenza vaccination for those individuals with chronic medical conditions. Recommendations for vaccination of healthcare workers (HCW) in various settings existed in most, but not all countries. Staff in hospitals and long-term care facilities were recommended vaccination in 23 countries, and staff in out-patient clinics in 22 countries. In the 2009 survey, the reported national estimates on vaccine coverage varied by country and risk group, ranging from 1.1% - 82.6% for the older adult population; to between 32.9% -71.7% for clinical risk groups; and from 13.4% -89.4% for HCW. Many countries that recommend the influenza vaccination do not monitor the coverage in risk groups. In 2008 and 2009 most countries recommended influenza vaccination for the main risk groups. However, despite general consensus and recommendations for vaccination of high risk groups, many countries do not achieve high coverage in these groups. The reported vaccination coverage still needs to be improved in order to achieve EU and World Health Organization goals.

Characterisation of Neisseria meningitidis C strains causing two clusters in the north of Italy in 2007 and 2008.

Two clusters of invasive meningococcal disease in the north of Italy both due to serogroup C/ST-11 clonal complex are here described. The objective of the investigation was to analyse the phenotype and the genotype of meningococci involved in the two clusters which were of national relevance due to the fatal outcome of the majority of cases (six of the total of 10 cases). All the strains were C:2a:P1.5 ST-11/ET-37 clonal complex. Two pulsed field gel electrophoresis (PFGE) and variable number tandem repeats (VNTR) profiles were identified, one for each cluster. VNTRs were different from those detected in Italy for C/ST-11 strains isolated from sporadic cases in the same period. This laboratory surveillance report highlights the importance and the crucial role of molecular characterisation to confirm the relatedness among meningococci responsible for clusters of cases.

Enhanced epidemiological surveillance of influenza A(H1N1)v in Italy.

As of 7 July 2009, a total of 158 laboratory-confirmed cases of influenza A(H1N1)v were reported in Italy, from half of the 21 Italian regions. To date all cases have had symptoms consistent with seasonal influenza and no severe or fatal cases have been reported. An active surveillance of cases has been set up in Italy in order to undertake appropriate measures to slow down the spread of the new virus. This report describes the routine and enhanced surveillance currently ongoing in Italy.

West Nile virus transmission with human cases in Italy, August - September 2009.

In 2009, to date 16 human cases of West Nile neuroinvasive disease (WNND) have been reported in Italy, in three regions: Veneto, Emilia-Romagna and Lombardia. The number of cases is higher compared with last year when nine cases were identified (eight cases of WNND and one case of West Nile fever) and the geographical distribution indicates spread from east to west.

Introduction of human papillomavirus (HPV) vaccination into national immunisation schedules in Europe: Results of the VENICE 2007 survey.

The European Union Member States are simultaneously considering introducing HPV vaccination into their national immunisation schedules. The Vaccine European New Integrated Collaboration Effort (VENICE) project aims to develop a collaborative European vaccination network. A survey was undertaken to describe the decision status and the decision-making process regarding the potential introduction of human papillomavirus (HPV) vaccination in to their national immunisation schedules. A web-based questionnaire was developed and completed online in 2007 by 28 countries participating in VENICE. As of 31 October 2007,five countries had decided to introduce HPV vaccination into the national immunisation schedule, while another seven had started the decision-making process with a recommendation favouring introduction. Varying target populations were selected by the five countries which had introduced the vaccination. Half of the surveyed countries had undertaken at least one ad hoc study to support the decision-making process. According to an update of the decision-status from January 2008, the number of countries which had made a decision or recommendation changed to 10 and 5 respectively. This survey demonstrates the rapidly evolving nature of HPV vaccine introduction in Europe and the existence of expertise and experience among EU Member States. The VENICE network is capable of following this process and supporting countries in making vaccine introduction decisions. A VENICE collaborative web-space is being developed as a European resource for the decision-making process for vaccine introduction.

National seasonal influenza vaccination survey in Europe, 2008.

A cross-sectional survey was undertaken with the European Union (EU) Member States and Norway and Iceland to describe seasonal influenza immunisation in the 2006-7 season, in particular to identify country-specific recommendations for risk groups, obtain vaccine uptake information and allow comparison with global recommendations. A standardised questionnaire was completed electronically by each country's project gatekeeper. Of the 29 countries surveyed, 28 recommended seasonal influenza vaccination for older age groups (22 for those aged > 65 years), and in one country vaccine was recommended for all age groups. All countries recommended vaccinating patients with chronic pulmonary and cardiovascular diseases and most countries advised to immunise patients with haematologic or metabolic disorders (n=28), immunologic disorders (n=27) and renal disease (n=27), as well as residents of long-term care facilities (n=24). Most countries recommended vaccination for staff in hospitals (n=25), long-term care facilities (n=25) and outpatient clinics (n=23), and one-third had such recommendations for workers in essential (n=10), military (n=10) and veterinary services (n=10) and poultry industry (n=13). Eight countries recommended vaccine for pregnant women; and five advised to vaccinate children (with age limits ranging from 6 months to 5 years). Twenty countries measured influenza vaccine uptake among those aged > 65 years (range 1.8%-82.1%), seven reported uptake in healthcare workers (range 14%-48%) and seven assessed coverage in persons with underlying medical conditions (range 27.6%-75.2%). The data provided by this study can assist EU states to assess and compare their influenza vaccination programme performance with other countries. The information provides a comprehensive overview of policies and programmes and their outcomes and can be used to inform joint discussions on how the national policies in the EU might be standardised in the future to achieve optimal coverage. Annual surveys could be used to monitor changes in these national policies.

Control of targeting ligand display by pH-responsive polymers on gold nanoparticles mediates selective entry into cancer cells.

Selective targeting of cells for intracellular delivery of therapeutics represents a major challenge for pharmaceutical intervention in disease. Here we show pH-triggered receptor-mediated endocytosis of nanoparticles via surface ligand exposure. Gold nanoparticles were decorated with two polymers: a 2 kDa PEG with a terminal folate targeting ligand, and a di-block copolymer including a pH-responsive and a hydrophilic block. At the normal serum pH of 7.4, the pH-responsive block (apparent pKa of 7.1) displayed a hydrophilic extended conformation, shielding the PEG-folate ligands, which inhibited cellular uptake of the nanoparticles. Under pH conditions resembling those of the extracellular matrix around solid tumours (pH 6.5), protonation of the pH-responsive polymer triggered a coil-to-globule polymer chain contraction, exposing folate residues on the PEG chains. In line with this, endocytosis of folate-decorated polymer-coated gold nanoparticles in cancer cells overexpressing folate receptor was significantly increased at pH 6.5, compared with pH 7.4. Thus, the tumour acidic environment and high folate receptor expression were effectively exploited to activate cell binding and endocytosis of these nanoparticles. These data provide proof-of-concept for strategies enabling extracellular pH stimuli to selectively enhance cellular uptake of drug delivery vectors and their associated therapeutic cargo.

Pneumococcal vaccination policy in Europe.

Infection due to Streptococcus pneumoniae (Pneumococcus) (Pnc) is an important cause of invasive clinical manifestations such as meningitis, septicaemia and pneumonia, particularly in young children and the elderly. A 23-valent polysaccharide Pnc vaccine (PPV) has been available for many years and a 7-valent conjugate Pnc vaccine (PCV) has been licensed since 2001 in Europe. As part of a European Union (EU) funded project on pneumococcal disease (Pnc-EURO), a questionnaire was distributed to all 15 EU member states, Switzerland, Norway and the 10 accession countries in 2003 to ascertain current pneumococcal vaccination policy. Twenty three of the 27 target countries, constituting the current European Union (plus Norway and Switzerland), completed the questionnaire. PPV was licensed in 22 of the 23 responding countries and was in the official recommendations of 21. In all the 20/21 countries for which information was available, risk groups at higher risk of infection were targeted. The number of risk groups targeted ranged from one to 12. At least 17 countries recommend that PPV be administered to all those >65 years of age (in three countries, to those over 60 years of age). Thirteen countries had developed national recommendations for PCV in 2003. No country recommended mass infant immunisation at that time, but rather targeted specific risk groups (between 1 and 11), particularly children with asplenia (n=13) and HIV infection (n=12). PCV use was restricted to children under two years of age in seven countries, and in four countries to children under five years of age. Future decisions on use of pneumococcal vaccines in Europe will be decided on the basis of several factors including: local disease burden; the predicted impact of any universal programme, particularly the importance of serotype replacement and herd immunity (indirect protection to the unvaccinated population); the effectiveness of reduced dose schedules, and vaccine cost. Indeed, at least one country, Luxembourg, has since implemented a universal infant PCV immunisation policy.

Pneumococcal vaccination policy in Europe.

Infection due to Streptococcus pneumoniae (Pneumococcus) (Pnc) is an important cause of invasive clinical manifestations such as meningitis, septicaemia and pneumonia, particularly in young children and the elderly. A 23-valent polysaccharide Pnc vaccine (PPV) has been available for many years and a 7-valent conjugate Pnc vaccine (PCV) has been licensed since 2001 in Europe. As part of a European Union (EU) funded project on pneumococcal disease (Pnc-EURO), a questionnaire was distributed to all 15 EU member states, Switzerland, Norway and the 10 accession countries in 2003 to ascertain current pneumococcal vaccination policy. Twenty three of the 27 target countries, constituting the current European Union (plus Norway and Switzerland), completed the questionnaire. PPV was licensed in 22 of the 23 responding countries and was in the official recommendations of 21. In all the 20/21 countries for which information was available, risk groups at higher risk of infection were targeted. The number of risk groups targeted ranged from one to 12. At least 17 countries recommend that PPV be administered to all those >65 years of age (in three countries, to those over 60 years of age). Thirteen countries had developed national recommendations for PCV in 2003. No country recommended mass infant immunisation at that time, but rather targeted specific risk groups (between 1 and 11), particularly children with asplenia (n=13) and HIV infection (n=12). PCV use was restricted to children under two years of age in seven countries, and in four countries to children under five years of age. Future decisions on use of pneumococcal vaccines in Europe will be decided on the basis of several factors including: local disease burden; the predicted impact of any universal programme, particularly the importance of serotype replacement and herd immunity (indirect protection to the unvaccinated population); the effectiveness of reduced dose schedules, and vaccine cost. Indeed, at least one country, Luxembourg, has since implemented a universal infant PCV immunisation policy.

[Antibiotic-resistance in Italy: activity of the first year of the surveillance project AR-ISS]. / Antibiotico-resistenza in Italia: un anno di attività del progetto di sorveglianza AR-ISS.

The antibiotic resistance surveillance project AR-ISS, started in 2001, is based on a network of 62 sentinel microbiological laboratories throughout the country. The laboratories collect and transmit data to the Istituto Superiore di Sanità on the antibiotic susceptibility of bloodstream isolates of 7 species: Staphylococcus aureus, Streptococcus pneumoniae, Enterococcus faecalis/faecium, Klebsiella pneumoniae/oxytoca ed Escherichia coli. They also send selected bacterial strains for further characterization. Results of the first year of surveillance are presented and are compared with data from the previous study EARSS-Italia and from other European countries. Oxacillin resistance in S. aureus appears to be stable, however, it remains one of the highest in Europe (41,5%). No strain with intermediate susceptibility or resistance to vancomycin has been isolated. In S. pneumoniae, the level of penicillin resistance is moderate (10,8%), but macrolide resistance has increased greatly (37,6% versus 28,6% of the previous study), following a tendency common to several European countries. Unexpectedly, vancomycin resistance in E. faecium was found to be 18%, the highest in Europe. Presumptive ESBL production in Gram-negative organisms can be estimated at 20% in Klebsiella and 1% in E. coli. Ampicillin and ciprofloxacin resistance in E. coli (respectively 50% and 18%) are among the highest in Europe. In conclusion, the rate of antibiotic resistance in the species studied is worrisome and requires continuing monitoring. Although some activities of AR-ISS need improvements, the surveillance has the potentiality to produce relevant and representative data about antibiotic resistance in Italy that can be used for comparison at the European level.

Tuberculosis in HIV-infected subjects in Italy: a multicentre study. The Gruppo Italiano di Studio Tubercolosi e AIDS.

OBJECTIVES: To evaluate the strength of the association between tuberculosis and HIV infection in Italy, to assess the pattern of this association in relation to HIV transmission categories, and to describe clinical presentation of tuberculosis in a large group of Italian HIV-infected subjects. DESIGN: Multicentre review of clinical records. SETTING: Twenty-one infectious disease hospital units in nine of the 20 administrative regions of Italy. PATIENTS, PARTICIPANTS: All HIV-infected adults observed by each participating unit (in- and outpatients) between 1985 and 1989. MAIN OUTCOME MEASURE: Culture-proven tuberculosis. RESULTS: A total of 306 cases of tuberculosis were observed. Of these, 85 were pulmonary, 167 extrapulmonary, and 54 both pulmonary and extrapulmonary. The proportion of HIV-infected subjects diagnosed with tuberculosis increased during the study period from three out of 1380 (0.2%) in 1985 to 152 out of 6504 subjects (2.3%) in 1989 (P less than 0.0001). Two hundred and twenty-six of the 2760 (8.19%) patients with AIDS had tuberculosis within 12 months of AIDS diagnosis; the proportion of AIDS patients with tuberculosis remained stable after 1985. Compared with AIDS patients who were intravenous drug users, only homosexual AIDS patients had a significantly lower proportion of tuberculosis (178 out of 1958 versus 30 out of 522; P less than 0.02). CONCLUSIONS: Our data show that tuberculosis is quite common among HIV-infected subjects in Italy, and suggest that the risk of tuberculosis in these subjects has not changed. There are some differences between the pattern of the association between tuberculosis and HIV infection in Italy, compared with other industrialized countries.

Incorporation of noncoded amino acids into the N-terminal domain 1-47 of hirudin yields a highly potent and selective thrombin inhibitor.

Hirudin is an anticoagulant polypeptide isolated from a medicinal leech that inhibits thrombin with extraordinary potency (Kd = 0.2-1.0 pM) and selectivity. Hirudin is composed of a compact N-terminal region (residues 1-47, cross-linked by three disulfide bridges) that binds to the active site of thrombin, and a flexible C-terminal tail (residues 48-64) that interacts with the exosite I of the enzyme. To minimize the sequence of hirudin able to bind thrombin and also to improve its therapeutic profile, several N-terminal fragments have been prepared as potential anticoagulants. However, the practical use of these fragments has been impaired by their relatively poor affinity for the enzyme, as given by the increased value of the dissociation constant (Kd) of the corresponding thrombin complexes (Kd = 30-400 nM). The aim of the present study is to obtain a derivative of the N-terminal domain 1-47 of hirudin displaying enhanced inhibitory potency for thrombin compared to the natural product. In this view, we have synthesized an analogue of fragment 1-47 of hirudin HM2 in which Val1 has been replaced by tert-butylglycine, Ser2 by Arg, and Tyr3 by beta-naphthylalanine, to give the BugArgNal analogue. The results of chemical and conformational characterization indicate that the synthetic peptide is able to fold efficiently with the correct disulfide topology (Cys6-Cys14, Cys16-Cys28, Cys22-Cys37), while retaining the conformational properties of the natural fragment. Thrombin inhibition data indicate that the effects of amino acid replacements are perfectly additive if compared to the singly substituted analogues (De Filippis V, Quarzago D, Vindigni A, Di Cera E, Fontana A, 1998, Biochemistry 37:13507-13515), yielding a molecule that inhibits the fast or slow form of thrombin by 2,670- and 6,818-fold more effectively than the natural fragment, and that binds exclusively at the active site of the enzyme with an affinity (Kd,fast = 15.4 pM, Kd,slow = 220 pM) comparable to that of full-length hirudin (Kd,fast = 0.2 pM, Kd,slow = 5.5 pM). Moreover, BugArgNal displays absolute selectivity for thrombin over the other physiologically important serine proteases trypsin, plasmin, factor Xa, and tissue plasminogen activator, up to the highest concentration of inhibitor tested (10 microM).

Drug use and HIV-1 infection: report from the Second Italian Multicenter Study.

A cross-sectional study was carried out in October 1988 among clients of public health centers in Italy that provide assistance for drug dependency. In addition to estimating the frequency of HIV-1 infection and of risk factors related to drug use, the study estimated the temporal gap between relevant events in the drug history of each subject. Forty-eight centers participated, representing 16 of the 20 Italian regions. Among 1,038/1,348 subjects, 395 (38%) were carriers of HIV-1 antibodies. Seropositivity was related to the length of heroin use (with the risk of being seropositive increasing by 1% for each month of use), to frequency of sharing injection equipment, and to sexual intercourse with a seropositive partner. Women were more likely to have shared injection equipment and to have engaged in sexual intercourse with seropositive partners. Most subjects began sharing injection equipment within a year of initiating drug use, and the median temporal gap between first drug use and first visit to a drug dependency center was 5 years. A high proportion of both seropositive (87%) and seronegative (74%) subjects reported the adoption of safer drug-use practices. In both groups many behavioral changes (38%) were reported to have been introduced before the initial HIV test. These findings confirm that efforts to reduce HIV infection among drug users in Italy will need to concentrate both on prevention of drug use and on early intervention to reduce high-risk behaviors.

Risk behaviors for HIV-1 infection in Italian drug users: report from a multicenter study. First Drug User Multicenter Study Group.

In June 1987, a cross-sectional study was carried out on drug users attending public centers for drug dependency in Italy. Observed proportions of HIV seropositives among the 1,363 subjects from 34 public centers in 11 regions included in the study varied widely, with an overall seropositivity rate of 37%. Sharing syringes/needles, already used by other intravenous drug users, for preparing and injecting drugs represented independent risk factors for HIV-1 infection, while sexual lifestyle did not. Risk of infection increased with frequency of sharing equipment for preparing and for injecting drugs. Modification of risk behaviors in drug use was reported more frequently than in sexual lifestyle; both were significantly associated with knowledge of being seropositive for HIV-1 infection.

Epidemiological use of drug prescriptions as markers of disease frequency: an Italian experience.

All Italian citizens are covered by the National Health Service (NHS) and medical records of individual drug prescriptions are routinely collected and processed. A procedure entitled EPIFAR has been developed which, on the basis of a computer routine, makes it possible to trace back the prescription history of each individual included in the NHS. The validity of information gathered through the EPIFAR procedure to provide estimates of tuberculosis (TB) prevalence has been evaluated. A comparison with routine surveillance data has been made. The EPIFAR procedure identified a total figure of TB patients seven times higher than that from official notifications. A sample survey was conducted among the prescribing physicians in order to quantify the proportion of TB cases among subjects receiving prescriptions of anti-TB drugs. According to general practitioner recall 66.4% of the patients were treated because of TB diagnosis, TB prophylaxis and TB relapse.