Trends in influenza coverage rates in five consecutive immunisation seasons in the Local Health Unit of Ferrara (North Italy).

Seasonal influenza epidemics yearly affects 5-15% of the world's population, resulting in 3-5 million serious cases and up to 650,000 deaths. Elderly, pregnant women and individuals with underlying conditions are at increased risk of complications. According to the Italian National Immunisation Prevention Plan 2017-2019, these categories benefit from free vaccination but coverage rate in Italy are below desirable levels. The study considered the coverage rate in five consecutive influenza seasons (2010/2011-2014/2015) in Local Health Unit (LHU) of Ferrara (Italy). The amount of delivered vaccinations was not constant, with a decreasing trend. Coverage rose with increasing age, but the 75% target of over-65 years old individuals immunised was never achieved. In addition to age, coverage rates varied also according to District (the area of residence within the LHU). The District with the lowest vaccination coverage was the Western District. Higher levels of immunisation were observed in South-Eastern District in the pediatric age and in North-Central District in adult age group with a statistically significant difference. In the considered timespan, the percentage of immunisations delivered by the General Practitioners (GPs) increased. The trend in the LHU of Ferrara was similar to regional and national data, conditioned in the 2014/2015 season by the spreading of worrying news, although unfounded, on the safety of the vaccine. The GPs were essential in ensuring vaccine uptake, growing the percentage of delivered doses and achieving as much as possible effective elderly immunisation.

Influenza coverage rates in subjects with chronic heart diseases: results obtained in four consecutive immunisation seasons in the Local Health Unit of Ferrara (North Italy)".

BACKGROUND: Seasonal influenza epidemics yearly affects 5-15% of the world's population, resulting in 3-5 million serious cases and up to 650,000 deaths. According to the 2017-2019 Italian National Immunisation Plan, free immunisation is offered to the categories at increased risk of experience the complications of the infection (over 65 years old subjects, pregnant women and individuals with underlying conditions, including chronic heart diseases). Rising evidence suggests that influenza can trigger adverse cardiovascular events therefore the vaccination is recommended for secondary prevention of cardiovascular diseases. Despite this, the influenza coverage rate in subjects with chronic heart disease is underestimated. METHODS: The study investigated the coverage rate in four consecutive influenza seasons (from 2011/2012 to 2014/2015) in subjects that benefit from exemption from paying healthcare costs for chronic heart disease living in Local Health Unit (LHU) of Ferrara (Italy), comparing the databases of exemptions and immunisations. RESULTS: The levels of influenza vaccine uptake were unstable, reaching the 50.3% in 2011/2012 immunisation season and falling to 42.2% in the following year. Coverage rates increased with increasing age, without achieving the 75% target, neither in over 65 years old subjects. The logistic regression analysis showed that influenza coverage rates were statistically significant different (p < 0.0001, 0.003 only for category of disease in 2011/2012 immunisation season) according to age, district of residence, category of chronic heart disease and length of exemption, but not influenced by gender. CONCLUSIONS: The recommendation of influenza immunisation was weakly followed in individuals with chronic heart diseases. A collaboration between cardiologists, GPs, scientific societies and patient associations could successfully support influenza vaccine uptake.

Identifying people at risk for influenza with low vaccine uptake based on deprivation status: a systematic review.

BACKGROUND: Influenza vaccination is an important public health intervention for controlling disease burden, but coverage rates are still low also in risk groups. In order to identify non-vaccinating subgroups, deprivation and socio-economic indices, i.e. measures used to synthetically describe people's socio-economic status while taking into account several dimensions, may be used. We aimed to synthetize evidence from studies investigating association between deprivation/socio-economic indices and influenza vaccination coverage in population at risk-persons ≥65 years of age, individuals with comorbidities, pregnant women and health-care workers. METHODS: We searched PubMed, ISI WoS, CINAHL and Scopus to identify observational studies published up to October 10th 2017 in English or Italian. Studies reporting quantitative estimates of the association between deprivation/socio-economic indices and influenza vaccination coverage in populations at risk were included. RESULTS: A total of 1474 articles were identified and 12 were eventually included in the final review. Studies were mostly cross-sectional, performed in European countries, from 2004 to 2017. Seven studies focussed on deprivation and five on socio-economic indices. Studies on deprivation indices and vaccination coverage showed that people from the most deprived areas had lower coverage. Regarding socio-economic condition, results were contrasting, even though it may also be concluded that people from lower groups have lower vaccination coverage. CONCLUSIONS: Our work supports the possibility to identify people likely to have lower influenza vaccination coverage based on deprivation/socio-economic indices. Efforts should be performed in order to further strengthen robustness, transferability and suitability of these indices in addressing public health problems.

Assessment of seroprevalence against poliovirus among Italian adolescents and adults.

In 2002, the WHO European Region was declared polio-free. Nonetheless global eradication has not yet been completed and the reintroduction from at risk areas is still possible. This seroprevalence study evaluated samples collected from each Italian region in the 12-50 years old age range to assess protection against Poliovirus (PV) 1, 2 and 3 among subjects immunised with different vaccination schedules. 1073 samples (50.5% females) were examined. WHO standardized microneutralization assay was used. Seroprotection rates were 92.9%, 96.2% and 83.4%, for PV1, PV2 and PV3, respectively. Geometric Mean Titres (GMTs) were higher for PV2 (52.8) and PV1 (41.1) than for PV3 (21.0). Increasing the age, a decreasing trend in seropositivity was observed, in particular for PV3. The 2017-2019 Italian National Immunisation Plan emphasises, as primary objective, the maintenance of the polio-free status and strongly validates the 2 + 1 schedule in the first year of life with IPV vaccine associated with the administration of booster doses at 6 years and during the adolescence. Surveillance system and high population immunity are crucial to ensure the maintenance of polio-free status.

Assessment of Malnutrition in Community-dwelling Elderly People: Cooperation among General Practitioners and Public Health.

BACKGROUND: Malnutrition, a very common condition in the elderly, is known to increase their vulnerability to adverse health events. This study aimed to estimate the prevalence of malnutrition in the over 75-yr-old community-dwelling population in the "Chiavarese" Local Health Unit district (North West Italy). METHODS: The short version of the Mini Nutritional Assessment (MNA-SF) was used by General Practitioners (GP) as a screening tool to investigate the nutritional status of elderly people (1039 subjects). The study was conducted in 2012-2013 in the Local Health Unit of Chiavari (Liguria Region), Italy. The malnutrition was subsequently confirmed by means of biochemical parameters. Subjects at risk of malnutrition or malnourished (n=22) received personalized dietary counseling by the GP. RESULTS: The MNA-SF recognized 21% of the elderly people being at risk of malnutrition and biochemical tests confirmed a malnutrition prevalence of 3.5%. The dietary counseling improved the MNA-SF score and biochemical parameters, but the difference was statistically significant only for the MNA-SF score (P=0.00613). CONCLUSION: Malnutrition can be evaluated with a simple tool such as the MNA-SF, recognized at the earliest stage and successfully treated by the GP.

Has VZV epidemiology changed in Italy? Results of a seroprevalence study.

The aim of the study was to evaluate if and how varicella prevalence has changed in Italy. In particular a seroprevalence study was performed, comparing it to similar surveys conducted in pre-immunization era. During 2013-2014, sera obtained from blood samples taken for diagnostic purposes or routine investigations were collected in collaboration with at least one laboratory/center for each region, following the approval of the Ethics Committee. Data were stratified by sex and age. All samples were processed in a national reference laboratory by an immunoassay with high sensitivity and specificity. Statutory notifications, national hospital discharge database and mortality data related to VZV infection were analyzed as well. A total of 3707 sera were collected and tested. In the studied period both incidence and hospitalization rates decreased and about 5 deaths per year have been registered. The seroprevalence decreased in the first year of life in subjects passively protected by their mother, followed by an increase in the following age classes. The overall antibody prevalence was 84%. The comparison with surveys conducted with the same methodology in 1996-1997 and 2003-2004 showed significant differences in age groups 1-19 y. The study confirms that in Italy VZV infection typically occurs in children. The impact of varicella on Italian population is changing. The comparison between studies performed in different periods shows a significant increase of seropositivity in age class 1 - 4 years, expression of vaccine interventions already adopted in some regions.

[Incidence of biological accidents at work and immune status for vaccine-preventable diseases among resident physicians in specialist training at Ferrara University Hospital]. / Studio di incidenza sugli infortuni biologici nei medici in formazione specialistica dell'Azienda Ospedaliero - Universitaria di Ferrara e stato immunitario nei confronti delle principali infezioni prevenibili.

The hospital as a work environment is particularly characterized by various risks for healthcare workers (HCWs). The main risk is represented by biological accidents, associated with the parenteral transmission of pathogens. Biological injuries can occur during the care service and the manipulation of biological fluids. Hepatitis B (and hepatitis D), hepatitis C and HIV are the most common infections transmitted by biological injuries. Physicians should acquire awareness of the risks associated with their professional activity during their training as medical residents (MRs). Some infectious diseases are preventable by vaccination and the "National Immunization Plan 2017-2019" (PNPV) recommends HCWs vaccination against hepatitis B, influenza, measles -mumps -rubella, chicken pox, and pertussis. Besides, not only HCWs' vaccination can prevent the disease in healthcare professionals, but it also may reduce the transmission to patients. Therefore, active immunization of HCWs by recommended vaccinations plays an important role to prevent disease cases, complications and death in patients. An increased awareness of risk behaviors is the first important point to address in order to reduce biological accidents and infectious diseases transmission, so as to reduce their frequency. Besides, HCWs' vaccination is useful to reinforce protection and to prevent the transmission of some infectious diseases in case of exposure. The aim of this five-year incidence study is to investigate the MRs' biological accidents characteristics and to analyze the MRs' immune status at the University of Ferrara in the period 2011-2015. Data on MRs' biological accidents and immune status at Azienda Ospedaliero-Universitaria of Ferrara in 2011-2015 were analyzed by Microsoft Excel 2007 Software. In this study, the percentage of MRs' biological injuries compared to the total number of MRs showed an annual variability, with a peak in 2011 (11.9%). During the analyzed period, there were 190 biological injuries among the MRs: 81% were percutaneous injuries and blood was the biological fluid involved in 86.3% of cases. The most frequent lesion was puncture (62.6%), occurred in 41.1% of cases by suture needles; 46.3% of accidents occurred in the operating block. These data can be explained by the more invasive and at risk activities carried out in these Operative Units. The high injuries percentage in MRs may be related to less work experience and inadequate training or informations about personal protective equipment use. Among MRs, 93.7%, 93.3% and 96.6% were immune to measles, chicken pox and hepatitis B, respectively; only in the case of rubella, 11.9% of MRs was not immune. This research showed, accordingly to published data, high adhesion to hepatitis B vaccination. However, the healthcare workers' vaccine coverage is still sub-optimal; active immunization by recommended vaccines should be implemented for both parenteral and airborne diseases. As a matter of fact, the recent measles outbreak has involved healthcare workers (4689 cases of measles, 305 in HCWs). Finally, the General Directorates of Health-care settings should improve healthcare personnel adhesion to vaccinations, such as influenza, by promotion activities in the workplace. A proposal in order to achieve coverage objectives could be making vaccinations mandatory, as well as already implemented in other countries.

Prevention of herpes zoster and its complications: from the clinic to the real-life experience with the vaccine.

The erpes zoster is an acute viral illness characterized by a vesicular rash of unilateral distribution, which can eventually cause severe complications, such as post-herpetic neuralgia, ophthalmic zoster, stroke or other neurological complications. In Europe, an incidence of between 2.0 and 4.6 cases per 1000 person-years is estimated, with an increase after 50 years of age. Currently, the therapeutic options for are only partially effective in limiting the acute phase, while the management of complications is frequently complex and not satisfactory. The overall burden of the disease and the elevated costs associated with diagnosis and clinical and therapeutic management led to the development of a new preventive approach through a live attenuated virus vaccine. The vaccine now available decreases the incidence of the disease, post-herpetic neuralgia and the burden of illness. Moreover, the vaccine is safe and well tolerated and it seems to confer long-term protection. Based on the clinical results and evidence provided by the Health Technology Assessment, several countries introduced immunization although with different recommendations and methods of funding.

Evaluation of the acceptability of a vaccine against herpes zoster in the over 50†years old: an Italian observational study.

OBJECTIVE: The aim of the study was to evaluate awareness of the varicella zoster virus and the acceptability of the newly available herpes zoster (HZ) vaccine in the over 50 years old general population. DESIGN: The research was observational. SETTING: The study was carried out in Ferrara by administering a questionnaire to patients of the Local Health Authority (LHA), general practitioners (GPs) and Public Health Department outpatient clinics. PARTICIPANTS: The questionnaire was completed by 1001 residents of Ferrara Province. RESULTS: Of the respondents, 98% and 95% (57% female) were aware of varicella and HZ, respectively, but 91% were unaware of the HZ vaccine. Nevertheless, 58% declared that they were in favour of vaccination in this regard, and the acceptability of the vaccine was positively affected by: age (p=0.005); knowing someone who had suffered from HZ (p=0.05); being in favour of vaccination in general (p<0.0001); receiving advice to do so from their GP (p<0.0001) and willingness to get vaccinated even on a fee-paying basis (p<0.0001). Indeed, most (73%) respondents were willing to pay to get vaccinated, indicating an ideal cost of €50. Higher education (p=0.04), being in favour of vaccinations in general (p<0.0001) and GP advice (p<0.0001) positively affected this choice. Furthermore, 61% of the participants initially unfavourable (p<0.0001) to this immunisation would change their decision not to vaccinate thanks to their GP's advice. CONCLUSIONS: This study assessed the level of awareness and the attitudes of the population aged over 50 years, highlighting aspects to be focused on in the promotion of the HZ vaccine.

Prevalence of Salmonella strains in wild animals from a highly populated area of north-eastern Italy.

INTRODUCTION: Salmonella is a ubiquitous pathogen that can infect host species, like wild birds, rodents, and/or arthropods, which may transmit infection to domestic animals and human population. AIM: In order to assess the related risk, a cross-sectional study was performed on 1114 carcasses of wild animals from a north-eastern area of the Emilia-Romagna Region, Italy. MATERIALS AND METHODS: During post mortem examination, intestine samples were cultured. A statistical analysis demonstrated that there is no correlation between the presence of sub-clinically infected animals and greater human population density. In contrast, a significant correlation between the number of carcasses positive for Salmonella spp. and greater spatial density of pig, poultry, and cattle farms was observed (p < 0.01). RESULTS: The results of the present study show that wild animals with omnivorous feeding habits are particularly exposed to Salmonella colonization and, consequently, to spreading the organism. Regarding drug resistance, this study confirms the resistance to antimicrobials is increasing in commensal and environmental isolates.

Meningococcal B vaccination: real-world experience and future perspectives.

Invasive meningococcal disease (IMD) represents a severe risk for health. It can be considered the most dangerous vaccine-preventable disease due to the high probability of related permanent sequelae and death. The introduction in many countries of the conjugate vaccines against A, C, W135, and Y meningococcal serogroups influenced significantly the impact of the disease. Recently, the difficulties in obtaining an effective vaccine against meningococcal serogroup B (MenB) have been get over through the reverse vaccinology, enabling the recognition of some antigens providing a response against most of circulating MenB strains worldwide. The new 4cMenB vaccine is recommended in Europe, Canada, Australia, the USA, and some Latin American countries. Even if sound data on efficacy and safety profile are available, the results in terms of effectiveness are still limited. The management of the MenB outbreaks in two US universities demonstrated the ability to quickly achieve high vaccination coverage rates and no new cases among immunized subjects were assessed. It is desirable that the opportunity to complete preventive intervention against IMD offered by the new 4cMenB vaccine should be recognized and that this vaccine is included in the vaccination schedule to complete the panel of immunization against Neisseria meningitidis.

[The nineteenth-century epidemic waves of influenza]. / L'influenza nelle ondate epidemiche del XIX secolo.

The retrospective analysis undertaken by our working group in the sphere of infectious diseases, with particular emphasis on nineteenth-century epidemics, regards influenza, which according to the scholar W.I. Beveridge, was defined as "one of the greatest enemies of man". The work is divided into three parts: influenza, its historical names and the characteristics of the recurrent epidemics from the sixteenth to the nineteenth century among the world's population. This part is followed by treatment and remedial action in the nineteenth century. The third, deals with death attributed to influenza and its complications observed in the city of Ferrara in the years when outbreaks occurred, affecting the majority of the populations: 1830-1833, 1836-1837, 1847-1848, 1857-1858, 1873-1875, 1889-1892, the latter known as the great pandemic.

Assessment of lifestyle and eating habits among undergraduate students in northern Italy.

AIM AND METHODOLOGY: Dietary habits of university students were analyzed in order to investigate any differences between students living at and away from home. Two hundred and fifty-eight undergraduate students attending University of Ferrara completed a self-administered questionnaire on demographic characteristics, food frequency consumption habits and body weight perception. RESULTS: Students living at home practiced more sport and consumed more frequently raw and cooked vegetables, fish, meat and poultry, fresh fruit, eggs, bread/cereals. Conversely, students living away from home consumed more often packaged/ready food, beer and spirits, milk and chips. The majority of students living alone reported a modification of dietary habits since leaving family. Furthermore they perceived to have a weight condition different from normal in a greater extent than students living with family. DISCUSSION: Students living alone encountered more difficulties in adopting a healthy diet so it would be desirable to adopt nutritional educational interventions on university students, usually neglected by these measures.

Knowledge, opinions and attitudes of Italian mothers towards HPV vaccination and Pap test.

AIM: This study evaluated the knowledge and attitudes of Italian mothers - whose daughters had been vaccinated in 2012 - towards primary (anti-HPV vaccination) and secondary (Pap test screening) cervical cancer prevention, as well as sources of information and mother-daughter communication on health issues. METHODS: The survey - part of a multicenter study carried out in 4 Italian cities (Ferrara, Rome, Cassino and Palermo) - was conducted through self-administered questionnaires. The first univariate analysis evaluated differences between mothers of under-18s and over-18s relative to knowledge and attitudes on HPV vaccination and Pap test. The second univariate analysis evaluated differences between the 2 groups of mothers and possible geographical variations regarding the sources of information on HPV and Pap test. RESULTS: The sample proved knowledgeable about the correlation between HPV and cervical cancer (>85%) but less aware of other HPV-related diseases. HPV vaccination should be administered before first sexual intercourse according to mothers of over-18s, and to 14- to 17-year-olds according to mothers of under-18s. Up to 88% of mothers of under-18s and 80% of mothers of over-18s declared that the vaccine should be given free of charge. More mothers of under-18s consulted a general practitioner (GP) or gynecologist before deciding to vaccinate their daughters. Mothers of under-18s received information on HPV vaccination mainly from GPs and gynecologists, while mothers of over-18s were informed through TV and books/journals. Over 80% of the sample declared satisfaction with the information received from their gynecologist during the Pap test. CONCLUSIONS: The findings provide useful information for the development of effective public health interventions that may help improve acceptance of HPV vaccination among mothers.

Cross-sectional seroprevalence of antibodies against 6, 11, 16 and 18 human papilloma virus (HPV) types among teenagers and young women in Italy.

BACKGROUND: Little is known about human papilloma virus (HPV) seroprevalence in the healthy Italian population. The aim of the study was to assess seroprevalence of antibodies against HPV 6, 11, 16 and 18 among girls and young women in Italy. METHODS: Sera were tested with a commercially available ELISA assay detecting specific IgG. RESULTS: Seroprevalence was 54.1% in girls between 11 to 18 years old and 8.2% in over 18s. Overall seropositivity in birth cohorts invited for free immunization reached 72.8% and was significantly higher than in other age subgroups. The highest levels of antibodies were detected in girls of 12 years old that should have just completed the vaccination schedule. CONCLUSION: A standardized seroepidemiological survey on HPV represents a useful tool for identifying groups at risk in which immunization is recommended, monitoring of vaccinated women, assessing whether booster vaccination is required.

[Malaria in endemic areas of Northern Italy and in the Italian context: remedies and substitutes in the nineteenth century medical practice]. / La malaria in aree ad elevata endemia del nord Italia e nel contesto italiano: rimedi e succedanei nella pratica medica dell'Ottocento.

Some areas of Northern Italy, especially Ferrara during the nineteenth century, represent privileged observatories regard to malaria, a disease that affected the poor, but did not spare the rich and powerful people. The so called Delta of the River Po, as well as the Maremma and other lowland areas in Italy, was particularly noted for its marshland environment (mosquito breeding grounds). Spared from Malaria because of the better hygienic conditions of the city that restricted the proliferation of anopheles, Ferrara represented an important study centre due to the presence of renowned physicians and scientists who exchanged knowledge and findings in the medical academies. Among these, Antonio Campana was very attentive to the latest scientific findings, and wrote about antimalarial remedies in his famous Ferrarese Pharmacopoeia. This paper analyses the main remedies listed in the various editions of Campana Pharmacopoeia since 1798 and particularly that of 1841, in the reports from the Accademia Medico Chirurgica di Ferrara and of Argenta physicians of the mid nineteenth century and in the Reports (1871 and 1876) from Alessandro Bennati, director of Arcispedale Santa Anna and concerned with hospital practice. Other printed documents referring to the town of Argenta are discussed.

[Sero-epidemiology of VZV infection in Italy: impact evaluation of extensive vaccination]. / Sieroepidemiologia dell'infezione da VZV in Italia: valutazione dell'impatto della vaccinazione estensiva.

OBJECTIVE: Eight Italian Regions have begun offering vaccination against varicella to children aged 13-15 months, with a second dose at 5-6 years of age. A serosurvey was conducted to evaluate the impact of extensive vaccination in these "pilot" Regions. DESIGN: Samples were collected in compliance with current legislation and after the approval of the Ethics Committee. The qualitative and quantitative determination of antibodies (IgG) against varicella was performed using an ELISA assay with high sensitivity and specificity. RESULTS: 1,470 samples were analyzed. After the decrease of seropositivity associated with the decay of passively acquired antibody titer, there was a progressive increase of seroprevalence in the other age groups. The comparison with what was recorded in two studies conducted with similar assays in the periods 1996/97 and 2003/04, showed a significant increase in seroprevalence following extensive immunization, particularly in the age classes 1 year, 2-4 years and 5-9 years. The proportion of seropositivity in the age classes 1 year and 2-4 years has more than doubled. CONCLUSIONS: Seroepidemiological studies are a useful tool to evaluate the distribution of susceptible individuals in the population. This study highlighted the impact of extensive vaccination against varicella in eight "pilot" Regions.

[Treatment and remedies against smallpox outbreaks in Ferrara in the late nineteenth century]. / Cure e rimedi contro le epidemie di vaiolo a Ferrara nella seconda metà del secolo XIX.

Health interventions against smallpox during the two epidemics in the second half of the 19th century are outlined. The 1871 hospital health report and the medical report on smallpox patients treated at the hospital and poorhouse of Ferrara between January 1891 and January 1892, drawn up by Alessandro Bennati, provide both interesting data and insights into the treatments and remedies of the time. The treatment of this illness was - and indeed could be - nothing other than symptomatic, there being no real means to halt the spread of the disease. Rather, other remedies were found by alleviating pain and regaining energy during the various stages of the disease. A close relationship between vaccination and the incidence and gravity of the illness is underlined. When the practice of vaccination started to be widely employed at the end of the century, there were almost no cases of death due to smallpox. The pharmacopoeias of the time, Antonio Campana's Farmacopea ferrarese in particular, proved an essential guide in the analysis of each document.

[The role of marine hospices as therapeutic support for scrofula treatment in Ferrara in nineteenth-century (corrected)]. / Il ruolo degli Ospizi Marini quale presidio terapeutico della scrofolosi a Ferrara nel XIX secolo.

The authors carried out an observational study for the years 1867-1874 on the morbidity of children from Ferrara suffering from scrofula, sent to marine hospices for sea bathing treatment. A total of 490 cases (250 F, 240 M) were studied in relation to the following variables: age, sex, forms of scrofula, years and outcome. In particular, the present work describes the preliminary organizational steps planned to allow the seaside stay, the clinical features and the outcomes. Dissemination of information to the public and to benefactors had the specific aim to strengthen these benefits for those children affected by the sad and serious consequences of scrofula.

Multidimensional evaluation of performance with experimental application of balanced scorecard: a two year experience.

BACKGROUND: In today's dynamic health-care system, organizations such as hospitals are required to improve their performance for multiple stakeholders and deliver an integrated care that means to work effectively, be innovative and organize efficiently. Achieved goals and levels of quality can be successfully measured by a multidimensional approach like Balanced Scorecard (BSC). The aim of the study was to verify the opportunity to introduce BSC framework to measure performance in St. Anna University Hospital of Ferrara, applying it to the Clinical Laboratory Operative Unit in order to compare over time performance results and achievements of assigned targets. METHODS: In the first experience with BSC we distinguished four perspectives, according to Kaplan and Norton, identified Key Performance Areas and Key Performance Indicators, set standards and weights for each objective, collected data for all indicators, recognized cause-and-effect relationships in a strategic map. One year later we proceeded with the next data collection and analysed the preservation of framework aptitude to measure Operative Unit performance. In addition, we verified the ability to underline links between strategic actions belonging to different perspectives in producing outcomes changes. RESULTS: The BSC was found to be effective for underlining existing problems and identifying opportunities for improvements. The BSC also revealed the specific perspective contribution to overall performance enhancement. After time results comparison was possible depending on the selection of feasible and appropriate key performance indicators, which was occasionally limited by data collection problems. CONCLUSIONS: The first use of BSC to compare performance at Operative Unit level, in course of time, suggested this framework can be successfully adopted for results measuring and revealing effective health factors, allowing health-care quality improvements.