Liquid and Vapor-Phase Activity of Artemisia annua Essential Oil against Pathogenic Malassezia spp.

Artemisia annua essential oil has given us many encouraging results for its numerous antimicrobial properties. In this study, the essential oil, both in liquid and in vapor phases, was tested against various Malassezia species closely related to many skin disorders in humans and animals. Malassezia treatment and eradication are mainly based on old azole drugs, which are characterized by poor compliance, unpredictable clinical efficacy, emerging resistance, and several side effects. Monoterpenes (ca. 88%) represent the most abundant group of compounds in the essential oil, mainly the oxygenated derivatives (ca. 74%) with camphor (25.2%), 1,8-cineole (20%), and artemisia ketone (12.5%). In vapor phase, monoterpenes represent more than 98% of the constituents, α-pinene being the main constituent (22.8%), followed by 1,8-cineole (22.1%) and camphene (12.9%). Essential oil of A. annua, both in vapor phase and liquid, showed strong antimicrobial activity towards almost the tested twenty strains of Malassezia analyzed. The minimum fungicidal concentrations from most of the strains tested were from 0.78 µL/mL to 1.56 µL/mL, and only three strains of Malassezia sympodialis required a higher concentration of 3.125 µL/mL. Overall, the minimal inhibitor concentrations obtained by vapor diffusion assay were lower than those obtained by the liquid method. The average values of minimal inhibitor concentrations obtained by the two methods at 72 h are 1.3 - 8.0 times higher in liquid compared to those in the vapor phase.

The antimicrobial effects of three phenolic extracts from Rosmarinus officinalis L., Vitis vinifera L. and Polygonum cuspidatum L. on food pathogens.

In this study three phenolic extracts were examined, without volatile fraction, against common food pathogens. The samples, all suitable for food application, were from the leaves of Rosmarinus officinalis L., Vitis vinifera L., and the root of Polygonum cuspidatum L. The microorganisms tested were Escherichia coli O157:H7, Salmonella Enteritidis, Salmonella Typhi, Yersinia enterocolitica and Listeria monocytogenes, well-known as important food pathogens. The results demonstrated a microbicidal activity of all the tested compounds at different concentrations; the rosemary extract showed greater efficacy than the other compounds against the tested microorganisms. In particular, the best results were obtained with rosemary extract against E. coli O157:H7 and L. monocytogenes with values of 200 and 270 µg/mL, respectively. Our results show that rosemary extract, often present as a natural antioxidant in food, can also be proposed as a natural disinfectant in the food field.

Focusing on the implementation of 21st century vaccines for adults.

Adult immunization is a priority for public health, particularly in countries where an aging population has become increasingly more numerous. Protection against diseases which typically affect adults (like flu, pneumococcal diseases and Herpes zoster), the shift of age of infections which originally affected children (like measles), the decreasing protection with time for infections which need periodical booster doses of vaccines (Tdap), the availability of vaccines which can also impact on adult health (HPV) are only some examples of the importance of implementing targeted vaccination strategies. The possibility to reach high coverage with immunizations that can guarantee a fundamental improvement of health for adults and the elderly can only be achieved through a coordinated effort where all stakeholders, under the coordination of public health, contribute to issue recommendations; create a functioning database for vaccine coverage registration; promote formative courses for healthcare workers and continuous information for the public; increase vaccines uptake among healthcare workers, who need to give the first testimony on the relevance of immunization.

Adherence to Mediterranean diet and nutritional status in a sample of nonagenarians.

OBJECTIVE: The aim is to describe the adherence to Mediterranean diet in a sample of nonagenarians and to analyse its cross-sectional association with anthropometric and bioelectrical parameters. DESIGN: A cross-sectional design was employed in this study. The adherence to the Mediterranean diet was measured through the Mediterranean Diet Score (MedDietScore). SETTING AND PARTICIPANTS: A representative sample of nonagenarian residents in the eight municipalities belonging to Mugello (Florence, Italy). MEASUREMENTS: The tools used to investigate the nutritional status and the body composition were: weight; ulna length to estimate the height; body mass index (BMI); mid-upper arm circumference (MUAC); calf circumference (CC); waist circumference (WC); hip circumference (HC); and specific bioelectrical impedance vector analysis (BIVAsp). RESULTS: All the measurements were carried out for 298 nonagenarians (70.8% of whom were females). The mean value of MedDietScore was 34.3±3.6. The MedDietScore was significantly correlated with CC (r=0.127), specific resistance (Rsp, r=0.152), and specific impedance (Zsp, r=0.153) in the whole sample, as well as with height (r=-0.222), Rsp (r=0.282), and Zsp (r=0.282) in males. In the whole sample, Rsp and Zsp mean values significantly increased by quartiles of MedDietScore; these results were confirmed by vector analysis. CONCLUSIONS: The high level of adherence to Mediterranean diet could contribute to explaining the longevity of our sample. Studying the influence of dietary lifestyle in nonagenarians in depth could help to promote healthy ageing.

Health literacy and vaccination: A systematic review.

This systematic review describes the current relationship between health literacy (HL) and vaccination (including attitude to vaccines, intention to vaccinate, and vaccine uptake). The aim is to comprehend the role of HL as a determinant of vaccine hesitancy. For this purpose, the following databases were explored from 1 January 2007 to 15 January 2017: PubMed, Embase, PsycINFO, ERIC, Health Evidence, Centre for Reviews and Dissemination, Scopus, Web of Science, and Cochrane Library. Nine studies were included in the final synthesis. The role of HL in predicting vaccine hesitancy or acceptance seems to be influenced by a few key factors. These include country, age, and type of vaccine. However, the relationship between HL and vaccination remains unclear. New research studies are needed-particularly longitudinal ones that use multiple measurement tools. This would facilitate a better understanding of the role of HL in predicting vaccine uptake.

Safety and perception: What are the greatest enemies of HPV vaccination programmes?

Vaccines stimulate a person's immune system to produce an adequate reaction against a specific infectious agent; i.e. the person is protected from that disease without having to get it first. As vaccines are administrated to healthy subjects, they are held to the highest standards of safety. Regarding human papillomavirus (HPV) vaccines, at present three prophylactic vaccines are licensed (bivalent HPV 16/18, quadrivalent HPV 6/11/16/18 and the nonovalent HPV 6/11/16/18/31/33/45/52/58 vaccine). Pre- and post-licensure studies (i.e. not yet for nonovalent HPV vaccine) confirm that HPV vaccines are generally safe and well-tolerated, site injections symptoms are the most common adverse events (AEs) reported, and pain is the most frequently referred local symptom. Serious AEs are rare and not associated with severe sequelae, at least no vaccine-related deaths have occurred. Despite these scientific evidences, it is still difficult to explain to the population the importance of a good vaccination programme. There are many determinants for HPV vaccines hesitancy which represent a barrier that must be overcome in order to increase vaccine coverage, including psychological reactions, religious or cultural aspects, and fear of possible AEs (demyelinating diseases, Complex Regional Pain Syndrome - CRPS, or Postural Orthostatic Tachycardia Syndrome - POTS). A weak communication strategy which frequently suffers due to spread of unverified news by media and websites may lead to the failure of a vaccination programme. Such a situation happened in Japan (2013), due to which a great number of women remain vulnerable to HPV-related cancers. In order to resolve the issues around HPV vaccines acceptance, it is necessary to use good communication strategies. Multicomponent and dialogue-based interventions seem to be the most effective, especially if an adequate language is used, customized according to the vaccination programme target.

The appropriateness of the use of influenza vaccines: Recommendations from the latest seasons in Italy.

Influenza is one of the major infectious causes of excess mortality, hospitalization, and an increase in healthcare expenditure in all countries. In an increasingly ageing population, many members are exposed to flu-related complications. Vaccination coverage rates for the elderly in most European countries, such as Italy, are not satisfactory, and have been decreasing with time due to a sense of skepticism toward vaccination. Nowadays, many types of vaccines are available on the Italian market to prevent influenza illness. Many studies have proven their effectiveness in preventing influenza-related complications in specific risk groups. Any vaccine can be crucial to avoid complications, hospitalizations and death, but use of the most appropriate vaccine could optimize the result at a very modest cost. General practitioners (GPs) should encourage their patients to take the influenza vaccination to prevent complications or deaths. Health authorities should give GPs the opportunity to choose the appropriate vaccines tailored to specific patients.

Health literacy in Italy: a cross-sectional study protocol to assess the health literacy level in a population-based sample, and to validate health literacy measures in the Italian language.

INTRODUCTION: Health literacy (HL) concerns the knowledge and competences necessary for people to meet complex health demands. The aims of this study are to assess the level of HL in a sample using the Italian version of the Newest Vital Sign and the association of HL and selected antecedents with health outcomes, and to develop and validate the Italian version of the three Brief Health Literacy Screeners, two subjective numeracy items and the short form and the short-short form of the European Health Literacy Survey Questionnaire. METHODS AND ANALYSIS: The study adopts a cross-sectional design and is being conducted in Florence, with information collected through telephone interviews. The population-based sample has been randomly selected using the registries of eight general practitioners (GPs). Based on a power calculation, 480 subjects will be included. Participants have been randomly offered two different questionnaires, each containing different HL measures. Data on sociodemographics and important antecedents and consequences of HL will be collected and the distribution of HL levels calculated. The mediating role of HL will be assessed using Preacher and Hayes' model. To assess the concurrent validity of the HL scales, correlation and receiver operating characteristic analyses will be performed. ETHICS AND DISSEMINATION: The study protocol has been approved by the Ethics Committee of the Area Vasta Centro. Results will be disseminated via scientific journals and conference presentations, and individual data made available to the GPs.

Assessment of Health Literacy and validation of single-item literacy screener (SILS) in a sample of Italian people.

BACKGROUND: Health literacy (HL) is a complex concept with multiple components; it involves the ability to effectively use and interpret texts, documents, and numbers. THE AIMS OF OUR STUDY WERE: to measure HL levels among a sample of adult Italian patients; to develop and validate the Italian version of the single-item literacy screener (SILS); to assess the diagnostic accuracy of the SILS as an indicator of limited reading ability regarding health documents, compared to the newest vital sign (NVS). METHODS: The subjects were enrolled in emergency departments, primary care settings, and specialist departments. The Italian versions of the NVS and of the SILS were administered to the patients, as well as a questionnaire aimed in collected socio-demographic information. RESULTS: Overall, 174 patients completed the interview (compliance: 87%). Considering the NVS, 24.1% of the subjects presented high likelihood of limited HL, 13.2% a possibility of limited HL, and 62.6% adequate HL. SILS has shown a good concurrent validity compared to NVS (Spearman's rho r = -0.679; p < 0.001). The diagnostic accuracy of the SILS was high. The best performance parameters in assessing the diagnostic accuracy of SILS are found to be for threshold value of 2 in in identifying subjects with high likelihood of limited HL at the NVS (sensitivity: 83.3%; specificity: 82.6%; accuracy: 82.8%; positive predicted value: 60.3%; negative predicted value: 94%; Cohen's kappa: 0.6). CONCLUSION: The Italian version of SILS - as an indicator of limited reading and understanding ability regarding health information - is a good tool to measure HL in comparison to more complex measurement instruments of functional HL, like NVS.

Waist-to-height ratio and its associations with body mass index in a sample of Tuscan children in primary school.

BACKGROUND: Visceral obesity in children increases the risk of developing cardiovascular diseases. To evaluate overweight children, in addition to Body Mass Index (BMI), waist-to-height ratio (WHtR) can be used to predict cardiometabolic risk. The goal of this study is to describe WHtR in a sample of Tuscan children. METHODS: A sample of children living in the province of Pistoia, Tuscany, was measured for the following anthropometric parameters: weight, height, and waist circumference. BMI and WHtR were calculated. For the latter indicator, a threshold of 0.5 was considered as a cardiovascular risk predictor. The subjects were classified into underweight, normal weight, overweight, and obese using Cole's cut-offs. RESULTS: The number of children enrolled were 1575 (821 males; 754 females), aged 6-11 years. Of them, 64.3% were normal weight, 4.9% underweight, 22.3% overweight, and 8.5% obese. Moreover, 12.8% had a WHtR ≥0.5 (85.7% males; 88.7% females). The average WHtR value was 0.45 ± 0.045, and was significantly different as per gender (F = 0.45 vs. M = 0.46). WHtR was significantly correlated with BMI (r = 0.766). CONCLUSION: The average WHtR value was in line with previous studies conducted among children of similar age groups. Large-scale perspective studies are needed to validate the Italian WHtR cut-offs for children.

The "Fluad Case" in Italy: Could it have been dealt differently?

During the influenza vaccination campaign 2014-2015, the reporting of 3 deaths within 48 hours of vaccination with Fluad brought the Italian Medicines Agency (AIFA) to pronounce the withdrawal of 2 batches of vaccine, based on the precautionary principle. Investigations by the Italian National Institute of Health, and by the Pharmacovigilance Risk Assessment Committee (PRAC), the committee at the European Medicines Agency (EMA) responsible for monitoring and assessing the safety profiles of human drugs, concluded that there was a lack of causality between the reported deaths and the vaccines administered. However, the media impact of the decision taken by AIFA, resulted in a lower influenza vaccination coverage compared with the previous years. The aim of our study was to identify possible critical points that may have led to a non-perfect management of the event. A review of the regulatory framework in place was performed, with a particular focus on the Guidelines on Good Pharmacovigilance Practices developed by the EMA to facilitate the signal management process. The management of reports involves the following steps: signal detection, its validation and confirmation, analysis and prioritization, assessment, recommendations for action and the exchange of information. In our opinion, both the signal detection phase and the phase of validation have been critical: the withdrawal of vaccine batches is possible even in case of a single suspected serious adverse reaction. However, aspects such as the biological plausibility, the presence of potential alternative causes and previous awareness should also be considered. Furthermore, the number of reported deaths was consistent with the expected background mortality rate in the vaccinated cohort. The disproportionate media coverage given to the AIFA decision resulted in a reduced vaccine confidence in the general population and in a decreased immunization coverage. Improving the communication on vaccine safety issues is crucial at this stage to restore a climate of trust in this powerful tool for primary prevention.

Vapour and Liquid-Phase Artemisia annua Essential Oil Activities against Several Clinical Strains of Candida.

Candida spp. are often the cause of infection in immune-compromised individuals. They are characterized by a strong resistance to antimicrobial drugs and disinfectants. The activity of Artemisia annua essential oil against Candida spp. was determined by vapour contact and microdilution assay. The oil was characterized by the presence of oxygenated monoterpenes (more than 75 % of the constituents), mainly represented by the irregular monoterpene artemisia ketone (ca. 22 %), and the widespread monoterpenes 1,8 cineole (ca. 19 %) and camphor (ca. 17 %). Other representative constituents were artemisia alcohol (5.9 %), α-pinene (5.7 %), and pinocarvone (3.0 %). Thujone, a typical toxic constituent of the Artemisia species, was not detected. The results are reported as minimum inhibitory concentration, minimum fungicidal concentration, and diameter of inhibition zone obtained by the vapour diffusion assay. We tested 10 clinical Candida strains, coming from both clinical samples and international collections. The results show that the antifungal activity of A. annua is influenced by the type of method adopted. The inhibitory action of the essential oil was, in fact, higher in the vapour than in the liquid phase. Our results show an average minimum inhibitory concentration in the liquid phase of 11.88 µL/mL, while in the vapour phase, the growth of all Candida strains tested at a concentration of 2.13 µL/cm(3) was inhibited. A strain of Candida glabrata was found to be less susceptible to the liquid medium than the vapour assay (50 µL/mL vs. 0.64 µL/cm(3), respectively). Candida albicans and Candida dubliniensis were the most susceptible to the vapour test, while Candida parapsilosis was the most resistant.

The right to food, food donation and microbiological problems of food safety: an experience in the territory of Florence.

AIM: The aim of this study is to understand whether the freezing without a rapid blast chiller represents a storage method for food at the end of shelf life that guarantees microbiological food safety, so to be considered an effective tool for the appropriate management of food in charitable organizations. METHODS: The study has been performed on 90 food samples, among those that a charitable foodservice trust receives by the large-scale distribution. The products have been frozen using a domestic refrigerator. The indicators used were: total aerobic microbial count, Escherichia coli, Salmonella spp, Staphylococcus aureus, Campylobacter spp, sulphite reducing clostridia. RESULTS: The results show that the preservation of the chosen fresh products at the end of shelf life in refrigerators, frozen without the use of chillers, is a potential management strategy to avoid the loss of edible food, while maintaining the safety standards.

Risk of malnutrition in a sample of nonagenarians: Specific versus classic bioelectrical impedance vector analysis.

OBJECTIVES: The aims were to describe the body composition and the risk of malnutrition in a sample of nonagenarians and to identify what bioelectrical impedance vector analysis (BIVA) approach (classic or specific) is more correlated with either the risk of malnutrition or various anthropometric parameters. METHODS: In the Mugello area (Italy), a representative sample of nonagenarians was enrolled in a survey aimed at investigating various health issues, including those related to nutritional status. The nutritional status was investigated using body mass index (BMI), mid-upper arm circumference (MUAC), calf circumference (CC), Malnutrition Universal Screening Tool (MUST), and BIVA. Two different approaches were used for the BIVA data analysis: the classic method and the specific method. RESULTS: All measurements were obtained from 321 nonagenarians (65.7% of the enrolled sample; 92 men and 229 women); 74.8% of the subjects were at low risk of malnutrition according to MUST, 62.5% exhibited CC values higher than 31 cm, and 86.8% exhibited MUAC values higher than 22 cm. The bioelectrical parameters varied with nutritional status, independent of the nutritional indicator used; the parameters also varied based on sex and BIVA approach. The bioelectrical parameters obtained by the specific BIVA approach were more strongly correlated with MUST score, MUAC, and CC values compared with the parameters calculated using the classic approach. CONCLUSIONS: Our study produced findings relevant to particular aspects of population aging. Above all, the specific BIVA was more effective at assessing nutritional status based on both anthropometric parameters and the risk of malnutrition.

The first italian validation of the most widespread health literacy assessment tool: the Newest Vital Sign.

OBJECTIVE: This work represents the first attempt to validate, for the Italian population, the most widespread health literacy assessment tool: the Newest Vital Sign (NVS). DESIGN: The UK version of this tool was adapted for Italy using a translation/back-translation process. A web-based survey was then administered to a multidisciplinary panel of experts to assess its face validity. Finally, a preliminary study of construct validity was conducted, focusing on efficiency, comprehensibility, reliability, and sensitivity of the items of the test. For the evaluation of these dimensions we adopted Pearson's r correlation and calculated the average scores obtained for the subscales. RESULTS: Data analysis shows that the NVS-IT can be considered, under every aspect, an adequate tool for the assessment of individual health literacy grade level, given the optimal correlation among the experts' judgments and the average scores above the acceptability threshold. CONCLUSION: Our study aims to encourage use of the NVS for the Italian population and, furthermore, introduce a scientific approach to health literacy, an issue that is gaining interest even in our country, though, to date, this has mainly resulted in the production of theoretical works.

Beliefs and Opinions of Health Care Workers and Students Regarding Influenza and Influenza Vaccination in Tuscany, Central Italy.

Immunization of health care workers (HCWs) against influenza has been associated with improvements in patient safety. The aim of this study is to assess the beliefs, attitudes, and knowledge of HCWs and health profession students regarding influenza. An anonymous questionnaire was distributed to HCWs in three local Florentine healthcare units, at Careggi University Teaching Hospital, and to students in health profession degree programs. A total of 2576 questionnaires were fully completed. A total of 12.3% of subjects responded that they were "always vaccinated" in all three of the seasonal vaccination campaigns studied (2007-2008 to 2009-2010), 13.1% had been vaccinated once or twice, and 74.6% had not received vaccinations. Although the enrolled subjects tended to respond that they were "never vaccinated," they considered influenza to be a serious illness and believed that the influenza vaccine is effective. The subjects who refused vaccination more frequently believed that the vaccine could cause influenza and that it could have serious side effects. More than 60% of the "always vaccinated" group completely agreed that HCWs should be vaccinated. Self-protection and protecting family members or other people close to the respondent from being infected and representing potential sources of influenza infection can be considered motivating factors for vaccination. The results highlight the importance of improving vaccination rates among all HCWs through multi-component interventions. Knowledge of influenza should be reinforced.

Adherence to Mediterranean diet in a sample of Tuscan adolescents.

OBJECTIVE: The aim of this study was to estimate the level of adherence to the Mediterranean diet in a group of Italian high school students, in relation to their lifestyles and social and family contexts, and to compare the nutrition habits of the sample with other similar groups. METHODS: The KIDMED index and an ad hoc questionnaire were administered to 1127 students (mean age 16.8 ± 1.6 y) in the province of Florence. Any significant associations between the level of adherence to the Mediterranean diet and the aforementioned variables were assessed by the χ(2) test and by logistic regression analysis. RESULTS: The adherence to the Mediterranean diet was good in 16.5%, average in 60.5%, and poor in 23% of the students. The students attending technical high schools, those who played sports less than "almost every day", those who spent >3 h/d in sedentary activities, those who defined their school performance as worse than "more than sufficient," and those who referred to use of a car/moped as the most frequent mode of transportation, had significantly higher odds of poor rather than average or good adherence to Mediterranean diet. Moreover, being normal weight or overweight/obese, and referring to health workers as source of information on diet, seem to be protective factors against poor adherence to Mediterranean diet. CONCLUSIONS: Our sample presents a departure from the Mediterranean dietary pattern. It is certainly necessary to implement public health policies targeting teenagers to promote healthier lifestyle choices; the nutritional patterns of the Mediterranean diet should be among these choices.

Essential Oil of Artemisia annua L.: An Extraordinary Component with Numerous Antimicrobial Properties.

Artemisia annua L. (Asteraceae) is native to China, now naturalised in many other countries, well known as the source of the unique sesquiterpene endoperoxide lactone artemisinin, and used in the treatment of the chloroquine-resistant and cerebral malaria. The essential oil is rich in mono- and sesquiterpenes and represents a by-product with medicinal properties. Besides significant variations in its percentage and composition have been reported (major constituents can be camphor (up to 48%), germacrene D (up to 18.9%), artemisia ketone (up to 68%), and 1,8 cineole (up to 51.5%)), the oil has been subjected to numerous studies supporting exciting antibacterial and antifungal activities. Both gram-positive bacteria (Enterococcus, Streptococcus, Staphylococcus, Bacillus, and Listeria spp.), and gram-negative bacteria (Escherichia, Shigella, Salmonella, Haemophilus, Klebsiella, and Pseudomonas spp.) and other microorganisms (Candida, Saccharomyces, and Aspergillus spp.) have been investigated. However, the experimental studies performed to date used different methods and diverse microorganisms; as a consequence, a comparative analysis on a quantitative basis is very difficult. The aim of this review is to sum up data on antimicrobial activity of A. annua essential oil and its major components to facilitate future approach of microbiological studies in this field.

Predictive factors associated with the acceptance of pandemic and seasonal influenza vaccination in health care workers and students in Tuscany, Central Italy.

Assessing the beliefs and attitudes of Health Care Workers (HCW) to influenza and influenza vaccination can be useful in overcoming low compliance rates. The purpose of our study is to evaluate the opinion of HCW and students regarding influenza, influenza vaccine and the factors associated with vaccination compliance. A survey was conducted between October 2010 and April 2011 in the Florence metropolitan area. A questionnaire was administered to HCW in three local healthcare units and at Careggi University Teaching Hospital. Students matriculating in health degree programs at Florence University were also surveyed. The coverage with vaccination against seasonal and pandemic influenza is generally low, and it is lower in students than in HCW (12.5% vs 15% for the seasonal vaccination, 8.5% vs 18% for the pandemic vaccination). Individuals comply with vaccination offer mainly to protect themselves and their contacts. Individuals not receiving vaccination did not consider themselves at risk, had never been vaccinated before or believed that pandemic influenza was not a public health concern. Physicians had the highest compliance to vaccination and women were less frequently vaccinated than men. HCW do not appear to perceive their possible influenza infections as a risk for patients: HCW receive vaccination mainly as a form of personal protection. Low compliance to vaccination is determined by various factors and therefore requires a multi-faceted strategy of response. This should include short-term actions to overcome organizational barriers, in addition to long-term interventions to raise HCW's level of knowledge about influenza and influenza vaccination.

[Tuberculosis in Tuscany: epidemiology and drug resistance]. / Tubercolosi in Toscana: epidemiologia e farmacoresistenza.

The aim of this study, conducted in collaboration with the Regional Mycobacteriology Centre at "Careggi" Hospital in Florence, was to describe the epidemiology of tuberculosis (TB) in Tuscany in the years 2007 to 2009. Epidemiological data and mycobacteriology results related to all subjects with confirmed TB in the three years considered were evaluated.Two hundred eighty-five patients were evaluated for the year 2007, 289 for 2008 and 240 for 2009 (data for three provinces are missing for 2009). A large percentage of patients were foreign-born (51.9% in 2007, 56.4% in 2008 and 66.3% in 2009) with the most frequent geographical areas of origin being Africa, Eastern Europe and Asian countries. Overall, the largest number of cases was reported in the cities of Florence and Prato. Among Italian-born patients, the disease was most frequent among patients above 75 years of age while the most frequently affected age group among foreign-born patients was 25-34 years.