Spinal epidural capillary hemangioma: A systematic literature review and an illustrative case.

BACKGROUND: Spinal hemangiomas are rare vascular malformations resulting from proliferation of vascular endothelial cells. The cavernous form is the most common and represents 5-12% of spinal vascular malformations, while the capillary form is rare. CASE DESCRIPTION: A 56-year-old patient with no past medical history presented with progressive spinal cord compression symptoms localizing to the T10 level with MRC grade 4 proximal paraparesis. Preoperative MRI demonstrated a well-delineated, dumbbell-shaped, epidural lesion, without bony involvement, resulting in spinal cord compression at the T7 and T8 levels. The patient underwent gross total surgical resection of the lesion. At the one month follow up, the patient's strength improved to MRC grade 5, and sensation had fully returned. The histopathological diagnosis was a capillary hemangioma. Exclusively epidural capillary hemangiomas are extremely rare with only 26 cases reported in the literature. They are mainly located at the thoracic level (T4-T6). The MRI features include a well-circumscribed mass, hyperintense on T2-weighted sequence in 92% of cases, isointense on T1-weighted sequence in 88% of cases, and homogeneous contrast enhancement in 100% of cases. No tumor recurrence has been observed after gross total surgical removal. CONCLUSIONS: When evaluating progressive spinal cord compression by a purely epidural spinal lesion, the differential diagnosis should include capillary hemangioma, in addition to schwannoma, meningioma, and lymphoma. Early and complete surgical removal is the first line treatment.

[Legionellosis, a long lasting problem in public health]. / Legionellosi, problema di sanitá pubblica di persistente attualitá

The author goes over the steps that have marked the individuation and knowledge of Legionellosis, from the point of view of Public Health. She stresses the importance of surveillance and discusses the disease precautionary measures and sanitary control.

Risk of parenterally transmitted hepatitis following exposure to surgery or other invasive procedures: results from the hepatitis surveillance system in Italy.

BACKGROUND/AIMS: To evaluate the strength of association between parenterally transmitted viral hepatitis and specific types of invasive procedures. METHODS: Data from the surveillance system for type-specific acute viral hepatitis (SEIEVA) during the period 1994-1999 were used. The association of acute hepatitis B virus (HBV) and hepatitis C virus (HCV) infection with the potential risk factors (odds ratios (OR)) was estimated comparing 3120 hepatitis B and 1023 hepatitis C cases with 7158 hepatitis A cases, used as controls, by multiple logistic regression analysis. RESULTS: Most procedures resulted in being associated with the risk of acquiring acute HBV or HCV. The strongest associations were: for HBV infection, abdominal surgery (adjusted OR = 3.9; 95% confidence intervals (CI) = 2.0-7.5), oral surgery (OR = 2.7; 95% CI = 1.6-4.5) and gynaecological surgery (OR = 2.6; 95% CI = 1.2-5.5); for HCV infection, obstetric/gynaecological interventions (OR = 12.1; 95% CI = 5.6-26.3), abdominal surgery (OR = 7.0; 95% CI = 3.2-14.9) and ophthalmological surgery (OR = 5.2; 95% CI = 1.1-23.2). Biopsy and/or endoscopy were associated with HCV, but not with HBV infection. CONCLUSIONS: Invasive procedures represent an important mode of HBV and HCV transmission. Since a large proportion of the adult general population is exposed to these procedures and an effective HCV vaccine is not yet available, non-immunological means of controlling iatrogenic modes of transmission are extremely important.

Changing epidemiology of parenterally transmitted viral hepatitis: results from the hepatitis surveillance system in Italy.

BACKGROUND: In 1991, compulsory hepatitis B virus vaccination and screening for anti-hepatitis C virus of blood banks were introduced in Italy. AIM: To evaluate the impact of preventive measures on the incidence and risk factors for parenterally transmitted viral hepatitis. METHODS: Data from the surveillance system for acute viral hepatitis for the period 1985-99 were used. Temporal trends in distribution of reported risk factors were analysed by comparing three-year periods: 1987-89 and 1997-99. RESULTS: The incidence (no. cases per 100,000 population) of hepatitis B was 12 in 1985 and 3 in 1999; the incidence of hepatitis non-A, non-B decreased from 5 to 1 in the same period. These decreases were more evident among young adults and before rather than after 1991. Multiple sexual partners, other parenteral exposures and dental treatment remain the most common risk factors for parenterally transmitted viral hepatitis. An increase in frequency over time was observed for other parenteral exposures, whereas a marked decrease was evident for blood transfusion and household contact with an HB-sAg carrier. Invasive medical procedures continue to represent an important source of infection. Intravenous drug use was reported particularly by young adults with non-A, non-B hepatitis, with increased frequency over time. CONCLUSIONS: Non-immunologic measures for preventing hepatitis B and non-A, non B due to iatrogenic and other parenteral exposures, combined with hepatitis B virus vaccination, could further reduce parenteral transmission.

Risk management of HBsAg or anti-HCV positive healthcare workers in hospital.

Recommendations are made for controlling the transmission of the hepatitis B and hepatitis C viruses from healthcare workers to patients. These recommendations were based both on the literature and on experts' opinions, obtained during a Consensus Conference. The quality of the published information and of the experts' opinions was classified into 6 levels, based on the source of the information. The recommendations can be summarised as follows: all healthcare workers must undergo hepatitis B virus vaccination and adopt the standard measures for infection control in hospitals; healthcare workers who directly perform invasive procedures must undergo serological testing and the evaluation of markers of viral infection. Those found to be positive for: 1) HBsAg and HBeAg, 2) HBsAg and hepatitis B virus DNA, or 3) anti-hepatitis C virus and hepatitis C virus RNA must abstain from directly performing invasive procedures; no other limitations in their activities are necessary. Infected healthcare workers are urged to inform their patients of their infectious status, although this is left to the discretion of the healthcare worker; whose privacy is guaranteed by law. If exposure to hepatitis B virus occurs, the healthcare worker must undergo prophylaxis with specific immunoglobulins, in addition to vaccination.

Changing epidemiology of parenterally transmitted viral hepatitis: results from the hepatitis surveillance system in Italy

BACKGROUND: In 1991, compulsory hepatitis B virus vaccination and screening for anti-hepatitis C virus of blood banks were introduced in Italy.AIM: To evaluate the impact of preventive measures on the incidence and risk factors for parenterally transmitted viral hepatitis.METHODS: Data from the surveillance system for acute viral hepatitis for the period 1985-99 were used. Temporal trends in distribution of reported risk factors were analysed by comparing three-year periods: 1987-89 and 1997-99. RESULTS: The incidence (no. cases per 100,000 population) of hepatitis B was 12 in 1985 and 3 in 1999; the incidence of hepatitis non-A, non-B decreased from 5 to 1 in the same period. These decreases were more evident among young adults and before rather than after 1991. Multiple sexual partners, other parenteral exposures and dental treatment remain the most common risk factors for parenterally transmitted viral hepatitis. An increase in frequency over time was observed for other parenteral exposures, whereas a marked decrease was evident for blood transfusion and household contact with an HB-sAg carrier. Invasive medical procedures continue to represent an important source of infection. Intravenous drug use was reported particularly by young adults with non-A, non-B hepatitis, with increased frequency over time. CONCLUSIONS: Non-immunologic measures for preventing hepatitis B and non-A, non B due to iatrogenic and other parenteral exposures, combined with hepatitis B virus vaccination, could further reduce parenteral transmission

The impact of the hepatitis B mass immunisation campaign on the incidence and risk factors of acute hepatitis B in Italy.

BACKGROUND/AIMS: This study aimed to evaluate the impact of the campaign for hepatitis B mass immunisation of children and teenagers, introduced in 1991, on the incidence of and risk factors for hepatitis B in Italy. METHODS: Hepatitis B cases reported to the surveillance system for type-specific acute viral hepatitis (SEIEVA) during the period 1987-1997 were used to estimate incidence. To assess the association between potential risk factors and hepatitis B cases, hepatitis A cases generated by the same surveillance system were used as controls. RESULTS: During the period 1987-1997, 8275 acute hepatitis B cases were reported to SEIEVA. Hepatitis B incidence declined from 10.4/100,000 in 1987 to 2.9/100,000 in 1997. The fall was more evident before than after the introduction of compulsory vaccination against hepatitis B. The results of multivariate analysis showed that during the years 1995-1997, blood transfusion, intravenous drug use, surgical intervention, dental therapy, other parenteral exposures, multiple sexual partners, and being in the household of a chronic HBsAg carrier were all exposures independently associated with hepatitis B. CONCLUSIONS: The strong association linking acute hepatitis B with iatrogenic exposures, which are more common in adults, suggests that the present immunisation strategy should be combined with the implementation of non-immunologic preventive measures.

Dose range evaluation of a new inactivated hepatitis A vaccine administered as a single dose followed by a booster.

A total of 242 healthy adults were immunised with a first dose of an investigational inactivated hepatitis A vaccine. Three concentrations (3, 6 and 12 EU [ELISA units]) of the experimental vaccine were used and compared to a licensed reference vaccine. The aim was to determine the antigenic concentration of the study vaccine inducing the highest seroconversion rate and anti-Hepatitis A virus (HAV) antibody response at 2 weeks after the primary immunisation. A booster dose was given at month 6. At 15 days after the primary immunisation the seroconversion rates in subjects vaccinated with the 6 and 12 EU vaccines were 78 and 94%, respectively. At 30 and 180 days after the primary immunisation the percentages of seropositivity were 100% for both groups. The antibody response to the 12 EU study vaccine was similar to that to the reference vaccine. The percentages of seropositivity at 15 and 180 days after the primary immunisation were 94 vs 93%, and 100 vs 93% in the experimental and reference vaccine respectively. Thus, because it induces early and lasting seroconversion, the 12 EU study vaccine seems to be the most effective as a high potency HAV vaccine.

Reactogenicity and immunogenicity of a new combined measles-mumps-rubella vaccine: results of a multicentre trial. The Cooperative Group for the Study of MMR vaccines.

A large single blind, multi-centre study involving 1779 children was performed in Italy. Infants, aged between 12 and 27 months were divided between two groups: group A received a single dose of a new MMR vaccine, 'Priorix'(3), while group B received a widely used MMR vaccine, Triviraten(4). Solicited local and general symptoms were recorded using diary cards and antibody levels were measured, prior to and 60 days post-vaccination, using ELISA assays. The incidence of solicited symptoms (evaluated in 1754 subjects) was comparable between groups, with the exception of fever which was significantly lower in group B. Immunogenicity was evaluated in 686 subjects. Of note, was the significantly higher anti-mumps seroconversion rate (p<0.001) observed in group A (97.0%) compared to group B (35.4%). However the anti-measles and anti-rubella seroconversion rates were equivalent between groups. Significantly higher (p<0.001) post-vaccination GMTs were in group A vs group B for anti-measles (2830 vs 784 IU/ml) and anti-mumps (1640 vs 469 U/ml), however the anti-rubella GMTs were significantly higher (p<0.001) in group B (117.6 IU/ml) compared to group A (92.6 IU/ml). The persistence of antibodies in 35 subjects was assessed 1 year after vaccination and the results showed no appreciable decline in titres with either vaccine. The trial demonstrates 'Priorix' is well tolerated and highly immunogenic.

Prevention of hepatitis C in Italy: lessons from surveillance of type-specific acute viral hepatitis. SEIEVA collaborating Group.

Using data from the surveillance system for type-specific acute viral hepatitis, the temporal incidence trend of non-A, non-B acute hepatitis and risk factors for acute hepatitis C have been evaluated in Italy. The association between hepatitis C and the potential risk factors (odds ratios, OR) was estimated using hepatitis A patients as controls. The independent roles of the different risk factors were estimated by multiple logistic regression analysis. The incidence of non-A, non-B acute hepatitis declined from 5 per 100 000 to 1 per 100 000 between 1985 and 1996. Anti-HCV data collected by SEIEVA since 1991 showed that 60% of patients with non-A, non-B acute hepatitis were positive for antibodies to the hepatitis C virus (anti-HCV) at the time of hospitalization. During the 6 months prior to the disease onset, the most frequently reported risk factors were multiple sexual partners, other parenteral exposure and intravenous drug use; transmission by blood transfusion declined from 20% in 1985 to 2% in 1996. On multivariate analysis, intravenous drug use (OR=35.5; 95% CI=23.1-54.4), surgical intervention (OR=4.6; 95% CI=3.3-6.5), dental treatment (OR=1.5; 95% CI=1.1-1.9) and two or more sexual partners (OR=2.2; 95% CI=1.6-3.0) were all independent predictors of hepatitis C. These findings indicate that HCV infection is decreasing in Italy. Intravenous drug use, multiple sexual partners, surgical intervention and dental therapy are the main modes of transmission.

Heterosexual transmission of hepatitis C in Italy.

Data from a surveillance system for type-specific acute viral hepatitis in Italy has been used to evaluate the risk of heterosexual transmission of hepatitis C virus (HCV) associated with sexual activity with multiple partners in subjects > or = 15 years of age. Hepatitis A cases were used as controls. During the period 1991-1996, 1,359 acute hepatitis C and 4,365 hepatitis A cases were recorded among subjects > or = 15 years of age. Intravenous drug use was the most frequent source of infection (35.9%) reported by HCV cases; two or more sexual partners during the 6 months before disease onset accounted for 34.9% of hepatitis C cases. Adjusting by multiple logistic regression analysis for the confounding effect of all risk factors considered (blood transfusion, intravenous drug use, surgical intervention, dental therapy, other parenteral exposure), and for age, sex, area of residence, and educational level of subjects, showed that having two or more sexual partners is an independent predictor of the likelihood of hepatitis C (OR=2.2; 95% CI=1.7-2.7). After excluding intravenous drug users and patients transfused with blood from analysis, the increase in the adjusted OR for the association between HCV and the number of sexual partners correlated with the increase in the number of sexual partners. The risk of hepatitis C was 2.0 times higher (95% CI=1.4-2.9) for subjects with two sexual partners and 2.8 times higher (95% CI=2.1-3.8) for subjects with three or more sexual partners, as compared to subjects with less than two sexual partners. These findings suggest that heterosexual transmission may play an important role in the spread of hepatitis C in Italy.

Safety and immunogenicity of a combined diphtheria-tetanus-acellular pertussis-hepatitis B vaccine administered according to two different primary vaccination schedules. Multicenter Working Group.

The reactogenicity and immunogenicity of a tetravalent diphtheria-tetanus-acellular pertussis-hepatitis B (DTPa-HB) vaccine (SmithKline Beecham) were studied in 565 infants immunized according to one of two different schedules, at 2, 4 and 6 months of age (group A n = 208) or at 3, 5 and 11 months of age (group B n = 357). The incidences of local and general reactions within the first 8 days after vaccination were similar in the two groups of infants, the vast majority being mild in intensity and occurring within 2-3 days of vaccine administration. Severe local symptoms were rare: pain after 0.6% of all doses, redness after 0.5% and 1.3%, and swelling after 0.3% and 1.5%, in group A and B, respectively. Only one infant in group A and one in group B had a temperature > 39.0 degrees C. Both schedules proved satisfactory in obtaining high levels of antibodies against all antigens. The rates of serologic response against the different antigens reached 100% in both groups. Antibody titres against all vaccine components were elevated following both schedules, but after the third dose of vaccine geometric mean antibody titres (GMTs) against D toxoid, filamentous haemagglutinin (FHA), pertactin (PRN) and hepatitis B (HB) were significantly higher in the 3, 5, 11 group than after the 2, 4, 6 schedule. Antibody titres measured at 7 months of age in the group immunized at 2, 4 and 6 months were higher than those reached at 6 months of age in infants immunized at 3, 5 and 11 months, but FHA and PRN were within the range of DTPa vaccine with proven efficacy. We conclude that DTPa-HB vaccine was safe, well tolerated and highly immunogenic. Both vaccination schedules (2, 4, 6 and 3, 5, 11) can be considered suitable for mass immunization programmes.

[Social determinants and risk of acute viral hepatitis]. / Determinanti sociali e rischio di epatite virale acuta.

The authors examined the relationship between viral hepatitis risk and social determinants in Piedmont region population surveyed by SEIEVA (sistema epidemiologico integrato dell'epatite virale acuta). The education and the working position showed different correlation with incidence rates of different types of viral hepatitis A, B, non-A non-B. The hepatitis A risk is proportional to education and the probability of hepatitis B and non-A non-B is higher in low social classes. This situation is only apparently a balanced risk: the clinical seriousness and the strong probability of complications of hepatitis B and non-A non-B make the risks deeply unequal.

Incidence of and risk factors for hepatitis A in Italy: public health indications from a 10-year surveillance. SEIEVA Collaborating Group.

BACKGROUND/AIMS: This study aimed to evaluate the incidence of and risk factors for acute viral hepatitis A (HAV) in Italy. METHODS: Data were from a surveillance system for type-specific acute viral hepatitis (SEIEVA). To estimate the association of hepatitis A cases with the potential risk factors (Odds Ratios) and the proportion of all hepatitis A cases attributable to a given risk factor (population attributable risk), hepatitis B cases were used as controls. Independent predictors of HAV were estimated by conditional multiple logistic regression. RESULTS: During the period 1985-1994, 25553 viral hepatitis cases were reported. Of these, 6408 (25%) were due to hepatitis A (HAV). HAV incidence declined from 10/100000 in 1985 to 2/100000 in 1987. Since 1991, however, an increase in HAV has been observed. The majority of cases were 15-24 years old; the incidence was higher in males and in subjects residing in southern Italy. Only one death (0.02%) was observed. Shellfish consumption was the most frequently reported risk factor (62%). The proportion of cases reporting personal contact with an icteric case, travel to a high-medium endemic areas, and family contact with a child attending a day-care centre (household of day-care child) was 17%, 19% and 15%, respectively. The results of multivariate analysis showed that shellfish consumption (OR=2.6; 95% CI=2.4-2.9), travel to endemic areas for people residing in northern and central Italy (OR=5.4; 95% CI=4.6-6.2) and household of day-care child (OR=1.2; 95% CI=1.03-1.4), were all types of exposure independently associated with HAV. The estimates of population-attributable risk show that shellfish consumption explained as many as 42.2%, travel to high-medium endemic areas for people residing in northern and central Italy 24.2%, and household of day-care child only 1.4% of all acute hepatitis A cases in Italy. CONCLUSIONS: These findings indicate that HAV in Italy is mainly a food-borne disease. Vaccination against hepatitis A is strongly recommended for travellers to endemic areas.

Case definitions.

The definition of a case of pertussis is an essential point in evaluating and comparing the results from the seven studies on pertussis vaccines presented at the Symposium. An assessment of the impact of case definition on the evaluation of vaccine efficacy has been performed on the Italian data-set, by comparing the clinical presentation of cough illnesses which were laboratory-confirmed as B. pertussis infection with those not-confirmed, by study vaccine. The results show that the estimate of vaccine efficacy is greatly variable by the choice of case definition and dependent on the study design. The assessment of the effect of each vaccine should be performed by using various clinical endpoints and the method used in detection of suspected cases in each study should be carefully evaluated to verify comparability of results.

Bordetella parapertussis infections.

The rate of isolation of Bordetella parapertussis among children with cough during the follow-up of different clinical efficacy studies has been evaluated. In the Italian trial, a comparison of clinical characteristics between B. pertussis and B. parapertussis infections showed lower frequencies and shorter duration of typical symptoms of whooping cough such as paroxysmal coughing, whooping, and vomiting in the group of children affected with B. parapertussis infections. In about 70% of B. parapertussis infections, there was a two-fold increase of IgA or IgG anti-FHA from acute- and convalescent-phase serum specimens. The analysis of the distribution of B. parapertussis cases in children fully immunized with each pertussis vaccine suggested that vaccination is irrelevant in preventing B. parapertussis infection.

Case fatality rate of acute hepatitis in Italy: results from a 10 year surveillance.

Using data from the surveillance system for acute viral hepatitis we have evaluated the case fatality rate of viral hepatitis in Italy. 71 deaths (0.3%) occurred among the 21,553 reported acute viral hepatitis cases from 1985-1994. None reported history of exposure to drugs or toxins. The highest case fatality rate was observed for B and NANB hepatitis (0.5%). One death occurred among the 6,353 (0.02%) hepatitis A cases and 1 among the 909 (0.1%) anti-HCV positive NANB hepatitis cases. The case fatality for Delta hepatitis was 0.2% (1/422). Case fatality rate was similar in both sexes; increasing with age; 0.03% were < 15 years of age, 0.1%, 15-24 year-old, and 0.5%, > or = 25 years. Subjects older than 24 years of age accounted for 81.4% of total deaths. Intravenous drug use, blood transfusion and other parenteral exposures were the three most frequent non-mutually exclusive sources of infection reported by subjects who died from B and NANB hepatitis. These findings indicate that the survival rate of acute B and NANB hepatitis is lower than that of acute hepatitis A; moreover in Italy, as in other Western countries, acute HCV seems to cause liver failure only rarely.

Incidence of non-A, non-B and HCV positive hepatitis in healthcare workers in Italy.

In Italy, using figures from a surveillance system for acute viral hepatitis, the incidence rate of acute non-A, non-B hepatitis (NANBH) and hepatitis C virus (HCV) hepatitis cases was evaluated in healthcare workers (HCWs) and the general population of the same age over the period 1988-1994. The NANBH incidence among the general population declined from 4.7/100,000 in 1988 to 2.1/100,000 in 1994; the corresponding figures among HCWs were 12.3/100,000 (RR 2.62; CI 95% = 1.66-4.15) in 1988 and 4.3/100,000 (RR 2.05; CI 95% = 1.13-3.77) in 1994. Since 1991, NANBH cases have been tested for antibodies to HCV (anti-HCV). During the period 1991-1994 the proportion of NANBH cases tested for anti-HCV was 81% (38/47) in HCWs and 85% (1019/1193) in other NANBH cases. A similar proportion of NANBH cases in each group (74% and 70%) were shown to be due to HCV. The incidence rate of HCV positive cases among the general population was 1.3/100,000 in 1991 and 1.8/100,000 in 1994; the corresponding figures among HCWs were 3.7/100,000 (RR 2.85; CI 95% = 1.42-5.92) in 1991 and 3.1/100,000 (RR 1.72; CI 95% = 0.88-3.59) in 1994. The proportion of cases with jaundice was 56.2% in HCWs and 63.7% in the general population. Needlestick injury without major risk factors such as blood transfusion, intravenous drug use or surgical intervention was reported by 12.0% of HCWs and by 0.1% of the general population. Lack of any risk factor was reported by 40.2% of HCWs. These findings strongly suggest that in Italy healthcare workers are at greater risk than the general population of acquiring NANBH, as well as HCV.