Regional-Scale Analysis of Antimicrobial Usage in Smallholder Cattle Herds (Aosta Valley, Italy): Why Surveillance Matters.

Optimising antimicrobial usage (AMU) in livestock is pivotal to counteract the emergence of antimicrobial resistance. We analysed AMU in more than 1000 cattle herds over 11 years (2008-2018) in the Aosta Valley (Italy), a region where 80% of farms house less than 50 cattle. Dairy cows accounted for over 95% of AMU. AMU was estimated using the defined daily dose animal for Italy (DDDAit) per biomass for the whole herd and a treatment incidence 100 (TI100) for cows. Average annual herd-level AMU was low, with 3.6 DDDAit/biomass (range: 3.2-4.0) and 1.2 TI100 in cows (range: 1.1-1.3). Third and fourth generation cephalosporins, which are critical for human medicine, represented almost 10% of usage, and intramammary antimicrobials accounted for over 60%. We detected significant downward temporal trends in total AMU, as well as a positive relationship with herd size. The magnitude of such effects was small, leaving scant room for further reduction. However, the frequent use of critical antimicrobials and intramammary products should be addressed, following the principles of prudent AMU. Our findings highlight the importance of monitoring AMU even in low-production, smallholding contexts where a low usage is expected, to identify any deficiencies and implement interventions for further AMU optimisation.

Using Expert Elicitation for ranking hazards, promoters and animal-based measures for on-farm welfare assessment of indoor reared beef cattle: an Italian experience.

On-farm welfare assessment gives the opportunity to monitor and improve the quality of the animal life on the farm. In order to build the first Italian public standard for the welfare of indoor reared beef cattle, a list of 25 potential hazards and 22 potential promoters of beef cattle welfare was judged by a group of national experts by taking into account their negative or positive impacts on the welfare-state of the target population. In addition, the experts were asked to rank a list of 11 animal-based measures for identifying the most appropriate and important for measuring negative welfare outcomes in beef cattle. Based on experts' ratings, an "impact score" (ISoverall) was calculated for the proposed measures. Management hazards and promoters were ranked to have a greater impact on beef cattle welfare than housing factors. Keeping cattle in large (≥ 40 animals) and heterogeneous groups obtained the highest ISoverall among the proposed hazards (ISoverall = 5.54), followed by the presence of animals without free access to drinking water (ISoverall = 4.39) and the use of high-concentrate corn silage diets (concentrate > 80% and fiber < 6%) (ISoverall = 4.39). On the other hand, housing animals in small (≤ 20 animals) and homogeneous groups (ISoverall = 5.41), checking them at least twice a day (ISoverall = 4.62) and rearing cattle in loose housing systems with access to an outdoor area/pasture (ISoverall = 4.27) were ranked among the top 3 promoters. Concerning animal-based measures, experts scored lameness, severe respiratory diseases, body condition scoring and mortality rate to be measures most important for assessing serious welfare impairment.

Periodontitis prevalence and severity in inflammatory bowel disease: A case-control study.

BACKGROUND: Recent evidence is supporting the notion of a microbiological and immunological continuum on the gum-gut axis in health and disease. Therefore, the purpose of this study was to assess the prevalence and risk indicators of periodontitis in patients with Crohn's disease (CD) or ulcerative colitis (UC) compared to age- and sex-matched controls without inflammatory bowel disease (IBD). METHODS: A total of 180 IBD (117 CD, 60 UC, 3 IBD-unclassified) and 180 healthy controls were compared for their periodontitis diagnosis (Centers for Disease Control and Prevention/American Academy of Periodontology [CDC/AAP] case definition) and full-mouth periodontal parameters. In addition, explorative logistic regression models were performed. RESULTS: Significantly more patients with IBD had moderate/severe periodontitis (85.6% vs. 65.6%, p < 0.001) and severe periodontitis (36.7% vs. 25.6%, p < 0.001) than controls. Differences were higher in the 35-50 and 51-65 age groups, without significant changes between CD and UC. IBD subjects presented chances ∼3.5 higher of having moderate/severe periodontitis (p < 0.001). Significant variables associated with periodontitis in the whole sample were older age, presence of IBD, and higher full-mouth plaque scores, whereas in the IBD group they were male sex, IBD-associated surgery, and IBD duration and localization (pancolitis). Positive risk indicators for IBD were periodontitis severity and higher bleeding scores, while smoking was negatively associated with UC. CONCLUSIONS: Relevant associations between IBD and periodontitis were found, being modified by CD and UC clinical characteristics. Preventive and therapeutic strategies involving the gum-gut axis should be enforced in IBD patients.

Comparison of the dento-skeletal effects produced by Leaf expander versus rapid maxillary expander in prepubertal patients: a two-center randomized controlled trial.

OBJECTIVE: This study aimed to compare the skeletal and dentoalveolar effects produced by slow maxillary expansion (SME) with the Leaf expander versus the conventional rapid maxillary expansion (RME) on digital dental casts, lateral and postero-anterior cephalometric radiographs. TRIAL DESIGN: This is a superiority, two-center, two arms parallel balanced randomization trial. METHODS: Patients in the mixed dentition were included with a transverse interarch discrepancy of at least 3 mm. An expansion screw using moderate continuous forces (Leaf group) was compared to a conventional RME screw (RME group). The primary response variable was the difference in maxillary intermolar width (U6-U6) measured at baseline (T0) and one-year follow-up (T1) on the digital dental casts. Other dento-skeletal variables were also measured on digital dental casts and cephalograms. Computer-generated block randomization was used with allocation concealed in sequentially numbered opaque sealed envelopes. The examiner was blinded on the type of expander used. Linear models were used for statistical analysis. RESULTS: Twenty-eight patients in the Leaf group and 28 patients in the RME group were randomized and included in the study. There were no dropouts. U6-U6 did not show a statistically significant difference between the two groups (-0.4 mm in favor of the RME group, 95% CI from -1.2 to 0.5, P = 0.365). As for the other secondary variables no statistically significant differences were found between the two groups except maxillary intercanine width (U3-U3, -0.9 mm in favor of the RME group, 95%CI from -1.5 to -0.3, P = 0.005) and maxillary skeletal width (Mx-Mx, -1.4 mm in favor of the RME group, 95%CI from -2.4 to -0.3, P = 0.013). CONCLUSIONS: No significant differences between the RME and Leaf groups were detected for any of the analyzed dento-skeletal variables except the T1-T0 differences in U3-U3 and Mx-Mx that were significantly greater in the RME group. REGISTRATION: The study was registered in the ISRCTN register on 08/11/2016 with the number ISRCTN18263886. FUNDING: No funding or conflict of interest to be declared.

Evolution of Free Amino Acids, Histamine and Volatile Compounds in the Italian Anchovies (Engraulis encrasicolus L.) Sauce at Different Ripening Times.

In this study, the evolution of the safety, nutritional, and volatile profile of a traditional Italian anchovy sauce with protected designation of origin (PDO), called "colatura di alici di Cetara", is investigated after 12, 24, and 48 months of aging in wooden barrels. Some physicochemical parameters, free amino acids, volatile compounds, and histamine contents were evaluated during the aging of the samples. Glutamate, which together with aspartate is responsible for the umami taste, was the predominant free amino acid in the tested fish sauce, with a significant increase during the 48 months of maturation. The total amino acid content of the anchovy sauce increased from 24 to 48 months of aging. The histamine content decreased significantly from 12 to 48 months of ripening. This point is particularly interesting for the sauce safety and confirms the importance of the maturation time of at least 9 months reported in the disciplinary of production. A total of 44 volatile compounds were found in the anchovy sauce samples, of which the largest class was acids, mainly isovaleric acid. The results show that prolonged maturation improves the safety, nutritional, and volatile components of the seasoning "colatura di alici".

The Relationship between Animal Welfare and Antimicrobial Use in Italian Dairy Farms.

Information regarding the relationship between animal welfare (AW) and antimicrobial use (AMU) in dairy cows is limited. The current study aimed to investigate this relationship on Italian farms and to identify potential targets of AMU reduction. The study was performed at 79 Italian dairy farms housing over 15,000 cows during 2019. AW was scored with an on-farm protocol assessing farm management and staff training, housing systems, and animal-based measures. AMU was estimated using a defined daily dose per kg of animal biomass (DDDAit/biomass) for Italy. The median AW score was 73% (range: 56.6-86.8%). The median AMU was 4.8 DDDAit/biomass (range: 0-11.8). No relationship between the total AMU and AW was found. Management and staff training were positively associated with the use of the European Medicines Agency's category B antimicrobials, which are critical for human medicine, and with intramammary products for dry cow therapy. In those farms, antimicrobial stewardship should aim to reduce the category B antimicrobials and selective dry cow therapy. Our results underline the importance of implementing both an integrated monitoring system (AW, AMU, etc.) and antimicrobial stewardship tailored to the specific needs of each dairy farm.

Best Farming Practices for the Welfare of Dairy Cows, Heifers and Calves.

The concept of animal welfare (AW) has many meanings. Traditionally, AW has been considered as freedom from disease and suffering. Nowadays, growing attention goes to the concept of "positive animal welfare" (PAW), which can be interpreted within the concept of quality of life (QoL), thinking about a "balance of positives over negatives" and a "life worth living". In this vision, where the QoL represents a continuum between positives and negatives, the Italian National Reference Centre for Animal Welfare (CReNBA), within the Istituto Zooprofilattico Sperimentale della Lombardia e dell'Emilia Romagna (IZSLER), has developed a welfare assessment protocol for dairy cows, heifers, and calves in loose housing systems, including both animal-based and non-animal-based indicators, in which not only hazards but also benefits are identified. This protocol is part of an integrated monitoring system called "ClassyFarm", belonging to the Italian Ministry of Health and developed by IZSLER. The aim of this paper is to extrapolate from the mentioned protocol, a list of 38 best farming practices (on managerial and equipment factors) for ensuring a high level of welfare in dairy cattle. All stakeholders (veterinarians, farmers, competent authorities, consumers, etc.) can benefit of these best practices as a guide or toolbox to ensure a life worth living for these animals.

Fast field cycling NMR relaxometry as a tool to monitor Parmigiano Reggiano cheese ripening.

It is widely recognized that the longer the ageing, the more valuable Parmigiano Reggiano (PR) cheese becomes, due to the improvement of its sensorial and nutritional properties. Up to now, the evaluation of PR properties has been performed on samples mainly aged up to 40 months. For this reason, this study was aimed at collecting information about the chemical-physical characteristics of PR cheeses after ageing at 24, 48 and 84 months. The basic analyses on water amount, protein content and volatile organic compounds (VOC) revealed that PR ageing is associated to the decomposition of the organic components into smaller units. This drives water molecules closer to the aforementioned units, thereby leading to a reduction of water activity. Moreover, it appears, from VOC investigation, that either the total amount of long chain fatty acids (LCFA) or the sole 9Z-octadecenoic acid considerably increased with PR aging, thereby making these molecular systems good fingerprint to monitor PR ripening. Fast field cycling (FFC) NMR relaxometry revealed different components of the molecular dynamics in the complex PR cheese samples, which were attributed to water trapped in casein micelles, water bound to polar groups in organic components, proteins, and fats. In particular, the reduction of the correlation times associated to the organic components was explained by the molecular size decrement following degradation processes. The ageing-independent component of the motion was assigned to water molecules bound to polar groups in organic moieties. Finally, the ageing-independent contribution to the overall relaxation rate was assigned to water molecules in casein micelles. This study revealed that FFC NMR relaxometry can be a promising technique to monitor the chemical physical changes during Parmigiano Reggiano cheese ripening.

Acute haemorrhagic oedema of infancy: a condition that is not always benign.

Acute haemorrhagic oedema of infancy (AHOI) is a rare condition and an unusual diagnosis for the paediatrician, as approximately 300 cases have been reported in literature so far. Although it was considered for years a less serious variant of Henoch-Schönlein purpura, nowadays it is thought to be a different entity, with his own characteristics and clinical outcome. In literature it is described as a benign condition, self-limiting and without any systemic involvement in most of the cases. We present an atypical case of AHOI with a severe presentation and which needed an aggressive and prolonged steroid therapy.

Management of pernio-like cutaneous manifestations in children during the outbreak of COVID-19.

During the outbreak of COVID-19 many pernio-like lesions have been increasingly reported. The aim of the study is to describe our management of these skin manifestations and to evaluate a possible correlation to SARS-CoV-2 infection. All patients underwent clinical and laboratory tests to detect a possible underlying connective disease and also to specific SARS-CoV-2 investigations such as oropharyngeal swab and IgG-IgM serology. Nine patients aged between 5 and 15 years old were evaluated. Skin lesions observed were purplish, erythematous and oedematous, in some cases painful and itchy. Six out of nine had respiratory and systemic symptoms (cough, nasal congestion, chills, fever, and asthenia) that preceded cutaneous findings of approximately 2 weeks. Concerning blood exams, three out of nine had D-dimer weakly increased, four had ANA positivity: two with a title 1:160, one with 1:320, and one with 1:5120 and a speckled pattern. The latter patient had also ENA SS-A positive and RF positivity, confirmed at a second check, so as to allow us to make a diagnosis of connective tissue disease. Four out of nine had aPL positivity (IgM). Reactants acute phase were all negative. Oropharyngeal swabs and serology tests for SARS-CoV-2 was negative (borderline in one patient for IgM). No treatment was needed. Even if we do not have enough data to prove it, we hypothesize a correlation between pernio-like lesions and SARS-CoV-2 infection for an increased number of these lesions described during the pandemic and also because such manifestations appeared when temperatures were mild and patients were at home in isolation for the lockdown. Many questions remain open about interaction host-virus.

Prickly Pear By-Product in the Feeding of Livestock Ruminants: Preliminary Investigation.

In Sicily, the current increasing cultivation of Opuntia ficus-indica corresponds to an availability of prickly pear by-product (PPB) that results from fruit processing for juice extraction. This investigation aims to evaluate the nutritional traits of PPB for ruminant feeding and its stability during a 21-day outdoor storage, using potassium metabisulfite (PMB) as a preservative agent, added to the PPB mass at different doses (0, 50, 100, and 150 g/kg). The fractioning of PPB showed that it included 28% of peel and pulp and 72% of seeds on a dry matter (DM) basis. On the whole, this by-product was low in crude protein (5.32% DM), high in fiber content (51.38%, 41.15% and 14.64% DM for NDFom, ADFom and ADL respectively), non-fiber carbohydrates (NFC, 29.68% DM), and soluble sugars (13.3% DM), with a moderate level of net energy for lactation (4.59 MJ/kg DM). Storage was the main factor of alteration of PPB chemical composition with the exception of ether extract. A decline of NFC and soluble sugars, due to microbial fermentation, was observed with all PMB treatments, especially during the first week of storage, probably due to evolution of both coccus (M17) and rod LAB (MRS), which increased their loads at the seventh day of storage.

Effects of adding solid and molten chocolate on the physicochemical, antioxidant, microbiological, and sensory properties of ewe's milk cheese.

A novel dairy product, namely "chocolate cheese", was produced with two typical Sicilian food products: Pecorino cheese, processed from ewe's milk, and Modica chocolate. The cheese, manufactured with 0%, 5%, 10%, and 15% (w/w) solid or molten chocolate, was evaluated after 0, 2, 4, and 6 weeks of vacuum storage for its nutritional and health properties. The addition of chocolate reduced the pH, protein, fat, and ash; the addition of 5% or 10% molten chocolate reduced hardness (N/mm2 ). The addition of either solid or molten chocolate resulted in a slight increase (P < 0.1038) in the total polyphenol content, a higher oleic acid content, and less oxidative stability. The microbiological profile showed that the total mesophilic count and the number of mesophilic coccus lactic acid bacteria (LAB) were approximately equal (about 108 CFU/g) in all cheese. The survival of the microorganisms was affected by both the chocolate added and the storage time. Chocolate cheese stored for 6 weeks had less Enterobacteriaceae than control cheese, whereas yeasts were detected at higher cell densities in the former cheese. Filamentous fungi were undetectable in some cheese. Differences were also observed in the number of mesophilic rod LAB, which increased progressively over time in all cheese, and in Enterobacteriaceae, yeasts, and filamentous fungi, which decreased during storage. Descriptive and hedonic sensory tests and principal component analysis showed that fresh cheese and cheese stored for 2 weeks, including 5% molten chocolate, were the most preferred by evaluators. Based on these results, chocolate cheese has the potential to be appreciated in the market for its nutritional, health, and sensory properties. PRACTICAL APPLICATION: Chocolate cheese, made by combining two typical Sicilian foods, Pecorino cheese and Modica chocolate, is proposed as a novel dairy product. The highest sensory acceptance was obtained with the addition of 5% molten chocolate and storage for 2 weeks. Given its improved antioxidant properties, healthier fat, and sensory properties, chocolate cheese has the potential to be appreciated in the market, especially by young consumers.

Meat Production from Dairy Breed Lambs Due to Slaughter Age and Feeding Plan Based on Wheat Bran.

This experiment aimed to investigate the possibility to increase the carcass weight of dairy breed lambs and produce moderate-fat meat by applying inexpensive feeding strategies based on restriction and through the use of a fibrous byproduct such as the durum wheat bran (DWB). Sixty-five 45-day-old lambs of the Valle del Belice breed, divided into 6 groups, were fed alfalfa hay supplemented with concentrate feeds including DWB at 0% or 20% (DWB0, DWB20), supplied ad libitum (L) or restricted at 75% (R), and slaughtered at 90 or 120 days of age. The groups were as follows: DWB0-90L (n = 14), DWB20-90L (n = 14), DWB0-120R (n = 10), DWB20-120R (n = 9), DWB0-120L (n = 9), DWB20-120L (n = 9). The diet did not affect feed intake, growth or carcass weight of lambs fed ad libitum, whereas 120-day-old lambs fed DWB associated to restriction showed the lowest weight gain (105 vs. 170, 185 and 190 g/day in DWD20-120R, DWB0-120R, DWB0-120L and DWB20-120L; p = 0.04). The incidence of fat tissue in the hind leg increased (p < 0.0001) from 90L (5.82 and 5.45% with DWB0 and DWB20) to 120R (8.80 and 8.43% with DWB0 and DWB20) and 120L lambs (10.7 and 11.8% with DWB0 and DWB20). Older lambs' meat, compared to that of 90L lambs, showed analogous levels of intramuscular fat, higher water retention, tenderness and lightness, and a more intense red colour. In meat from 120-day-old lambs, DWB intake tended to reduce the fat level (p = 0.009) and increased polyphenol content (1.10 vs. 1.62, and 1.02 vs. 1.65 g GAE/kg dry matter (DM) in 120R and 120L lambs; p = 0.02), antioxidant capacity (12.8 vs. 14.9, and 12.8 vs. 15.7 mmol trolox eq/kg DM in 120R and 120L lambs; p = 0.02), and the presence of n-3 polyunsaturated fatty acids (FA) (1.61 vs. 2.81, and 1.43 vs. 2.61 g/100 g FA in 120R and 120L lambs; p = 0.007), thereby improving the meat's health properties. The panelists perceived the effects of DWB inclusion as well as the feeding level with triangle tests.

Molecular Detection of Bovine Papillomavirus DNA in the Placenta and Blood of Healthy Mares and Respective Foals.

Despite the characteristic species specificity of Papillomaviruses (PVs), the bovine papillomavirus (BPV) types 1, 2, and-more rarely-13, can cross-infect equids, where they are involved in the pathogenesis of sarcoid neoplasms. Sarcoids are locally invasive fibroblastic skin tumors that represent the most common skin neoplasms in horses worldwide. The transmission mechanism of BPV is still controversial in horses. Thus far, direct and indirect routes have been implicated, while vertical transmission has been suggested after the detection of viral DNA in the semen of healthy stallions. Testing of the blood and placenta of non-sarcoid baring mares and their respective foals revealed that the equine placenta can harbor BPV DNA, leading us to speculate a possible prenatal vertical DNA transmission in equids.

Incident genital HPV infections and potential impact of HPV vaccines in adult women living with HIV/AIDS.

This study aims to describe and characterize incident HR-HPV infections and associated diseases in HIV-infected women. 805 HIV-infected women enrolled in the VALHIDATE Study were screened and followed-up for HPV by co-testing. Social, behavioral and health data were collected. HPV-DNA positive samples were typed using a commercial kit or RFLP analysis. Conventional Pap-smears were evaluated using the 2001 Bethesda System. The participants with abnormal cytological results were referred for colposcopy. 565 HIV-infected women (median age: 43 years) were analysed, 40.9% had >5 lifetime sexual partners, 77.2% contracted HIV through sexual intercourse, 93% were receiving antiretroviral treatment and 77.3% had undetectable HIV-RNA. The women underwent 1254 follow-ups (median follow-up: 33 months) for 1430.6 PersonYear-Follow-Up. 37.4% of baseline HPV-negative women acquired incident HPV-infections, 69.6% of which were HR-HPVs. HPV-53 was the most common HPV type detected (9.3%). 18.2% of women showed incident or progressive cytological abnormalities (7.8% ASC-US, 9.7% LSIL and 0.6% HSIL) and colposcopy revealed CIN2 (N = 2), CIN1 (N = 2) and VIN3 (N = 1). The preventable fraction of incident infections was 11.3%, 16.7%, and 35.2% for the 2v-4v-9v-HPV vaccines respectively (χ2 p < 0.0001). The overall burden of incident lesions attributable to the vaccine types were 9.1% for 2v-, 14.5% for 4v- and 30.9% for 9v-vaccine. High HPV incidence rates and high percentages of multiple HR-HPV infections were observed in a cohort of HIV-infected women receiving effective antiretroviral treatment. Primary prevention strategies based on the new 9v-HPV vaccine may help to prevent incident infections and disease progression in this cohort of women.

Risk of cervical HPV infection and prevalence of vaccine-type and other high-risk HPV types among sexually active teens and young women (13-26 years) enrolled in the VALHIDATE study.

HPV vaccination is expected to reduce the incidence of cervical cancer. The greatest and the earliest health gains will be ensured by high vaccine coverage among all susceptible people. The high costs and the risk of a reduced cost/effectiveness ratio in sexually active girls still represent the main obstacles for a more widespread use of HPV vaccination in many countries. Data on the rate, risk factors, and HPV types in sexually active women could provide information for the evaluation of vaccination policies extended to broader age cohorts. Sexually active women aged 13-26 years enrolled in an Italian cohort study were screened for cervical HPV infections; HPV-DNA positive samples were genotyped by InnoLipa HPV Genotyping Extra or by RFLP genotype analysis.: Among the 796 women meeting the inclusion criteria, 10.80% (95% CI 8.65-12.96) were HPV-DNA infected. Age>18 years, lifetime sexual partners>1, and history of STIs were associated to higher risk of HPV infection in the multivariable models adjusted for age, lifetime sexual partners, and time of sexual exposure. The global prevalence of the four HPV vaccine-types was 3.02% (95% CI 1.83-4.20) and the cumulative probability of infection from at least one vaccine-type was 12.82% in 26-years-old women and 0.78% in 18-years-old women.: Our data confirm most of the previously reported findings on the risk factors for HPV infections. The low prevalence of the HPV vaccine-types found may be useful for the evaluation of the cost/efficacy and the cost/effectiveness of broader immunization programs beyond the 12-years-old cohort.

High performance of a new PCR-based urine assay for HPV-DNA detection and genotyping.

Human papillomavirus (HPV) testing has been proposed as a means of replacing or supporting conventional cervical screening (Pap test). However, both methods require the collection of cervical samples. Urine sample is easier and more acceptable to collect and could be helpful in facilitating cervical cancer screening. The aim of this study was to evaluate the sensitivity and specificity of urine testing compared to conventional cervical smear testing using a PCR-based method with a new, designed specifically primer set. Paired cervical and first voided urine samples collected from 107 women infected with HIV were subjected to HPV-DNA detection and genotyping using a PCR-based assay and a restriction fragment length polymorphism method. Sensitivity, specificity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV) were calculated using the McNemar's test for differences. Concordance between tests was assessed using the Cohen's unweighted Kappa (k). HPV DNA was detected in 64.5% (95% CI: 55.1-73.1%) of both cytobrush and urine samples. High concordance rates of HPV-DNA detection (k = 0.96; 95% CI: 0.90-1.0) and of high risk-clade and low-risk genotyping in paired samples (k = 0.80; 95% CI: 0.67-0.92 and k = 0.74; 95% CI: 0.60-0.88, respectively) were observed. HPV-DNA detection in urine versus cervix testing revealed a sensitivity of 98.6% (95% CI: 93.1-99.9%) and a specificity of 97.4% (95% CI: 87.7-99.9%), with a very high NPV (97.4%; 95% CI: 87.7-99.9%). The PCR-based assay utilized in this study proved highly sensitive and specific for HPV-DNA detection and genotyping in urine samples. These data suggest that a urine-based assay would be a suitable and effective tool for epidemiological surveillance and, most of all, screening programs.