Determinants of success and sustainability of the WHO multimodal hand hygiene promotion campaign, Italy, 2007-2008 and 2014.

A national hand hygiene promotion campaign based on the World Health Organization (WHO) multimodal, Clean Care is Safer Care campaign was launched in Italy in 2007. One hundred seventy-five hospitals from 14 of 20 Italian regions participated. Data were collected using methods and tools provided by the WHO campaign, translated into Italian. Hand hygiene compliance, ward infrastructure, and healthcare workers' knowledge and perception of healthcare-associated infections and hand hygiene were evaluated before and after campaign implementation. Compliance data from the 65 hospitals returning complete data for all implementation tools were analysed using a multilevel approach. Overall, hand hygiene compliance increased in the 65 hospitals from 40% to 63% (absolute increase: 23%, 95% confidence interval: 22-24%). A wide variation in hand hygiene compliance among wards was observed; inter-ward variability significantly decreased after campaign implementation and the level of perception was the only item associated with this. Long-term sustainability in 48 of these 65 hospitals was assessed in 2014 using the WHO Hand Hygiene Self-Assessment Framework tool. Of the 48 hospitals, 44 scored in the advanced/intermediate categories of hand hygiene implementation progress. The median hand hygiene compliance achieved at the end of the 2007-2008 campaign appeared to be sustained in 2014.

Event-Based Surveillance During EXPO Milan 2015: Rationale, Tools, Procedures, and Initial Results.

More than 21 million participants attended EXPO Milan from May to October 2015, making it one of the largest protracted mass gathering events in Europe. Given the expected national and international population movement and health security issues associated with this event, Italy fully implemented, for the first time, an event-based surveillance (EBS) system focusing on naturally occurring infectious diseases and the monitoring of biological agents with potential for intentional release. The system started its pilot phase in March 2015 and was fully operational between April and November 2015. In order to set the specific objectives of the EBS system, and its complementary role to indicator-based surveillance, we defined a list of priority diseases and conditions. This list was designed on the basis of the probability and possible public health impact of infectious disease transmission, existing statutory surveillance systems in place, and any surveillance enhancements during the mass gathering event. This article reports the methodology used to design the EBS system for EXPO Milan and the results of 8 months of surveillance.

Increased incidence of invasive meningococcal disease of serogroup C / clonal complex 11, Tuscany, Italy, 2015 to 2016.

We report an increase of serogroup C Neisseria meningitidis invasive meningococcal disease in Tuscany. From January 2015 to end February 2016, 43 cases were reported, among which 10 were fatal, compared to two cases caused by serogroup C recorded in 2014 and three in 2013. No secondary cases occurred. Thirty-five strains belonged to C:P1.5-1,10-8:F3-6:ST-11(cc11). Control measures have been adopted and immunisation campaigns implemented. Studies on risk factors and carriage are ongoing.

Key Role of Sequencing to Trace Hepatitis A Viruses Circulating in Italy During a Large Multi-Country European Foodborne Outbreak in 2013.

BACKGROUND: Foodborne Hepatitis A Virus (HAV) outbreaks are being recognized as an emerging public health problem in industrialized countries. In 2013 three foodborne HAV outbreaks occurred in Europe and one in USA. During the largest of the three European outbreaks, most cases occurred in Italy (>1,200 cases as of March 31, 2014). A national Task Force was established at the beginning of the outbreak by the Ministry of Health. Mixed frozen berries were early demonstrated to be the source of infection by the identity of viral sequences in patients and in food. In the present study the molecular characterization of HAV isolates from 355 Italian cases is reported. METHODS: Molecular characterization was carried out by PCR/sequencing (VP1/2A region), comparison with reference strains and phylogenetic analysis. RESULTS: A unique strain was responsible for most characterized cases (235/355, 66.1%). Molecular data had a key role in tracing this outbreak, allowing 110 out of the 235 outbreak cases (46.8%) to be recognized in absence of any other link. The data also showed background circulation of further unrelated strains, both autochthonous and travel related, whose sequence comparison highlighted minor outbreaks and small clusters, most of them unrecognized on the basis of epidemiological data. Phylogenetic analysis showed most isolates from travel related cases clustering with reference strains originating from the same geographical area of travel. CONCLUSIONS: In conclusion, the study documents, in a real outbreak context, the crucial role of molecular analysis in investigating an old but re-emerging pathogen. Improving the molecular knowledge of HAV strains, both autochthonous and circulating in countries from which potentially contaminated foods are imported, will become increasingly important to control outbreaks by supporting trace back activities, aiming to identify the geographical source(s) of contaminated food, as well as public health interventions.

Measles in Italy: Co-circulation of B3 variants during 2014.

In 2013, the majority of the WHO/EUR countries reported an annual incidence of >1 case per one million population indicating that the elimination target is far from being met. Thus, there is the urgent need to uncover and analyze chains of measles virus (MV) transmission with the objective to identify vulnerable groups and avoid possible routes of introduction of MV variants in the European population. The analysis of molecular epidemiology of MV B3 strains identified in 2014 has shown that four different variants co-circulated in Italy, including the strain that caused a cruise-line ship outbreak at the beginning of the year.

Vaccine coverage in Italy and assessment of the 2012-2014 National Immunization Prevention Plan.

BACKGROUND: In 2012, the ItalianMinistry of Health issued the National Immunization Prevention Plan (Piano Nazionale Prevenzione Vaccinale, or PNPV 2012-2014), with the aim of harmonizing immunization strategies across the country and ensuring equitable access to infectious disease prevention to all citizens. The Plan defines the immunization standards all regions should comply with. OBJECTIVE AND METHODS: As new evidence has accumulated in the field of immunization, and the new National Immunization Prevention Plan is about to be launched, the aim of the current study is to: i. present immunization coverage data (2000-2014) for 14 vaccines included in the PNPV to be offered to the general population, ii. assess to what extent the PNPV coverage targets and objectives have been met, and iii. report on how the PNPV was transposed into regional immunization programs. Data are also available for the eight regions that piloted varicella immunization. RESULTS: The 2012-2014 PNPV first introduced a "lifecourse" approach to vaccination at the institutional level, and has been a milestone for prevention in the Italian health policy agenda. However, infant vaccine coverage rates have been decreasing over the last years, as has influenza immunization in the elderly. HPV vaccine coverage has been increasing for all birth cohorts, but is still far below the targets set in the Plan. Promising preliminary data show that pneumococcal and meningococcal C conjugate vaccines were well introduced in regional immunization schedules. CONCLUSION: The 2012-2014 PNPV objectives have only been partially met, due to several factors, in particular increase in vaccine hesitancy. Strengthened efforts are needed to promote immunization. The new National Immunization Prevention Plan should introduce new vaccines and extend immunization programs to other target populations on the basis of the most recent scientific evidence available. It is of crucial importance that interventions of proven efficacy be planned and implemented to contrast the growing phenomenon of vaccine hesitancy and ultimately increase immunization uptake.

Measles in Italy, laboratory surveillance activity during 2010.

INTRODUCTION: The European Regional Office of the World Health Organization (WHO/Europe) developed a strategic approach to stop the indigenous transmission of measles in its 53 Member States by 2015. This study describes the measles laboratory surveillance activity performed by the National Reference Laboratory for Measles and Rubella at the Italian National Institute of Health (Istituto Superiore di Sanità) during 2010. METHODS: Urine, oral fluid and capillary blood samples from 211 suspected measles cases arrived to the NRL from different regions of Italy for confirmation of the clinical diagnosis. Serological and/or molecular assays were performed; after molecular detection, positive samples were sequenced and genotyped. RESULTS AND DISCUSSION: 85% (180/211) of the specimens were confirmed as measles cases and 139 of these were analyzed phylogenetically. The phylogenetic analysis revealed a co-circulation of D4 and D8 genotypes for the reviewed period.

An early warning system based on syndromic surveillance to detect potential health emergencies among migrants: results of a two-year experience in Italy.

Profound geopolitical changes have impacted the southern and eastern Mediterranean since 2010 and defined a context of instability that is still affecting several countries today. Insecurity combined with the reduction of border controls has led to major population movements in the region and to migration surges from affected countries to southern Europe, especially to Italy. To respond to the humanitarian emergency triggered by this migration surge, Italy implemented a syndromic surveillance system in order to rapidly detect potential public health emergencies in immigrant reception centres. This system was discontinued after two years. This paper presents the results of this experience detailing its strengths and weaknesses in order to document the applicability and usefulness of syndromic surveillance in this specific context.

Molecular characterization of hepatitis A outbreak in the province of Rome, Lazio region, Italy, January-July 2013.

Reduced circulation of hepatitis A virus lead to an increase of susceptible individuals, and outbreaks occurred recently. In Northern Italy an outbreak is ongoing, attributed to a monophyletic genotype IA strain, with mixed frozen berries as probable source. From 01/01/2013 to 07/15/2013, 30 cases were diagnosed at National Institute for Infectious Diseases, Rome, Italy, representing about twice the number of cases in whole 2012. Phylogenetic analysis indicated that most, although not all, infections were attributable to the same monophyletic genotype IA strain identified in the contemporary Northern Italy outbreak. This strain is also very similar to previous isolates from Venezuela.

[Polio vaccination failure in Italy, years 2006-2010]. / Mancata vaccinazione antipolio in Italia, anni 2006-2010.

OBJECTIVE: The purpose of this paper is to describe the lack of antipolio vaccination and its reasons, in the period 2006-2010. STUDY DESIGN, SETTING AND PARTICIPANTS. Until 2014 the data on vaccination activities, aggregated at the regional level, were sent to the Ministry of Health using a paper form used to collect the data and then to calculate vaccine coverage (CV) at 24 months. This form contains a section for identifying the reasons for polio vaccination failure. RESULTS: During the reporting period the national CV was always above 95%. The highest rates of non-vaccination were always observed in the same Region. Polio vaccination failure is well explained in 82%of cases, but only three Regions have always provided an explanation, while two have extremely low percentages of explanation, less than 50%. The dominant mode is «noncompliant ¼ (45.5%), followed by «undetectable¼ (26.5%). CONCLUSIONS: The percentage of explanation of non-vaccination was lower than expected. At the moment we cannot clarify why, but only speculate that the lack of a computerized immunization registry has been a key element. Probably, the form used was not sufficiently detailed to monitor the phenomenon of non-vaccination and program interventions. Updating the form, in 2013, we took into account these and other critical issues.

Integrated human surveillance systems of West Nile virus infections in Italy: the 2012 experience.

In Italy, a West Nile virus (WNV) surveillance plan was firstly implemented in 2008 and 2009 in two affected regions and, since 2010, according to a national plan, a WNV neuroinvasive disease (WNND) surveillance has to be carried out each year during the period 15 June-30 November, in those regions where WNV circulation has been demonstrated among humans, animals or vectors. Moreover, since WNV can be transmitted to humans even by blood transfusions and organ transplants obtained from infected donors, the national surveillance integrates the blood transfusions and organs transplant surveillances too. The paper describes the results of this integrated human surveillance in Italy in 2012. Overall, in 2012, 28 autochthonous confirmed cases of WNND were reported, 14 blood donations were found WNV positive by Nucleic Acid Amplification Test and no solid organ donors tested positive for WNV. Moreover, 17 cases of WNV fever were confirmed in Veneto region. When comparing the number of WNND cases reported to the surveillance system in previous 4 years (43 cases during the period 2008-2011), with those reported in 2012 an important increase was observed in 2012. The geographic distribution of human cases was consistent with the WNV circulation among animals and vectors. Moreover, the implementation of preventive measures for WNV transmission through blood components allowed the detection of blood donors positive for WNV, avoiding the further spread of the disease. Since surveillance strategies and preventive measures are based on the integration among human, animal and vector control activities, the Italian experience could be considered a good example of collaboration among different sectors of public health in a "one health" perspective.

Estimated imported infections of Chikungunya and Dengue in Italy, 2008 to 2011.

BACKGROUND: In temperate countries, where the competent vector is present, the risk of introduction and transmission of Chikungunya (CHIKV) and Dengue (DENV) cases is particularly high. Thus, epidemiological surveillance is crucial to rapidly identify imported cases in order to introduce measures to reduce mosquito density in the area. METHODS: We analyze imported cases of CHIKV and DENV reported to the National Institute of Health (ISS) and the Ministry of Health, from January 2008 through October 2011 within the National Surveillance system in Italy. Moreover, considering the worldwide spread of DENV and CHIKV and the consequent importation of cases in Italy we estimate the number of imported cases using data on airport arrivals of travelers to the Italian international airports. RESULTS: From January 2008 to October 2011 a total of 130 cases of DENV/CHIKV were reported in travelers returning to Italy. In our study, 42.8% of CHIKV cases were imported from Indian Ocean Islands (Mauritius, Maldives, Bali, and Sri Lanka), whereas, for DENV 40.4% of imported cases reported to have visited Asia within the incubation period. The estimated number of exposed travelers to CHIKV and DENV arriving in Italy was higher compared to notified cases, suggesting a possible underestimation of the real number of imported cases. CONCLUSIONS: Integrated human and entomological surveillance is crucial to monitor the spread of emerging vector-borne diseases and to implement public health measures in order to avoid transmission and control such diseases in humans.

Lessons learnt from pandemic A(H1N1) 2009 influenza vaccination. Highlights of a European workshop in Brussels (22 March 2010).

This European workshop identified a number of lessons learnt in the field of vaccine licensure, prioritization of target groups, communication on pandemic vaccines, implementation of vaccination and safety monitoring. The mild severity of the pandemic A(H1N1) 2009 influenza virus influenced the perception of pandemic vaccines, as previous pandemic preparedness had anticipated a more virulent virus. This vaccination experience provides an important opportunity for research on the long-term immunogenicity and safety of pandemic vaccines in pregnant women and children, as well as on the long-term safety of adjuvants. Preparedness for future pandemics could involve improved decision-making on target groups and increased communication on vaccine safety.

Incidence of malaria and risk factors in Italian travelers to malaria endemic countries.

BACKGROUND: Imported malaria has been an increasing problem in Italy in the last three decades of the 1900s, representing the main risk for travelers visiting tropical and sub-tropical countries where malaria is endemic. Even though the total number of imported cases has been declining since 2000, malaria still represents the most frequent notifiable imported disease in Italy. The present study analyzes all the malaria cases reported in Italy in 2000-2006 in order to assess the trend of incidence over the time and reviewing the risk factors for travelers visiting malaria endemic countries. METHODS: All 2000-2006 case report forms were analyzed. The incidence of malaria in Italian travelers was calculated by continent and by countries most visited, using data provided by the Ministry of Transportation. RESULTS: Out of the 5219 malaria cases reported and confirmed in the study period five were autochthonous and 5214 imported, 1518 of which occurred in Italian citizen and 3696 in foreigners. Between 2000 and 2006 imported malaria cases fell from 977 to 630 respectively, with a total reduction of about 36%. Most of the cases were contracted in Africa (93%) and Plasmodium falciparum was the etiological agent in 83% of the cases, with an annual average fatality rate of about 0.5%. The average of the crude incidence rate (CIR) among Italians was calculated by continent for both global cases (gCIR) and for P. falciparum cases (pfCIR) resulting of 1.2/1000 and 0.9 for Africa, 0.08/1000 and 0.02 for Asia, 0.03/1000 and 0.003 for Central and South America, respectively. The gCIR by continent slightly but decreased constantly over the study period. DISCUSSION: The different factors which may influence the risk of contracting malaria for travelers visiting endemic countries and the strategy to reduce completely the number of fatal cases were considered and discussed.

Aspects of the Italian legislation related to HIV testing.

Italy has adhered to international declarations regarding the prevention, care, and treatment of HIV/AIDS and has adopted the fundamental interventions for surveillance and control; access to testing is defined by Law 135 of 5 June 1990. At the time, the Ministry of Health issued decrees to define national epidemiological surveillance systems for new HIV infections. The decree provides indications on the data to be collected, data flow, the modes of data transmission respecting security measures and some recommendations regarding access to HIV testing. It is thus necessary to develop national recommendations on appropriate methods for considering the diverse phases of access to testing in relation to the level of awareness of the minor, the outcome and divulging of the test.

Water-related diseases outbreaks reported in Italy.

Water related disease outbreak (WRDO) statistics in Italy from 1998 to 2005 have been discussed in this paper. The true incidence of WRDO is not reflected in the National Surveillance System (NSS), although this study has provided information on pathogens associated to different water sources, incidence in Regions and inadequacy of regulations. 192 outbreaks and 2546 cases of WRD were reported to the NSS, an average of 318 cases per year. Cases were associated to shellfish (58.79%), drinking water (39.94%) and agricultural products (1.25%). WRDs have been detected in 76% of Regions: central and southern Regions showed lower percentage of cases (35.4%) due to under-reporting. Most of WRD cases in the North were related to drinking water; WRDs in marine coastal Regions were mostly related to shellfish. 49% of Districts (Province) notified WRDs, including only 101 Municipalities. Pathogenic microorganisms were identified in a few cases from clinical investigations. They included enteric viruses, Norwalk viruses, Salmonella, Shigella, Giardia and Campylobacter. There is the need to improve the existing NSS in relation to WRDs. An adequate WRDs Surveillance System should be based on connection between health and environmental authorities, priority pathogens and critical areas identification, response capability and contingency plans.

Role of beauty treatment in the spread of parenterally transmitted hepatitis viruses in Italy.

The aims of the study were to evaluate the role of beauty treatments in the spread of acute viral hepatitis B (HBV) and acute viral hepatitis C (HCV) in Italy. Data from the surveillance system for acute viral hepatitis (SEIEVA) during the period 1997-2002 were used. After exclusion of subjects <15 years or >55 years old and reporting intravenous drug use or blood transfusion, the association of acute HBV and HCV cases with beauty treatments (tattooing, piercing, manicure/chiropody, and barber shop shaving) was estimated comparing 2,964 hepatitis B and 598 hepatitis C cases with 7,221 hepatitis A cases, used as controls, by multiple logistic regression analysis. The population attributable risk (PAR) to beauty treatments was estimated according to Levin's formula. Beauty treatments were associated with acute HBV (OR = 1.8; CI 95% = 1.5-2.1) and acute HCV (OR = 1.7; CI 95% = 1.2-2.3). The strongest association was found with barber shop shaving for HBV (OR = 1.8; CI 95% = 1.5-2.2) and with tattooing for HCV cases (OR = 5.6; CI 95% = 2.8-11.0). The estimates of the population attributable risk (PAR) indicate that nearly 15% of all acute HBV (17.4% in males) and 11.5% of all acute HCV cases (16.4% in males) occurring in 15-55 year old subjects not exposed to intravenous drugs or blood transfusion in Italy are due to beauty treatments. It is concluded that certain beauty treatments play an important role in the spread of HBV and HCV infections in Italy.