Decennial diphtheria-tetanus adult boosters: are they really necessary?

Available epidemiological data shows that an average number of 59 cases of tetanus per year are still reported in Italy. Most of cases (80.2%) occur in subjects > 64 years-old. Furthermore, the proportion of females among subjects ≥ 65 years-old is significantly higher than males (87.7% vs. 64.4%, p < 0.0001). Seroprevalence data show that the percentage of subjects with protective tetanus antibody levels (> 0.1 IU/ml) decreases with increasing age. Most people aged ≥ 65 years are unprotected. The antibody levels are higher in males than females (p < 0.001) in subjects > 25 years-old. Conversely, extensive childhood immunization and adequate boosting vaccination of adults led to the near-elimination of diphtheria in Western countries. The current Italian National Immunization Prevention Plan 2012- 2014 recommends the administration of a primary vaccine course in the first year of life and booster at the preschool age, in adolescents and in adults every 10 years. Nevertheless, the need for decennial booster doses is debated by some experts, who state that the best time to offer a single dose of vaccine against tetanus and diphtheria is the age of 50, since low levels of antibody titers are observed. Considering the availability of combined vaccines against diphtheria, tetanus and pertussis (DTaP or dTaP), and the increasing incidence of pertussis in infants, who are at highest risk of serious complications, in adolescents and in adults, some countries have introduced decennial dTaP in the adults immunization schedule. It is desirable that this recommendation is also introduced in the future Italian Immunization Prevention Plan. The present review overviews the epidemiological data and the immunization strategies against tetanus, diphtheria and pertussis in Italy, discussing the rationale not only of decennial dT booster but also of the dTaP booster.

Invasive bacterial diseases: national surveillance in Italy and vaccination coverage in the Local Health Agency 4 "Chiavarese", Liguria region (Italy).

INTRODUCTION: In 2007 in Italy, the National Institute of Health published a new protocol for the National Surveillance of Invasive Bacterial Diseases, in order to enhance the notification system of these diseases and to improve immunization strategies. Available vaccines to prevent these diseases were introduced for the first time into the 1999-2000 National Immunization Plan (NIP) (vaccination against Haemophilus influenzae type b) and the 2005-2007 NIP (vaccination against Streptococcus pneumoniae and Neisseria meningitidis serogroup C). We evaluated the frequency of invasive diseases, on the basis of the number of notifications, the different immunization strategies in the Italian Regions and the vaccination coverage in Local Health Agency 4 "Chiavarese" (LHA) in the Liguria Region (Italy). MATERIALS AND METHODS: We evaluated the number of notifications of invasive diseases collected by the national databank coordinated by the ISS (Informative System of Infectious Diseases, SIMI) from 1994 to 2011. We also examined regional regulations concerning immunization policies. Immunization coverage was calculated by means of the "OASIS" software (version 9.0.0) used in our LHA. RESULTS AND DISCUSSION: Available data indicate that the large-scale vaccination policy begun in 1999 in Italy has led to a great reduction in Haemophilus influenzae-related diseases in the pediatric age. Meningococcal diseases have declined to a lesser degree; this is due to the more recent introduction of vaccination against serogroup C (in 2005), the variability of the immunization strategies adopted in the different Italian Regions and the availability of the vaccination against serogroup C only in the pediatric age. The diseases caused by Streptococcus pneumoniae seem to have increased since 2007 because of the implementation of the Surveillance of Invasive Diseases Program and the subsequent notification of all invasive diseases (not only meningitis). Furthermore, the various Italian Regions have adopted different immunization strategies against this disease, too. We evaluated vaccination coverage in LHA 4 from 2003 to 2008. VC levels against Haemophilus influenzae are excellent; the objective indicated in the 2005-2007 NIP (> or = 95%) has therefore been reached. Vaccination coverage levels against Streptococcus pneumoniae and Neisseria meningitidis serogroup C at the 24th month of age are also good. However, we need to implement specific immunization strategies for adolescents, since the vaccination coverage levels are not completely satisfactory. CONCLUSIONS: The improvement of the national invasive disease surveillance system has provided better knowledge of the size of the problem and the impact of immunization strategies on the incidence of invasive bacterial diseases. Furthermore, immunization policies in Italy display territorial heterogeneity. Vaccination coverage levels against Haemophilus influenzae, Streptococcus pneumoniae and Neisseria meningitidis at the 24th month in LHA 4 are very high. In adolescents (15 year-olds) the immunization coverage are good but needs to be improved through specific strategies, such as raising the awareness of healthcare workers, involving general practitioners and educating the target population.

Prevention of invasive diseases: strategies to increase vaccination coverage in children and adolescents.

INTRODUCTION: Vaccines able to prevent invasive bacterial diseases have been introduced into national and/or regional immunization plans through different strategies. We evaluated Haemophilus influenzae type b, Pneumococcus and Meningococcus C vaccination coverage in the 5 Ligurian Local Health Agencies, in the Liguria Region, and in Italy in order to assess the efficacy of current immunisation policies concerning children at the 24th month and adolescents. Furthermore, we considered new strategies for increasing vaccination coverage. MATERIALS AND METHODS: We estimated the vaccination coverage of Local Health Agency 4 by means of the "OASIS" software. The regional mean vaccination coverage was calculated from the data provided by the other four Local Health Agencies in Liguria. National data were obtained from the database of the Ministry of Health and from the last report of the ICONA Working Group. We used a questionnaire to evaluate the knowledge of Meningococcus C vaccination among the pediatricians and general practitioners operating in our Local Health Agency. RESULTS: The regional vaccination coverage at the 24th month proved to be: > 95% for Haemophilus influenzae type b, 93% for Pneumococcus and 87% for Meningococcus C. The national mean is: > 95% for Haemophilus influenza type b, 55% for Pneumococcus and 37% for Meningococcus C. Meningococcus C vaccination coverage among adolescents is 49% in Liguria, while the national mean is 16%. The questionnaire administered to the physicians was composed of 5 questions, which were answered by 81% of pediatricians and only 22% of general practitioners. Reducing the incidence of invasive meningococcal diseases through large-scale vaccination was deemed very important by 92% of pediatricians and 81% of general practitioners. About 92% of pediatricians and 85% of general practitioners considered the vaccine safe and effective. All (100%) physicians expressed their agreement with the Ligurian immunization strategy. However, while all the pediatricians reported recommending this vaccination, only 76% of general practitioners did so. Finally, all the physicians interviewed stated their willingness to collaborate with the Department of Prevention to increase vaccination coverage. DISCUSSION: VC against Hib at the 24th month, in both Liguria and Italy, proved excellent. Compliance with vaccination against Pneumococcus has been very high since its introduction in 2003 in Liguria, while the national mean is suboptimal. The regional vaccination coverage against Meningococcus C at the 24th month is good; the national value, however, is low because some Italian Regions have not yet introduced this vaccination into their immunization plans. Vaccination coverage in adolescents varies widely among the Ligurian Local Health Agencies and needs to be increased; the national figure is very low because few Regions have introduced this vaccination. However, achieving compliance with vaccinations in adolescents is difficult. The questionnaire indicated that general practitioners place less emphasis on vaccinations than pediatricians. Nevertheless, both general practitioners and pediatricians expressed their willingness to collaborate with the Department of Prevention of Local Health Agency 4 in improving the immunization strategies aimed at adolescents. CONCLUSIONS: In conclusion, we consider it very important to create a network involving the Department of Prevention, pediatricians and general practitioners, in order to share the best immunization strategies.

Investigation on seasonal influenza vaccination among children with high-risk medical conditions who live in the area of Local Health Agency 4 "Chiavarese".

INTRODUCTION: The Italian Ministry of Health recommends influenza vaccination in patients with chronic diseases associated with an increased risk of influenza complications. We estimated the number of patients aged from 6 months to 14 years with chronic diseases living in the area of Local Health Agency 4 "Chiavarese". MATERIALS AND METHODS: In order to estimate the number of children with chronic diseases, we evaluated data from three sources: the Health Charge Exemption Records Office; the "Nocchiero Project", implemented by the Regional Health Agency in 2009, and independent pediatricians. RESULTS: The pediatric population in the district of Local Health Agency 4 "Chiavarese" consists of 16,118 subjects. The percentage of children with high-risk medical conditions is 4.14% of the pediatric population according to records of health-charge exemption, 6.36% according to the "Nocchiero Project" data and 3.38% according to the data provided by pediatricians. In the 2010-2011 influenza vaccination campaign, 415 children were vaccinated at Local Health Agency 4 "Chiavarese"; 335 of these had chronic diseases. Vaccination coverage was estimated as 50.07% on the basis of the list of patients exempt from health care charges, as 65.68% by the independent pediatricians and as 31.45% according to the "Nocchiero Project" data. DISCUSSION: Our investigation underlines the difficulty of dividing subjects into different risk categories. The data provided by independent pediatricians yielded higher estimates of vaccination coverage in pediatric patients than the data from the other two sources. CONCLUSIONS: Estimates of vaccination coverage vary according to the source of data. However, pediatricians seem to be the most reliable source, as they know their patients better. Collaboration between health authorities and independent pediatricians should therefore be improved in order to obtain the best results in terms of influenza prevention in high-risk groups.

Molecular epidemiology and case-control approaches for management of an outbreak of hepatitis A in Liguria, Italy.

INTRODUCTION AND METHODS: Hepatitis A remains an important public health problem in low endemicity areas, because of the social and economic high burden of cyclical outbreaks. In this study we described an outbreak of HAV infection occurred in the city of Genoa and in its proximity and the viral circulation in the post-epidemic period. In order to identify risk factors associated to the illness and to determine the source of infection and the dynamics of virus evolution, we conducted an epidemiological and molecular investigation by a case-control study and by sequence analysis of high variable regions of the genome. RESULTS: From May to October 2005, 58 HAV hepatitis cases were notified. The case-control study showed that beach establishment attending is strongly associated with HAV hepatitis (OR = 24.5, p-value < 0.01), at multivariate analysis. The profile of epidemic curve, the clinical onset of primary cases who occurred in few weeks and the geographic distribution of cases clearly indicated a common exposure to a point source: the outbreak can be probably associated with a contaminated food product dispensed in the affected area. The outbreak has been mainly caused by a single variant, confirming the common exposure to a point source; this variant previously circulated within homosexual man (MSM) network in Northern Europe. During the outbreak and in the following months, different variants originating from Southeast Asia, Southern America and Northern Africa, have co-circulated: all these cases were related to international travel and none of these had determined secondary cases. DISCUSSION: The epidemiological picture of hepatitis A in Liguria is characterized by a wide heterogeneity of circulating HAV strains. This pattern could be associated with the increase of imported cases and transmission within network of persons with similar risk factors. Molecular approach coupled to descriptive and analytical epidemiological studies appeared un-replaceable tools for management and control of HAV outbreaks, because of their capacity to recognize infection origin, transmission patterns and dynamics of virus evolution.

The pattern of gastroesophageal reflux in asthmatic children.

The association between gastroesophageal reflux (GER) and asthma is not fortuitous. The objective of our study was to test a group of children with asthma by, 24 hr gastroesophageal pH monitoring and to relate the results to the patients medical history and clinical data. We studied 77 children aged from 39 to 170 months suffering from particularly recurrent and/or therapy-resistant asthma. Medical history data were collected for each patient and included: severity and characteristics of respiratory symptoms, presence, if any of allergy; presence, if any, of GER-related symptoms; and presence, if any, of esophagitis-related symptoms. Esophageal pH was measured by 24 hr computerized monitoring of the main measures in all patients. Forty-seven children were also examined by gastroesophageal endoscopy. The prevalence of GER was 61% on the basis of the reflux index (cutoff: 4.2%). Gastroesophageal reflux in these asthmatic children was characterized mainly by short-lasting daytime episodes. The patients tended to present GER mainly associated with vomiting but not with signs and symptoms of esophagitis. The short-lasting nature of the reflux episodes demonstrates good esophageal clearance. The time of onset of respiratory symptoms (day/night) was not associated with any particular type of GER, the severity of which tends to be proportional to the seriousness of the asthma. No correlation was found between GER and allergy. No statistically significant differences were found in clinical or medical history findings between patients with pathologic and nonpathologic GER.

Childhood obesity: different definition criteria, different prevalence rate.

BACKGROUND: Evaluate the influence of reference growth curves on determination of prevalence of obesity in children and particularly compare two indicators most commonly used, overweight (OW%) and body mass index (BMI centile), measured in the same population. DESIGN: cross-sectional study. SUBJECTS: 40,068 children (19,892 males, 20,176 females) aged from 3 to 17 years. RESULTS: The results obtained in this study show different prevalence rates according to the indicators used to define childhood obesity and according to the reference curves adopted. When Tanner-Whitehouse curves were used, prevalence peaked at age 9-13 years in males and age 8-14 years in females, with rates of up to 18%. When using our own curves to calculate ideal weight, the peak prevalence of obesity was at 12 years in males and 10 years in females, with prevalence rates of 11.8 and 13.7%, respectively. The prevalence of obesity, calculated using the BMI 90th percentile as the cut-off, ranged from 8 to 12%, with rates similar to those observed with OW% in children aged from 8 to 17 years, whereas the differences were greater in children aged from 3 to 8 (2.1% with OW% and 10.24% with BMI centile at 3 years). CONCLUSIONS: Prevalence rates are influenced by the reference curves used and the obesity indicator adopted. It would be desirable for epidemiological studies to use the same indicator, the same cut-off and, whenever possible, recent reference curves suitable for the particular population surveyed.

BMI centile as an indicator of degree of obesity in childhood.

OBJECTIVE: To evaluate body mass index (BMI centile) as an indicator of degree of obesity in childhood. DESIGN: Random. SETTING: Obese and nonobese healthy children were recruited in the Verona University Department of Pediatrics and Division of Pediatrics of the Verona City Hospital. SUBJECTS AND METHODS: 70 males aged 9.7 +/- 2.75 years and 55 females aged 9.9 +/- 3 years. Percentage fat mass was estimated by bioelectrical impedance analysis using Kushner's equation, and Italian BMI charts (A. Luciano et al. 1997) were used to calculate the BMI centile (BMI > 90 degrees in 76 subjects and BMI < 90 degrees in 59 subjects). RESULTS: Linear regression analysis and correlations between percentage fat mass and BMI centile were significant in males (P = 0.000, r = 0.6) and females (P = 0.000, r = 0.7) in both obese and nonobese subjects. CONCLUSIONS: BMI is a reliable, easy-to-use indicator of degree of obesity in childhood. Pediatricians should be encouraged to use BMI centiles to assess childhood obesity and particularly the onset of overweight, its evolution and its response to different types of management.

[Neurologic outcome in infants surgically treated for congenital cardiopathy: preliminary data]. / Outcome neurologico di lattanti operati per cardiopatia congenita: dati preliminari.

INTRODUCTION: Both surgical techniques for correction of congenital heart diseases (CHD) and intraoperatory neurologic protection improved during the last 20 years. Nevertheless cardiac surgery is still a risk for neurologic morbidity. METHODS AND PATIENTS: Analysis of the postoperative neurologic status of infants younger than 6 months who underwent cardiac surgery from January 1998 to December 1999. We reviewed the EEG tracings, cranial ultrasound reports (CUS) and CT scans of 48 patients. Diagnoses were: ventricular septal defect = 15, Fallot (TOF) = 9, patent ductus arteriosus (PDA) = 5, coarctation of aorta = 4, atrio-ventricular septal defect = 4, transposition of great arteries (TGA) = 3, hypoplastic left heart syndrome = 2, pulmonary atresia = 2, total anomalous pulmonary veins drainage = 2, double outlet right ventricle = 1, cor triatriatum = 1. Mean age (range) at intervention was 54 days (2-150), 44 infants (91.7%) survived at follow-up: 23 EEG, 22 CUS and 2 CT were performed in the recent postoperative. Among survivors 5/44 had neurologic complications. EEG was altered in 4: two of them (1 TOF, 1 TGA) had pathologic CUS and CT as well (ischemic pattern in the former, atrophy in the latter). Finally a preterm newborn with PDA had mild abnormalities at CUS. After a mean follow-up of 16 +/- 6 months 3/5 patients had mild-to-moderate psychomotor delay and 2 recovered. CONCLUSIONS: According to our preliminary data the prevalence of neurologic complications in infants who undergo cardiac surgery seems to be low. The pathological findings of the recent postoperative seem to recover up to normalization in some cases at mid-term follow-up. As expected, permanent complications effect more often complex CHD. Further follow-up studies to school age will be mandatory to check the very final results of cardiac surgery performed during early infancy.

Psychological problems connected to the dietary restrictions in the adolescent with coeliac disease.

AIMS: To assess the influence of dietary restrictions on psychological development in adolescents with coeliac disease. DESIGN: Statistical analysis on coeliac patients on gluten-free diet who agreed to answer the questionnaire. SETTING: Children with coeliac disease on gluten-free diet followed by the Department of the Pediatric Division of the City Mayor Hospital, Chair of Paediatrics, Verona University. SUBJECT: 39 patients (15 male and 24 female) from 10 years old to 21 who chose to answer a questionnaire of 25 questions dealing with the psychological implications of coeliac disease and with the need of following a particular dietary regime, in the presence of a psychologist. The questionnaire was made up of 6 SIGNALLING questions, 15 EVALUATING questions, 4 FILTER questions. They also filled up an information sheet on the composition and social position of the family. RESULTS: Fathers were on average 45.5 years old, mothers 43. Only 2 parents had no educational qualifications. Father's professions were of various kinds, 22 mothers were housewives. Only 4 patients were only children, 22 had one brother or sister. 13 patients only out of 39 claimed not to have been admonished by their parents, though, showed a conflictual relationship with food. The awareness of their difference from friends was: a) lack in children 10 to 12, b) uneasiness in adolescents 13 to 17, c) maturation and consensus in older patients. A significant number of patients feel different from their friends and these patients showed a latent envy to friends on free diet. A sense of latent envy towards the condition of independence was exhibited by patients who felt different from friends. CONCLUSIONS: The acceptance of a gluten-free diet is problematic for the majority of coeliac children and adolescents, particularly for those between 12 and 17. In this group the search of an individual personality is disturbed. Difficulties connected with gluten-free diet seem to be absent in the family environment, whereas difficulties emerge significantly when relating with friends. The number of cases of our study was limited but we consider these conclusions quite significant. DESCRIPTORS: Gluten-free diet, adolescents and children, relationship with parents, relationship with friends.

The influence of maternal passive and light active smoking on intrauterine growth and body composition of the newborn.

OBJECTIVE: To assess the influence of passive and light active smoking on the reduction of intrauterine growth of the foetus and on modifications in the body composition of the newborn. DESIGN: Random. SETTING: Full term newborn infants at the Department of the Pediatric and Gynaecological Divisions of the City Major Hospital, Chair of Paediatrics, Verona University. SUBJECTS: One hundred and twelve mothers selected after having completed a questionnaire on smoking habits during pregnancy. One hundred and twelve newborn infants were divided into three groups: Group 1: non-smoking and non-exposed mothers; Group 2: non-smoking but exposed mothers; Group 3: light smoking mothers (under 10 cigarettes/d, whether or not also exposed to passive smoking). Examination within 24 h of birth established the anthropometric measurements and estimates of body composition through indices or equations. RESULTS: Newborns of groups 2 and 3 had a statistically significant reduction of fat mass and most anthropometric measurements: fat mass according to Dauncey (P < 0.001), birth-weight (P < 0.013), crownheel length (P < 0.000), upper- and lower-arm length (P < 0.000) and circumference (P < 0.002), triceps skinfold and sum of all skinfolds (P < 0.004). Student t-test, between groups 2 and 3, did not evidence intergroup differences. CONCLUSIONS: Exposure of the foetus to passive and/or light active smoking involves a reduction of most auxiological parameters and not only weight. As regards body composition, smoking appears to reduce fat mass. The prevention of smoking during pregnancy is therefore extremely important, as intrauterine growth seems to be negatively influenced not only by active smoking, but also by passive and light active smoking.

The intestinal ecosystem in chronic functional constipation.

Chronic functional constipation is common in infants, and the bacterial composition of stools in this condition is not known. The study aims were to: (i) investigate the composition of the intestinal ecosystem in chronic functional constipation; (ii) establish whether the addition of the water-holding agent calcium polycarbophil to the diet induces an improvement in constipation; and (iii) determine the composition of the intestinal ecosystem after the use of this agent. In total, 42 children (20F, 22M; mean age: 8.6 +/- 2.9 y) were studied. Twenty-eight children with functional chronic constipation without anatomical disorders were treated double-blind in random sequence for 1 month with an oral preparation of calcium polycarbophil (0.62 g/twice daily) or placebo. Intestinal flora composition was evaluated by standard microbiological methods and biochemical assays on faecal samples collected before and after treatment. Fourteen healthy children were studied as controls. The results show that (i) the constipated children presented a significant increase in clostridia and bifidobacteria in faeces compared to healthy subjects--different species of clostridia and enterobacteriaceae were frequently isolated; no generalized overgrowth was observed; Clostridia outnumbered bacteroides and E. coli mean counts by 2-3log, while bacteroides and E. coli counts were similar (5-6 log10/g fresh faeces); these intestinal disturbances could be defined as a dysbiosis, i.e. a quantitative alteration in the relative proportions of certain intestinal bacterial species. (ii) Clinical resolution of constipation was achieved only in 43% of treated children and an improvement in 21% (one bowel movement every 2 d). (iii) Calcium polycarbophil treatment induced no significant changes in the composition of the intestinal ecosystem, nor in blood chemistry parameters.

[Probioticss, prebiotics,synbiotics and eubiotics]. / Probiotici, prebiotici, sinbiotici ed eubiotici.

The Author summarizes the most widely definitions of agents affecting the intestinal ecosystem. Probiotic is a live microbial feed which beneficially affects the intestinal microbial balance. Prebiotic is a non digestible food which improves the growth of bacteria in the colon. Synbiotic or eubiotic is a mixture of probiotics and prebiotics.

Respiratory quotient changes in full term newborn infants within 30 hours from birth before start of milk feeding.

OBJECTIVE: To evaluate substrate utilization in full-term newborn infants, fed every 3-4 h with glucose 10% solution, within 30 h from birth. DESIGN: Random. SETTING: Full term newborn infants at the Paediatric Division City Major Hospital, Chair of Paediatrics, Verona University. SUBJECTS: Forty-six newborn infants, 24 females and 22 males of 39+/-2 weeks gestational age. METHODS: Oxygen consumption (VO2) and CO2 production (VCO2) were measured. Permitting the computation of the respiratory quotient (RQ), which expresses substrate oxidation, at 6 and 30 h from birth. An indirect calorimeter (Deltratrac TMII-MBM-200-DATEX) was used to measure components of energy-balance. RESULTS: Energy expenditure calculated at 6 h was 8.130 (+/-1.5757) kJ/kg/h. At 30 h the value changed to 8.858 (+/-1.483) kJ/kg/h. Statistical evaluation (t-student) showed a significant (P=0.000) variation in RQ values (6 h: RQ=0.94; 30 h: R=0.88). CONCLUSIONS: Respiratory quotient suggests an increase of energy derived from fat metabolism at 30 h from birth. Our data confirm that early breast feeding or formula milk feeding could represent a physiological approach to nutritional regimen of the newborn infant.

[Basal metabolism and respiratory quotient in obese children]. / Metabolismo basale e quoziente respiratorio in bambini obesi.

Childhood obesity represents an increasing dysmetabolic condition. The aim of our study was to evaluate the influence of Fat Mass (FM%) on Resting Metabolic Rate (RMR) and Respiratory Quotient (RQ) as indicator of substrate oxidation. FFM and FM were estimated by bioelectrical impedance analysis (BIA), using the Kushner equation. Resting metabolic rate was determined by open-circuit indirect calorimetry. The mean (SD) of RMR 1517.6 (236.8) was found to be different from predicted RMR 1470.6 (190) calculated using the Fleisch equations. The best predictors of RMR were weight (p = 0.000) and FFM (p = 0.000); whereas correlation between RMR and fat mass (FM%) was not significant. Therefore low RMR cannot be responsible of fat mass degree, in fact, it is not reduced in obese children. Different values of RQ were found suggesting different metabolic behaviours to oxidate substrates. These data indicate that genetics may play a significant role in the development of many types of obesity.