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.

gamma-Globulin level and dietary protein intake during the first year of life.

To investigate the possible causes of relatively low blood gamma-globulin levels (less than or equal to 0.5 gm/dl) during the first year of life, 287 patients less than 1 year of age who were suffering from mild diseases were studied retrospectively. They were divided into two groups, those with a gamma-globulin level less than 0.5 gm/dl and those with a gamma-globulin level greater than 0.5 gm/dl. By reconstructing the diets given, it was found that they had been receiving isocaloric diets that differed only in protein supply: patients with lower gamma-globulin levels received 2.9 gm/kg/day of protein and patients with higher gamma-globulin levels received 4.0 gm/kg/day. Fifty-five healthy subjects were studied prospectively during the first year of life on two isocaloric diets that differed only in their protein content: the first one supplied 2.5 gm/kg/day of protein and the second supplied 4.0 gm/kg/day. At approximately 5, 7, and 10 months of age, hemoglobin, total protein, albumin, globulins, immunoglobulins, and other common blood parameters were measured. Patients on the lower protein diet had a gamma-globulin concentration of less than or equal to 0.5 gm/dl and those on the higher protein diet had a gamma-globulin concentration of greater than or equal to 0.8 gm/dl. Immunoglobulin levels, particularly IgG, were lower in patients on the lower protein diet. The subjects with lower protein intake and lower levels of gamma-globulin and immunoglobulins showed significantly higher morbidity.

Body mass index reference curves for children aged 3-19 years from Verona, Italy.

OBJECTIVE: To compile curves for Body Mass Index (BMI) for Italian children and adolescents. DESIGN: Cross sectional study. SETTING: All primary and secondary schools of Verona, Italy between October 1986 and January 1987. SUBJECTS: 20,796 males and 21,073 females children, aged 3-19 y. METHODS: Weight and height were measured using Salus balances, and age in days was calculated between the date of measurement and that of birth: centiles of BMI by age were calculated by the LMS method of Cole (1990). RESULTS: The centiles obtained were similar to those obtained in UK by Cole et al, 1995. Compared to Cachera's data for France and Hammer's for USA, our BMI values are higher, though closer to the American than the French ones.

Height and weight reference charts for children aged 2-18 years from Verona, Italy.

OBJECTIVE: To compile curves for growth in weight and height for Italian children and adolescents. DESIGN: Cross-sectional. SETTING: All primary and secondary schools in the area of Verona, Italy, between October 1986 and January 1987. SUBJECTS: 20534 female and 20345 male children aged 2-18 years. METHODS: Weight and height were measured using Salus balances, and age in days was calculated between the date of measurement and that of birth: centiles of weight and height by age were calculated by the LMS method of Cole (1990). RESULTS: The height and weight curves were similar for both boys and girls to those obtained in Switzerland by Prader & Budliger (1977). However pre-pubertal Italian boys and girls are taller and heavier than the standards for France (Sempè & Pedron, 1953-1970) or for the UK by Tanner & Whitehouse (1976).

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.

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.

[Physiology of pubertal maturation]. / Fisiologia della maturazione puberale.

Most important features of puberty are described. The puberty is the age of development of sexual characters. In females it appears between 10 and 15 years +/- 1 year whereas in males signs of puberty are visible between 11 and 15 years. In our country menarche appears at the mean age of 12 years and 2 months +/- 1 year and 2 months. Precocious puberty in females is that which appears before 8 years and 6 months and in males before 10 years. Delayed puberty is that which appears in females after 15 years and in males after 16. Nowadays is possible to keep off puberty when it is too soon by means of an analogous of LH-RH and as the result the subject reaches a better statural growth. The puberty should not be confused with the adolescence which is characterized by psycho-social maturity.

[The most common gastrointestinal problems in pediatric practice]. / I più frequenti problemi gastroenterologici nella pratica pediatrica.

In this review the Author expose the most common gastroenterological problems in pediatric practice. The following illnesses are examined: infantile colics, recurrent abdominal pain, gastroesophageal reflux, vomiting, alimentary intolerances, coeliac disease, malabsorption syndromes, hepatic pathologies, acute diarrhoea, persistent postenteric diarrhoea, chronic constipation. For all problems are provided the actual indications of diagnosis and therapy on the basis of modern literature suggestions.

[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.

[Hypoallergenic milks (HA formulas) in infant nutrition]. / I latti ipoallergenici (formule HA) nella nutrizione del lattante.

According to the definition of the European Scientific Committee for Food, hypoallergenic or hypoantigenic formulas (HA-formulas) are those which contain hydrolysed protein derived both from casein or whey. Soy-based formulas are not comprised in this definition since it has been demonstrated from several years that soy-protein, in several circumstances, may be highly allergenic. Hypoallergenic formulas contain besides hydrolysed protein, carbohydrate and lipid in amount and proportion similar to those indicated by ESPGAN recommendations on adapted formulas. As far as it concerns composition in lipid, recently great attention has been given to optimal supply and ratio of omega 3 and omega 6 fatty acids. Hypoallergenic formulas are therefore suitable for balanced nutrition of suckling infants. Specific indications on prevention of atopic diseases are not treated.

[The lipid status, insulinemia and fat mass in 40 children with essential obesity]. / Assetto lipidico, insulinemia e massa grassa in 40 bambini affetti da obesità essenziale.

Obesity is usually defined on the basis of body composition measurements. Body composition can be assessed using elaborate methods or anthropometry. Obese children are characterized by increased serum total cholesterol and triglycerides, reduced high-density-lipoprotein(HDL)-cholesterol concentrations, and hyperinsulinemia. Such a metabolic profile may create favorable conditions for atherogenesis and cardiovascular disease later in life. In fourty obese children aged 6-14 years were evaluated plasma insulin after OGTT, serum lipids and body composition. The correlation analysis between insulin, lipids and fat mass (%), based on skinfold measurements was not significative. These results are possible because with skinfold measurements are not separated the subcutaneous and intraabdominal compartments; infarct, only abdominal obesity is associated with the increased risk factors (hyperinsulinemia, hyperlipidemia, ecc.).

[Nutrition in the first months of life with a new formula containing maltodextrins and enriched with long-chain fatty acids]. / Nutrizione nei primi mesi di vita con una nuova formula adattata integrata con maltodestrine ed arricchita di acidi grassi a catena lunga.

According to the recent acquisition about the biochemical properties of the carbohydrates contained in human milk, the addition of maltodextrins to infant formulas became recommended. We refer about the preliminary data of the first utilization of a new formula (Aptamil 1 "Nuova Formula") in which both maltodextrins and Long Chain Fatty Acids are added. Sixty-seven infants were enrolled to the study for the first 4 months of life. Forty-three of them (64%) completed the study and were grouped as follows: Group 1 = 15 subjects exclusively formula-fed (4F, 11M), Group 2 = 21 infants with mixed feeding (breast + formula), Group 3 = 7 cases in which Aptamil 1 "Nuova Formula" substituted another formula (4F, 3M). Auxologic parameters (weight, length, head circumference) were among the normal standard limits according to the percentile charts of the Boston Children's Medical Center. All infants enjoyed the taste of the milk we tested. The food regimen was changed in 4/67 (6%) infants because of alimentary intolerance suspicion but 2/4 infants were subsequently fed with soya milk formula and with an "hypoallergenic" milk respectively, the other 2 continued with another formula. The weight growth chart in infants of Group 1 tended to bend down a little bit between the 3rd and 4th month, reminding the breast-fed infants behavior. Considering the daily milk volume assumed by the same subjects, we found a statistical difference (p < or = 0.01) between the volumes of milk assumed in the 2nd and the 3rd month of life but from the 3rd to the 4th month there was no statistical difference in daily milk volumes. This resembles the breast-fed infants behavior as well. According to our preliminary results the new milk formula we tested seems a very good substitute when an infant can't be breast-fed for any reason.

[Intraesophageal pH measurement in childhood: the technic and indications]. / La pH-metria intraesofagea in età pediatrica: tecnica ed indicazioni.

This review evaluates methodologic problems concerning esophageal pH monitoring in pediatric patients. Prolonged intraesophageal pH recording (twenty-two or twenty-four hour) is considered as the gold standard for all reflux investigations. The indications to pH monitoring and the interpretation of long-term pH studies data are discussed in details in the paper.

[Blood insulin values after the oral glucose tolerance test (OGTT) and the body composition in 30 obese children]. / Valori di insulinemia dopo test da carico orale di glucosio (OGTT) e composizione corporea in 30 bambini obesi.

The body composition and plasma insulin after OGTT were evaluated in 30 obese children, aged 6 to 14 years. The obese children higher serum insulin after OGTT. There was a relationship between plasma insulin and Body Mass Index (MBI) and between plasma insulin and Weight For Height (WFH) (p < 0.001). There is the accumulating evidence that chronic day-long hyperinsulinemia is associated with an insulin-resistance syndrome characterized by the development of hypertension, hyperlipidemia, atherosclerosis and non insulin depend diabetes.

[Congenital hepatic fibrosis: a report of a case in a child with Down's syndrome]. / Fibrosi epatica congenita: descrizione di un caso in un bambino con sindrome di Down.

An association of congenital hepatic fibrosis and Down syndrome in an 8-year-old boy is described. The child presented a form of congenital hepatic fibrosis with portal hypertension, splenomegaly and platelets loss. In the patient's family there are no manifestations of hepatic and renal disease.

[Cholesterol cholelithiasis. A clinical case]. / Colelitiasi colesterinica. Un caso clinico.

The Authors present a case of cholesterinic cholelithiasis, in a patient 13 years of age. The case is interesting because the cholesterol gallstones are uncommon in childhood, with women showing a higher prevalence than men.