Mariateresa Romano

Close Encounters in a Pediatric Ward: Measuring Face-to-Face Proximity and Mixing Patterns with Wearable Sensors

Background Nosocomial infections place a substantial burden on health care systems and represent one of the major issues in current public health, requiring notable efforts for its prevention. Understanding the dynamics of infection transmission in a hospital setting is essential for tailoring interventions and predicting the spread among individuals. Mathematical models need to be informed with accurate data on contacts among individuals. Methods and Findings We used wearable active Radio-Frequency Identification Devices (RFID) to detect face-to-face contacts among individuals with a spatial resolution of about 1.5 meters, and a time resolution of 20 seconds. The study was conducted in a general pediatrics hospital ward, during a one-week period, and included 119 participants, with 51 health care workers, 37 patients, and 31 caregivers. Nearly 16,000 contacts were recorded during the study period, with a median of approximately 20 contacts per participants per day. Overall, 25% of the contacts involved a ward assistant, 23% a nurse, 22% a patient, 22% a caregiver, and 8% a physician. The majority of contacts were of brief duration, but long and frequent contacts especially between patients and caregivers were also found. In the setting under study, caregivers do not represent a significant potential for infection spread to a large number of individuals, as their interactions mainly involve the corresponding patient. Nurses would deserve priority in prevention strategies due to their central role in the potential propagation paths of infections. Conclusions Our study shows the feasibility of accurate and reproducible measures of the pattern of contacts in a hospital setting. The obtained results are particularly useful for the study of the spread of respiratory infections, for monitoring critical patterns, and for setting up tailored prevention strategies. Proximity-sensing technology should be considered as a valuable tool for measuring such patterns and evaluating nosocomial prevention strategies in specific settings.

Detection of Streptococcus pneumoniae and Identification of Pneumococcal Serotypes by Real-Time Polymerase Chain Reaction Using Blood Samples from Italian Children ≤5 Years of Age with Community-Acquired Pneumonia

Streptococcus pneumoniae is a leading cause of severe life-threatening infections. Laboratory identification and serotyping of this pathogens is desirable to monitor vaccine impact and coverage; however, especially in pediatric patients, the yield of traditional microbiological diagnostic procedures can be very low. The aim of this study was to develop real-time polymerase chain reaction (PCR)-based assays to be performed directly on blood samples to identify the most common capsular serotypes causing pneumonia in Italian children (≤ 5 years of ages) after the introduction of the 7-valent conjugate vaccine. Our real-time PCR-based assays showed high sensitivity (at least 35 fg of pneumococcal DNA), and they were validated with 49 well-characterized pneumococcal isolates, 8 nonpneumococcal isolates, 13 simulated blood clinical samples loaded with S. pneumoniae of known serotypes, and 46 blood clinical samples. All the strains tested and the simulated blood clinical samples were correctly typed by the technique. Real-time PCR allowed serotyping in 37/46 children ≤ 5 years of age (80.4%) in whom pneumonia was diagnosed in four Italian hospitals. Non-PCV7 serotypes accounted for at least 47.8% (22/46) of cases, serotype 19A being the most common (34.7%, 16/46). Although, it is not known at present whether the incidence of 19A serotype is attributable to the use of PCV7 only, expanding pneumococcal serotype coverage has clearly the potential to prevent a larger number of pneumonias in Italian children less than ≤ 5 years of age. Molecular methods are of increasing importance in the diagnosis of pneumococcal pneumonia and in monitoring serotype distribution and replacement.

Switched memory B cells maintain specific memory independently of serum antibodies: the hepatitis B example.

The immunogenicity of a vaccine is conventionally measured through the level of serum Abs early after immunization, but to ensure protection specific Abs should be maintained long after primary vaccination. For hepatitis B, protective levels often decline over time, but breakthrough infections do not seem to occur. The aim of this study was to demonstrate whether, after hepatitis B vaccination, B‐cell memory persists even when serum Abs decline. We compared the frequency of anti‐hepatitis‐specific memory B cells that remain in the blood of 99 children five years after priming with Infanrix®‐hexa (GlaxoSmithKline) (n=34) or with Hexavac® (Sanofi Pasteur MSD) (n=65). These two vaccines differ in their ability to generate protective levels of IgG. Children with serum Abs under the protective level, <10 mIU/mL, received a booster dose of hepatitis B vaccine, and memory B cells and serum Abs were measured 2 wk later. We found that specific memory B cells had a similar frequency in all children independently of primary vaccine. Booster injection resulted in the increase of memory B cell frequencies (from 11.3 in 106 cells to 28.2 in 106 cells, p<0.01) and serum Abs (geometric mean concentration, GMC from 2.9 to 284 mIU/mL), demonstrating that circulating memory B cells effectively respond to Ag challenge even when specific Abs fall under the protective threshold.

Effect of duration of breastfeeding on neuropsychological development at 10 to 12 years of age in a cohort of healthy children

Aim  The aim of this article was to explore the effect of duration of breastfeeding on neurocognitive development.

The effect of physician’s recommendation on seasonal influenza immunization in children with chronic diseases

BackgroundDespite recommendations by Health Authorities, influenza immunization coverage remains low in children with chronic diseases. Different medical providers involved in the management of children with chronic conditions may affect the pattern of influenza vaccine recommendations and coverage. The likelihood of vaccination by type of provider in children with chronic conditions is poorly understood. Therefore, the objectives of this study were to analyze the pattern and the effect of recommendations for seasonal influenza immunization provided by different physician profiles to families of children with chronic diseases and to measure the frequency of immunization in the study population.MethodsWe recruited children with chronic diseases aged 6 months–18 years who subsequently presented to specialty clinics for routine follow-up visits, during spring 2009, in three Italian Regions Families of children with chronic diseases were interviewed during routine visits at reference centers through a face-to-face interview. We analyzed the following immunization predictors: having received a recommendation toward influenza immunization by a health provider; child’s sex and age; mothers and fathers’ age; parental education and employment; underlying child’s disease; number of contacts with health providers in the previous year. Influenza immunization coverage was calculated as the proportion of children who received at least one dose of seasonal influenza vaccine in the previous season. We calculated prevalence ratios and we used a generalized linear model with Poisson family, log link and robust error variance to assess the effect of socio-demographic variables, underlying diseases, and recommendations provided by physicians on influenza immunization.ResultsWe enrolled 275 families of children with chronic diseases. Overall influenza coverage was 57.5%, with a low of 25% in children with neurological diseases and a high of 91.2% in those with cystic fibrosis. While 10.6% of children who did not receive any recommendation toward influenza immunization were immunized, among those who received a recommendation 87.5-94.7% did, depending on the health professional providing the recommendation. Receiving a recommendation by any provider is a strong predictor of immunization (PR = 8.5 95% CI 4.6;15.6) Most children received an immunization recommendation by a specialty (25.8%) or a family pediatrician (23.3%) and were immunized by a family pediatrician (58.7%) or a community vaccinator (55.2%).ConclusionsReceiving a specific recommendation by a physician is a strong determinant of being immunized against seasonal influenza in children with chronic diseases independently of other factors. Heterogeneity exists among children with different chronic diseases regarding influenza recommendation despite international guidelines. Increasing the frequency of appropriate recommendations toward influenza immunization by physicians is a single powerful intervention that may increase coverage in children with chronic conditions.

Women participating in a web-based preconception study have a high prevalence of risk factors for adverse pregnancy outcomes

BackgroundAdverse pregnancy outcomes (APOs) can be increased by preconception risk factors and lifestyles.We measured the prevalence of preconception risk factors for APOs in a population of Italian women of childbearing age enrolled in a web-based study.MethodsParticipants were enrolled through a web platform (http://www.mammainforma.it). After enrollment, participants filled in a questionnaire regarding socio-demographic characteristics, clinical data and preconception risk factors for adverse pregnancy outcomes. Through logistic regression, we explored how the prevalence of risk factors was affected by age, education level, employment, parity, physician’s recommendation and knowledge of the specific risk factor.ResultsWe enrolled a total of 728 women. Sixty-two percent had a University degree, 84% were employed and 77% were planning their first pregnancy.Nearly 70% drank alcohol in any quantity; 16% were smokers; 6% was underweight; 21.4% was overweight; 51.6% did not assume folic acid; 22% was susceptible to rubella, 44.5% to hepatitis b and 13.2% to varicella.According to the multivariate analysis, compared to women who already had at least one pregnancy, nulliparous women had a higher BMI [OR 1.60 (CI 1.02;2.48)] and were less likely to be susceptible to rubella [OR 0.33 (CI 0.20;0.58)] and to be consuming alcohol [OR 0.47 (CI 0.31;0.70)] or cigarettes [OR 0.48 (CI 0.26;0.90)].Appropriate knowledge was associated with a correct behavior regarding smoking, drinking alcohol and folic acid supplementation.ConclusionsThis study shows that the prevalence of risk factors for APOs in our population is high.Interventions aimed at reducing risk factors for APOs are needed and, to this purpose, a web intervention may represent a feasible tool to integrate tailored information and to inform preconception counseling targeting a specific group of women planning a pregnancy who are engaged on the web.

The combination of bortezomib with chemotherapy to treat relapsed/refractory acute lymphoblastic leukaemia of childhood

Achieving complete remission (CR) in childhood relapsed/refractory acute lymphoblastic leukaemia (ALL) is a difficult task. Bortezomib, a proteasome inhibitor, has in vitro activity against ALL blasts. A phase I‐II trial, reported by the Therapeutic Advances in Childhood Leukaemia and Lymphoma (TACL) consortium, demonstrated that bortezomib with chemotherapy has acceptable toxicity and remarkable activity in patients with relapsed ALL failing 2–3 previous regimens. We evaluated bortezomib in combination with chemotherapy in 30 and 7 children with B‐cell precursor (BCP) and T‐cell ALL, respectively. Bortezomib (1·3 mg/m2/dose) was administered intravenously on days 1, 4, 8, and 11. Chemotherapy agents were the same as those used in the TACL trial, consisting of dexamethasone, doxorubicin, vincristine and pegylated asparaginase. Three patients (8·1%) died due to infections. Twenty‐seven patients (72·9%) achieved CR or CR with incomplete platelet recovery (CRp). Fourteen had minimal residual disease (MRD) lower than 0·1%. Twenty‐two of 30 BCP‐ALL patients (73·3%) and 5/7 patients (71%) with T‐cell ALL achieved CR/CRp. The 2‐year overall survival (OS) is 31·3%; CR/CRp patients with an MRD response had a remarkable 2‐year OS of 68·4%. These data confirm that the combination of bortezomib with chemotherapy is a suitable/effective option for childhood relapsed/refractory ALL.

Use of the internet by Italian pediatricians: habits, impact on clinical practice and expectations.

BackgroundMedical professionals go online for literature searches and communication with families.We administered a questionnaire to members of the Italian Society of Pediatrics to assess determinants of their use of the Internet, of social platforms and of personal health records during clinical practice.MethodsAll the 9180 members of the Italian Society of Pediatrics were invited to fill in a questionnaire concerning use of the Internet and usefulness of Internet-based tools during clinical practice. The questionnaire was administered through the SurveyMonkey® web platform. Logistic regression analysis was used to study factors affecting use and influence of the Internet in clinical practice.ResultsA total of 1335 (14.5%) members returned the questionnaire. Mean age was 49.2 years, 58.6% were female. 32.3% had access to the Internet through a Smartphone. 71.9% of respondents used the Internet during clinical practice, mainly searching for guidelines and drug references. Use of the Internet during clinical practice was more frequent among younger pediatricians (OR 0.964; 95% CI 0.591-0.978), males (OR 1.602; 95% CI 1.209-2.123) and those living in Northern and Central Italy (OR 1.441; 95% CI 1.111-1.869), while it was lower among family pediatricians. 94.6% of respondents were influenced in their clinical practice by information found on the Internet, in particular younger pediatricians (OR 0.96, 95% CI 0.932-0.989), hospital pediatricians (OR 2.929, 95% CI 1.708-5.024), and other pediatric profiles (OR 6.143, 95%CI 1.848-20.423). 15.9% of respondents stated that social networks may be useful in pediatric practice. Slightly more than half (50.5%) of respondents stated that personal health records may be clinically relevant. Registrars and hospital pediatricians were more likely to perceive personal health records as useful tools for clinical practice. Additional resources pediatricians would like to access were free bibliographic databases and tools for interacting with families.ConclusionsItalian pediatricians frequently use the Internet during their practice. One-third of them access the Internet through a Smartphone. Interaction with families and their empowerment can be improved by the use of Internet tools, including personal health records, toward which respondents show a significant interest. Though, they show a general resistance to the introduction of social networks in clinical practice.

Re-emergence of measles in young infants

To the Editors: The World Health Organization goal of eliminating measles in Europe will not be met by the targeted year 2010. In Italy measles incidence declined since vaccine introduction in 1998. Childhood vaccination coverage at 24 months has increased from 56% in 1998 to 90% in 2008. Although public health authorities have made extraordinary efforts, measles is still spreading throughout Europe. After sporadic cases or clusters nationwide during the previous years, we recently observed a local resurgence of measles. At Bambino Gesù Hospital, in Rome, we had no hospitalizations associated with measles from January 2009 to February 2010, whereas we admitted into hospital 26 laboratory confirmed cases from March to September 2010. The median age was of 6 years (range from 1 month to 17 years). The observed complications were dehydration in 13 cases, pneumonia in 11 cases, and otitis in 2 cases. None of them died or had disabling sequelae after discharge. Measles circulation is likely a result of suboptimal vaccination coverage, even if vaccine is offered free-of-charge in a 2-dose routine immunization program, at 12 to 15 months and at 5 to 6 years of age. Vaccine coverage depends strongly on the acceptance of vaccination by parents, as well as on recommendations by pediatricians. Parents are free to decide on their child’s vaccinations and measles immunization is not mandatory for school admission. Parents may consider the potential profit for the community—due to herd immunity effects and a reduced economical burden—as less important than the individual risk from potential vaccination side-effects. Among our hospitalized children, 7 were too young to be vaccinated. Four children were 3 months or younger and 3 were less than 12 months of age. Only one of the mothers of these children was immunized. Four mothers developed the disease 1 week before their children and they were the likely source of infection. In 1 case, the older sister experienced measles 10 days before and probably transmitted the disease to the infant. As for the other infants, parents were not able to identify the source of infection. Immunization was delayed or not consented by the parents of the older 19 children, who then likely had been infected in the household or at school. Among the reasons for not getting vaccinated were: (a) fear of injections or of side effects; (b) perception of measles as a benign disease; (c) no need of vaccination as the child seemed to be healthy; (d) perception of measles as an eliminated disease from Europe and consequently vaccination as unnecessary. Finally, we should consider the important role of the not yet vaccinated infants who may not be protected by passive immunity or who can experience waning immunity. In fact, measles immunity transmitted by mothers may wane shortly after birth. In conclusion, to prevent perspective outbreaks and interrupt measles circulation, strong efforts should be made to achieve and maintain routine coverage over 95%, to adhere to the immunization schedule, to immunize susceptible adults, and to consider offering the vaccine at 9 months of age. Elena Bozzola, MD Anna Quondamcarlo, MD Andrzej Krzysztofiak, MD Laura Lancella, MD Infection Unit Ospedale Pediatrico Bambino Gesù

Cord blood transplantation in children with hemoglobinopathies

Introduction: Current challenges in the field of hematopoietic stem cell transplantation (HSCT) for hemoglobinopathies include the possibility of using alternative donors to expand the number of candidates to an allograft. Umbilical cord blood transplantation (UCBT) have extended the access to HSCT in patients lacking matched related or unrelated adult donors, and appears particularly appealing in non-malignant diseases by virtue of the associated low incidence of graft-versus-host disease (GVHD). Areas covered: Outcomes of patients with thalassemia or sickle cell disease given related UCBT is at least as good as that of patients receiving bone marrow (BM) allograft from human leucocyte antigen (HLA)-identical siblings, provided the UCB unit contains adequate cell dose. The experience with unrelated UCBT has been less encouraging, primarily due to low engraftment rates and delayed hematopoietic recovery. New promising approaches of ex vivo graft manipulation aimed at overcoming the drawback of cell dose limitation are under investigation. Expert opinion: We suggest that HSCT should be pursued whenever an HLA-identical CB unit is available, employing it either alone or in combination with BM from the same donor. Based on currently reported data, unrelated UCBT appears to be a suboptimal strategy for patients with hemoglobinopathies, unless it is performed in the context of clinical trials aimed at exploring specific treatment platforms of ex vivo UCB-graft manipulation.