Pier Luigi Lopalco

A nosocomial measles outbreak in Italy, February-April 2017

We describe a nosocomial outbreak of measles that occurred in an Italian hospital during the first months of 2017, involving 35 persons and including healthcare workers, support personnel working in the hospital, visitors and community contacts. Late diagnosis of the first case, support personnel not being promptly recognised as hospital workers and diffusion of the infection in the emergency department had a major role in sustaining this outbreak.

Unplanned readmissions within 30 days after discharge: improving quality through easy prediction

ObjectivenTo propose an easy predictive model for the risk of rehospitalization, built from hospital administrative data, in order to prevent repeated admissions and to improve transitional care.nnnDesignnRetrospective cohort study.nnnSettingnAzienda Ospedaliero Universitaria Pisana (Pisa University Hospital).nnnParticipantsnPatients residing in the territory of the province of Pisa (Tuscany Region) with at least one unplanned hospital admission leading to a medical Diagnosis-Related Group (DRG) in the calendar year 2012.nnnInterventionnWe compared two groups of patients: patients coded as RA30 (readmitted within 30 days after the previous discharge) and patients coded as NRA30 (either admitted only once or readmitted after 30 days since the latest discharge).nnnMain Outcome MeasuresnThe effect of age, sex, length of stay, number of diagnoses, normalized number of admissions and presence of diseases on the probability of rehospitalization within 30 days after discharge was evaluated.nnnResultsnThe significant variables included in the predictive model were: age, odds ratio (OR) = 1.018, 95% confidence interval (CI) = 1.011-1.026; normalized number of admissions, OR = 1.257, CI = 1.225-1.290; number of diagnoses, OR = 1.306, CI = 1.174-1.452 and presence of cancer diagnosis, OR = 1.479, CI = 1.088-2.011.nnnConclusionsnThe model can be easily applied when discharging patients who have been hospitalized after an access to the Emergency Department to predict the risk of rehospitalization within 30 days. The prediction can be used to activate focused hospital-primary care transitional interventions. The model has to be validated first in order to be implemented in clinical practice.Objective To propose an easy predictive model for the risk of rehospitalization, built from hospital administrative data, in order to prevent repeated admissions and to improve transitional care. Design Retrospective cohort study. Setting Azienda Ospedaliero Universitaria Pisana (Pisa University Hospital). Participants Patients residing in the territory of the province of Pisa (Tuscany Region) with at least one unplanned hospital admission leading to a medical Diagnosis-Related Group (DRG) in the calendar year 2012. Intervention We compared two groups of patients: patients coded as RA30 (readmitted within 30 days after the previous discharge) and patients coded as NRA30 (either admitted only once or readmitted after 30 days since the latest discharge). Main Outcome Measures The effect of age, sex, length of stay, number of diagnoses, normalized number of admissions and presence of diseases on the probability of rehospitalization within 30 days after discharge was evaluated. Results The significant variables included in the predictive model were: age, odds ratio (OR) = 1.018, 95% confidence interval (CI) = 1.011-1.026; normalized number of admissions, OR = 1.257, CI = 1.225-1.290; number of diagnoses, OR = 1.306, CI = 1.174-1.452 and presence of cancer diagnosis, OR = 1.479, CI = 1.088-2.011. Conclusions The model can be easily applied when discharging patients who have been hospitalized after an access to the Emergency Department to predict the risk of rehospitalization within 30 days. The prediction can be used to activate focused hospital-primary care transitional interventions. The model has to be validated first in order to be implemented in clinical practice.

Detection of viable but non-culturable legionella in hospital water network following monochloramine disinfection

BACKGROUNDnPrevention of legionellosis remains a critical issue in healthcare settings where monochloramine (MC) disinfection was recently introduced as an alternative to chlorine dioxide in controlling Legionella spp. contamination of the hospital water network. Continuous treatments with low MC doses in some instances have induced a viable but non-culturable state (VBNC) of Legionella spp.nnnAIMnTo investigate the occurrence of such dormant cells during a long period of continuous MC treatment.nnnMETHODSnBetween November 2010 and April 2015, 162 water and biofilm samples were collected and Legionella spp. isolated in accordance with standard procedures. In sampling sites where MC was <1.5mg/L, VBNC cells were investigated by ethidium monoazide bromide (EMA)-real-time polymerase chain reaction (qPCR) and resuscitation test into Acanthamoeba polyphaga CCAP 1501/18. According to the Health Protection Agency protocol, free-living protozoa were researched in 60 five-litre water samples.nnnFINDINGSnIn all, 136 out of 156 (87.2%) of the samples taken from sites previously positive for L.xa0pneumophila ST269 were negative by culture, but only 47 (34.5%) negative by qPCR. Although no positive results were obtained by EMA-qPCR, four out of 22 samples associated with MC concentration of 1.3xa0±xa00.5mg/L showed VBNC legionella resuscitation. The presence of the amoeba A.xa0polyphaga in the hospital water network was demonstrated.nnnCONCLUSIONnOur study is the first report evidencing the emergence of VNBC legionella during a long period of continuous MC treatment of a hospital water network, highlighting the importance of keeping an appropriate and uninterrupted MC dosage to ensure the control of legionella colonization in hospital water supplies.

Health literacy, emotionality, scientific evidence: Elements of an effective communication in public health

ABSTRACT The importance of healthcare providers communication abilities is still underestimated. Informing the population on the basis of documented evidence is essential but not enough to induce a change in the beliefs of who is doubtful or does not accept preventive interventions, such as vaccination. Lining up the offer of prevention to the knowledge of the citizens, also improving Health Literacy skills, is a critical step toward their empowerment and behavior change. The 2017 Erice Declaration was drafted to propose to the Institutions and the scientific community the main goals to improve communication and counteract Vaccine Hesitancy, at a very critical time, when mandatory vaccination was introduced in Italy.

Overcoming barriers in HPV vaccination and screening programs

The Human Papillomavirus Prevention and Control Board brought together experts to discuss optimizing HPV vaccination and screening programs. Board members reviewed the safety profile of licensed HPV vaccines based on clinical and post-marketing data, reaching a consensus that current safety data is reassuring. Successful vaccination programs used well-coordinated communication campaigns, integrating (social) media to spread awareness. Communication of evidence supporting vaccine effectiveness had beneficial effects on the perception of the vaccine. However, anti-vaccination campaigns have threatened existing programs in many countries. Measurement and monitoring of HPV vaccine confidence over time could help understand the nature and scale of waning confidence, define issues and intervene appropriately using context-specific evidence-based strategies. Finally, a broad group of stakeholders, such as teachers, health care providers and the media should also be provided with accurate information and training to help support prevention efforts through enhanced understanding of the risks and benefits of vaccination. Similarly, while cervical cancer screening through population-based programs is highly effective, barriers to screening exist: awareness in countries with population-based screening programs, access for vulnerable populations, and access and affordability in low- and middle-income countries. Integration of primary and secondary prevention has the potential to accelerate the decrease in cervical cancer incidence.

Access and Barriers to Childhood Immunization Among Migrant Populations

Vaccine preventable diseases are mostly under control in the EU, thanks to successful immunisation programmes. Nevertheless, immunisation gaps still exist among the European child population. Pockets of susceptible population may jeopardise priority public health programmes like the measles and rubella elimination programme and represent a threat for keeping the polio-free status. Children belonging to disadvantaged groups, including families with migrant background, are considered at higher risk for some vaccine preventable disease. The increased risk is mainly linked to difficult access to vaccination services and subsequent low vaccination coverage in local communities. Language barriers, lack of targeted communication strategies, the absence of diversity-oriented organisation behaviours, altogether contribute to create a hostile environment for improving the compliance of migrant families to childhood vaccination programmes.

Assessing natural mineral water microbiology quality in the absence of cultivable pathogen bacteria

Italian Directives recommend the good quality of natural mineral waters but literature data assert a potential risk from microorganisms colonizing wellsprings and mineral water bottling plants. We evaluated the presence of microorganisms in spring waters (SW) and bottled mineral waters (BMW) samples. Routine microbiological indicators, additional microorganisms like Legionella spp., Nontuberculous mycobacteria (NTM) and amoebae (FLA) were assessed in 24 SW and 10 BMW samples performing cultural and molecular methods. In 33 out of 34 samples, no cultivable bacteria ≥10 CFU/L was found. Cultivable FLA were detected in 50% of water samples. qPCR showed the presence of Legionella qPCR units in 24% of samples (from 1.1 × 102 to 5.8 × 102 qPCR units/L) and NTM qPCR units in 18% of samples (from 1 × 102 to 1 × 105 qPCR units/L). Vermamoeba vermiformis and Acanthamoeba polyphaga were recovered respectively in 70% of BMW samples (counts from 1.3 × 103 to 1.2 × 105 qPCR units/L) and 42% of SW samples (from 1.1 × 103 to 1.3 × 104 qPCR units/L). Vahlkampfia spp. was detected in 42% of SW and 70% of BMW samples (from 1.2 × 103 to 1.2 × 105 qPCR units/L). Considering the presence of FLA, we underline the importance of a wider microbiological risk assessment in natural mineral waters despite the absence of cultivable bacteria.

Life-course immunization as a gateway to health

ABSTRACT Introduction: Extending the benefits of vaccination against infectious diseases from childhood throughout the entire life-span is becoming an increasingly urgent priority in view of the world’s aging population, emergence and reemergence of infectious diseases, and the necessity to invest more on prevention versus cure in global healthcare. Areas covered: This perspective discusses how life-course immunization could benefit human health at all stages of life. To achieve this, the current vaccination paradigm should be changed and all stakeholders have a role to play. Expert commentary: To enhance immunization confidence in the population, it is essential that stakeholders eliminate complacency toward infectious diseases, improve vaccination convenience, remove barriers among different healthcare specialties, and address prevention as a single entity. They must also consider societal and cultural mindsets by understanding and including public viewpoints. A new “4Cs’ model encompassing convenience, confidence, complacency, and cultural acceptance is proposed to convert ‘vaccine availability’ to ‘vaccination acceptance’ throughout life. Life-course vaccination should become the new social norm of a healthy life-style, along with a healthy diet, adequate physical exercise, and not smoking. We are ‘all in’ to make life-course immunization a gateway for all people to lead longer, healthier lives.

Impact of hepatitis B vaccination on acute hepatitis B epidemiology in European Union/European Economic Area countries, 2006 to 2014

Hepatitis B prevention in European Union/European Economic Area (EU/EEA) countries relies on vaccination programmes. We describe the epidemiology of acute hepatitis B virus (HBV) at country and EU/EEA level during 2006–2014. Using a multi-level mixed-effects Poisson regression model we assessed differences in the acute HBV infection notification rates between groups of countries that started universal HBV vaccination before/in vs after 1995; implemented or not a catch-up strategy; reached a vaccine coverageu2009≥u200995% vsu2009<u200995% and had a hepatitis B surface antigen prevalenceu2009≥u20091% vsu2009<u20091%. Joinpoint regression analysis was used to assess trends by groups of countries, and additional Poisson regression models to evaluate the association between three-dose HBV vaccine coverage and acute HBV infection notification rates at country and EU/EEA level. The EU/EEA acute HBV infection notification rate decreased from 1.6 per 100,000 population in 2006 to 0.7 in 2014. No differences (pu2009>u20090.05) were found in the acute HBV infection notification rates between groups of countries, while as vaccine coverage increased, such rates decreased (pu2009<u20090.01). Countries with universal HBV vaccination before 1995, a catch-up strategy, and a vaccine coverageu2009≥u200995% had significant decreasing trends (pu2009<u20090.01). Ending HBV transmission in Europe by 2030 will require high vaccine coverage delivered through universal programmes, supported, where appropriate, by catch-up vaccination campaigns.

Evaluation and control of microbial and chemical contamination in dialysis water plants of Italian nephrology wards

BACKGROUNDnPatients receiving haemodialysis are exposed to a large volume of dialysis fluid. The Italian Society of Nephrology (ISN) has published guidelines and microbial quality standards on dialysis water (DW) and solutions to ensure patient safety.nnnAIMnTo identify microbial and chemical hazards, and evaluate the quality of disinfection treatment in DW plants.nnnMETHODSnIn 2015 and 2016, water networks and DW plants (closed loop and online monitors) of nine dialysis wards of Italian hospitals, hosting 162 dialysis beds overall, were sampled on a monthly basis to determine the parameters provided by ISN guidelines. Chlorinated drinking water was desalinated by reverse osmosis and distributed to the closed loop which feeds all online monitors. Disinfection with peracetic acid was performed in all DW plants on a monthly basis.nnnFINDINGSnOver the 24-month study period, seven out of nine DW plants (78%) recorded negative results for all investigated parameters. Closed loop contamination with Burkholderia cepacia was detected in a DW plant from January 2015 to March 2015. Pseudomonas aeruginosa was isolated from March 2016 to May 2016 in the closed loop of another DW plant. These microbial contaminations were eradicated by shock disinfection with sodium hypochlorite and peracetic acid, followed by water flushing.nnnCONCLUSIONnThese results highlight the importance of chemical and physical methods of DW disinfection. The maintenance of control measures in water plants hosted in dialysis wards ensures a microbial risk reduction for all dialysis patients.