S. Barbuti

Hepatitis A and B in children and adolescents – what can we learn from Puglia (Italy) and Catalonia (Spain)?

Viral hepatitis remains a major contributor to the global disease burden. Mass immunisation strategies against hepatitis B have been adopted by more than 90 developing and industrialised countries. Countries with low hepatitis A endemicity are experiencing cyclical outbreaks and an epidemiological shift, with larger numbers of individuals at risk of infection at an older age, resulting in increased morbidity. The high cost of outbreaks in these countries has made immunisation strategies cost-effective. The development of a vaccine against hepatitis A and a combined vaccine against hepatitis A and hepatitis B offers potentially exciting opportunities for a preventative approach in areas of both low and high endemicity. Existing mass immunisation programmes against hepatitis B will facilitate the adoption of joint strategies illustrated by the examples of Puglia (Italy) and Catalonia (Spain).

Outbreak of Infection with Hepatitis A Virus (HAV) Associated with a Foodhandler and Confirmed by Sequence Analysis Reveals a New HAV Genotype IB Variant

ABSTRACT An outbreak of infection with hepatitis A virus associated with a foodhandler and involving 26 subjects occurred in Southern Italy. Sequence analysis of the VP3-VP1 and VP1-P2A junctions confirmed that the outbreak was due to a point source and allowed the identification of a new genotype IB variant. This report confirms the usefulness of sequence-based molecular fingerprinting during outbreaks.

PREVALENCE RATES OF VIRAL HEPATITIS INFECTIONS IN REFUGEE KURDS FROM IRAQ AND TURKEY

Abstract.Background: Since little is known about the burden of viral hepatitis in Kurds, the prevalence of infection with hepatitis A virus (HAV), hepatitis E virus (HEV), hepatitis B virus (HBV) and hepatitis C virus (HCV) was investigated in a sample of refugee Kurds from Iraq and Turkey. Patients and Methods: A cross-sectional study was carried out. Serological markers to hepatitis viruses were determined for 1,005 subjects from all age-groups of which 36.6% were from Turkey and 63.4% from Iraq. Results: Overall seroprevalence for anti-HAV was 94.4% and 14.8% for anti-HEV. A significantly higher prevalence for anti-HEV was found among Iraqis (17.5%) compared to Turkish immigrants (10.0%). The prevalence of hepatitis B surface antigen (HBsAg) and total anti-HBc (core) was 6.8% and 35.6% in Turkish Kurds and 2.2% and 12.7% in Iraqis, respectively. Only 10% of children aged up to 10 years and 2.8% of subjects aged 11–20 years had been vaccinated against HBV, the majority of them coming from Iraq. One subject was confirmed as positive for anti-HCV (0.1%) and HCV-RNA and analysis showed a 4c/4d genotype. Conclusion: This survey shows a high prevalence of enterically transmitted viral hepatitis in Kurds. HBV infection is moderately endemic, while the prevalence of HCV infection is low. There is a need for a universal immunization strategy for HBV in the Kurd population.

HBV, HCV and HDV infections in Albanian refugees in Southern Italy (Apulia region)

The seroprevalence of hepatitis B, C and D markers was assessed in a sample of 670 Albanian refugees in Southern Italy in 1997. The mean age was 25 years (S.D. = 12.3). Of study subjects 62.1% (95% CI: 58.4-65.7) were positive for anti-HBc antibodies and 13.6% (95% CI: 10.9-16.1) for HBsAg. The prevalence of anti-HBs was 47.6% (95% CI: 43.8-51.3). Among HBsAg carriers the prevalence of HBeAg was 7.7% (95% CI: 2.2-13.1). The highest carrier rate for HBsAg (25.5%; 95% CI: 16.7-34.3) was found in the age group 21-25 years. A relevant finding was a prevalence of HBsAg of 8.1% in children 10 years and under. The prevalence of anti-HCV antibodies was 0.3% (95% CI: 0.0-0.7) while only one of the HBsAg carriers was positive for anti-HDV (1.1%, 95% CI: 0-3.2). In Albania, hepatitis B infection represents a public health priority that should be addressed by a universal vaccination campaign.

Seroimmunity to poliomyelitis in an Albanian immigrant population

The immunity against poliomyelitis in a representative sample of the Albanian population recently immigrant to Italy was evaluated. A significant number of the subjects examined lacked protective antibodies against one or more polioviruses. The most prevalent seronegativity related to poliovirus type 3 (41.3%), followed by poliovirus type 1 (21.5%). This result was more consistent in the younger age groups. Our data suggest the hypothesis that this problem arises from the use of a vaccine of discontinuous efficacy caused by defective preservation. A poliovaccine booster dose for all emigree subjects aged less than 15 years is suggested.

Clinical-environmental surveillance of legionellosis: an experience in Southern Italy.

In Italy, although the number of cases of legionellosis notified to the health authorities has significantly increased in recent years, the incidence is still believed to be underestimated. To verify the true frequency and identify the sources of infection, an active clinical–environmental surveillance program was instituted in three hospital facilities in Southern Italy. Between January 2001 and March 2005, a total of 1000 patients admitted to the three hospitals with a diagnosis of pneumonia were enrolled. The urinary antigen and anti-Legionella antibody titre were assayed in each subject, and direct searches for the microorganism were made in biological specimens. Legionellosis was found to be present in 5.9% of the patients. For each of the cases of legionellosis, microbiological surveys were made of the water supply in the public and/or private facilities involved. Overall, 197 water samples of hospital origin and 218 of community origin were analysed: Legionella spp was isolated in 44.2 and 36.7% of the cases, respectively. Comparison of our data with those of the routine surveillance system for the same area (only 7 cases during the period 1997–2000), showed that the frequency of legionellosis is grossly underestimated in Southern Italy. It is therefore necessary to set up more rigorous controls in both hospital and community facilities, so that timely preventive measures can be taken to avoid any further spread of the disease.

HIV transmission by Fellatio

Anal and vaginal intercourse are considered the most efficient sexual means of transmission of the human immunodeficiency virus (HIV). Doubt remains concerning the role of oral sex in transmitting the infection. However, a single subject may engage in many different sexual practices, and it may be quite difficult to document this latter type of transmission even when it occurs (4). We report a case in which HIV infection appeared to have been sexually transmitted from female to male following a single oral exposure. Our patient, a 25-year-old man, had been examined for HIV infection because of unexplained lymphadenopathy. He was HIV-seropositive in both enzyme-linked immunosorbent assay (ELISA) and Western blot analysis. The patient reported that five months before he had developed symptoms of a mononucleosis-like illness that had lasted for some weeks. He had been tested for rubeola, mononucleosis, toxoplasmosis and cytomegalovims infection, but all results were negative. HIV infection had not been suspected. After having verified that the patient was seropositive for HIV we concluded he had developed symptoms of primary HIV infection and subsequently a persistent generalized lymphadenopathy (PGL). The subject denied history of homosexual practices, intravenous drug abuse or transfusion of blood products. Heterosexual contact was, thus, the only reasonable risk factor. Analysis of his sexual history during the last few years revealed a stable relationship with a female partner who did not belong to any of the recognized MDS risk-groups. Our tests showed that she was HIV seronegative. The patient reported a single episode of fellatio that had taken place with an occasional sexual partner about one month before the appearance of the mononucleosislike syndrome. The young woman in question was not a prostitute. The patient was umcircumcised. He denied the existence of genital ulcers or other lesions at the time of exposure, and he had no past history or serological evidence of syphilis or genital herpes. On the basis of these data, the only point of risk appeared to be the fellatio episode with the occasional sexual partner. Although no information is available on the HIV serostatus of this young woman, this case suggests female-to-male transmission of HIV through fellatio. Several studies of specific sexual practices in homosexual men (2, 3, 8) and heterosexual couples (1, 5) have failed to identify oral sex as an independent risk factor for HIV infection. However, a more recent epidemiologic study in homosexual men (6) has reported that oral sex is associated with a risk for HIV transmission, and a case report (7) has suggested that the infection can be transmitted from a woman to a man through oral sex. Our case provides further evidence for the possibility of HIV transmission by oral sex. Although the risk of acquiring H1V infection with a single sexual contact is still unknown, this case suggests that HIV transmission can occur through an isolated oral exposure. Therefore, we wish to stress the fact that oral sex should not be excluded as potential mode of H1V

Immunity to diphtheria among refugees in southern Italy.

This study assessed the immune status against diphtheria of a sample of refugees (mainly Kosovars and Kurds) in southern Italy (Puglia). The 54.8% of 1128 subjects showed full protection against diphtheria, 30.1% had basic protection and 15.1% resulted seronegative for antitoxin antibody. Only from 45.9 to 73.9% of 0-10 years old refugees were fully protected while from 12.3 to 24.2% were seronegative to diphtheria with the poorest protection rate among Kurdish children from Turkey. Kosovars showed the highest protection rate to diphtheria whereas data suggest a probable endemic level of diphtheria in Iraq. The screening of refugees revealed a low coverage rate for diphtheria, especially in children, probably due to deterioration of the health service infrastructure or intermittent basic health care in the country of provenience. In terms of public health measures, there is the need of administering booster doses to all refugees coming into Italy and into other host countries to increase the coverage rate against diphtheria. The implementation of the immunization programs against diphtheria in the countries of provenience is also strongly recommended.

Enterovirus surveillance of Italian healthy children.

Surveillance of acute flaccid paralysis (AFP) is the golden strategy recommended by the WHO to verify the condition of polio eradication in a country. Because of the difficulty to detect all of the expected AFP cases and to reach the target incidence of 1/100,000 requested by WHO, the surveillance of enteroviruses in the population has been adopted by several countries as an important additional method to verify the absence of wild-poliovirus circulation. To complete the results of AFP surveillance set up in Italy in 1996, we have conducted a wild poliovirus surveillance by examining stool samples from 1551 healthy children aged less than 5 years, collected during the period January 1997 to January 1998. The children were from three cities (Parma, Rome and Bari) located in northern, central and southern Italy. Thirty-nine polioviruses, 72 non-polio enteroviruses and 50 enteric, non-entero (NE), viruses were isolated from stool specimens. Polioviruses identified were nine type 1, seven type 2 and twenty-three type 3. Characterization of isolates by both antigenic and molecular methods showed that all polioviruses were of vaccine origin. As expected, most polioviruses, especially types 2 and 3, presented retromutations known to be associated with loss of the Sabin attenuated phenotype. The results of this study support the data obtained from the active AFP surveillance conducted in Italy in the same period – on the absence of paralytic disease due to wild poliovirus – and altogether demonstrate the effectiveness of the vaccination program.

HTLV-I and HTLV-II infections in subjects at risk for HIV-1 infection from southeastern Italy (Apulia region)

To assess the prevalence of HTLV‐I and HTLV‐II infections in different groups at risk for HIV‐I infection, a study on 867 subjects was carried out by means of serological and PCR analyses. Serum specimens were collected from 268 intravenous drug users (IVDU), 66 homosexual men, 248 subjects with sexually transmitted diseases (STD), 105 thalassemics and 180 hemophiliacs. Sera from 3 IVDU and a sample from an STD patient were confirmed as HTLV‐II seropositive; a thalassemic patient was seropositive for HTLV‐I; a homosexual man, though confirmed as HTLV‐I/II‐seroreactive, could not be typed by serological methods. No hemophiliac was found to be HTLV‐I/II‐reactive. All 3 HTLV‐II‐seroreactive IVDU and the HTLV‐I‐infected thalassemic were confirmed by PCR; an additional sample from an IVDU, indeterminate by Western blot, was confirmed to be positive for HTLV‐II by PCR. Subtyping of HTLV‐II samples indicated the presence of II/b subtype in all 4 cases. Up to now, the reservoir for HTLV‐II infection in southeastern Italy is mainly represented by IVDU, while HTLV‐I infection seems to be sporadic.