Silvia Cocchio

Impact of universal vaccination against varicella in Italy

In Italy, the introduction of Universal Varicella Vaccination (UVV) has been decided but postponed, as a national programme, until 2015, when data from Regions which have already implemented it will be available. Starting from 2003, eight Italian Regions (Basilicata, Calabria, Friuli Venezia Giulia, Apulia, Sardinia, Sicily, Tuscany and Veneto) have progressively introduced UVV, in their immunization programme, with different schedules in children aged 13–15 months and 5–6 years, currently a two-dose schedule is adopted by all Regions. In June 2013, an Interregional Group on Varicella Vaccination (IGVV) has been established in order to assess the effectiveness of varicella vaccination with standardized and shared tools. The aim of this study was to evaluate the impact of varicella vaccination on the incidence and hospitalizations due to varicella and its complications in the period 2003–2012 in order to support the Italian decision makers on the future national adoption. Preliminary data showed that a general reduction of incidence and hospitalization rates was observed in the study period, resulting in relevant savings for the National Health Service. Immunization coverage with first dose at 24 months of age was high in all Regions (84%–95%) in 2012. Adverse events due to varicella vaccines were rare and without permanent sequelae. Underreporting of varicella cases and delays in the administration of the first dose of varicella vaccines were the main critical issues. In conclusion, solid evidences in support of universal UVV arise from the experiences available today in Italy.

A population-based study on the impact of hospitalization for pneumonia in different age groups

BackgroundPneumonia is an important cause of illness and death, particularly in elderly adults. This retrospective study was conducted to estimate the trend of hospitalization for pneumonia in the Veneto from the records of all hospitals in the region (serving a population of 4.81 million) during the years 2004 through 2012.MethodsThe cases of pneumonia identified in the hospital discharge records were all cases in which the first-listed diagnosis was pneumonia, or meningitis, septicemia or empyema associated with pneumonia. The annual total and age-specific hospitalization rates and trends were calculated and correlated with vaccine coverage. Total related costs were also calculated.ResultsThere were 110,927 hospitalizations for pneumonia, meaning an annual rate of 256.3/100,000 population, with peaks in children and elderly people. The overall pneumonia-related hospitalization rate did not change significantly during the study period (AAPC: 1.3% [95% CI: −0.5, 3.1]). The rate dropped significantly among the 0- to 4-year-olds, however, from 617.3/100,000 in 2004 to 451.8/100,000 in 2012 (AAPC: −2.5% [95% CI: −4.5; −0.5]), while it increased slightly in adults aged 80+ (AAPC: 1.2% [95% CI: −0.9; 3.4]). The overall pneumonia-related mortality rate was 10.7%. The estimated cost per hospitalized patient was €3,090.ConclusionThis study shows that hospitalization for pneumonia has a considerable impact on the health services, especially for children and the elderly. No decline in hospitalization rates was seen for the very elderly after the introduction of pneumococcal conjugate vaccination for children.

Seroepidemiology of Polioviruses among University Students in Northern Italy

ABSTRACT The widespread use of poliovirus vaccination schemes has led to a marked decline in the incidence of paralytic poliomyelitis worldwide, but wild poliovirus is still endemic in some developing countries, and in 2009 a total of 23 countries reported at least 1 case of poliomyelitis caused by wild-strain polio viruses. A serological survey was thus conducted on the immunological status against polioviruses of 318 young adults, classified by their country of origin. Immunity to poliomyelitis was assessed by neutralizing antibody titration in tissues cultured on microplates. The rate of seronegativity (≤1:8) in the study population was 26.7% for poliovirus type 1, 7.2% for type 2, and 22.6% for type 3. In our sample of 318 individuals, 219 (68.9%) were Italian and 99 (31.1%) were from outside the European Union (EU). The proportion of cases found seropositive to polioviruses 1 and 3 decreased significantly with older age; this age-related decrease was more evident in the Italian group than among the non-EU subjects. Any risk of the wild virus recurring and causing paralytic poliomyelitis must be prevented, keeping Europe polio free by means of appropriate immunological protection, until polio has been conclusively eradicated all over the world. Judging from our findings, it may be worth considering administering a fifth dose of polio vaccine to adolescents.

Hospitalization for diseases attributable to human papillomavirus in the Veneto Region (North-East Italy).

BackgroundHuman papillomavirus (HPV) is one of the most common sexually-transmitted pathogens. A number of studies in the literature have estimated the burden of HPV-related diseases by collecting data at primary care level, while a comprehensive assessment of the global burden of HPV-related diseases on hospital resources is still lacking.MethodsThis was a retrospective cohort study based on hospital discharge data collected from 2000 to 2010 in the Veneto Region (north-east Italy). All hospitalizations for diseases potentially associated with HPV were identified by searching the hospital discharge records, then the proportion of these hospitalizations relating to diseases attributable to the HPV infection was calculated.ResultsOverall, the annual hospitalization rate for HPV-related diseases was 21.3 per 100,000 individuals in the general population, 15.8 per 100,000 males, and 27.6 per 100,000 females. Hospitalizations were due mainly to genital warts, and peak among 15- to 44-year-olds in both genders. Taking both sexes together, the hospitalizations attributable to HPV dropped from 24.5/100,000 in 2000 to 17.5/100,000 in 2011, showing a significant decline during this period, with an average annual percent change (AAPC) of −1.9% (CI 95%: -2.8, -0.9;). On the other hand, the hospitalization rate for genital warts tended to increase significantly (AAPC 3.0% [CI 95%: 1.4;4.7]), whilst there was a significantly declining trend in the hospitalization rate for anal cancer (AAPC - 5.0% [CI 95%: -7.7;-2.2]), genital cancer (AAPC −6.2% [CI 95%: -7.8;-4.6]) and oropharyngeal cancer (AAPC −4.3% [CI 95%: -4.8;-3,8]).ConclusionData derived from the hospital records indicate that HPV-related diseases are an important public health issue.

Pneumococcal Conjugated Vaccine Reduces the High Mortality for Community-Acquired Pneumonia in the Elderly: an Italian Regional Experience

Background Community-acquired pneumonia (CAP) is an important cause of illness and death worldwide, particularly among the elderly. Previous studies on the factors associated with mortality in patients hospitalized for CAP revealed a direct association between the type of microorganism involved, the characteristics of the patient and mortality. Vaccination status against pneumococcal disease was not considered. We conducted a retrospective analysis on the mortality rates after a first hospitalization for CAP in north-east Italy with a view to examining especially the role of anti-pneumococcal vaccination as a factor associated with pneumonia-related mortality at one year. Method Between 2012–2013, patients aged 65+ hospitalized with a primary diagnosis of CAP, identified based on International Classification of Diseases, Ninth Revision, Clinical Modification codes 481–486, were enrolled in the study only once. Patients were divided into three groups by pneumococcal vaccination status: 1) 13-valent pneumococcal conjugate vaccine (PCV13) prior to their hospitalization; 2) 23-valent pneumococcal polysaccharide vaccine (PPV23) within 5 years before hospitalization and 3) unvaccinated or PPV23 more than 5 years prior to admission. Gender, age, length of hospital stay and influenza vaccination were considered. Comorbidities were ascertained by means of a properly coded diagnosis. Every patient was followed up for 1 year and the outcome investigated was mortality for any cause and for pneumonia. Results A total of 4,030 patient were included in the study; mean age at the time of admission to hospital was 84.3±7.7; 50.9% were female. 74.2% of subjects had at least one comorbidity; 73.7% has been vaccinated against influenza. Regard to pneumococcal vaccine, 80.4% of patients were not vaccinated, 14.5% vaccinated with PPV23 and 5.1% with PCV13. The 1-year survival rates after hospitalization for pneumonia were 83.6%, 85.9% and 89.3% in the unvaccinated, PPV23 and PCV13 groups, respectively. Regression analysis indicated that the risk of death due to pneumonia increased significantly with age (adjusted OR: 1.073; 1.061–1.085), shorter hospital stay (adjusted OR: 0.981; 0.971–0.990), and male gender (adjusted OR: 1.372; 1.165–1.616). The model also confirmed the pneumococcal 13-valent conjugated vaccine as an independent protective factor for mortality-related pneumonia (adjusted OR: 0.599; 0.390–0.921). Conclusion The main finding of our observational cohort study is a high mortality rate among elderly patients admitted to hospital for pneumonia. The present study suggests a protective role for PCV13 vaccination.

A surveillance system of Invasive Pneumococcal Disease in North-Eastern Italy.

BACKGROUND From 2007, in the Veneto Region (Italy), a surveillance system for invasive pneumococcal diseases (IPD) was implemented to estimate the regional epidemiology of IPD and to evaluate the impact of 13-valent pneumococcal conjugate vaccine (PCV13) vaccination. METHODS Data were collected from 2007 to 2014 and the total, annual and age-specific IPD notification rates were calculated. A Poisson regression model was used to identify the possible risk factors for developing IPD. RESULTS A total of 713 IPD cases were notified and the overall IPD notification rate was equal to 2.0 cases per 100,000 population (95% CI: 1.7-2.1), with an increasing trend between 2007 and 2014. The pneumococcal serotypes were identified in 608 (85.3%) isolates from biological specimens, and the most distributed serotypes were those contained in PCV13. Children <5 year-old and the adults over 65 year-old showed the highest PCV13 vaccine-type IPD notification rate, equal to 2.7/100,000 and 2.8/100,000, respectively. The risk to develop IPD was greater in children aged <5 years (RR = 8.9, 95% CI: 5.1-15.9; p<0.0001) and in adults aged >65 years (RR = 4.3, 95% CI: 2.7-6.9; p<0.0001), especially in males > 65 years of age (RR = 1.7, 95% CI: 1.0-2.8; p = 0.042). The invasive pneumococcal disease was mainly caused by the PCV13 serotypes (RR = 2.9, 95%CI: 2.3-3.9; p<0.0001), principally after the PCV13 introduction (RR = 2.3, 95% CI: 1.4-3.8; p<0.001). In spite of that, a significant reduction of the overall IPD incidence is evident in the period following the PCV13 vaccine introduction (RR = 0.4, 95% CI: 0.3-0.5; p<0.0001), particularly in children aged <5 years (RR = 0.3, 95% CI: 0.2-0.7; p = 0.002), demonstrating the real efficacy of PCV13 immunization for children. CONCLUSIONS In the Veneto Region, the surveillance system has allowed to describe the detailed epidemiological profile of invasive pneumococcal disease, pointing out that the most circulating pneumococcal serotypes were those contained in the PCV13 vaccine.

Decline in hospitalization for genital warts in the Veneto region after an HPV vaccination program: an observational study

BackgroundHuman papillomavirus (HPV) is one of the most common sexually transmitted pathogens. This observational study was conducted to estimate the trend of hospitalization for genital warts (GWs) in the Veneto region (Italy) from 2004 to 2015.MethodsAll patients with GWs were identified in the hospital discharge records of all public and accredited private hospitals that related to Veneto residents and contained the ICD9-CM code 078.11 associated with a genital surgical procedure (vulval/vaginal warts, penile warts and anal warts). Annual total and sex- and age-specific hospitalization rates and trends were calculated and correlated with the different HPV vaccine coverage over the study period.ResultsAn annual rate of 11.8 per 100,000 population (8.6 per 100,000 males, and 14.8 per 100,000 females) was found, corresponding to 6076 hospitalizations for condyloma (53.3% vulval/vaginal, 35.8% anal, 8.3% penile, and 2.6% both penile or vulval/vaginal and anal). Among females, the rate of overall GWs remained stable to 2007 (19.1 per 100,000), then dropped significantly, reaching a rate of 11.3 per 100,000 in 2015 (average annual percent changes [AAPC]: -6.1%; 95% CI: -8.4; −3.7). For males, the overall rate increased over the study period (from 6.4 per 100,000 in 2004 to 10.8 per 100,000 in 2015; AAPC: 3.8%; 95% CI: 1.2; 6.4).Among the potentially vaccinated females (12- to 20-year-olds) there was a 62.1% decrease in the number of vulval/vaginal warts from the years 2010-2012 to the years 2013-2015 due to an increase in the HPV coverage rate. A similar reduction among males was observed in the same period and the same age group for penile warts (−68.2%).ConclusionGWs have an important impact on the health services and data suggest that GW-related hospitalization rates rapidly decline in a population with a high HPV vaccination coverage (about 75%). Further efforts should be made to better clarify the epidemiological picture regarding HPV-related diseases, with particular regard to sexual behavior.

Can We Have Routine Measurement of Patient Satisfaction in Acute Psychiatric Settings? A Cross Sectional Study

Patient satisfaction is considered an important indicator of the quality of care in psychiatric services. Its importance has been widely studied, but the literature identifies methodological problems deriving from samples with low response rates and exclusion criteria which would seem to imply a kind of exclusion in the evaluations of less compliant patients. The aim of this study is to test a methodology to assess patient satisfaction with the quality of care received at an acute psychiatric ward in terms of its application in daily routine. In this cross sectional survey inpatients were given the Rome Opinion Questionnaire (ROQ). Our patients, involuntary patients included, with a 92.3% participation rate (47 patients out of 51), returned a mean general satisfaction score of 7.7/9. This response rate is higher than that reported in most previously published studies, which shows that a good level of both voluntary and involuntary patient participation may be achieved when an appropriate methodological approach is adopted. Not acknowledging patient satisfaction reduces the possibility of more effective caring actions. Measuring patient satisfaction, through use of short questionnaires, should become a routine in daily practice.

Clean Colon Software Program (CCSP), Proposal of a standardized Method to quantify Colon Cleansing During Colonoscopy: Preliminary Results

Background and study aims: Neoplastic lesions can be missed during colonoscopy, especially when cleansing is inadequate. Bowel preparation scales have significant limitations and no objective and standardized method currently exists to establish colon cleanliness during colonoscopy. The aims of our study are to create a software algorithm that is able to analyze bowel cleansing during colonoscopies and to compare it to a validate bowel preparation scale. Patients and methods: A software application (the Clean Colon Software Program, CCSP) was developed. Fifty colonoscopies were carried out and video-recorded. Each video was divided into 3 segments: cecum-hepatic flexure (1st Segment), hepatic flexure-descending colon (2nd Segment) and rectosigmoid segment (3rd Segment). Each segment was recorded twice, both before and after careful cleansing of the intestinal wall. A score from 0 (dirty) to 3 (clean) was then assigned by CCSP. All the videos were also viewed by four endoscopists and colon cleansing was established using the Boston Bowel Preparation Scale. Interclass correlation coefficient was then calculated between the endoscopists and the software. Results: The cleansing score of the prelavage colonoscopies was 1.56 ± 0.52 and the postlavage one was 2,08 ± 0,59 (P < 0.001) showing an approximate 33.3 % improvement in cleansing after lavage. Right colon segment prelavage (0.99 ± 0.69) was dirtier than left colon segment prelavage (2.07 ± 0.71). The overall interobserver agreement between the average cleansing score for the 4 endoscopists and the software pre-cleansing was 0.87 (95 % CI, 0.84 – 0.90) and post-cleansing was 0.86 (95 % CI, 0.83 – 0.89). Conclusions: The software is able to discriminate clean from non-clean colon tracts with high significance and is comparable to endoscopist evaluation.

Burden of Disease of Human Papillomavirus (HPV): Hospitalizations in the Marche and Veneto Regions. An observational study

Background and ObjectivesHPV (human papillomavirus) is the virus most often responsible for sexually transmitted infections. The burden of HPV-related diseases on hospital resources represents a major public health problem. The aim of this study was to assess the economic burden of HPV-related diseases (anal cancer, genital cancer, genital warts, oropharyngeal cancer) on hospital resources in two Italian regions.MethodsA retrospective, non-randomized, observational study was developed in the Marche and Veneto Regions, based on patients receiving hospitalization between 2008 and 2011. All hospitalizations were identified through administrative archives, according to the International Classification of Diseases (ICD-9 CM) to which a defined tariff was assigned.ResultsWe identified 5299 hospitalized patients in Veneto and 1735 in the Marche Region. The mean annual hospitalization rate was 49.44 per 100,000 individuals in Veneto and 48.41 in Marche. The total mean annual cost attributable to HPV-related diseases was €5.78 (SD 0.80) million in Veneto and €2.24 (SD 0.17) million in Marche. Costs associated with genital cancer amounted to €1.61 million in Veneto and €1.06 million in Marche (28% and 47% of the total mean annual cost, respectively). Oropharyngeal cancer accounted for 36% in Veneto (€2.08 million) and 28% in Marche (€632,645). Hospitalization costs related to anal cancer were €882,567 in Veneto and €377,719 in Marche; genital warts accounted for €1.19 million in Veneto and €171,406 in Marche. Finally, the mean cost per patient was €4364 in Veneto and €5176 in Marche.ConclusionsThe present work estimated the cost of HPV-related diseases for hospitalized patients in two Italian regions. The considerable estimated annual economic burden is a powerful driver for the governance of the public health sector.