Foreigners living in Tuscany at the time of coronavirus outbreak

Background During the coronavirus outbreak, a worldwide state of emergency and lockdown significantly affected the volunteer services for foreigners. The SARS-CoV-2 surveillance program was strengthened among migrants arriving in Italy. However, few screening measures for SARS-CoV2 infection have been conducted on the foreign population already present in Italy. In Tuscany, a great effort was made to know the epidemiological features of coronavirus outbreaks in the foreigners. Based on these premises, this study describes the prevalence and characteristics of SARS-CoV-2 infection in foreigners present in the Tuscan territory during the months of the highest incidence of this pandemic. Methods Ministry of Health established the COVID-19 surveillance and predisposed the methods for reporting cases of SARS-CoV-2 infection in agreement with the Department of Infectious Diseases of the Istituto Superiore di Sanità. Data on SARS-CoV-2, updated daily, were collected based on the platform of the Istituto Superiore di Sanità. For each patient were available data on diagnosis, gender, age, nationality, exposure place, hospitalisation and symptoms severity. Symptoms severity was classified using a 6-level scale (asymptomatic,paucisymptomatic, mild symptoms, severe symptoms, critic, and died). Results By July 14, 2020, 10,090 SARS-CoV-2 cases were recorded. Out of 10,090 cases, 8,947 were Italians (88.7%), 608 foreigners (6%);in 535 patients (5.3%) citizenship was missing. The average age of foreigners was 44.1 years (range: 42.9-45.4), compared to 61.1 years (range: 60.7-61.5) of Italians. Chronic pathologies affected 16.8% of foreigners (14.0% -20.0%) and 36.4% of Italians (35.4% -37.4%). Foreigners with asymptomatic or mild symptoms of COVID-19 were 81.7% (78.4% -84.6%), while the Italians were 67% (66.6% -68.5%). Foreigners with severe COVID-19 were 15.2% (12.6% -18.4%) and Italians were 17.6% (16.8% -18.4%). Foreigners in critical conditions were 1.0% (0.5% -2.2%) and Italians were 2.6% (2.3% -3.0%). 38.6% (33.7% -43.7%) of foreigners were infected at the workplace as a health or social-health worker, compared to 24.2% (23.1% -25.4%) of Italians. Conclusion The time between the onset of symptoms and the execution of the laboratory tests was similar between foreigners and Italians. The foreigners infected by SARS-COV-2 were younger compared to the Italians. Foreigners showed few comorbidities, and asymptomatic or mild symptomatic COVID-19, and consequently, a low lethality index. National and Tuscanypolicy decisions are needed to create equity in the access to the health care system for immigrants and their families, regardless of their immigration status.

Foreigners living in Tuscany at the time of coronavirus outbreak.

Background: During the coronavirus outbreak, a worldwide state of emergency and lockdown significantly affected the volunteer services for foreigners. The SARS-CoV-2 surveillance program was strengthened among migrants arriving in Italy. However, few screening measures for SARS-CoV2 infection have been conducted on the foreign population already present in Italy. In Tuscany, a great effort was made to know the epidemiological features of coronavirus outbreaks in the foreigners. Based on these premises, this study describes the prevalence and characteristics of SARS-CoV-2 infection in foreigners present in the Tuscan territory during the months of the highest incidence of this pandemic. Methods: Ministry of Health established the COVID-19 surveillance and predisposed the methods for reporting cases of SARS-CoV-2 infection in agreement with the Department of Infectious Diseases of the Istituto Superiore di Sanità. Data on SARS-CoV-2, updated daily, were collected based on the platform of the Istituto Superiore di Sanità.For each patient were available data on diagnosis, gender, age, nationality, exposure place, hospitalization and symptoms severity. Symptoms severity was classified using a 6-level scale (asymptomatic, paucisymptomatic, mild symptoms, severe symptoms, critic, and died). Results: By July 14, 2020, 10,090 SARS-CoV-2 cases were recorded. Out of 10,090 cases, 8,947 were Italians (88.7%), 608 foreigners (6%); in 535 patients (5.3%) citizenship was missing. The average age of foreigners was 44.1 years (range: 42.9-45.4), compared to 61.1 years (range: 60.7-61.5) of Italians. Chronic pathologies affected 16.8% of foreigners (14.0% -20.0%) and 36.4% of Italians (35.4% -37.4%). Foreigners with asymptomatic or mild symptoms of COVID-19 were 81.7% (78.4% -84.6%), while the Italians were 67% (66.6% -68.5%). Foreigners with severe COVID-19 were 15.2% (12.6% -18.4%) and Italians were 17.6% (16.8% -18.4%). Foreigners in critical conditions were 1.0% (0.5% -2.2%) and Italians were 2.6% (2.3% -3.0%). 38.6% (33.7% -43.7%) of foreigners were infected at the workplace as a health or social-health worker, compared to 24.2% (23.1% -25.4%) of Italians. Conclusion: The time between the onset of symptoms and the execution of the laboratory tests was similar between foreigners and Italians. The foreigners infected by SARS-COV-2 were younger compared to the Italians. Foreigners showed few comorbidities, and asymptomatic or mild symptomatic COVID-19, and consequently, a low lethality index. National and Tuscany policy decisions are needed to create equity in the access to the health care system for immigrants and their families, regardless of their immigration status.

Access to SARS-CoV-2 diagnostic tests: are there barriers for the immigrants in Italy?

OBJECTIVES: to describe the epidemiology of SARS-CoV-2 infection in relation with the use of nasal swabs in the immigrant population in Italy, using data from the COVID-19 national surveillance system and to verify if a difference is present comparing natives and immigrant. DESIGN: descriptive study based on longitudinal health-administrative data. SETTING AND PARTICIPANTS: general population of six Italian Regions (Piedmont, Lombardy, Veneto, Emilia-Romagna, Tuscany, Lazio) covering about 55% of the resident population and 72% of foreigners' population. MAIN OUTCOME MEASURES: regional rates of access to at least a nasal swab, separately by country of origin. RESULTS: across all the periods, a lower rate in the foreigners' group was observed, with the only exception of the period May-June 2021. Considering separately High Migratory Pressure Countries (HMPCs) and Highly Developed Countries (HDCs), a higher proportion of nasal swabs performed in people coming from HDC with respect to HMPCs and natives was noticed. This observation is consistent in males and females. CONCLUSIONS: during the first wave of the pandemic, Italians have had a higher proportion of nasal swabs compared to migrants across all Regions. This difference disappeared in the following periods, probably due to a major availability of diagnostic tests.

[Impact of COVID-19 on the immigrant population in the Veneto Region (Northern Italy), by geographical area of origin]. / Impatto del COVID-19 nella popolazione immigrata in Veneto, per area geografica di provenienza.

OBJECTIVES: to examine the differences in SARS-CoV-2 infection and hospitalization rates among migrant populations in Veneto Region (Northern Italy), according to the geographic area of origin. SETTING AND PARTICIPANTS: all residents in Veneto Region aged <65 years were included in the analyses. All subjects infected by SARS-CoV-2 and hospitalized for COVID-19 were identified by means of the regional biosurveillance system. MAIN OUTCOME MEASURES: age- and gender-specific infection and hospitalization rates were stratified by geographic area of origin and were estimated using the number of incident cases over the resident population in Veneto on 01.01.2021. Incidence rate ratios (IRR) for infection and hospitalization rates were estimated using a Poisson model, adjusted for age and gender, among migrants compared to Italians. RESULTS: compared to Italians, SARS-CoV-2 infection rates were significantly higher among migrants from Central and South America and Central and South Asia, lower among those from North Africa and High-Income Countries (HIC), and were approximately halved for those coming from Other Asian Countries (mainly represented by China). Hospitalization rates were significantly higher for all migrant populations when compared to Italians, with the exception of those coming from HIC. Neither age nor gender seemed to modify the association of the geographic area of origin with SARS-CoV-2 infection and hospitalization rates. IRR for SARS-CoV-2 infection of migrants compared to Italians showed how migrants from Other Asian Countries had the lowest infection rates (-53%), followed by people from HIC (-25%), North Africa (-21%), and Eastern Europe (-10%). Higher infection rates were present for Central and South America and Central and South Asia (+17% and +10, respectively). Hospitalization rates were especially high among migrants from Central and South Asia, Africa, and Central and South America, ranging from 1.84 to 3.14 times those observed for Italians. CONCLUSIONS: a significant heterogeneity in SARS-CoV-2 infection and hospitalization rates of migrant populations from different geographic areas of origin were observed. The significantly lower incidence rate ratio for infections, compared to that observed for hospitalizations, is suggestive of a possible under-diagnosis of SARS-CoV-2 infection among migrant populations. Public health efforts should be targeted at increasing support among migrants to contrast the spread of the pandemic by potentiating vaccination campaigns, contact tracing, and COVID-19 diagnostic tests.

[The impact of the COVID-19 pandemic on the Italian and foreign population in the various phases: the results of an interregional multicentre project]. / L'impatto della pandemia di COVID-19 nella popolazione italiana e straniera residente nelle diverse fasi: i risultati di un progetto multicentrico inter-regionale.

OBJECTIVES: to analyze the difference of the SARS-CoV-2 infection impact between Italian and foreigner subjects, evaluating the trend of infections and access to diagnostic tests (molecular or antigenic swabs for the detection of SARS- CoV-2) in the two different populations, inducing the detection of new positive cases in the population. DESIGN: retrospective population study for the period February 2020-June 2021. SETTING AND PARTICIPANTS: Italian and foreign resident population on 1st January of the years 2020 and 2021 in the Regions participating to the project: Piedmont, Lombardy, Veneto, Emilia-Romagna (Northern Italy), Tuscany, Lazio (Central Italy), and Sicily (Southern Italy). MAIN OUTCOME MEASURES: in the two populations, for every week and aggregated by macropandemic period were calculated: • the test rate (people tested on the population); • the swab positivity rate (positive subjects on those who are tested); • the new positives (positive subjects on study population); • the percentage of foreigners among the new positive cases. The ratio of the value of the indicators in the foreign and Italian populations (with 95% confidence interval) was calculated to evaluate the association between nationality (Italian vs not Italian) and outcome. The analyses were conducted at the regional level and at pool level. RESULTS: the trend of new positives by nationality (Italian vs not Italian) has a similar tendency in the different pandemic waves. However, the incidence of new positives during pandemic waves among foreigners is lower than in Italians, while it tends to increase during intermediate periods. Except for the summer periods, foreigners are less tested than Italians, but the percentage of new positives out of the total of new ones tested is higher among foreigners compared to Italians. The relative weight of new positives among foreigners tends to increase in periods with the greatest risk of inflow of SARS-CoV-2 for foreigners. CONCLUSIONS: the epidemic trends in the two populations are similar, although foreigners tend to show lower incidence values, probably in part because they are tested less frequently. Furthermore, in foreigners compared to Italians, there is a greater risk of contracting SARS-CoV-2 infection, especially in periods of relaxation of containment Coronavirus measures, reopening of national borders, production and commercial activities.

[Hospital assistance for COVID-19: a comparison between non-Italian and Italian resident population in five Italian Regions since the beginning of the pandemic until June 2021]. / Un confronto tra italiani e stranieri residenti nell'assistenza ospedaliera per COVID-19 in cinque Regioni italiane da inizio pandemia a giugno 2021.

OBJECTIVES: to describe trends of overall and intensive care hospitalization for COVID-19 since the beginning of the pandemic in Italy until June 2021, and to compare the results between foreign and Italian population. DESIGN: retrospective observational study. SETTING AND PARTICIPANTS: hospital discharges of 28 million people living in Lombardy, Piedmont, Emilia-Romagna (Northern Italy), Toscana and Lazio (Central Italy) occurred between 22.02.2020 and 02.07.2021 in the hospitals located in each considered Region. MAIN OUTCOME MEASURES: two weekly outcomes were examined: 1. the overall number of COVID-19 hospitalizations; 2. the number of COVID-19 hospitalizations in intensive care units. RESULTS: a higher COVID-19 overall and intensive care unit hospitalization was found among the foreign population compared to Italians. The association emerged only after the adjustment for age, and it was consistent among all Regions, though less marked in Lombardy. The association varied across epidemic phases. CONCLUSIONS: the issue of vulnerability of migrants to the risk of severe COVID-19 calls for a diversity-sensitive approach in prevention. The specific country of origin and the prevalence of preventable co-morbidities that are often underestimated in the migrant populations, and related to COVID-19 complications, should be taken into consideration in future analyses.

[SARS-CoV-2 epidemic among Italians e resident immigrant population: differential incidence from an interregional multicentre study]. / L'epidemia di SARS-CoV-2 nella popolazione italiana e straniera: differenze di incidenza che emergono da uno studio multicentrico interregionale.

OBJECTIVES: to describe differences in the incidence of SARS-CoV-2 infections between Italians and foreigners residing in seven Italian Regions during the different phases of the pandemic and by gender. DESIGN: retrospective observational study. SETTING AND PARTICIPANTS: all confirmed SARS-CoV-2 infections from 02.02. 2020 to 16.07.2021 in the seven Regions under study were included. Italian resident population calculated by the National Institute of Statistics as of 01.01.2020 was used to calculate the rates. The considered period is divided into 5 sub-periods (phases). MAIN OUTCOME MEASURES: number of confirmed SARS-CoV-2 infections in the five phases of the pandemic and crude rates by citizenship (Italian vs foreign). Distribution of infections by age group and by week. Crude and age-adjusted incidence rates ratios (IRR) were calculated, by Region, gender, and phase of the pandemic. RESULTS: an epidemic curve delay was observed in foreigners in the first phase of the epidemic, in particular in the northern Regions, the most affected in that phase. The first phase of the epidemic was characterized by a greater proportion of cases occurred in people aged over 60 years than the other phases, both in Italians and in foreigners. The incidence among foreigners is higher during the summer of 2020 (intermediate period: June-September 2020) and during the last period (May-July 2021) in all Regions. The overall figure shows a lower incidence among foreigners than Italians, except for males in Tuscany. CONCLUSIONS: the lower incidence rates among foreigners should be interpreted with caution as the available data suggest that it is at least partly attributable to less access to diagnostic tests. Regional differences found in the study deserve further research together with the effect of gender and country of origin.

SARS-CoV-2 Vaccination and the Bridge between First and Fourth Dose: Where Are We?

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has induced the explosion of vaccine research. Currently, according to the data of the World Health Organization, there are several vaccines in clinical (145) and preclinical (195) stages, while at least 10 are already in clinical phase 4 (post-marketing). Vaccines have proven to be safe, effective, and able to reduce the spread of SARS-CoV-2 infection and its variants, as well as the clinical consequences of the development of coronavirus disease-19 (COVID-19). In the two-dose primary vaccination, different time intervals between the two doses have been used. Recently, special attention has been paid to assessing the immunogenicity following booster administration. The third dose of the vaccine against COVID-19 may be administered at least 8 weeks after the second dose. In Israel, a fourth dose has already been approved in immunocompromised groups. The main objective of this review is to describe the principal results of studies on the effectiveness of first-to-fourth dose vaccination to reduce reinfection by variants and the incidence of severe disease/death caused by COVID-19. Vaccines have shown a high level of protection from symptomatic infection and reinfection by variants after a third dose. Accelerating mass third-dose vaccination could potentially induce immunogenicity against variants.

Exploring the evidence for the effectiveness of health interventions for COVID-19 targeting migrants: a systematic review protocol.

INTRODUCTION: Owing to their inherent vulnerabilities, the burden of COVID-19 and particularly of its control measures on migrants has been magnified. A thorough assessment of the value of the interventions for COVID-19 tailored to migrants is essential for improving their health outcomes as well as promoting an effective control of the pandemic. In this study, based on evidence from primary biomedical research, we aimed to systematically identify health interventions for COVID-19 targeting migrants and to assess and compare their effectiveness. The review will be conducted within a programme aimed at defining and implementing interventions to control the COVID-19 pandemic in Italy, funded by the Italian Ministry of Health and conducted by a consortium of Italian regional health authorities. METHODS AND ANALYSES: Data sources will include the bibliographic databases MEDLINE, Embase, LOVE Platform COVID-19 Evidence, and Cochrane Central Register of Controlled Trials. Eligible studies must evaluate health interventions for COVID-19 in migrants. Two independent reviewers will screen articles for inclusion using predefined eligibility criteria, extract data of retained articles and assess methodological quality by applying the Cochrane Risk of Bias tool. Disagreements will be resolved through consensus or arbitrated by a third reviewer if necessary. In synthesising the evidence, we will structure results by interventions, outcomes and quality. Where studies are sufficiently homogenous, trial data will be pooled and meta-analyses will be performed. Data will be reported according to methodological guidelines for systematic review provided by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. ETHICS AND DISSEMINATION: This is a review of existing literature, and ethics approval is not required. We will submit results for peer-review publication and present at relevant conferences. The review findings will be included in future efforts to develop evidence-informed recommendations, policies or programmatic actions at the national and regional levels and address future high-quality research in public health.

[Covid-19 and clinical-epidemiological research in Italy: proposal of a research agenda on priority topics by the Italian association of epidemiology]. / Covid-19 e ricerca clinico-epidemiologica in Italia: proposta di un'agenda di ricerca su temi prioritari da parte dell'Associazione italiana di epidemiologia.

BACKGROUND: the Covid-19 pandemic has provoked a huge of clinical and epidemiological research initiatives, especially in the most involved countries. However, this very large effort was characterized by several methodological weaknesses, both in the field of discovering effective treatments (with too many small and uncontrolled trials) and in the field of identifying preventable risks and prognostic factors (with too few large, representative and well-designed cohorts or case-control studies). OBJECTIVES: in response to the fragmented and uncoordinated research production on Covid-19, the   italian Association of Epidemiology (AIE) stimulated the formation of a working group (WG) with the aims of identifying the most important gaps in knowledge and to propose a structured research agenda of clinical and epidemiological studies considered at high priority on Covid-19, including recommendations on the preferable methodology. METHODS: the WG was composed by 25 subjects, mainly epidemiologists, statisticians, and other experts in specific fields, who have voluntarily agreed to the proposal. The agreement on a list of main research questions and on the structure of the specific documents to be produced were defined through few meetings and cycles of document exchanges. RESULTS: twelve main research questions on Covid-19 were identified, covering aetiology, prognosis, interventions, follow-up and impact on general and specific populations (children, pregnant women). For each of them, a two-page form was developed, structured in: background, main topics, methods (with recommendations on preferred study design and warnings for bias prevention) and an essential bibliography. CONCLUSIONS: this research agenda represents an initial contribution to direct clinical and epidemiological research efforts on high priority topics with a focus on methodological aspects. Further development and refinements of this agenda by Public Health Authorities are encouraged.

A longitudinal observation of general psychopathology before the COVID-19 outbreak and during lockdown in Italy.

OBJECTIVE: Italy has been largely involved by the COVID-19 pandemic. The present study aimed at evaluating the impact of the lockdown during the pandemic on mental health adopting both a longitudinal and a cross-sectional design. Accordingly, the study investigated general psychopathology a few weeks before the COVID-19 outbreak (T0) and during lockdown (T1), and the associations between lockdown-related environmental conditions, self-perceived worsening in daily living and psychopathology. METHODS: 130 subjects (aged 18-60 years) were included in the longitudinal design, and an additional subsample of 541 subjects was recruited for the in-lockdown evaluation. Socio-demographic data and the Brief Symptom Inventory were collected both at T0 and T1. Moreover, at T1 an online survey was administered for the evaluation of lockdown-related environmental conditions and self-perceived variations in daily living induced by quarantine, along with the Impact of Event Scale-Revised. RESULTS: Longitudinal analysis showed that phobic anxiety and depressive symptoms increased at T1 as compared with T0, whereas interpersonal sensitivity and paranoid ideation decreased. Pre-existing general psychopathology predicted COVID-19-related post-traumatic symptomatology. Cross-sectional analyses underlined that self-perceived deteriorations in various areas of daily living were associated with general and post-traumatic psychopathology, and with several lockdown-related conditions, especially economic damage. CONCLUSION: The present study underlined a different trend of increased internalizing and decreased interpersonal symptoms during COVID-19 quarantine in Italy. Furthermore, the results showed that subjects with pre-existing psychopathology and those reporting economic damage during the pandemic were more likely to develop deterioration of their mental health.

Update on Hepatitis C Epidemiology: Unaware and Untreated Infected Population Could Be the Key to Elimination.

Globally, the World Health Organization (WHO) estimates that 71 million people have chronic hepatitis C virus (HCV) infection. A significant number of these will develop cirrhosis or liver cancer. Currently, during the COVID-19 outbreak, a high mortality rate has been found in patients with COVID-19 and cirrhosis. New direct-acting antiviral agents can cure more than 90% of HCV-infected patients. The new WHO strategy has introduced global goals against viral hepatitis, including a 30% reduction in new HCV cases and a 10% reduction in mortality by 2020. HCV transmission has changed considerably, reflecting both the evolution of medicine and health and social changes. The HCV is usually spread through blood-to-blood contact. After the discovery of HCV in 1989, antibody screening has drastically decreased the incidence of post-transfusion hepatitis. Nowadays, routine blood donor screening by nucleic acid amplification testing for the presence of HCV RNA has been introduced in many countries. It is conceivable that HCV screening could be offered to people born between 1946 and 1964 in the developed world and to people at high risk for HCV infection such as those who have received blood transfusions, blood products or organ donations before the 1990s, prisoners, health care workers, drug users and infants born to HCV-infected women. To achieve HCV elimination, health programmes should include improvement to access to health care services, increased screening and new projects to identify a submerged portion of patients with HCV infection. Submerged people with HCV infection are both people who are unaware of their condition and people diagnosed with HCV but not yet treated. Based on these premises, this review will examine and discuss the epidemiological changes in contracting HCV, highlighting the ways in which to identify a submerged portion of patients with HCV infection.

Treatment for COVID-19: An overview.

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by coronavirus-2 (SARS-CoV-2) that causes a severe acute respiratory syndrome, a characteristic hyperinflammatory response, vascular damage, microangiopathy, angiogenesis and widespread thrombosis. Four stages of COVID-19 have been identified: the first stage is characterised by upper respiratory tract infection; the second by the onset of dyspnoea and pneumonia; the third by a worsening clinical scenario dominated by a cytokine storm and the consequent hyperinflammatory state; and the fourth by death or recovery. Currently, no treatment can act specifically against the SARS-CoV-2 infection. Based on the pathological features and different clinical phases of COVID-19, particularly in patients with moderate to severe COVID-19, the classes of drugs used are antiviral agents, inflammation inhibitors/antirheumatic drugs, low molecular weight heparins, plasma, and hyperimmune immunoglobulins. During this emergency period of the COVID-19 outbreak, clinical researchers are using and testing a variety of possible treatments. Based on these premises, this review aims to discuss the most updated pharmacological treatments to effectively act against the SARS-CoV-2 infection and support researchers and clinicians in relation to any current and future developments in curing COVID-19 patients.