Seroprevalence of five neglected parasitic diseases among immigrants accessing five infectious and tropical diseases units in Italy: a cross-sectional study.

OBJECTIVE: This multicentre cross-sectional study aims to estimate the prevalence of five neglected tropical diseases (Chagas disease, filariasis, schistosomiasis, strongyloidiasis and toxocariasis) among immigrants accessing health care facilities in five Italian cities (Bologna, Brescia, Florence, Rome, Verona). METHODS: Individuals underwent a different set of serological tests, according to country of origin and presence of eosinophilia. Seropositive patients were treated and further followed up. RESULTS: A total of 930 adult immigrants were enrolled: 477 men (51.3%), 445 women (47.9%), eight transgender (0.8%); median age was 37.81 years (range 18-80 years). Most of them had come from the African continent (405/930, 43.5%), the rest from East Europe, South America and Asia, and 9.6% (89/930) were diagnosed with at least one of the infections under study. Seroprevalence of each specific infection varied from 3.9% (7/180) for Chagas disease to 9.7% (11/113) for toxocariasis. Seropositive people were more likely to be 35-40 years old and male, and to come from South East Asia, sub-Saharan Africa or South America. CONCLUSIONS: The results of our study confirm that neglected tropical diseases represent a substantial health problem among immigrants and highlight the need to address this emerging public health issue.

Clinical and epidemiological features of HIV/AIDS infection among migrants at first access to healthcare services as compared to Italian patients in Italy: a retrospective multicentre study, 2000-2010.

PURPOSE: Migrants account for approximately 8.7% of the resident population in Italy. The immigration status deeply influences access to prevention and care, thus contributing to increase the burden of HIV/AIDS among such a fragile category. The aim of this study was to investigate socio-demographic and baseline clinical and immunological features of HIV-infected migrants, as compared to Italians. METHODS: We retrospectively analysed data for all the 1,611 HIV-infected migrant patients and a random sample of 4,230 HIV-infected Italian patients aged 18 or older who first accessed nine Italian clinical centres in 2000-2010 and were followed up at least 1 year. Differences in baseline characteristics between migrants and Italians were evaluated in univariate analysis, while factors associated with late presentation were evaluated in multivariate analysis using logistic regression models. RESULTS: The baseline profile differs between the HIV-infected migrant and Italian patients, substantially reflecting what reported by current statistics in terms of gender, age, risk category as well as clinical features. Late presenters were more frequent among migrants as compared to Italians (53.0 vs 45.8%; adjusted odds ratio [(AOR) = 1.55, 95% confidence interval (CI) 1.34-1.78]. Other factors associated with late presentation included increasing age, as well as undocumented legal status among foreign-born subjects (AOR = 1.41, 95% CI 0.97-2.04), though of borderline significance. CONCLUSIONS: Late presentation still represents a relevant problem despite the advances in the management of HIV infection. More efforts are needed to allow early diagnosis and access to care among the most vulnerable, such as undocumented foreign-born subjects in a country where migration flows are on the rise.

New Italian guidelines for malaria prophylaxis in travellers to endemic areas.

BACKGROUND AND METHODS: As a consequence of the rapid evolution of malaria prophylaxis recommendations throughout the world, the Italian Society of Tropical Medicine (SIMET-Società Italiana di Medicina Tropicale) has set up a working group in charge of preparing a new national guideline. Other scientific societies interested in the topic were also involved in the project. RESULTS AND CONCLUSIONS: The group stated that awareness about malaria risk and characteristics, as well as protection from mosquito bites, are recommended for all travellers visiting malaria-endemic countries. The risk and benefit of malaria chemoprophylaxis must be carefully balanced before prescribing drugs: the disease-related risk must outweigh the possibility of drugs' side effects. As a general rule, malaria pills are the first choice for travellers to high-risk areas, such as sub-Saharan Africa, Eastern India, Myanmar, Eastern Indonesia, Papua New Guinea and, with some limitations, South-East Asia, and the Amazon part of Venezuela, Guyana and French Guyana. However, several other factors, such as itinerary, season, duration of trip, availability of insect bite protection, pre-existing conditions and compliance, must be taken into account. In low-risk areas, stand-by emergency treatment is the first option. In minimal-risk areas and in Plasmodium vivax areas, a prompt diagnosis only is advised (Central America, South America outside the Amazon basin, Middle East, China, Thailand, Nepal). Recommendations may be modified when particular groups of travellers are concerned, such as long-term residents, visiting friends and relatives, patients with pre-existing conditions, pregnant women and children.

Factors influencing the normalization of CD4+ T-cell count, percentage and CD4+/CD8+ T-cell ratio in HIV-infected patients on long-term suppressive antiretroviral therapy.

We evaluated factors associated with normalization of the absolute CD4+ T-cell counts, per cent CD4+ T cells and CD4+/CD8+ T-cell ratio. A multicentre observational study was carried out in patients with sustained HIV-RNA <50 copies/mL. Outcomes were: CD4-count >500/mm(3) and multiple T-cell marker recovery (MTMR), defined as CD4+ T cells >500/mm(3) plus%CD4 T cells >29%plus CD4+/CD8+ T-cell ratio >1. Kaplan-Meier survival analysis and Cox regression analyses to predict odds for achieving outcomes were performed. Three hundred and fifty-two patients were included and followed-up for a median of 4.1 (IQR 2.1-5.9) years, 270 (76.7%) achieving a CD4+ T-cell count >500 cells/mm(3) and 197 (56%) achieving MTMR. Using three separate Cox models for both outcomes we demonstrated that independent predictors were: both absolute CD4+ and CD8+ T-cell counts, %CD4+ T cells, a higher CD4+/CD8+ T-cell ratio, and age. A likelihood-ratio test showed significant improvements in fitness for the prediction of either CD4+ >500/mm(3) or MTMR by multivariable analysis when the other immune markers at baseline, besides the absolute CD4+ count alone, were considered. In addition to baseline absolute CD4+ T-cell counts, pretreatment %CD4+ T cells and the CD4+/CD8+ T-cell ratio influence recovery of T-cell markers, and their consideration should influence the decision to start antiretroviral therapy. However, owing to the small sample size, further studies are needed to confirm these results in relation to clinical endpoints.

[The role of the ASL of Brescia in the health and safety of immigrant workers]. / Il ruolo dell'ASL di Brescia nella tutela della salute e della sicurezza dei lavoratori immigrati.

According to available studies, migrant workers represent a vulnerable workers' category. For this reason, the Italian law on safety and health at work (art. 11, D.Lgs 81/08) points out the need for Public Administration initiatives devoted to migrant workers' health and safety at work. Local Public Health Department of Brescia for years now had a significant commitment in migrants' health. Thanks to the collaboration of occupational physicians and expert physicians on migration health, it was developed a multidimensional method to assess working risks taking into account also the fragile conditions of migrant workers, considering both personal and social characteristics and professional experience, in order to support companies in the planning of necessary actions to improve health and safety at work. The method was shared by both local industrial association and trade unions and then tested in some manufactures.

Genotyping analyses of tuberculosis transmission among immigrant residents in Italy.

We used DNA fingerprinting to analyse tuberculosis (TB) epidemiology in immigrant patients living in two major northern Italian urban areas. The study population included 1999 TB patients (1500 Italian-born and 499 immigrants). Univariate and multivariate logistic regression models were used to identify risk factors related to clustering similar proportions of immigrant and Italian-born patients (46%) had infection with TB strains that belonged to genetic clusters. This supports the hypothesis that the disease in foreign patients is more likely to have arisen from reactivation of latent infection acquired in the country of origin than from recent transmission. Gender, age, human immunodeficiency virus infection and drug resistance were not significantly linked to TB clustering. Risk factors associated with strain clustering were country of origin (Somalia, adjusted OR (AOR) 3.19, p 0.017; Peru, AOR 2.86, p 0.014; and Senegal, AOR 2.60, p 0.045) and city of residence. Immigrant status in the larger urban area was an independent risk factor for infection with clustered TB, as reinforced by a subanalysis of the Senegalese group. In conclusion, variations in TB transmission were observed among immigrants from different countries and even within national groups, where living conditions have been found to exert a profound impact. These results emphasize the importance of improving social integration of immigrant subjects in order to limit risks of TB transmission in developed countries.

Merkel cell carcinoma and HIV infection: a case report and review of the literature.

Merkel cell carcinoma (MCC) is a skin cancer of neuroendocrine origin that occurs most often in sun-exposed areas. In the general population, it is a disease of older adults, with only 5% of cases occurring below the age of 50 years. Immunosuppression is the significant risk factor for the development of MCC and recently it was suggested that individuals with HIV have a relative risk of 13.4 to developed MCC in comparison with the general population. We report a case of MCC in an HIV-infected patient and we review nine patients with HIV with MCC. Our patient was a 54-year-old man who came to our attention without a known HIV diagnosis. He was apparently in good health and had no risk factor for HIV, but by the atypical site of the lesion and by the relative young age of the patient we suspected a case of immunosuppression and for this reason we did HIV test that had a positive result. The patient was treated with surgery and chemotherapy but died as a result of liver metastases 25 months after his tumor was diagnosed.

Access to HAART in HIV-infected immigrants: a retrospective multicenter Italian study.

Since 1996, AIDS has declined in the Italian population, but cases in foreign patients, including both recent immigrants and long-term residents, have increased from 3.9% in 1995-1996 to 15.4% in 2001-2002. This increase can only be partly explained by a higher migratory flow and might reflect a delayed access to health facilities and to antiretroviral therapy in migrants. We performed a survey for the year 2003 of HIV-infected immigrants to Italy from countries outside the European Union to verify which factors might influence a lack of access to highly active antiretroviral therapy (HAART). Italian centers of infectious diseases were requested to send sociodemographic and clinical data of HIV-infected immigrant patients. A total of 553 HIV-infected immigrants (49.9% women) were evaluated, representing 6.5% of all HIV-infected patients from these centers. The mean duration of residency in Italy was 6.6 +/- 5.0 years. The country of origin was Africa (64.5%), North and South America (24.2%), Eastern Europe (7.0%), and Asia (3.8%). A total of 407 of 553 patients (73.6%) were taking antiretroviral drugs at the time of screening. Females presented a younger age (p = 0.001), a lower frequency of Centers for Disease Control (CDC) stage B/C (p = 0.008) and a more frequent heterosexual exposure to HIV (p < 0.001), while no differences were observed for time of first positive serology (p = 0.7). CD4 cell count (p = 0.9) and log plasma HIV-RNA (p = 0.1). Characteristics of HAART patients were compared to those of nontreated patients, despite a CD4 cell count less than 350 cells/mm(3). No significant difference was found for gender, country of origin, risk factor, and years of Italian residence, while legal immigrants (p = 0.018) and registered in the National Health Service (p = 0.014) were significantly more likely to receive HAART compared to illegal immigrants.

[Epidemiologic multicenter study of the prevalence of hepatitis in hospitalised immigrants in Italy in the year 2002]. / Studio epidemiologico multicentrico sulla prevalenza di epatiti virali in immigrati ospedalizzati in Italia nel 2002.

AIM: To retrospectively evaluate the prevalence of hepatitis in immigrant patients hospitalised in 48 Italian Operative Unit of Infectious Diseases during 2002. METHODS AND PATIENTS: in our study we included the clinical data of 2255 immigrated patients hospitalised, during the period between 01/01/2002-31/12/2002, in ordinary admission or in Day Hospital in Infectious Diseases O.U. and we have evaluated the prevalence of hepatitis in this population. RESULTS: 282 patients affected by hepatitis has been evidenced (12.5% of total hospitalised patients). The prevalent form was HBV-related (41.6% in chronic forms and 48.4% in acute), while the rate for HCV were less (37.5% in chronic and 3% in acute). The most part of patient were men (59.6%), with a mean age of 34.2 years and come from east-European countries (34.39%). CONCLUSION: Viral hepatitis are the third infectious diseases evidenced in immigrated population. HBV-chronic hepatitis is the prevalent form in immigrated patients, as expression of absence of vaccine prophylaxis in many countries. HCV-form was less frequent and it is particularly presents in east-European patients, probably as expression of endogenous drug abuse.

Simit epidemiological multicentric study on hospitalized immigrants in Italy during 2002.

The aim of this article is to retrospectively evaluate the patient characteristics and the most common infectious diseases in immigrant patients hospitalized in 46 Italian infectious disease clinics during 2002. The main Italian infectious disease clinics were invited to fill in a questionnaire that regarded the number and type of hospital admissions, the country of origin, and demographic features (age, sex, and resident state) of immigrants. A total of 46 clinics including 2255 patients participated in the study. Most patients were men (63%) with an age between 16 and 40 years (63.4%) covered by the National Health Service (71%) and coming from Africa (44.3%). The main infectious diseases observed were: 378 (16.76%) cases of HIV infection, 303 (13.43%) cases of tuberculosis diseases, 282 (12.5%) cases of various forms of viral hepatitis, 177 (7.84%) cases of respiratory diseases, and 196 (8.69%) gastrointestinal diseases. Tropical diseases found were 134 (5.94%) including 95 cases of malaria (70.9%). In conclusion, a broad range of diseases was noted in immigrants which were directly correlated with conditions of poverty. Only a few tropical diseases were diagnosed and therefore the immigrant should not be considered as an infectious disease carrier.

Completion of screening for latent tuberculosis infection among immigrants.

The objective of our study was to evaluate the sociodemographic factors associated with completion of screening for latent tuberculosis infection (LTBI) among undocumented immigrants in Brescia, Italy. Screening for LTBI was offered to 649 immigrants; 213 (33%) immigrants completed the first step of screening; only 44% (55/124) of individuals with a positive tuberculin skin test result started treatment for LTBI. The univariate analysis showed that being unmarried, of Senegalese nationality and being interviewed by a health-care worker with the same native language as the immigrant were significantly associated with completion of screening for LTBI. In the multiple logistic regression, being interviewed in the native language of the health-care worker (OR 2.5, 95% CI 1.3-4.8, P = 0.004) and being of Senegalese origin (OR 2.3, 95% CI 1.4-3.6, P = 0.0005) were independently associated with adherence to LTBI screening. Our results suggest that knowledge of the sociodemographic characteristics of immigrants, and the participation of health-care workers of the same cultural origin as the immigrant during the visits, can be an important tool to improve completion of screening for LTBI.

Prevalence of HIV infections in hospitalised immigrants in Clinics of Infectious Diseases in Italy: a multicentric survey.

Our aim was to evaluate the prevalence of HIV infection in immigrants hospitalised in infectious disease settings in Italy during 2002. Each participating centre filled in a CRF which regarded the number of immigrants hospitalised in ordinary regime or in day-hospital during 2002 and, for HIV-positive patients only, some demographic (age, sex, origin) and clinical features (only HIV positivity or AIDS, new diagnosis or not, diagnosis of opportunistic infections). A total of 46 Infectious Diseases Units participated in the study and a total number of 2255 patients were tested for anti-HIV, irrespective of the cause of hospitalization, with 378 (16%) cases of positivity. Women accounted for 47.9%; the mean age of the population was 34.5 years. African patients showed a higher prevalence of HIV infections than subjects from other geographical areas (61.9% of all cases). Most HIV-infected patients were unaware of their positivity. In conclusion, HIV infection represents one of the main health problems among immigrants, particularly of African origin.

Clustering of tuberculosis among senegalese immigrants in Italy.

OBJECTIVE: To study clustered Mycobacterium tuberculosis isolates as an indicator of recent TB transmission in a small urban setting in Italy, and to determine associated risk factors. METHODS: M. tuberculosis strains isolated between 1991 and 1997 were characterised by IS6110 restriction fragment length polymorphism (RFLP) analysis. RESULTS: One hundred and ninety-five isolates were available for RFLP analysis, which revealed 163 different patterns. Available cases were represented by 137 Italians (70%), 32 Senegalese (17%), and 26 other foreign-born cases (13%). A unique fingerprint pattern was found in 143 cases (73.3%), while 52 strains (26.7%) were grouped into 20 clusters. Nineteen cases (10%) were resident in the same quarter of Brescia with a high density of Senegalese immigrants (Area A). An increased probability of yielding clustered M. tuberculosis strains was associated with residence in Area A (OR 3.87, 95%CI 1.42-10.56; P = 0.02) and being Senegalese (OR = 5.96, 95%CI 1.48-23.97; P = 0.005). In the logistic regression analysis, being Senegalese was independently associated with yielding a clustered M. tuberculosis strain. CONCLUSIONS: Our results demonstrate a clustering of TB cases among Senegalese immigrants and suggest that RFLP analysis may be used to identify geographical areas where efforts can be targeted to interrupt TB transmission.

Screening for tuberculosis and latent tuberculosis infection among undocumented immigrants at an unspecialised health service unit.

SETTING: Practical or cost-effective strategies to identify undocumented immigrants with latent tuberculosis infection and to deliver treatment for latent TB infection are still unavailable. OBJECTIVES: To compare completion rates of screening procedures for TB infection and disease among undocumented immigrants at specialised (TB) and unspecialised health services in Italy. DESIGN: A TB unit (TBU) and an unspecialised health service unit for migrants (MHCU) served as recruitment sites for recent undocumented immigrants from TB endemic areas. The screening included a symptom questionnaire, a tuberculin skin test and a chest X-ray. RESULTS: Of 1318 eligible subjects, 1232 (93.4%) accepted the screening. Screening was completed by 993 (80.6%) individuals overall, 86.5% and 71.4% at the TBU and MHCU services, respectively. In a multivariate analysis model, the only variable associated with an increased probability of completing screening was being enrolled at the TBU site (OR 2.5, 95%CI 1.8-3.5; P < 0.001). Three hundred and ninety-two subjects (39.4%) had a TST test of > or = 10 mm. Eight cases of active tuberculosis were detected, with a calculated prevalence of disease of 650/100,000. CONCLUSIONS: Undocumented immigrants to Italy can be screened for TB at an unspecialised health service unit, although not as efficiently as at a specialised TB unit.

Supervised preventive therapy for latent tuberculosis infection in illegal immigrants in Italy.

In a multicenter, prospective, randomized, open-label study of isoniazid-preventive therapy (IPT) for latent tuberculosis infection, illegal immigrants from countries where tuberculosis is highly endemic were enrolled at two clinical sites in Northern Italy. Of 208 eligible subjects, 82 received supervised IPT at a dose of 900 mg twice weekly for 6 mo (Regimen A), 73 received unsupervised IPT 900 mg twice weekly for 6 mo (Regimen B), and 53 received unsupervised IPT 300 mg daily for 6 mo (Regimen C). Supervised IPT was delivered at either one tuberculosis clinic or one migrant clinic. The probability of completing a 26-wk regimen was 7, 26, and 41% in Regimens A, B, and C, respectively (p < 0.005, Log- rank test calculated using Kaplan-Meier plots). The mean time to dropout was 3. 8, 6, and 6.2 wk in Regimens A, B, and C, respectively (p = 0.003 for regimen A versus either Regimens B or C). Treatment was stopped in five subjects (2.4%) because of adverse events. The rate of completion of preventive therapy for latent tuberculosis infection among illegal immigrants was low. Supervised, clinic-based administration of IPT significantly reduced adherence. Alternative strategies to implement preventive therapy in illegal immigrants are clearly required.

Neurocysticercosis in an Italian traveler to Latin America.

Neurocysticercosis is rarely reported in short-term travelers, although the disease remains a major public health problem in tropical regions. We present a case of neurocysticercosis that was probably acquired by ingestion of Taenia solium eggs contained in the stomach of a pig butchered by the traveler. Complete clinical resolution was obtained by medical treatment, underlying the importance of early suspicion and diagnosis of the disease.

Incidence of tuberculosis in a community of Senegalese immigrants in Northern Italy.

SETTING: Tuberculosis is the world's foremost cause of death from a single infectious agent among adults. Although morbidity and mortality rates are highest in low income countries, industrialized countries have also faced a recent resurgence of the tuberculosis epidemic. In Europe and the United States increasing tuberculosis incidence rates are observed, particularly among persons with the human immunodeficiency virus infection and immigrants from highly endemic countries. OBJECTIVE: To measure the incidence of tuberculosis in a retrospective cohort of Senegalese immigrants in a closed community. DESIGN: During 1991, 721 of 794 (91%) community residents were actively screened using the tuberculin skin test and chest X-ray. In 1995 the out-patient clinical charts and the tuberculosis notification registers were reviewed to determine tuberculosis incidence. RESULTS AND CONCLUSION: A total of 328 subjects (45.4% of those screened) was retrospectively followed for a cumulative period of 10 147 months. Ten cases of active tuberculosis were detected. The annual incidence rate for tuberculosis was 11.8/1000, compared to 15.1/ 100 000 in the general population. Tuberculosis incidence was similar in subjects with a positive (12.3/1000), compared to a negative baseline tuberculin test (12.5/1000). Tuberculosis incidence is very high, and recent infections might account for a substantial proportion of cases among immigrants living in closed communities.

Malaria in migrants.

An increasing proportion of malaria cases in Italy is observed in immigrants revisiting their country of origin, but little specific research work has been carried out in this field. All malaria cases occurring from 1990 to 1998 at the Reference Clinic for Infectious and Tropical Diseases in Brescia were prospectically evaluated to compare clinical outcome in migrant and non-immune cases. No difference was observed between parasitaemia at diagnosis and time to clearance of peripheral parasitaemia. Clinical presentation was milder in migrants than in non-immunes, with an OR for severe malaria of 0.27 (c.i. = 0.09-0.84) (p = 0.01). Fever clearance time was significantly shorter in migrants (3.0 days, SD = 1.2) than in non-immunes (4.3 days, SD = 1.7) (p < 0.001). Among immigrants, the proportion of severe cases was higher in residents since 2 years or less (12.5%) compared to residents since 2 to 5 years (3.3%) and residents since more than 5 years (0.9%) (p = 0.02). The proportion of malaria cases who had used chemoprophylaxis was significantly lower among immigrants (30/272, 11.0%) compared to non-immunes (41/74, 55.4%) (p < 0.001). In a population based malaria KAP analysis among 504 migrants from malaria endemic countries, correct knowledge of malaria risk was reported by 351 (69.5%). Of 170 subjects who reported at least one visit back to the home country, 30 (17.6%) had sought pre-travel advice, 24 (14.1%) had started chemoprophylaxis and 7 (4.1%) had completed it during the last visit. Of 140 migrants who failed to seek pre-travel advice, 73 (52%) were unaware of malaria risk, 56 (40%) did not know how to protect themselves, and 11 (8%) refused to use protective measures. Migrants account for a significant proportion of imported malaria cases in industrialised countries. Clinical presentation is milder compared to non-immune subjects. The proportion of migrants who adopt malaria protective measure while returning home is very low, due to both unawareness of risk and inappropriateness of medical advice.

[Cholestatic liver disease and thrombocytopenia associated with long exposure to ticlopidine]. / Colestasi epatica e trombocitopenia associate a trattamento protratto con ticlopidina.

A 45-year-old woman was admitted to the hospital because of cholestatic liver disease and severe thrombocytopenia following a 4-day history of fever and malaise. In her childhood the patient suffered from acute rheumatic fever with secondary mitral stenosis. Three years before admission, an atrial fibrillation had been diagnosed for which the patient was put on ticlopidine, 250 mg daily, that was taken regularly, without any adverse event. The patient had no history of cholestatic hepatitis or biliary colic. The abdominal ultrasonography was negative for biliary tract diseases and histological features were compatible with drug induced hepatotoxicity. Laboratory tests for viral and bacterial infection were negative. No other medications, apart from 2 doses of nimesulide, had been taken by the patient in the previous days. Ticlopidine was discontinued on admission and both bilirubin and platelet count rapidly normalized. We think that, in our patient, ticlopidine may be responsible of concomitant hematologic and hepatic toxicity and the trigger event might have been the reduced renal excretion of the drug following acute renal failure.