Measles outbreak in the Lazio region of Italy: surveillance and impact on emergency departments and hospitalizations.

BACKGROUND: The World Health Organization's (WHO) Regional Office for Europe had committed to 2015 as the year to eliminate measles from the region but several outbreaks have been reported recently from several areas of the continent. Here we describe an outbreak that occurred in 2010-2011 in Lazio region, Central Italy, and its impact on some health care services (i.e., Emergency Departments (EDs) and hospital clinics). METHODS: We analyzed cases of measles reported to the infectious diseases surveillance system and accesses to EDs and hospitalizations for measles in the Lazio Region (central Italy, population of about 5,730,000 people). RESULTS: In 2010-2011, 2,956 cases were reported to the surveillance system (incidence rate: 18.4 and 33.3 per 100,000 in 2010 and 2011, respectively). The incidence rates varied greatly with the territory. The outbreak occurred mainly among children <1 year old and among adolescents, most unvaccinated and did not seem to be related to cases imported from Eastern Europe. Complications were reported in 37.4% of the cases. The epidemic was mainly related to an accumulation of adolescents susceptible to measles due to unsatisfactory vaccination coverage in the early nineties. The outbreak had a strong impact on the health system with 2,881 ED visits and 1,168 hospitalizations. Outbreak-associated costs were considerable. CONCLUSIONS: An additional intervention should be considered aimed at improving routine immunization coverage in children and at planning catch-up vaccination of 6-18 year olds not previously vaccinated. Further, timely surveillance is needed and specific protocols should be implemented to limit secondary cases.

Meta-analysis: adherence to colorectal cancer screening and the detection rate for advanced neoplasia, according to the type of screening test.

BACKGROUND: A variety of tests have been proposed for colorectal cancer (CRC), giving rise to uncertainty regarding the optimal approach. The efficacy and effectiveness of different tests are related to both screened participation and the detection rate. AIM: To perform a meta-analysis on adherence and detection rates of CRC screening tests. METHODS: Relevant publications were identified by MEDLINE/EMBASE and other databases for the period 1999-2012. A previous systematic review was used for the period before 1966-1999. RCTs and controlled studies including a direct comparison of the uptake rates among different options for CRC screening were included. Adherence and detection rates for advanced neoplasia and cancer were extracted. Risk for bias was ascertained according to CONSORT guidelines. Forrest plots were produced based on random-effect models. RESULTS: Fourteen studies provided data on 197 910 subjects. Endoscopic strategies were associated with a lower participation (RR: 0.67, 95% CI: 0.56, 0.80) rate, but a higher detection rate of advanced neoplasia (RR: 3.21, 95% CI: 2.38, 4.32) compared with faecal tests. FIT was superior to g-FOBT with regard to both adherence (RR: 1.16, 95% CI 1.03, 1.30) and detection of advanced neoplasia (RR: 2.28, 95% CI 1.68, 3.10) and cancer (RR: 1.96, 95% CI: 1.2, 3.2). CONCLUSION: The superior accuracy of endoscopy compared with faecal tests minimised any impact of the participation rate in determining the detection rate of advanced neoplasia in a screening setting.

How to increase uptake in oncologic screening: a systematic review of studies comparing population-based screening programs and spontaneous access.

BACKGROUND: Cervical, breast and colorectal cancer (CRC) screenings are universally recommended interventions. High coverage of the target population represents the most important factor in determining their success. This systematic review aimed at assessing the effectiveness of population-based screening programs in increasing coverage compared to spontaneous access. METHODS: Electronic databases and national and regional websites were searched. We included all studies on interventions aimed at increasing screening participation published between 1999 and 2009; for those published before, we consulted the Jepson et al. review (2000). We compared spontaneous access (including no intervention) vs population-based screening programs actively inviting the target population. Among the latter, we compared GP-based vs invitation letter-based interventions. RESULTS: The invitation letter vs no intervention showed significantly more participation (RR=1.60 95%CI 1.33-1.92; RR=1.52 95%CI 1.28-1.82; RR=1.15 95%CI 1.12-1.19, for breast, cervical and CRC screenings, respectively). GP-based interventions, although more heterogeneous, showed a significant effect when compared with no intervention for breast (RR=1.74 95%CI 1.25-2.43), but not for cervical and CRC. No significant differences were found between invitation letter-based and GP-based organization (RR=0.99 95%CI 0.94-1.05; RR=1.08 95%CI 0.99-1.17, for breast and cervical cancer, respectively). CONCLUSION: Population-based programs are more effective than spontaneous screening in obtaining higher testing uptake. Both invitation letter-based and GP-based programs are effective.

Immunization coverage and timeliness of vaccination in Italian children with chronic diseases.

Since children with chronic diseases represent a primary target for immunization strategies, it is important that their immunization coverage and timeliness of vaccines is optimal. We performed a study to measure immunization coverage and timeliness of vaccines in children with type 1 diabetes, HIV infection, Down syndrome, cystic fibrosis, and neurological diseases. A total of 275 children aged 6 months-18 years were included in the study. Coverage for diphtheria-tetanus-pertussis (DTP), polio (Pol), and hepatitis B (HBV) vaccines approximated 85% at 24 months, while measles-mumps-rubella (MMR) coverage was 62%. Immunization coverage for seasonal influenza was 59%. The analysis of timeliness revealed that there was heterogeneity among children with different chronic diseases. A proportional hazard model showed that children with HIV infection had the longest time to complete three doses of DTP, Pol, and HBV, and those with neurological diseases received the first dose of MMR later than the other categories. Causes of missing or delayed vaccination mostly included a concurrent acute disease. Children with chronic diseases should be strictly monitored for routine and recommended vaccinations, and health care providers and families should be properly informed to avoid false contraindications.

Suspected transmission of tuberculosis in a maternity ward from a smear-positive nurse: preliminary results of clinical evaluations and testing of neonates potentially exposed, Rome, Italy, 1 January to 28 July 2011.

We report preventive measures adopted after tuberculosis(TB) transmission from a nurse to a newborn assessed in late July 2011. All exposed neonates born between January and July 2011 were clinically evaluated and tested by QuantiFERON TB gold in-tube; newborns testing positive were referred for prophylaxis.Of 1,340 newborns, 118 (9%) tested positive and no other active cases of TB were found. Active surveillance for TB will be continued over the next three years for all those exposed.

Validity of caregiver-reported hospital admission in a study on the quality of care received by terminally ill cancer patients.

BACKGROUND: The clinical status of terminally ill patients often makes it impossible for them to report information directly, which indicates the need to rely on information from indirect sources, such as from caregivers. This information needs to be validated, and particular attention must be given to the accuracy of recall. OBJECTIVE: The objective of this study is to evaluate the agreement between caregiver-reported hospital admissions with the data reported in the regional hospital information system. METHODS: A two-level probabilistic sample of cancer deaths from the ISDOC (Italian Survey on Dying of Cancer). For the 2,000 deceased sampled, hospitalizations were identified from the administrative data and reported by the caregivers via a questionnaire. We calculated Cohen's kappa, sensitivity and specificity using the regional archives as the gold standard. A multivariate analysis was performed to assess possible variables that may influence agreement. RESULTS: We interviewed 1,271 caregivers. Sensitivity and specificity were, respectively, 82% (95% confidence interval [CI]=79-84) and 65% (95% CI=60-69). Kappa statistic was 0.46 (95% CI=0.40-0.52). Multivariate analysis showed that agreement increases with educational level and caregiver age. CONCLUSION: The validation of caregiver's recall for medical procedures has important implications for research and care, because often it is the only information source we can rely on. The questionnaire showed good sensitivity and poor specificity concerning real hospitalizations, and had moderate degree of agreement with the data reported in the administrative data.

Prevalence, distress, management, and relief of pain during the last 3 months of cancer patients' life. Results of an Italian mortality follow-back survey.

BACKGROUND: This study estimates prevalence, management, and relief of pain during the last 3 months of life of a representative sample of dying cancer patients in Italy. PATIENTS AND METHODS: This is a mortality follow-back survey (the Italian Survey of the Dying of Cancer). Caregivers were interviewed, after the patient's death, about pain experienced by the patients in all settings of care. RESULTS: According to caregivers' reports, 82.3% [95% confidence interval (CI) 79.9% to 84.4%] patients experienced pain, and 61.0% (95% CI 57.9% to 64.0%) very distressing pain. The younger population experienced a higher prevalence of pain in respect to older patients (P < 0.01). Patients with tumors of the central nervous system experienced the lowest prevalence (51.9%). According to caregivers' reports, only 59.5% (95% CI 3.7% to 65.0%) received analgesic treatment with opioids for moderate to severe pain. Not surprisingly, pain was 'only partially relieved' or 'not relieved at all' in 54% of the patients with very distressing pain. CONCLUSIONS: Although potentially slightly biased, the results from this survey regarding undermedication and poor treatment results for cancer related pain are unequivocal. The research agenda should focus on testing the effectiveness of interventions to improve the quality of pain assessment and management.

Syndromic surveillance: sensitivity and positive predictive value of the case definitions.

The aim of the study was to measure the positive predictive value (PPV) and sensitivity of operational case definitions of 13 syndromes in a surveillance system based on the Emergency online database of the Lazio region. The PPVs were calculated using electronic emergency department (ED) medical records and subsequent hospitalizations to ascertain the cases. Sensitivity was calculated using a modified capture-recapture method. The number of cases that fulfilled the case definition criteria in the 2004 database ranged from 27 320 for gastroenteritis to three for haemorrhagic diarrhoea. The PPVs ranged from 99.3 to 20; sepsis, meningitis-like and coma were below 50%. The estimated sensitivity ranged from 90% for coma to 22% for haemorrhagic diarrhoea. Syndromes such as gastroenteritis, where the signs, symptoms, and exposure history provide immediate diagnostic implications fit this surveillance system better than others such as haemorrhagic diarrhoea, where symptoms are not evident and a more precise diagnosis is needed.

Tuberculosis incidence, hospitalisation prevalence and mortality in Lazio, Italy, 1997-2003.

SETTING: Lazio region (5.15 million, including Rome, 2.8 million), Italy. OBJECTIVE: To monitor pulmonary tuberculosis (TB) epidemiology from 1997 to 2003. DESIGN: We used data from the mandatory National Infectious Diseases Surveillance system, the regional Hospital Information System and the regional Mortality Register. The number of prevalent pulmonary TB cases hospitalised was determined by linking notifications and hospitalisations. To estimate incidence, we excluded all cases with previous TB hospitalisations since 1995, and those reported as a secondary diagnosis in the Hospital Information System. Mortality rates were ascertained from mortality records reporting TB as the principal cause of death. RESULTS: The record linkage identified 4885 incident cases, 9010 hospital prevalent cases and 217 deaths. Incidence decreased from 15/100000 in 1997 to 11 in 2003, and consistent decreases were also observed in hospitalisation prevalence and mortality (P for trend <0.0005, <0.0005 and =0.063, respectively). The number of AIDS-related TB cases dropped from 85 to 49 (P < 0.0005). The number of incident cases in non-Italians increased significantly, from 171 to 267 (P < 0.0005). Notification underreporting was estimated at 39%. CONCLUSIONS: Despite a decreasing trend, TB incidence is still over 10/100000 in Lazio region. Targeted interventions for immigrant populations are essential for controlling TB.

[Colorectal cancer screening: survey of endoscopy center's physicians in Lazio region]. / Screening per il cancro del colon retto: indagine sui medici endoscopisti della regione Lazio.

The aim of the present work is to describe the characteristics of digestive endoscopy centers and the physicians that work there, with particular attention to their attitudes and practices in colorectal cancer screening. A questionnaire was sent to all 80 digestive endoscopy centers in the Lazio region, identified by the annual census of Italian Society of Digestive Endoscopy (Società Italiana di Endoscopia Digestiva, SIED). Seventy-one centers (89%), returned the questionnaire. Screening activity on average represents 14% of the centers' colonoscopy workload. Colonoscopy was considered to be a "very effective" screening test by 96% of physicians, the faecal occult blood test "very effective" by 20%, and flexosigmoidoscopy "very effective" by 11%. Ninety-seven percent (97%) of physicians reported recommending any test for screening: 80% colonoscopy, 61% faecal occult blood test, 14% double contrast barium enema and 11% flexosigmoidoscopy. Despite the fact that almost all physicians reported recommending screening, the centres are only marginally involved in screening practice. Endoscopy centers' physicians tend to have an aggressive strategy for colorectal cancer prevention and exclusive trust in colonoscopy; an attitude more consistent with a clinical-diagnostic approach than with real mass screening of a healthy population.

Diagnosis and prognosis disclosure among cancer patients. Results from an Italian mortality follow-back survey.

BACKGROUND: The observed cultural changes in truth-telling attitudes suggest a radical change in the practice of delivering information to cancer patients, but limited research is available from countries known for their policy of non-disclosure. This study estimates the proportion of Italian who died of cancer who had received information about diagnosis and prognosis, and explores the variables associated with disclosure. MATERIALS AND METHODS: This is a mortality follow-back survey of 1271 non-professional caregivers of Italians who died of cancer in 2002, representative of the approximate 160 000 Italian annual cancer deaths. Caregivers were interviewed after the patient's death about the process of diagnosis and prognosis disclosure. RESULTS: It was estimated that 37% of people who died of cancer had received information about diagnosis and 13% about poor prognosis. A consistent proportion, although non-informed, knew the diagnosis (29%) and the poor prognosis (50%). The probability to be informed was higher for patients living in the north of Italy, young, well educated, with longer survival, and with breast or head and neck tumor. CONCLUSIONS: These findings suggest that not necessarily the observed cultural changes towards a less paternalistic approach in medical care translate into an effective change in the quantity of information delivered to the patients.

[Risk management in a regional screening program for breast cancer in the region of Lazio, Italy]. / Garantire la sicurezza dei pazienti in un intero profilo assistenziale: il programma di gestione del rischio clinico nello screening mammografico della Regione Lazio.

In the Lazio Region, it has been put into effect a plan of clinical Risk Management for the Breast Cancer Screening Regional Program (BCSP), involving all of the 12 Local Health Units and the Public Health Agency of Lazio (ASP). Being the BCSP a health care service, it consists of a perfect integration of health care structures, professionals and skills working for the citizens. This program originates from an unexpressed health need and leads to a evidence-based health benefit. The BCSP provides free breast screening for 700,000 women aged between 50 and 69 in the Lazio region; the Public Health Agency carries out the clinical governance of the BCSP The prevention of errors and incidents represents a fundamental basis of governance: it is a contribution to the achievement of efficacy in breast cancer screening. The BCSP deals with screening incidents from a systemic point of view and actively involves several Local Health Units staff going through each step of the whole patient's clinical path, from the identification of the target population, to the oncological treatment of positive cases. The programme is an integration of different tools: literature research, process analysis using the HFMEA methodology and reporting system. The results reached so far are the following: the regional severity rating scale, the regional Master-List of possible adverse events, occurrence and detection rating scale.

[Evidence-based planning: the case of mass screening for colorectal cancer in the Lazio region of Italy]. / Programmazione basata sulle prove di efficacia: il caso dello screening del cancro colorettale nel Lazio.

Several population-based trials have shown the efficacy of colorectal cancer mass-screening based on guaiac faecal blood testing in a generic risk population. SCCR represents a very complex and resource-demanding public health intervention and, for this reason, its planning requires actual efficacy as a main goal. Since evidence of efficacy demonstrated by population-based trials may not actually generate effectiveness, the Regional Government of Latium Region decided to implement some experimental studies before introducing a screening programme, in order to define an evidence-based organisational model of SCCR and a feasibility evaluation of the real needs for screening. The aims of the pilot studies were to define an evidence-based organisational model, to evaluate the necessary resources and the actual quality standard of clinical examination, treatment and surgery. The aim of the feasibility study is to test the organisational model for SCCR for about 300,000 citizens residing in the Latium region. The present article illustrates the scheduling path set out, which is based on the involvement of experts, GP representatives and specialists from scientific societies and it is planned by the following actions: Definition of evidence-based recommendations; identification of further investigations; realization of experimental studies; definition of an evidence-based organisational model. The main research areas have been dealt with using randomised trials, in order to evaluate the efficacy of the involvement of GPs and the kind of test for RSOF Our work has produced evidences which were sometimes in contrast with information in the literature, demonstrating that guaiac RSOF testing is less reproducible and determines lower uptake than immunochemical testing. Our work also shows that the involvement of GPs should be based on their personal skills rather than on their role. Such evidences are fundamental to the definition of the organisational model and confirm the need of basing an evidence-based planning not only on evidences found in the literature. The necessity of this approach is strengthened by the level of organisational complexity and by the amount of resources needed to put a public health intervention into practice.

[Injuries in immigrants from non-industrialized countries: analysis of emergency admissions in Lazio, Italy, in the year 2000]. / I traumi negli immigrati da paesi non industrializzati: analisi degli accessi in pronto soccorso nel Lazio nell'anno 2000.

Aim of the study is to describe the characteristics of road, home and work-related traumas among adult immigrants born in non-industrialised Countries, and to compare the consequent probability of hospitalisation with Italian adults in Lazio Region, year 2000. Source of data is the Emergency-based Surveillance System, which collects all the emergency ward visits in Lazio region. Accident incidence has been estimated using alternatively the residence permits and the roman resident population born in non-industrialised Countries. The 7.7% of all the emergency visits of immigrants are trauma-related. Road traffic accident visits are more appropriate and urgent. Immigrants have a higher risk of hospitalisation both for road and home accidents compared to the Italians (OR = 1.59 and OR = 1.37 respectively). Immigrants use emergency wards for severe and urgent trauma-related accidents, they have higher probability of hospitalisation compared to the Italians. Our analysis highlights the necessity to improve tools to study immigrant health.

Assessing effectiveness of home care for persons with AIDS: analysis of methodological problems.

The aim of this paper is to assess the methodological problems of an unsuccessful randomized controlled trial (RCT) conducted to evaluate the effectiveness, in terms of survival and quality of life, of the early offer of home care (HC) to persons with AIDS (PWA). The study carried out was an intention-to-treat RCT. Persons in the treatment group (TG) received the offer of HC at the moment of AIDS diagnosis; those in the control group (CG) received it six months from diagnosis. Many problems have hindered the progress of the study: particularly, the low compliance to the offer and the failure to enroll the required sample size have made the results unreliable. Analogous problems have been reported within other trials evaluating HC in different fields. The present study thoroughly evaluates the specific ethical and methodological problems encountered in designing and conducting a RCT on HC for PWA. We conclude that, before designing and conducting a RCT in this field, it is advisable to examine some main issues carefully, such as the acceptability of the offer of treatment, the expected compliance and the required size of the study population. If one or more of these elements prove to be problematic, the results of the trial risk being seriously compromised, and alternative approaches should be considered.

Application of random effect ordinal regression model for outcome evaluation of two randomized controlled trials.

Cluster randomization is often used in intervention trials, yet when individuals nested within clusters are considered as the units of analysis for outcome evaluation, it cannot be assumed that the observations are statistically independent. Observations that are not statistically independent also result when repeated measures are taken over time for the same individual. Ignoring clustered observations when performing data analysis can lead to the erroneous conclusion that the intervention under study had a statistically significant effect. Moreover, individual responses are often collected on ordinal scales; thus models for continuous or categorical data are usually not appropriate. We applied a random effect ordinal regression model to data sets from two randomized controlled intervention trials that measured graded scale non-independent responses. The first trial compared two school programmes for AIDS prevention in terms of impact (i.e., changes in the frequency of condom use). The second trial used the MOS-HIV questionnaire to measure the quality of life of new AIDS cases four times over a one-year follow-up period (only results of the role-functioning scale are reported). Regarding the first data set, the effect of the intervention was not significant, and the post-intervention frequency of condom use was mainly attributable to the pre-intervention frequency (p<0.01), with no differences among schools. Regarding the second data set, a borderline significant increase in the role-functioning scale scores was observed over the follow-up period; the results differed only slightly by intervention group; a significant (p<0.01) intra-individual correlation of 0.4 was found.

The chsA gene from Aspergillus nidulans is necessary for maximal conidiation.

A fragment from the open reading frame of the cloned chsA gene from Aspergillus nidulans was deleted and replaced with the argB gene. The resulting construct was used to replace the wild-type chsA gene in an argB deletion strain. The growth and morphology of the vegetative hyphae from the resulting chsA disruptant strain were indistinguishable from those of a wild-type strain but the chitin content of the hyphae from the disruptant was reduced to approximately 90% of that of wild-type. The disruptant showed reduced ability to produce the asexual spores (conidia) that are formed by differentiated aerial hyphae called conidiophores. The ability to form undifferentiated aerial hyphae was not impaired in the disruptant. The conidiophores and conidia produced by the disruptant were indistinguishable from those of wild-type. Conidium formation by the disruptant grown on a variety of media was reduced to about 30% of the wild-type. A chsE null strain did not show a defect in conidiation but a strain in which both chsA and chsE were inactivated produced about 3% of the conidia of wild-type. That finding supports the hypothesis that chsA and chsE encode a partially redundant function necessary for conidiophore development.

The balance of positive and negative effects of specific messages in the evaluation of interventions for preventing HIV infection.

The study objectives were to determine the effects of a large-scale school-based HIV prevention campaign, in terms of both positive and negative effects of each single message, and to identify sub-populations more at risk. Forty-six schools, randomly sampled from all schools in the Lazio region, were randomized to either an intervention or a control group. The study population consisted of 3866 students. Questionnaires on AIDS-related knowledge and risk perceptions were administered to students before and after the intervention. Odds ratios were calculated to represent the extent to which the intervention was associated with an improvement (OR+), and the extent to which it prevented a worsening (OR-). Overall, the intervention was successful in communicating important messages, such as the impossibility of transmitting HIV through social contacts (OR+ all significantly > 1 and OR- always< 1), the meaning of 'seropositivity' (OR+: 1.28, 95% CI: 0.99-1.64; OR-: 0.73, 95% CI: 0.58 0.91), and the lack of a resolutive cure for AIDS (OR+: 1.61, 95% CI: 1.10-2.36; OR-: 0.76, 95% CI: 0.57-1.02). The worst results were observed in vocational and art schools, where OR + > 1 were observed for only three questions and OR- values usually exceeded 1. This study highlights the necessity of remodelling the intervention, indicating which messages need to be modified. The low impact of educational programmes among students of vocational and art schools makes them a population more at risk, that should be considered as a priority target population for interventions.

Heterogeneity of home care assistance needs of people with AIDS.

A multidisciplinary home care service for people with AIDS (PWAs) was started in Rome in September 1990. This paper describes the features of the home care service offered by the Associated Health Care Workers' Co-operative (OSA), an example of the integration of private and state systems. We detail the types and numbers of visits that PWAs have needed, and we explore the possible correlation between demographic and clinical variables and the care required. As of September 1994 service had been provided to 372 PWAs. During the 4-year period, 62,927 home care visits were made (an average of 4.3 visits/patient/week): 66% were made by psychologists, social workers and home helps, and 34% by health professionals. PWAs who, at the outset of their home care, suffered from AIDS-dementia complex (ADC), toxoplasmosis, wasting syndrome or cytomegalovirus retinitis required the highest number of visits. Psychologists, social workers and home care helps made more frequent visits than health professionals for all AIDS-defining conditions except retinitis (for which 63% of visits were for health care). Our study shows that careful assessment of patients receiving home care helps in planning visits and in organizing available resources. A controlled randomized multicentre study is under way with the aim of determining the effectiveness of home care in terms of survival, quality of life and care workload and related costs.

[Evaluation of training programs for purchasing and using pesticides]. / Valutazione dei corsi per l'abilitazione all'acquisto ed uso dei fitofarmaci.

Courses to enable farmers to use pesticides are an ideal opportunity to implement prevention programs. The aim of this study was to evaluate the efficacy of the courses and to define parameters to validate the teaching methods used. The population consisted of 307 individuals who followed the courses during 1991 in the province of Viterbo. A multiple choice questionnaire was administered before and after the course. A knowledge coefficient (KC) was considered as an indicator of knowledge improvement gained by the course. Wilcoxon's non-parametric test was used to compare pre- and post-test scores. A multivariate logistic model was designed to assess the effect of descriptive variables (age, educational level, years of work in agriculture, etc.) on KC. Post-test scores were significantly higher than pre-test scores and the mean KC was 60%, suggesting a general efficacy of the courses. A marked effect of age and educational level on KC was observed: KC values decreased with increase in age and with decrease in educational level. It is recommended to vary the courses according to age and educational level in view of the high proportion of older subjects and the low educational level (about 50%). Active learning methods should also be used as far as possible.