Knowledge, attitudes, and practices of occupational health physicians in the promotion of vaccinations recommended for health care workers: An Italian study

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Evaluation of a vaccination strategy by serosurveillance data: The case of varicella

Serological studies have many important epidemiologic applications. They can be used to investigate acquisition of various infections in different populations, measure the induction of an immune response in the host, evaluate the persistence of antibody, identify appropriate target groups and the age for vaccination. Serological studies can also be used to determine the vaccine efficacy. Since 1995 a varicella vaccine is available and it has been recommended in several countries (e.g. USA, Australia, Canada, Costa Rica, Ecuador, etc.). Nevertheless few varicella seroprevalence studies in countries that adopted an URV are available. It is related to the relatively recent introduction of the vaccination and to the lack of structured and collaborative surveillance systems based on serosurvey at national or regional level. Varicella seroprevalence data collected before the introduction of vaccination strategies allowed to establish the age of vaccination (e.g., indicated the opportunity to offer the vaccine to Italian susceptible adolescents). In the post-vaccination era, seroprevalence data demonstrated vaccine as immunogenic and excluded an increase of the age of infection linked to the vaccination strategy. New seroprevalence studies should be performed to answer to open questions, such as the long-term immunity and the change of the herpes zoster epidemiological pattern related to the vaccine

Serosurveillance of hepatitis A in a region which adopted the universal mass vaccination

Hepatitis A is a common infectious disease worldwide that was endemic in many regions of Southern Italy, such as Apulia region. After a large hepatitis A outbreak occurred between 1996 and 1997, in Apulia an active-free immunization program that was targeted to new-borns and adolescents was started. The aim of this study is to investigate the hepatitis A seroprevalence in the adult Apulian population 18 years after the immunization program introduction, in order to evaluate the risk of new epidemics onset.The study was carried out from May 2011 to June 2012 among blood donors from Department of Transfusion Medicine and Blood Bank of Policlinico General Hospital in Bari. Participants signed a written consent and filled out a questionnaire including items on demographic characteristics, risk factors, disease memory, and raw food consumption. Serum samples, collected from each patient, were tested for anti-HAV using the chemiluminescent microparticle immunoassay. Vaccination status against hepatitis A was checked on Regional Digital Immunization Registry (GIAVA).In total 1827 donors agreed to participate (77.7% male) with a mean age of 38.4 ± 11.7 years. However, 1172 (64.1%) donors were seropositive with no difference by sex. The highest proportion of seronegative subjects was in the 27 to 35 years age group. 91.8% of 1-dose vaccinated subjects (n = 190/207; 95%CI = 87.2-95.1) and 96.1% (n = 171/178; 95%CI = 92.1-98.1) of 2-doses vaccinated subjects were immune to the disease. Sensitivity of disease memory in unvaccinated subjects was 14.4% (95%CI = 12.2-16.7), specificity was 97.8% (95%CI = 96.3-98.8), positive predictive value was 91% (95%CI = 85.3-95), and negative predictive value was 42.6% (95%CI = 40-45.2). Raw seafood consumption in unvaccinated subjects was associated with the anti-HAV IgG positivity (OR = 2.1; 95%CI = 1.7-2.7; z = 7.4; P < 0.0001).The vaccination program seems to have changed the virus circulation pattern, with a higher seronegativity rate among subjects not included in the vaccination strategy: 67% of susceptible subjects were among younger people aged 27 to 35 years. Immunization program implementation with a catch-up strategy may be needed to avoid a possible increase of hepatitis A incidence and outbreaks in Apulia. Epidemiological surveillance should be continued and vaccination should actively be offer for free to all the cases contacts, in order to prevent new outbreaks onset

Migrant health: the Apulian model

Since the 1990s Puglia has been totally involved in the reception and assistance of refugees. The prevention of infectious diseases among migrants, especially those residing in communities, is an important concern for public health authorities, since infectious diseases eliminated in Europe may still be widespread in the migrants' countries of origin, and other diseases may have a higher incidence than in European countries. Thus immigrants may contribute to the burden and spread of infectious diseases

Clinical benefits of routine varicella vaccination for adults

Varicella is a highly contagious disease caused by varicella zoster virus. In children, it is generally a mild to moderate illness while it is often more severe in adults, with serious complications as dehydration, pneumonia, bleeding problems, infection or inflammation of the brain, secondary bacterial infections, sepsis, toxic shock syndrome, bone infections, joint infections and deaths. Some groups of adults are at major risk of complications, in particular immunocompromised persons as subjects with impaired humoral immunity and who is receiving systemic steroids, persons who live or work in environments in which transmission of varicella is likely, health-care personnel and pregnant women. After the introduction of Universal Mass Vaccination (UMV), the first mathematical models suggested that vaccination will lead to a shift in the average age at infection from children to adults with an increasing numbers of complicated forms, nevertheless new models predicted that, although an upward shift in the age at infection may occur, the overall morbidity due to varicella is likely to decrease. Current literature seems to suggest that for public health authorities the key action to prevent an increase of varicella incidence among adults is to achieve high vaccination coverage among babies and adolescents in countries who adopted UMV

How will the MMR universal mass vaccination change the epidemiologic pattern of mumps? A 2012 Italian serosurvey

To investigate the changes in the epidemiologic pattern of mumps, we carried out a serosurvey among young adults from Apulia, Italy. A convenience sample of 1,764 blood donors were enrolled in 2012: 93.4% (95% confidence interval, 92.1-94.5) showed a positive antimumps immunoglobulin G titre, geometric mean titer was 2.05. Results were consistent with previously published data on the immunogenicity of mumps vaccine but showed a lack of immunity (10% of people aged 18-26 years susceptible for mumps). Future research must be focused on the long-time immunogenicity of the mumps vaccine

REDUCTION OF INVASIVE DISEASE IN CHILDREN TWO DECADES AFTER THE INTRODUCTION OF HAEMOPHILUS INFLUENZAE TYPE B CONJUGATE VACCINATION IN APULIA REGION, ITALY

Background Haemophilus influenzae type b conjugate (Hib) monovalent vaccination, consisting of 2p+1 doses at 3, 5, and 11 months of age, was introduced in the Italy’s infant immunization schedule in 1999 and included in the DTaP-HBV-IPV/Hib hexavalent vaccine since 2001. The estimated vaccination coverage was 83.4% in 2002, >90% by 2005, and >95% by 2011 [1-4]. In the Apulia region of Italy (about 4,000,000 inhabitants), vaccination coverage for 3 doses reached 75% in 2001, >90% by 2002, and >95% by 2007 (Graph. 1).Methods We considered annual age-specific hospitalization rates in infants <1 year and children 1-4 years as a proxy for incidence in the period 1996-2014. The attributable benefit was calculated as the reduction in incidence of Haemophilus influenzae invasive disease among vaccinated children attributable to the routine use of Hib monovalent vaccine during 1999-2000 (“Hib-monovalent period”) and of the hexavalent DTPa-HBV-IPV/Hib vaccine in the period 2001-2014 (“DTPa-HBV-IPV/Hib period”). The prevented fraction was calculated as the proportion of hypothetical total cases that were prevented by the use of monovalent and hexavalent vaccine, respectively (Panel A) [5]Results The hospitalization rate for Haemophilus influenzae invasive disease among infants decreased from 11.5 (95% CI= 1.4-21.6) per 100,000 in the 1996-1998 pre-vaccination period to 6 (95% CI= -1.4-13.3) per 100,000 in the “Hib-monovalent period”, with an estimated AleB of -5.5 per 100,000 and a PedF of 48.2%. It declined further to 1 (95% CI= -2.2-4.1) per 100,000 in the “DTaP-HBV-IPV/Hib period”, with an AleB of -10.5 per 100,000 and a PedF of 91.6% (Graph. 2). The rate of hospitalization among children aged 1-4 year remained stable at 2.4 per 100.000 from the pre- vaccination period through “Hib-monovalent period” (AleB=0; PedF=2%) and declined to 0.1 (95% CI= - 0.4-0.7) per 100,000 in the “DTaP-HBV-IPV/Hib period”, with an AleB of -2.3 per 100,000 and a PedF of 94.3% (Graph. 3)Conclusions * Hib-monovalent period - ** DTPa-HBV-IPV/Hib period In the Apulia region of Italy, the proportion of Haemophilus influenzae invasive disease requiring hospitalization in children aged <5 years presumably prevented by the introduction of Hib universal vaccination amounted to more than nine in ten cases. These findings are consistent with increased vaccine coverage rates as a result of the wide use of the hexavalent combination vaccines

Immunization coverage among splenectomized patients: Results of an ad hoc survey in Puglia Region (South of Italy)

Patients with anatomic or functional asplenia have a 10-50&nbsp;times higher risk than general population to develop Overwhelming Post-Splenectomy Infection. Evidences are unanimous in recommending splenectomised patients to receive meningococcal, antipneumococcal and Haemophilus influenzae type B vaccinations according to a specific timing. In Italy there are no current data on the immunisation coverage in these patients. This study aims to investigate immunisation coverage in patients undergoing elective or urgent splenectomy for 2012-2013 in the 3 Apulian hospitals. The patients discharged with the code ICD-9-CM 41.5 - "Total splenectomy" were enrolled. The administration of vaccines was verified through consultation of medical records, archives of general practitioners and vaccination offices. In the study period, 166 subjects underwent splenectomy and none of them received vaccinations during hospitalization. 25 splenectomised patients (15.1%) received at least one of the recommended vaccinations. 21 patients (12.6%) received vaccine against Streptococcus pneumonia, 13 (7.8%) meningococcal vaccine, 10 patients (6%) Haemophilus influenzae type B vaccine. The low vaccination coverage could be due both to poor perception of the risk of infection and to a lack of knowledge on vaccinations by surgeons. For this reason it is necessary to draw up and share operational protocols that establish the administration of vaccines

Systematic causality assessment of adverse events following HPV vaccines: Analysis of current data from Apulia region (Italy)

Since 2013, World Health Organization (WHO) recommended that adverse events following immuniza- tion (AEFIs) should be evaluated by a standardized algorithm for causality assessment, however the use of WHO procedure is rarely adopted. In Italy, AEFIs (classified only by temporal criteria) are registered in the National Drug Authority (AIFA) database, but causality assessment is not mandatory. Every year AIFA publishes the AEFIs report, that doesn’t contain information about causal correlation between events and vaccines. From AIFA database, we selected AEFIs following human papillomavirus vaccination (HPV) reported in Apulia (about 4,000,000 inhabitants) during 2008–2016. For serious AEFIs, we applied WHO causality assessment criteria; for cases hospitalized, we repeated the assessment getting additional information from health documentation. In 2008–2016, 100 HPV AEFIs (reporting rate: 17.8 per 100,000 doses) were registered of which 19 were serious (rate: 3.4 per 100,000 doses) and 12 led to hospitaliza- tion. After causality assessment, for 9 AEFIs the classification was ‘‘consistent causal association to immunization”, for 3 indeterminate, for 5 ‘‘inconsistent causal association to immunization” and for 2 not-classifiable. Among hospitalized patients, 5 AEFIs were consistent, 5 inconsistent, 1 not-classifiable and 1 indeterminate; adding information from health documentation, the results were similar except for indeterminate and not classifiable AEFIs that turned into ‘‘not consistent”. Only half of severe AEFIs could be associated with vaccination and this suggests that AIFA report provides a incomplete picture of HPV vaccine safety, with a risk for readers to confound ‘‘post hoc” and ‘‘propter hoc” approach without considering the causality assessment results. In the view of the systematic use of WHO causality assess- ment algorithm in the AEFI surveillance, the efforts of Public Health must be focused on the improvement of the quality of the information provided to reduce conclusions inter-observer variability; the routine follow-up of reports, also to collect additional information, must be guaranteed

Community-wide outbreak of haemolytic uraemic syndrome associated with Shiga toxin 2-producing Escherichia coli O26:H11 in southern Italy, summer 2013

In summer 2013, an excess of paediatric cases of haemolytic uraemic syndrome (HUS) in a southern region of Italy prompted the investigation of a community-wide outbreak of Shiga toxin 2-producing Escherichia coli (STEC) O26:H11 infections. Case finding was based on testing patients with HUS or bloody diarrhoea for STEC infection by microbiological and serological methods. A case-control study was conducted to identify the source of the outbreak. STEC O26 infection was identified in 20 children (median age 17 months) with HUS, two of whom reported severe neurological sequelae. No cases in adults were detected. Molecular typing showed that two distinct STEC O26:H11 strains were involved. The case-control study showed an association between STEC O26 infection and consumption of dairy products from two local plants, but not with specific ready-to-eat products. E.coli O26:H11 strains lacking the stx genes were isolated from bulk milk and curd samples, but their PFGE profiles did not match those of the outbreak isolates. This outbreak supports the view that infections with Stx2-producing E. coli O26 in children have a high probability of progressing to HUS and represent an emerging public health problem in Europe