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Aguilar R, Cruz A, Jiménez A, Almuedo A, Saumell CR, Lopez MG, Gasch O, Falcó G, Jiménez-Lozano A, Martínez-Perez A, Sanchez-Collado C, Tedesco A, López MC, Pinazo MJ, Leonel T, Bisoffi Z, Färnert A, Dobaño C, Requena-Méndez A. Evaluation of the accuracy of a multi-infection screening test based on a multiplex immunoassay targeting imported diseases common in migrant populations. Travel Med Infect Dis 2024; 57:102681. [PMID: 38141899 DOI: 10.1016/j.tmaid.2023.102681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 12/08/2023] [Accepted: 12/15/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND We aimed to evaluate the performance of a novel multiplex serological assay, able to simultaneously detect IgG of six infections, as a screening tool for imported diseases in migrants. METHODS Six panels of 40 (n = 240) anonymized serum samples with confirmed infections were used as positive controls to assess the multiplex assay's sensitivity. One panel of 40 sera from non-infected subjects was used to estimate the seropositivity cutoffs, and 32 non-infected sera were used as negative controls to estimate each serology's sensitivity and specificity. The multi-infection screening test was validated in a prospective cohort of 48 migrants from endemic areas. The sensitivity of the Luminex assay was calculated as the proportion of positive results over all positive samples identified by reference tests. The specificity was calculated using 32 negative samples. Uncertainty was quantified with 95 % confidence intervals using receiver operating characteristic analyses. RESULTS The sensitivity/specificity were 100 %/100 % for HIV (gp41 antigen), 97.5 %/100 % for Hepatitis B virus (HBV-core antigen), 100 %/100 % for Hepatitis C virus (HCV-core antigen), 92.5 %/90.6 % for strongyloidiasis [31-kDa recombinant antigen (NIE)], 97.5 %/100 % for schistosomiasis (combined serpin Schistosoma mansoni and S.haematobium antigens) and 95 %/90.6 % for Chagas disease [combined Trypanosoma cruzi kinetoplastid membrane protein-11 (KMP11) and paraflagellar rod proteins 2 (PFR2) antigens]. In the migrant cohort, antibody response to the combination of the T.cruzi antigens correctly identified 100 % individuals, whereas HBV-core antigen correctly identified 91.7 % and Strongyloides-NIE antigen 86.4 %. CONCLUSIONS We developed a new, robust and accurate 8-plex Luminex assay that could facilitate the implementation of screening programmes targeting migrant populations.
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Affiliation(s)
- Ruth Aguilar
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic-Universitat de Barcelona, Carrer Roselló 132, 08036, Barcelona, Spain
| | - Angeline Cruz
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic-Universitat de Barcelona, Carrer Roselló 132, 08036, Barcelona, Spain
| | - Alfons Jiménez
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic-Universitat de Barcelona, Carrer Roselló 132, 08036, Barcelona, Spain; Biomedical Research Networking Center for Epidemiology and Public Health (CIBERESP), Avenida Monforte de Lemos 3-5, 28029, Madrid, Spain
| | - Alex Almuedo
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic-Universitat de Barcelona, Carrer Roselló 132, 08036, Barcelona, Spain
| | - Carme Roca Saumell
- Centre d'Atenció Primaria El Clot, Institut Català de la Salut (ICS), Carrer Concilio de Trento 25, 08018, Barcelona, Spain; Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Carrer Casanova, 143, 08036, Barcelona, Spain
| | - Marina Gigante Lopez
- Centre d'Atenció Primaria Center Numància, Institut Català de la Salut (ICS), Carrer Numància 23, 08029, Barcelona, Spain
| | - Oriol Gasch
- Infectious Diseases Department, Hospital Universitari Parc Taulí. Institut d'Investigació i Innovació Parc Taulí. Universitat Autònoma de Barcelona, Parc Taulí, 1, 08208, Sabadell-Barcelona, Spain
| | - Gemma Falcó
- Centre d'Atenció Primaria Sant Miquel, Institut Català de la Salut (ICS), Carrer Francesc Macià i Llussà, 154, 08401, Granollers-Barcelona, Spain
| | - Ana Jiménez-Lozano
- Centre d'Atenció Primaria Adrià 5A Marc Aureli, Institut Català de la Salut (ICS), Carrer Vallmajor, 34, 08021, Barcelona, Spain
| | - Angela Martínez-Perez
- Centre d'Atenció Primaria Casanova. Consorci d'Atenció Primària de Salut de l'Eixample (CAPSBE) Casanova. Carrer Rosselló 161, 08036, Barcelona, Spain
| | - Consol Sanchez-Collado
- Centre d'Atenció Primaria Torelló, Institut Català de la Salut (ICS), Avenida Pompeu Fabra, 8, 08570, Torelló-Barcelona, Spain
| | - Andrea Tedesco
- Department of Infectious Tropical diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Via Sempreboni 5, 37024, Negrar di Valpolicella, Italy
| | - Manuel Carlos López
- Spanish National Research Council (IPBLN-CSIC), Avenida del Conocimiento 17, Parque Tecnológico de Ciencias de la Salud, 18016, Granada, Spain
| | - María Jesús Pinazo
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic-Universitat de Barcelona, Carrer Roselló 132, 08036, Barcelona, Spain; Biomedical Research Networking Center (CIBER) of Infectious Diseases, Carlos III Health Institute (CIBERINFEC, ISCIII), Carrer Melchor Fernández Almagro, 3, 28029, Madrid, Spain; Drugs for Neglected Diseases Iniciative (DNDi), Switzerland
| | - Thais Leonel
- Liver Unit, Hospital Clínic, University of Barcelona, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Biomedical Research Networking Center of Hepatic and Digestive Diseases (CIBEREHD), Carrer Villarroel, 170, 08036, Barcelona, Spain
| | - Zeno Bisoffi
- Department of Infectious Tropical diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Via Sempreboni 5, 37024, Negrar di Valpolicella, Italy
| | - Anna Färnert
- Department of Medicine Solna, Karolinska Institutet, Solnavägen 1, 17177, Solna-Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Solnavägen 1, 17177, Solna-Stockholm, Sweden
| | - Carlota Dobaño
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic-Universitat de Barcelona, Carrer Roselló 132, 08036, Barcelona, Spain; Biomedical Research Networking Center (CIBER) of Infectious Diseases, Carlos III Health Institute (CIBERINFEC, ISCIII), Carrer Melchor Fernández Almagro, 3, 28029, Madrid, Spain
| | - Ana Requena-Méndez
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic-Universitat de Barcelona, Carrer Roselló 132, 08036, Barcelona, Spain; Biomedical Research Networking Center (CIBER) of Infectious Diseases, Carlos III Health Institute (CIBERINFEC, ISCIII), Carrer Melchor Fernández Almagro, 3, 28029, Madrid, Spain; Department of Medicine Solna, Karolinska Institutet, Solnavägen 1, 17177, Solna-Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Solnavägen 1, 17177, Solna-Stockholm, Sweden.
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Requena-Méndez A, Roos E, van der Werff SD, Wyss K, Davidsson L, Naucler P, Färnert A, Asgeirsson H. Clinical presentation and diagnosis of imported strongyloidiasis at a tertiary hospital, Stockholm, Sweden. Travel Med Infect Dis 2023; 56:102666. [PMID: 37977232 DOI: 10.1016/j.tmaid.2023.102666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/18/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Since Strongyloides can persist in its host for decades, and cause life threatening infections data on prevalence, the burden and risk factors for infection is crucial in migrant populations. METHODS In this observational retrospective cohort study, we describe the epidemiological, clinical, and microbiological characteristics of imported strongyloidiasis diagnosed at the Karolinska University Hospital, Stockholm, Sweden, during 2010-2021. RESULTS We identified 98 individuals with strongyloidiasis, 89 (90.8%) born in endemic and 9 (9.2%) in non-endemic countries. Sub-Saharan Africa was the most common origin among the group born in endemic countries (62, 69.7%), (p < 0.005). There were 22 individuals with an underlying immunosuppressive condition. Gastrointestinal symptoms (53/98, 54.1%) were the symptoms most frequently described, and were more frequent in adults (57.0%) vs children (0%) (p = 0.013). Eosinophilia was detected in 74 (75.5%), being more frequent in the endemic-borne group (79.8% vs 33.3%, p = 0.002). Eight persons developed complications of strongyloidiasis because of either hyperinfection or disseminated disease. No people living with HIV with CD4 <500/mm3 (n = 6) developed severe strongyloidiasis. CONCLUSION A limited number of strongyloidiasis cases was identified, with few complicated cases in immunosuppressed patients. Further studies focusing on identifying and exploring the risk of complicated strongyloidiasis in immunosuppressed patients are needed.
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Affiliation(s)
- Ana Requena-Méndez
- Division of Infectious Diseases, Department of Medicine Solna Karolinska Institutet, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden; Barcelona Institute for Global Health, (ISGlobal, University of Barcelona), Spain; CIBERINFEC, ISCIII - CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Madrid, Spain.
| | - Emilia Roos
- Division of Infectious Diseases, Department of Medicine Solna Karolinska Institutet, Stockholm, Sweden
| | - Suzanne D van der Werff
- Division of Infectious Diseases, Department of Medicine Solna Karolinska Institutet, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Katja Wyss
- Division of Infectious Diseases, Department of Medicine Solna Karolinska Institutet, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | | | - Pontus Naucler
- Division of Infectious Diseases, Department of Medicine Solna Karolinska Institutet, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Färnert
- Division of Infectious Diseases, Department of Medicine Solna Karolinska Institutet, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Hilmir Asgeirsson
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden; Division of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
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Chen YA, Hsu HM, Wang H, Lan HH, Huang SH, Hung CC, Su KE. Epidemiology, clinical features, and outcomes of strongyloidiasis in Taiwan from 1988 to 2020: A case series and literature review. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2023; 56:172-181. [PMID: 35922269 DOI: 10.1016/j.jmii.2022.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 05/14/2022] [Accepted: 06/29/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVES We described a case of Strongyloides hyperinfection syndrome, reported a case series, and reviewed published cases of strongyloidiasis in Taiwan. METHODS Confirmed cases of strongyloidiasis at the National Taiwan University Hospital (NTUH) and NTUH Hsin-Chu Branch from 1988 to 2020 were identified in the medical record database. Literature search was carried out through Pubmed, Google Scholar, and Index to Taiwan Periodical Literature System to identify published cases of strongyloidiasis in Taiwan from 1979 to 2020. Data pertaining to the demographics, underlying medical conditions, clinical manifestations, laboratory findings, and outcomes were extracted. RESULTS A total of 117 cases of strongyloidiasis were identified, including 20 previously unpublished cases from the two hospitals and 97 published cases in the literature. Overall, 85 (73%) were male and the mean age was 64 years (range, 6-95 years). Classical symptoms such as diarrhea, cough, and skin rash were only observed in 43%, 37%, and 18% of the patients, respectively, whereas eosinophilia at presentation was only found in 48%. Strongyloides hyperinfection syndrome and disseminated strongyloidiasis were identified in 41 (35%) and 4 (3%) patients, respectively. Four (3%) patients had concurrent meningitis. In univariable analysis, being older and having pre-existing chronic obstructive pulmonary disease or asthma were associated with hyperinfection or dissemination (p = 0.024 and 0.003, respectively). The mortality rate was 43% among those with hyperinfection or disseminated infection. CONCLUSIONS Strongyloidiasis can cause serious complications and mortality. Efforts to diagnose strongyloidiasis early are urgently needed to improve the outcome of patients with strongyloidiasis in Taiwan.
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Affiliation(s)
- Yung-An Chen
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan
| | - Hong-Ming Hsu
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsuan Wang
- Department of Pathology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Hung-Hsue Lan
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Sung-Hsi Huang
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan.
| | - Chien-Ching Hung
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan; Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kua-Eyre Su
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan
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Wikman-Jorgensen PE, Llenas-Garcia J, Shedrawy J, Gascon J, Muñoz J, Bisoffi Z, Requena-Mendez A. Cost-effectiveness of different strategies for screening and treatment of Strongyloides stercoralis in migrants from endemic countries to the European Union. BMJ Glob Health 2021; 5:bmjgh-2020-002321. [PMID: 32461226 PMCID: PMC7254101 DOI: 10.1136/bmjgh-2020-002321] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The best strategy for controlling morbidity due to imported strongyloidiasis in migrants is unclear. We evaluate the cost-effectiveness of six possible interventions. METHODS We developed a stochastic Markov chain model. The target population was adult migrants from endemic countries to the European Union; the time horizon, a lifetime and the perspective, that of the health system. Average and incremental cost-effectiveness ratios (ACER and ICER) were calculated as 2016 EUR/life-year gained (LYG). Health interventions compared were: base case (no programme), primary care-based presumptive treatment (PCPresTr), primary care-based serological screening and treatment (PCSerTr), hospital-based presumptive treatment (HospPresTr), hospital-based serological screening and treatment (HospSerTr), hospital-based presumptive treatment of immunosuppressed (HospPresTrim) and hospital-based serological screening and treatment of the immunosuppressed (HospSerTrim). The willingness to pay threshold (WTP) was €32 126.95/LYG. RESULTS The base case model yielded a loss of 2 486 708.24 life-years and cost EUR 3 238 393. Other interventions showed the following: PCPresTr: 2 488 095.47 life-years (Δ1 387.23LYG), cost: EUR 8 194 563; ACER: EUR 3573/LYG; PCSerTr: 2 488 085.8 life-years (Δ1377.57LYG), cost: EUR 207 679 077, ACER: EUR 148 407/LYG; HospPresTr: 2 488 046.17 life-years (Δ1337.92LYG), cost: EUR 14 559 575; ACER: EUR 8462/LYG; HospSerTr: 2 488 024.33 life-years (Δ1316.08LYG); cost: EUR 207 734 073; ACER: EUR 155 382/LYG; HospPresTrim: 2 488 093.93 life-years, cost: EUR 1 105 483; ACER: EUR -1539/LYG (cost savings); HospSerTrim: 2 488 073.8 life-years (Δ1365.55LYG), cost: EUR 4 274 239; ACER: EUR 759/LYG. One-way and probabilistic sensitivity analyses were undertaken; HospPresTrim remained below WTP for all parameters' ranges and iterations. CONCLUSION Presumptively treating all immunosuppressed migrants from areas with endemic Strongyloides would generate cost savings to the health system.
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Affiliation(s)
- Philip Erick Wikman-Jorgensen
- Medicina Interna, Hospital Universitari San Juan de Alicante, San Juan de Alicante, Alicante, Spain .,Foundation for the Promotion of the Research in Healthcare and Biomedicine, Valencia, Spain
| | - Jara Llenas-Garcia
- Medicina Interna/Enfermedades Infecciosas, Hospital Vega Baja-FISABIO, San Bartolome-Orihuela, Alicante, Spain.,Clinical Medicine, Universidad Miguel Hernandez de Elche Facultad de Medicina, Sant Joan D'Alacant, Spain
| | - Jad Shedrawy
- Public Health, Karolinska Institutet, Stockholm, Stockholm County, Sweden
| | | | | | - Zeno Bisoffi
- Infectious Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Veneto, Italy.,Diagnostics and Public Health, University of Verona, Verona, Veneto, Italy
| | - Ana Requena-Mendez
- Instituto de Salud Global Barcelona, Barcelona, Spain.,Division of Infectious Diseases, Department of Medicine-Solna, Karolinska Institutet, Stockholm, Sweden
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Lucas Dato A, Pacheco-Tenza MI, Borrajo Brunete E, Martínez López B, García López M, González Cuello I, Gregori Colomé J, Navarro Cots M, Saugar JM, García-Vazquez E, Ruiz-Maciá JA, Llenas-García J. Strongyloidiasis in Southern Alicante (Spain): Comparative Retrospective Study of Autochthonous and Imported Cases. Pathogens 2020; 9:pathogens9080601. [PMID: 32717912 PMCID: PMC7460300 DOI: 10.3390/pathogens9080601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/14/2020] [Accepted: 07/20/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Strongyloidiasis is a parasitic disease with global prevalence. In Spain, autochthonous cases are concentrated in the Mediterranean basin. We aimed to analyze clinical and epidemiological characteristics of Strongyloides stercoralis infection in Vega Baja del Segura (Spain), comparing autochthonous versus imported cases. METHODS Observational retrospective study of all strongyloidiasis cases from January 2009 to January 2019. Cases were diagnosed by stool larvae visualization, positive culture, PCR, Strongyloides serology, and/or compatible histology. RESULTS We included 36 patients (21 men) with a mean age of 60.8 years ±17.6; 15 cases were autochthonous and 21 imported 80.9% from Latin America. Autochthonous cases were associated with older age (mean 71.3 vs. 53.3 years; p = 0.002), male sex (odds ratio (OR) 5.33; 95% confidence interval (CI) 1.15-24.68; p = 0.041), and agricultural activity (OR 13.5; 95% CI 2.4-73.7; p = 0.002). Fourteen were asymptomatic, three autochthonous cases presented with hyperinfection syndrome, and two patients died. There was no difference between autochthonous versus imported origin in eosinophilia at diagnosis (93.3% vs. 75%; p = 0.207), treatment received, or clinical response (85.7% vs. 88.9% cured; p = 1). CONCLUSION In our region, imported strongyloidiasis coexists with autochthonous cases, which are mainly in older male farmers who are diagnosed at more advanced stages. Systematic screening programs are needed.
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Affiliation(s)
- Ana Lucas Dato
- Internal Medicine Department, Hospital Vega Baja, 03314 Orihuela, Spain; (B.M.L.); (M.G.L.); (I.G.C.); (J.G.C.)
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (E.B.B.); (M.N.C.)
- Correspondence: (A.L.D.); (J.L.-G.)
| | - María Isabel Pacheco-Tenza
- Internal Medicine Department, Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain;
| | - Emilio Borrajo Brunete
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (E.B.B.); (M.N.C.)
- Microbiology Department, Hospital Vega Baja, 03314 Orihuela, Spain
| | - Belén Martínez López
- Internal Medicine Department, Hospital Vega Baja, 03314 Orihuela, Spain; (B.M.L.); (M.G.L.); (I.G.C.); (J.G.C.)
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (E.B.B.); (M.N.C.)
| | - María García López
- Internal Medicine Department, Hospital Vega Baja, 03314 Orihuela, Spain; (B.M.L.); (M.G.L.); (I.G.C.); (J.G.C.)
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (E.B.B.); (M.N.C.)
| | - Inmaculada González Cuello
- Internal Medicine Department, Hospital Vega Baja, 03314 Orihuela, Spain; (B.M.L.); (M.G.L.); (I.G.C.); (J.G.C.)
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (E.B.B.); (M.N.C.)
| | - Joan Gregori Colomé
- Internal Medicine Department, Hospital Vega Baja, 03314 Orihuela, Spain; (B.M.L.); (M.G.L.); (I.G.C.); (J.G.C.)
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (E.B.B.); (M.N.C.)
| | - María Navarro Cots
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (E.B.B.); (M.N.C.)
- Microbiology Department, Hospital Vega Baja, 03314 Orihuela, Spain
| | - José María Saugar
- Parasitology Department, Centro Nacional de Microbiología, Instituto Carlos III, 28903 Madrid, Spain;
| | - Elisa García-Vazquez
- Infectious Diseases Unit, Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain;
- Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, 30120 Murcia, Spain
| | - José Antonio Ruiz-Maciá
- Pathological Department, Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain;
| | - Jara Llenas-García
- Internal Medicine Department, Hospital Vega Baja, 03314 Orihuela, Spain; (B.M.L.); (M.G.L.); (I.G.C.); (J.G.C.)
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (E.B.B.); (M.N.C.)
- Clinical Medicine Department, Universidad Miguel Hernández de Elche, 03202 Elche, Spain
- Correspondence: (A.L.D.); (J.L.-G.)
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Strong-LAMP Assay Based on a Strongyloides spp.-Derived Partial Sequence in the 18S rRNA as Potential Biomarker for Strongyloidiasis Diagnosis in Human Urine Samples. DISEASE MARKERS 2020; 2020:5265198. [PMID: 32566039 PMCID: PMC7281818 DOI: 10.1155/2020/5265198] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 04/24/2020] [Indexed: 01/14/2023]
Abstract
Human strongyloidiasis a soil-transmitted infection caused by Strongyloides stercoralis is one of the most neglected amongst the so-called Neglected Tropical Diseases (NTDs). S. stercoralis is a nematode, which is distributed worldwide; it has been estimated that it could affect millions of people, mainly in tropical and subtropical endemic regions. The difficulties of diagnosis lead to infection rates being underreported. Asymptomatic patients have chronic infections that can lead to severe hyperinfection syndrome or disseminated strongyloidiasis in immunocompromised patients. Strongyloidiasis can easily be misdiagnosed because conventional faecal-based techniques lack of sensitivity for the morphological identification of infective larvae in faeces. None of the currently used molecular methods have used urine samples as an alternative to faecal samples for diagnosing strongyloidiasis. This study was thus aimed at comparing, for the first time, the use of a new loop-mediated isothermal amplification (LAMP) molecular assay (Strong-LAMP) to traditional methods on patients' urine samples. Twenty-four urine samples were taken from patients included in a study involving two Spanish hospitals for strongyloidiasis screening using parasitological and serological tests. Strongyloides larvae were found in 11 patients' faecal samples, thereby ascertaining that they had the disease. Other patients had high antibody titres but no larvae were found in their faeces. All urine samples were analysed by PCR and Strong-LAMP assay. No amplification occurred when using PCR. Strong-LAMP led to detecting S. stercoralis DNA in urine samples from patients having previously confirmed strongyloidiasis by parasitological tests and/or a suspicion of being infected by serological ones. The Strong-LAMP assay is a useful molecular tool for research regarding strongyloidiasis in human urine samples. After further validation, the Strong-LAMP assay could also be used for complementary and effective diagnosis of strongyloidiasis in a clinical setting.
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Juthong S, Geater AF, Dekumyoy P, Hortiwakul T, Siripaitoon B, Aiewruengsurat D, Thongbun N. Prevalence and risk factors of strongyloidiasis in patients with systemic lupus erythematosus in Southern Thailand. Lupus 2020; 29:539-546. [PMID: 32183590 DOI: 10.1177/0961203320911091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Strongyloidiasis can be fatal in systemic lupus erythematosus (SLE) patients, but few epidemiological
studies have investigated the burden of this tropical disease among the SLE population. This study aimed to assess the prevalence and associated factors of strongyloidiasis among SLE patients in Southern Thailand. Methods A cross-sectional study was conducted on 180 SLE patients attending the Rheumatology Clinic at
Songklanagarind Hospital. Stool specimens were collected and examined using the direct smear technique and agar plate culture technique. Serum anti-Strongyloides stercoralis IgG was measured by IgG-ELISA. Results The overall prevalence of strongyloidiasis by combined parasitologyl and/or serology was 15.6%. The prevalence of strongyloidiasis by parasitological methods was 2.2%. Positive parasitology and/or serology was associated with male sex and a SLE disease duration of less than two years. Conclusion Strongyloidiasis is highly prevalent among the SLE population. A combination of serological and parasitological methods increases the rate of diagnosis of strongyloidiasis in SLE patients.
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Affiliation(s)
- Siriporn Juthong
- Allergy and Rheumatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Alan F Geater
- Epidemiology Unit, Faculty of Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Paron Dekumyoy
- Department of Helminthology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Thanaporn Hortiwakul
- Infectious Disease Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Boonjing Siripaitoon
- Allergy and Rheumatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Duangkamol Aiewruengsurat
- Allergy and Rheumatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Nannapas Thongbun
- Division of Clinical Microbiology, Department of Pathology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
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Rathod P, Sharma A, Mishra B, Thakur A, Loomba P, Bajaj A, Das M. Intestinal strongyloidiasis in a patient of myasthenia gravis and diabetes mellitus. SAUDI JOURNAL FOR HEALTH SCIENCES 2020. [DOI: 10.4103/sjhs.sjhs_225_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Prevalence and Associated Risk Factors of Strongyloides sp. Infection in Diabetic Patients in the Central Part of Mazandaran, Northern Iran. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2019. [DOI: 10.5812/archcid.86569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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10
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Prevalence and risk factors of Strongyloides stercoralis infection among Orang Asli schoolchildren: new insights into the epidemiology, transmission and diagnosis of strongyloidiasis in Malaysia. Parasitology 2019; 146:1602-1614. [PMID: 31303180 DOI: 10.1017/s0031182019000945] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
This cross-sectional study aimed to determine the prevalence and risk factors of S. stercoralis infection among 1142 Orang Asli primary schoolchildren in six different states of Peninsular Malaysia. Fecal samples were examined using direct smear, formalin-ether sedimentation (FES), agar plate culture (APC) and PCR techniques. Overall, 15.8% of the children were found to be infected with S. stercoralis. The prevalence was 0.2, 1.3, 15.2 and 13.7% by direct smear, FES, APC and PCR, respectively. Multivariate analysis showed that an age of >10 years, being male, belonging to a Proto-Malay tribe, belonging to the Senoi tribe, indiscriminate defecation, using an unimproved water source for drinking water and not wearing shoes when outside were the significant risk factors of infection among these children. In conclusion, we provide new evidence on the occurrence of S. stercoralis in Malaysia to show that there is a relatively high prevalence of infection among Orang Asli schoolchildren. Therefore, the use of specific methods for detecting S. stercoralis should be considered when screening these children for intestinal parasites. Moreover, prevention and control measures specific to S. stercoralis should be integrated into the intestinal parasitic infections control programme in Malaysia.
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Javanian M, Gorgani-Firouzjaee T, Kalantrai N. Comparison of ELISA and PCR of the 18S rRNA gene for detection of human strongyloidiasis using serum sample. Infect Dis (Lond) 2019; 51:360-367. [PMID: 30773081 DOI: 10.1080/23744235.2019.1575978] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Strongyloides stercoralis infection is a neglected tropical disease with global distribution which is fatal in immunosuppressed patients. This study aimed to determine the prevalence of strongyloidiasis in immunocompromised individuals and cases with infectious diseases, as well as comparing ELISA and conventional PCR with coprological examination, in the central parts of Mazandaran province, northern Iran. METHODS A single serum and a fresh stool samples were obtained from 272 and 220 patients, respectively. Serum was tested by ELISA and PCR of the 18S rRNA gene, and stool samples were examined with various parasitological methods. The optimum point for ELISA reaction and cut-off points were recognized by receiver operating characteristic curves (ROC). RESULTS Out of 220 stool specimens, 14(6.3%) cases were positive for S. stercoralis larvae. The overall seroprevalence rate was 27.9% (76/272). The seroprevalence rate was 25.2% and 30.1% in immunocompromised group and patients with infection, respectively. Based on the ROC curve of ELISA compared with microscopy, the optimum cut-off point was 12.74 with 79% sensitivity and 76% specificity. The optimum cut-off point was 10.42 with 69% sensitivity and specificity using ROC curve of ELISA compared with PCR. CONCLUSIONS This study seroprevalence rate for Strongyloides infection in the studied group. It also observed that the ELISA technique and the PCR used here have 100 demonstrated a high % sensitivity and acceptable specificity compared with coprological examination. It seems that the ELISA technique is a good screening assay in ruling out strongyloidiasis in such patients.
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Affiliation(s)
- Mostafa Javanian
- a Infectious Diseases and Tropical Medicine Research Center , Babol University of Medical Science , Babol , Iran
| | - Tahmineh Gorgani-Firouzjaee
- b Department of Parasitology and Mycology, School of Medicine , Babol University of Medical Science , Babol , Iran
| | - Narges Kalantrai
- c Cellular and Molecular Biology Research Center, Health Research Institute , Babol University of Medical Sciences , Babol , Iran
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Nunes JB, Emídio TCDO, Marques MJ, Caldas IS, Souza RLM, Kanamura HY, Costa-Cruz JM. Seroepidemiological aspects of human infection by Strongyloides stercoralis in Alfenas, southern Minas Gerais, Brazil. Rev Soc Bras Med Trop 2018; 51:855-859. [PMID: 30517543 DOI: 10.1590/0037-8682-0090-2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 05/15/2018] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION In most Strongyloides stercoralis infected individuals, nematoidosis occurs asymptomatically, but in immunocompromised patients, it can cause hyperinfection. Serological techniques seem to be a good alternative for detecting this parasite. METHODS The frequency of seropositivity for strongyloidiasis in Alfenas, MG, was estimated using the enzyme linked immunosorbent assay on blood samples, between May and August of 2015. RESULTS Out of 258 samples tested, 53.9% were positive, and the frequency of seropositive individuals was higher in the peripheral districts of the municipality. CONCLUSIONS The results indicate high seropositivity rates for strongyloidiasis among the residents of Alfenas city.
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Affiliation(s)
- Juliana Barbosa Nunes
- Departamento de Patologia e Parasitologia, Instituto de Ciências Biomédicas, Universidade Federal de Alfenas, Alfenas, MG, Brasil
| | | | - Marcos José Marques
- Departamento de Patologia e Parasitologia, Instituto de Ciências Biomédicas, Universidade Federal de Alfenas, Alfenas, MG, Brasil
| | - Ivo Santana Caldas
- Departamento de Patologia e Parasitologia, Instituto de Ciências Biomédicas, Universidade Federal de Alfenas, Alfenas, MG, Brasil
| | - Raquel Lopes Martins Souza
- Departamento de Patologia e Parasitologia, Instituto de Ciências Biomédicas, Universidade Federal de Alfenas, Alfenas, MG, Brasil
| | - Herminia Yohko Kanamura
- Departamento de Patologia e Parasitologia, Instituto de Ciências Biomédicas, Universidade Federal de Alfenas, Alfenas, MG, Brasil
| | - Julia Maria Costa-Cruz
- Laboratório de Diagnóstico de Parasitoses, Departamento de Parasitologia, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, MG, Brasil
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Buonfrate D, Requena-Mendez A, Angheben A, Cinquini M, Cruciani M, Fittipaldo A, Giorli G, Gobbi F, Piubelli C, Bisoffi Z. Accuracy of molecular biology techniques for the diagnosis of Strongyloides stercoralis infection-A systematic review and meta-analysis. PLoS Negl Trop Dis 2018; 12:e0006229. [PMID: 29425193 PMCID: PMC5823464 DOI: 10.1371/journal.pntd.0006229] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 02/22/2018] [Accepted: 01/10/2018] [Indexed: 12/11/2022] Open
Abstract
Background Strongyloides stercoralis infection is a neglected tropical disease which can lead to severe symptoms and even death in immunosuppressed people. Unfortunately, its diagnosis is hampered by the lack of a gold standard, as the sensitivity of traditional parasitological tests (including microscopic examination of stool samples and coproculture) is low. Hence, alternative diagnostic methods, such as molecular biology techniques (mostly polymerase chain reaction, PCR) have been implemented. However, there are discrepancies in the reported accuracy of PCR. Methodology A systematic review with meta-analysis was conducted in order to evaluate the accuracy of PCR for the diagnosis of S. stercoralis infection. The protocol was registered with PROSPERO International Prospective Register of Systematic Reviews (record: CRD42016054298). Fourteen studies, 12 of which evaluating real-time PCR, were included in the analysis. The specificity of the techniques resulted high (ranging from 93 to 95%, according to the reference test(s) used). When all molecular techniques were compared to parasitological methods, the sensitivity of PCR was assessed at 71.8% (95% CI 52.2–85.5), that decreased to 61.8% (95% CI 42.0–78.4) when serology was added among the reference tests. Similarly, sensitivity of real-time PCR resulted 64.4% (95% CI 46.2–77.7) when compared to parasitological methods only, 56.5% (95% CI 39.2–72.4) including serology. Conclusions PCR might not be suitable for screening purpose, whereas it might have a role as a confirmatory test. Strongyloides stercoralis is a worm that can potentially kill affected immunosuppressed individuals. The parasite is not easily detected with stool microscopy, hence novel tests have been implemented, such as polymerase chain reaction (PCR), that can detect the DNA of the parasite. This work aims at evaluating the performance of PCR for the diagnosis of S. stercoralis through a revision of diagnostic studies available in literature. According to the results of this work, PCR for S. stercoralis still misses a relevant proportion of infected people, while a positive result confirms the presence of the infection.
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Affiliation(s)
- Dora Buonfrate
- Centre for Tropical Diseases, Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy
| | - Ana Requena-Mendez
- Barcelona Institute for Global Health, ISGlobal-CRESIB, Universitat de Barcelona, Spain
| | - Andrea Angheben
- Centre for Tropical Diseases, Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy
| | - Michela Cinquini
- IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Mario Cruciani
- Centre of Community Medicine and Infectious Diseases Service, ULSS 9 Scaligera, Verona, Italy
| | | | - Giovanni Giorli
- Centre for Tropical Diseases, Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy
| | - Federico Gobbi
- Centre for Tropical Diseases, Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy
| | - Chiara Piubelli
- Centre for Tropical Diseases, Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy
| | - Zeno Bisoffi
- Centre for Tropical Diseases, Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy
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Requena-Méndez A, Buonfrate D, Gomez-Junyent J, Zammarchi L, Bisoffi Z, Muñoz J. Evidence-Based Guidelines for Screening and Management of Strongyloidiasis in Non-Endemic Countries. Am J Trop Med Hyg 2017; 97:645-652. [PMID: 28749768 DOI: 10.4269/ajtmh.16-0923] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Strongyloidiasis is an intestinal parasitic infection becoming increasingly important outside endemic areas, not only because of the high prevalence found in migrant populations, but also because immunosuppressed patients may suffer a potentially fatal disseminated disease. The aim of these guidelines is to provide evidence-based guidance for screening and treatment of strongyloidiasis in non-endemic areas. A panel of experts focused on three main clinical questions (who should be screened and how, how to treat), and reviewed pertinent literature available in international databases of medical literature and in documents released by relevant organizations/societies. A consensus of the experts' opinion was sought when specific issues were not covered by evidence. In particular, six systematic reviews were retrieved and constituted the main support for this work. The evidence and consensus gathered led to recommendations addressing various aspects of the main questions. Grading of evidence and strength of recommendation were attributed to assess the quality of supporting evidence. The screening of individuals at risk of the infection should be performed before they develop any clinical complication. Moreover, in immunosuppressed patients, the screening should be mandatory. The screening is based on a simple and widely accessible technology and there is now a universally accepted treatment with a high efficacy rate. Therefore, the screening could be implemented as part of a screening program for migrants although further cost-effectiveness studies are required to better evaluate this strategy from a public health point of view.
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Affiliation(s)
- Ana Requena-Méndez
- Barcelona Institute for Global Health (ISGlobal-CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
| | - Dora Buonfrate
- Centre for Tropical Diseases, Sacro Cuore Hospital, Negrar, Verona, Italy
| | - Joan Gomez-Junyent
- Barcelona Institute for Global Health (ISGlobal-CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
| | - Lorenzo Zammarchi
- Clinica Malattie Infettive, Dipartimento di Medicina Sperimentale e Clinica, Universita Degli Studi di Firenze, Florence, Italy
| | - Zeno Bisoffi
- Centre for Tropical Diseases, Sacro Cuore Hospital, Negrar, Verona, Italy
| | - José Muñoz
- Barcelona Institute for Global Health (ISGlobal-CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
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Buonfrate D, Baldissera M, Abrescia F, Bassetti M, Caramaschi G, Giobbia M, Mascarello M, Rodari P, Scattolo N, Napoletano G, Bisoffi Z. Epidemiology of Strongyloides stercoralis in northern Italy: results of a multicentre case-control study, February 2013 to July 2014. ACTA ACUST UNITED AC 2017; 21:30310. [PMID: 27525375 PMCID: PMC4998510 DOI: 10.2807/1560-7917.es.2016.21.31.30310] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 02/18/2016] [Indexed: 12/04/2022]
Abstract
Strongyloides stercoralis is a soil-transmitted helminth widely diffused in tropical and subtropical regions of the world. Autochthonous cases have been also diagnosed sporadically in areas of temperate climate. We aimed at defining the epidemiology of strongyloidiasis in immigrants and Italians living in three northern Italian Regions. Screening for S. stercoralis infection was done with serology, confirmation tests were a second serological method or stool agar culture. A case–control approach was adopted and patients with a peripheral eosinophil count ≥ 500/mcL were classified as cases. Of 2,701 individuals enrolled here 1,351 were cases and 1,350 controls; 86% were Italians, 48% women. Italians testing positive were in 8% (97/1,137) cases and 1% (13/1,178) controls (adjusted odds ratio (aOR) 8.2; 95% confidence interval (CI): 4.5–14.8), while positive immigrants were in 17% (36/214) cases and in 2% (3/172) controls (aOR 9.6; 95% CI: 2.9–32.4). Factors associated with a higher risk of infection for all study participants were eosinophilia (p < 0.001) and immigration (p = 0.001). Overall, strongyloidiasis was nine-times more frequent in individuals with eosinophilia than in those with normal eosinophil count.
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Affiliation(s)
- Dora Buonfrate
- Centre for Tropical Diseases, Sacro Cuore Hospital, Negrar (Verona), Italy
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Buonfrate D, Formenti F, Perandin F, Bisoffi Z. Novel approaches to the diagnosis of Strongyloides stercoralis infection. Clin Microbiol Infect 2015; 21:543-52. [PMID: 25887711 DOI: 10.1016/j.cmi.2015.04.001] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 03/31/2015] [Accepted: 04/01/2015] [Indexed: 12/23/2022]
Abstract
Strongyloides stercoralis differs from the other soil-transmitted helminths because it puts infected subjects at risk of a fatal syndrome (in cases of immunosuppression for medical conditions, immunosuppressant therapies, or both). Chronic strongyloidiasis is often a non-severe condition, or is sometimes even asymptomatic, but diagnosis and effective therapy are essential in order to eradicate the infection and the life-long risk involved. Therefore, diagnostic methods need to be highly sensitive. Stool microscopy and the Kato-Katz technique are commonly used in prevalence studies, but they are inadequate for S. stercoralis detection. This is probably the main reason why the global prevalence has long been underestimated. Concentration methods, the Baermann technique and Koga agar plate culture have better, but still unsatisfactory, sensitivity. Serological tests have demonstrated higher sensitivity; although some authors have concerns about their specificity, it is possible to define cut-off values over which infection is almost certain. In particular, the luciferase immunoprecipitation system technique combined with a recombinant antigen (NIE) demonstrated a specificity of almost 100%. ELISA coproantigen detection has also shown promising results, but still needs full evaluation. Molecular diagnostic methods are currently available in a few referral centres as in-house techniques. In this review, on the basis of the performance of the different diagnostic methods, we outline diagnostic strategies that could be proposed for different purposes, such as: prevalence studies in endemic areas; individual diagnosis and screening; and monitoring of cure in clinical care and clinical trials.
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Affiliation(s)
- D Buonfrate
- Centre for Tropical Diseases, Sacro Cuore Hospital, Negrar, Verona, Italy
| | - F Formenti
- Centre for Tropical Diseases, Sacro Cuore Hospital, Negrar, Verona, Italy
| | - F Perandin
- Centre for Tropical Diseases, Sacro Cuore Hospital, Negrar, Verona, Italy
| | - Z Bisoffi
- Centre for Tropical Diseases, Sacro Cuore Hospital, Negrar, Verona, Italy.
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