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Yuan Y, Wang X, Zhou Y, Zhou C, Li S. Prevalence and risk factors of latent tuberculosis infection among college students: a systematic review and meta-analysis. Public Health 2022; 213:135-146. [PMID: 36410119 DOI: 10.1016/j.puhe.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/11/2022] [Accepted: 10/04/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVES College students are at increased risk of tuberculosis (TB), which increases their likelihood of developing latent tuberculosis infections (LTBI). This study aimed to estimate the pooled prevalence of LTBI and identify its risk factors. STUDY DESIGN Systematic review and meta-analysis. METHODS We searched PubMed, Embase, Scopus, Web of Science, CNKI, Wanfang and CBM databases (10 March 2022) for studies published in any language. The pooled prevalence of LTBI was estimated using random effects methods. Factors associated with LTBI were evaluated by determining standardised mean difference (SMD) with 95% confidence interval (CI). All analyses were performed using the Stata 15.1. RESULTS A total of 50 studies from 18 countries were included, with 44 tuberculin skin test (n = 623,732) and 19 interferon gamma release assay (n = 38,266) estimates. The prevalence of a positive tuberculin skin test was 20% (95% CI: 17-23%), and the prevalence of a positive interferon gamma release assay was 9% (95% CI: 7%-11%) among college students. Older age (SMD: 1.67, 95% CI: 1.31-2.13), no Bacillus Calmette-Guérin vaccination/scar (SMD: 1.51, 95% CI: 1.06-2.16), contact with TB cases (SMD: 1.34, 95% CI: 1.11-1.62), clinical training (SMD: 1.93, 95% CI: 1.65-2.26) and overweight/obesity (SMD: 1.17, 95% CI: 1.06-1.30) were associated with a higher prevalence of LTBI. Sex was not associated with LTBI prevalence. CONCLUSION College students have an increased risk of LTBI, although it varies by geographical area. This meta-analysis provides evidence of risk factors for LTBI in college students. Infection control measures should be conducted for college students with LTBI.
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Affiliation(s)
- Yemin Yuan
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China; Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China
| | - Xiyuan Wang
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China
| | - Yanxin Zhou
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China
| | - Chengchao Zhou
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China; NHC Key Laboratory of Health Economics and Policy Research, Shandong University, Jinan, 250012, China.
| | - Shixue Li
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China; NHC Key Laboratory of Health Economics and Policy Research, Shandong University, Jinan, 250012, China.
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da Silva EH, Lima E, dos Santos TR, Padoveze MC. Prevalence and incidence of tuberculosis in health workers: A systematic review of the literature. Am J Infect Control 2022; 50:820-827. [PMID: 35108578 DOI: 10.1016/j.ajic.2022.01.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 01/12/2022] [Accepted: 01/13/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To identify the prevalence and incidence of tuberculosis in health workers. METHOD Systematic literature review, according to the protocol of the Joanna Briggs Institute and report following PRISMA guidelines. Primary studies containing data on the incidence or prevalence of active or latent tuberculosis infection in health workers were considered. RESULTS 2,310 potentially relevant studies were identified in ten databases, of which 24 were included. The prevalence of latent tuberculosis varied between 0.1% and 62.0%, and the annual incidence rate varied from 1.4% to 11.4%. A meta-analysis combining data from the studies identified the prevalence as 28% (95% CI 21-36). Occupational risk factors are related to direct contact with patients having active tuberculosis, and more years of professional experience. CONCLUSIONS Evidences show that tuberculosis is an important occupational problem in health care; however, there are still gaps in information about the epidemiology of tuberculosis in health workers, mainly related to the risk factors.
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Dinkar PK, Kumar S, Kumar S, Verma SK, Kumar S, Kamal A, Chaudhary E. To study the prevalence of latent tuberculosis infection among medical students. INDIAN JOURNAL OF COMMUNITY HEALTH 2022. [DOI: 10.47203/ijch.2022.v34i02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background: Risk of developing latent tuberculosis infection increases in medical students with their higher exposure to TB care facilities. Objective: To study the prevalence of latent TB infection among students attending professional degrees MBBS, BDS, MD, MS, MDS at King George’s Medical University, India. Methods: This study was carried out with Tuberculin skin testing among students and active TB cases were excluded. A standard dose of 0.1?mL of purified protein derivative was slowly injected intra dermally into non-dominant forearm. After 48-72 hours, the reaction was estimated by measuring the transverse diameter of the induration. Results: Total 561 students had given consent to get enrolled. Prevalence of latent tuberculosis infection was significant with period of clinical exposure (p-value < 0.05), average size of induration (p-value < 0.001), and history of prior Tuberculin Skin Test (p-value < 0.001). However it was not significant with the age (p-value > 0.05), gender (p-value > 0.05), and history of contact with active cases of TB (p-value > 0.05). Conclusion: The prevalence of latent tuberculosis infection is higher in post graduate students followed by interns and final year students due to more exposure to patients in wards and clinics at King George’s Medical University, India.
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Malsam R, Nienhaus A. Occupational Infections among Dental Health Workers in Germany-14-Year Time Trends. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:10128. [PMID: 34639430 PMCID: PMC8508029 DOI: 10.3390/ijerph181910128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 12/25/2022]
Abstract
Dental health workers (DHW) are at increased risk of acquiring occupational infections. Due to various protective measures, it can be assumed that infections have decreased over the past 14 years. Secondary data from a German accident insurance company was analyzed in terms of reported and confirmed occupational diseases (OD) in DHW from 2006 to 2019. A total of 271 claims were reported, of which 112 were confirmed as OD, representing an average of eight per year. However, the number of claims and confirmed ODs has decreased by 65.6% and 85.7%, respectively. The decrease was most evident for hepatitis B (HBV) and C (HCV) infections, while tuberculosis (TB) infections were stable. A total of 44 HCV, 33 HBV, 6 TB and 24 latent TB infections were confirmed as ODs. For DHW, 0.05, and for hospital workers, 0.48 claims per 1000 full-time equivalents (FTE) were registered in 2019. In a separate documentation system, between March 2020 and February 2021, 155 COVID-19 claims were registered, and 47 cases were confirmed as ODs. For DHW, 0.7, and for hospital workers, 47.3 COVID-19 claims per 1000 FTE were registered since 2020. Occupational infectious diseases rarely occur among DHW. Nevertheless, new infectious diseases such as COVID-19 pose a major challenge for DHW. Continued attention should be paid to infectious disease prevention.
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Affiliation(s)
- Rebecca Malsam
- Competence Center for Epidemiology and Health Services Research for Healthcare Professionals (CVcare), Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), 20246 Hamburg, Germany;
| | - Albert Nienhaus
- Competence Center for Epidemiology and Health Services Research for Healthcare Professionals (CVcare), Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), 20246 Hamburg, Germany;
- Department for Occupational Medicine, Hazardous Substances and Health Sciences (AGG), Institution for Statutory Accident Insurance in the Health and Welfare Services (BGW), 22089 Hamburg, Germany
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Coppeta L, Somma G, Baldi S, Tursi E, D’Alessandro I, Torrente A, Perrone S, Pietroiusti A. Cost-Effectiveness of Annual Screening for Tuberculosis among Italian Healthcare Workers: A Retrospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17051697. [PMID: 32150923 PMCID: PMC7084819 DOI: 10.3390/ijerph17051697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 02/28/2020] [Accepted: 03/03/2020] [Indexed: 11/16/2022]
Abstract
Background. In the past few years, healthcare workers (HCWs) have been considered at higher risk for tuberculosis (TB) infection than the general population. On the other hand, recent studies have reported a low conversion rate among these workers. Recently, the Center for Disease Control (CDC) updated its recommendations, suggesting that an annual screening should not be performed in the absence of a documented exposure but only in workers with high-risk duties or with job tasks in settings at high risk of tuberculosis contagion (e.g., departments of infectious or pulmonary diseases). In fact, some studies showed that annual tuberculosis screening for all the HCWs was not cost-effective in countries with a low incidence of TB. In this study, we evaluated the conversion rate and the cost-effectiveness of two different tuberculosis screening strategies in a large population of Italian HCWs. Methods. In our retrospective study, we reviewed data coming from a tuberculosis screening conducted on 1451 HCWs in a teaching hospital of Rome. All workers were evaluated annually by means of the Quantiferon test (QFT) for a five-year period. Then, the conversion rate was calculated. Results. We found a cumulative conversion rate of 0.6%. Considering the cost of the QFT test (48.26 euros per person), the screening of the HCWs resulted in a high financial burden (38,902.90 euros per seroconversion). Only one seroconversion would have been missed by applying the CDC updated recommendations, with a relevant drop of the costs: 6756.40 euros per seroconversion, with a global save of 296,075.10 euros. Conclusion: The risk of TB conversion among our study population was extremely low and it was related to the risk classification of the setting. Giving these results, the annual tuberculosis screening appeared to not be cost effective. We conclude that a targeted screening would be a better alternative in HCWs with a higher risk of TB exposure.
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Verso MG, Serra N, Ciccarello A, Romanin B, Di Carlo P. Latent Tuberculosis Infection among Healthcare Students and Postgraduates in a Mediterranean Italian Area: What Correlation with Work Exposure? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 17:ijerph17010137. [PMID: 31878124 PMCID: PMC6982061 DOI: 10.3390/ijerph17010137] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/19/2019] [Accepted: 12/21/2019] [Indexed: 01/29/2023]
Abstract
Background: Tuberculosis screening is part of the standard protocol for evaluating the risk of infection in healthcare workers. The aim of this study was to evaluate the prevalence of latent tuberculosis infection (LTBI) among students attending various healthcare profession degree courses and postgraduate medical courses at the School of Medicine of the University of Palermo, Italy, and assess the possible professional origin of infection. Methods: In total, 2946 students (2082 undergraduates and 864 postgraduates) took part in a screening program for LTBI between January 2014 to April 2019 using the tuberculin skin test (TST). Students with a positive TST result underwent a Quantiferon-TB test (QFT). Results: Among the 2082 undergraduates, 23 (1.1%) had a positive TST; the result was confirmed with QFT for 13 (0.62%) of them. Among the 864 postgraduate students, 24 (2.78%) had a positive TST and only 18 (2.08%) showed a positive QTF. Latent tuberculosis infections were significantly more frequent among postgraduates than undergraduates (2.08% > 0.62%, p < 0.0001). There was a higher number of subjects previously vaccinated for TB (18.87% > 0.24%, p < 0.0001), and of vaccinated subjects found positive for TST and QTF (66.67% > 7.69%, p = 0.001) in the postgraduate group. Conclusion: Latent TB is relatively low among medical school students in our geographic area. Nevertheless, this infectious disease must be regarded as a re-emerging biohazard for which preventive strategies are required to limit the risk of infection, especially among exposed workers.
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Affiliation(s)
- Maria Gabriella Verso
- Occupational Health Unit, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties “G. D’Alessandro”, University of Palermo, via del Vespro 143, 90127 Palermo, Italy
- Correspondence:
| | - Nicola Serra
- Statistics Unit—Department of Public Health, University Federico II of Naples, via Sergio Pansini, 5, 80131 Naples, Italy;
| | - Antonina Ciccarello
- School of Specialization in Occupational Health, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties “G. D’Alessandro”, University of Palermo, via del Vespro 143, 90127 Palermo, Italy;
| | - Benedetta Romanin
- School of Specialization in Infectious Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties “G. D’Alessandro”, University of Palermo, via del Vespro 129, 90127 Palermo, Italy;
| | - Paola Di Carlo
- Infectious Diseases Unit, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties “G. D’Alessandro”, University of Palermo, via del Vespro 129, 90127 Palermo, Italy;
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Anwar MM, Ahmed DM, Elareed HR, Abdel-Latif RAR, Sheemy MS, Kamel NM, Mohamed MF. Screening for Latent Tuberculosis among Healthcare Workers in an Egyptian Hospital Using Tuberculin Skin Test and QuantiFERON-TB Gold In-Tube Test. Indian J Occup Environ Med 2019; 23:106-111. [PMID: 31920258 PMCID: PMC6941335 DOI: 10.4103/ijoem.ijoem_184_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 08/17/2019] [Accepted: 08/27/2019] [Indexed: 12/05/2022] Open
Abstract
Background: Early detection of latent tuberculosis infection (LTBI) might prevent active TB development in healthcare workers (HCWs). The aim of the study is to assess the prevalence of LTBI among HCWs exposed to active TB, compare QFT-GIT and TST in the diagnosis of LTBI, and explore possible risk factors of LTBI. Setting and Design: This was a cross-sectional study for a period of 6 months among 153 HCWs in high-risk departments dealing with TB infection – Beni-Suef University Hospital, Egypt. Materials and Methods: HCWs were asked to fill a questionnaire for possible LTBI risk factors, and tuberculin skin test (TST) and serum QuantiFERON test were used for LTBI screening. Statistical Analysis: Statistical Package for Social Science (SPSS-18) was used for data analysis; qualitative data were compared using Chi-square test, while associations between risk factors for TB and positive QFT or TST were analyzed by a logistic regression model. Results: LTBI detected by QuantiFERON-TB Gold In-Tube Test (QFT-GIT) and by TST was 9.1% and 34.6%, respectively (kappa = 0.028). Logistic regression showed that departments, duration of work, the use of N95 masks, and training in infection control practices were significant predictors for positive QFT-GIT among participants (P < 0.05). Conclusion: Work duration of >10 years, nurse profession, diabetics, and smokers were at increased risk of having LTBI. Increased training programs and implementation of infection control measures TB to reduce the risk of LTBI are recommended.
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Affiliation(s)
- Manal Mohamed Anwar
- Department of Public Health and Community Medicine, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Doaa Mabrouk Ahmed
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Heba Reda Elareed
- Department of Public Health and Community Medicine, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | | | - Mostafa Saleh Sheemy
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Nesreen Mostafa Kamel
- Department of Clinical Pathology, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Maha Fathy Mohamed
- Department of Chest Diseases, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
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Coppeta L, Pietroiusti A, Neri A, Janni A, Baldi S, Papa F, Magrini A. Prevalence and Risk Factors for Latent Tuberculosis Infection among Healthcare Workers in a Low Incidence Country. Open Respir Med J 2019; 13:1-4. [PMID: 31908683 PMCID: PMC6918539 DOI: 10.2174/1874306401913010001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/30/2019] [Accepted: 04/08/2019] [Indexed: 11/30/2022] Open
Abstract
Background: Tuberculosis prevention is a major goal in the hospital setting. Because of the possible progression or reactivation of latent disease, the screening of healthcare workers is an important issue in the TB control program. The aim of the study was to assess the prevalence of LTBI (latent tuberculosis infection) and to evaluate the main risk factors related to this condition in a teaching hospital in Italy. Methods: We reviewed the data of a tuberculosis screening conducted on 3622 healthcare professionals in a teaching hospital in Rome. All subjects were evaluated by QuantiFERON test which if positive, was followed by appropriate clinical and diagnostic procedures. Results: Latent Tuberculosis Infection LTBI condition was detected in 2.1% of the cases, most commonly in men. Male gender, higher age class, country of birth and nurse job were statistically related with the positivity to QuantiFERON test. Conclusion: LTBI was relatively uncommon in our population, however, given the potential risk of reactivation and progression to overt disease, the screening of healthcare workers and students is recommended in the hospital of low-incidence countries.
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Affiliation(s)
- Luca Coppeta
- Occupational Medicine Department, University of Rome "Tor Vergata", Viale Oxford 81, 00133 Roma, Italy
| | - Antonio Pietroiusti
- Occupational Medicine Department, University of Rome "Tor Vergata", Viale Oxford 81, 00133 Roma, Italy
| | - Anna Neri
- Occupational Medicine Department, University of Rome "Tor Vergata", Viale Oxford 81, 00133 Roma, Italy
| | - Aurelio Janni
- Occupational Medicine Department, University of Rome "Tor Vergata", Viale Oxford 81, 00133 Roma, Italy
| | - Savino Baldi
- Occupational Medicine Department, University of Rome "Tor Vergata", Viale Oxford 81, 00133 Roma, Italy
| | - Francesca Papa
- Occupational Medicine Department, University of Rome "Tor Vergata", Viale Oxford 81, 00133 Roma, Italy
| | - Andrea Magrini
- Occupational Medicine Department, University of Rome "Tor Vergata", Viale Oxford 81, 00133 Roma, Italy
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Lamberti M, Muoio M, Arnese A, Borrelli S, Di Lorenzo T, Garzillo EM, Signoriello G, De Pascalis S, Coppola N, Nienhaus A. Prevalence of latent tuberculosis infection in healthcare workers at a hospital in Naples, Italy, a low-incidence country. J Occup Med Toxicol 2016; 11:53. [PMID: 27904647 PMCID: PMC5122022 DOI: 10.1186/s12995-016-0141-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 11/11/2016] [Indexed: 12/03/2022] Open
Abstract
Background Healthcare workers (HCWs) are at higher risk than the general population of contracting tuberculosis (TB). Moreover, although subjects with latent TB infection (LTBI) are asymptomatic and are not infectious, they may eventually develop active disease. Thus, a fundamental tool of TB control programs for HCWs is the screening and treatment of LTBI. Methods From January 2014 to January 2015, hospital personnel at Azienda Ospedaliera Universitaria, Naples, Italy, were screened for TB. To this end, a tuberculin skin test (TST) was administered as an initial examination, unless when contraindicated, in which case the QuantiFERON® TB-Gold (QFT) assay was performed. Moreover, QFT was carried out on all TST-positive cases to confirm the initial result. Results Of 628 personnel asked to participate, 28 (4.5%) denied consent, 533 were administered TST as the baseline examination, and 67 were tested only with QFT. In the TST group, 73 (13.2%) individuals were found positive, 418 (78.4%) were negative, and 42 (7.9%) were absent for the reading window; QFT confirmed the result in 39 (53.4%) TST-positive individuals. In the QFT-only group, 44 (65.7%) individuals were found positive. All TST- and/or QFT-positive subjects were referred for chest X-ray and examination by an infectious diseases specialist. None were found to have active TB, and were thus diagnosed with LTBI. Conclusions Although Italy is a low-incidence country regarding TB, our findings suggest that the prevalence of LTBI in HCWs may be relatively high. As a result, active screening for TB and LTBI is needed for these workers. Electronic supplementary material The online version of this article (doi:10.1186/s12995-016-0141-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Monica Lamberti
- Department of Experimental Medicine, Section of Hygiene, Occupational Medicine and Forensic Medicine, Second University of Naples, Via dei Crecchi 16, 80133 Naples, Italy
| | - Mariarosaria Muoio
- Department of Experimental Medicine, Section of Hygiene, Occupational Medicine and Forensic Medicine, Second University of Naples, Via dei Crecchi 16, 80133 Naples, Italy
| | - Antonio Arnese
- Department of Experimental Medicine, Section of Hygiene, Occupational Medicine and Forensic Medicine, Second University of Naples, Via dei Crecchi 16, 80133 Naples, Italy
| | - Sharon Borrelli
- Department of Experimental Medicine, Section of Hygiene, Occupational Medicine and Forensic Medicine, Second University of Naples, Via dei Crecchi 16, 80133 Naples, Italy
| | - Teresa Di Lorenzo
- Department of Experimental Medicine, Section of Hygiene, Occupational Medicine and Forensic Medicine, Second University of Naples, Via dei Crecchi 16, 80133 Naples, Italy
| | - Elpidio Maria Garzillo
- Department of Experimental Medicine, Section of Hygiene, Occupational Medicine and Forensic Medicine, Second University of Naples, Via dei Crecchi 16, 80133 Naples, Italy
| | - Giuseppe Signoriello
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, Second University of Naples, Naples, Italy
| | - Stefania De Pascalis
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, Second University of Naples, Naples, Italy
| | - Nicola Coppola
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, Second University of Naples, Naples, Italy
| | - Albert Nienhaus
- Institute for Health Services, Research in Dermatology and Nursing, Germany, Institution for Statutory Accident Insurance and Prevention in Healthcare and Welfare Services, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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