Association between mothers' screening uptake and daughters' HPV vaccination: a quasi-experimental study on the effect of an active invitation campaign

OBJECTIVES

In Emilia-Romagna, the Human Papillomavirus (HPV) vaccination campaign started in 2008 offering free vaccines for 1996 and 1997 cohorts. Systematic active invitation was implemented for the 1997 cohort. Our study aimed at measuring the impact of the active invitation campaign on HPV vaccine coverage and on coverage inequalities in 11-year-old girls. Second, we evaluated the effect of the HPV vaccination campaign on participation in cervical cancer screening by mothers of target girls.

METHODS

We collected information on vaccination status for girls residing in Reggio Emilia in 2008 and mothers' screening history, before and after the 2008 vaccination campaign. Log-binomial regression models were performed to estimate Relative Risk (RR) and 95% confidence intervals (CIs) of being vaccinated as regarded citizenship, siblings, mothers' education, marital status and screening history, stratified by birth cohort. We also calculated RR of receiving a Pap test after the vaccination campaign as regarded education, daughter's cohort and mothers' decision to have their daughter vaccinated. Interaction between education and cohort in mothers overdue for Pap testing was calculated.

RESULTS

Vaccination coverage was 46.3% for the uninvited cohort (1046/2260) and 77.9% for the invited cohort (1798/2307). In the uninvited cohort, daughters' vaccination showed association with mothers' education (8 to 11 years of education vs. graduated mothers, RR 1.61 95% CI 1.14-2.28), citizenship (foreigners vs. Italians, RR 0.45 95% CI 0.37-0.56) and screening history (regular vs. non-participant; RR 1.72 95% CI 1.26-2.36). In the invited cohort, only a slight association with screening history persisted (regular vs. non-participant; RR 1.20 95% CI 1.04-1.40). Highly educated under-screened mothers of the invited cohort showed a higher probability of receiving a Pap test after the vaccination campaign period (RR 1.27 95% CI 1.04-1.56) compared with those not invited, CONCLUSION: Active invitation could increase overall HPV immunisation coverage and reduce socio-demographic inequalities and the association with mothers' screening participation.

[Extension of the target age range of mammography screening programme and governance of mammography practice in the Emilia-Romagna Region (Northern Italy)]

"OBJECTIVES: to evaluate the effectiveness of the regional law No.1035 enacted in 2009 by the local government of the Emilia- Romagna Region (Northern Italy) with the purpose of revising the rules of access to breast-care services. The law dictated the extension of the organised mammography screening programme to women aged 45-49 and 70-74 years in order to decrease their spontaneous screening rates and, thus, the waiting times for the access to diagnostic mammography by women of all ages.

DESIGN

study of time trends (joinpoint regression analysis and before/ after analysis) in annual percent mammography rates and in waiting times for access to clinical radiology facilities (2006-2014) among resident women. The information was taken from the regional Department of Health.

SETTING

public and accredited private radiology facilities.

MAIN OUTCOME MEASURES

age-specific and waiting-time-specific (months) percent rates of organised screening mammography, spontaneous screening mammography, and diagnostic mammography.

RESULTS

following the regional law No.1035, screening rates among women aged 45-49 and 70-74 years reached levels comparable to those attained by women aged 50-69 years. Spontaneous screening rates dropped and waiting times for spontaneous screening mammography (women aged 40-44 years) were cut. For diagnostic mammography, the rates remained stable, except for a decrease among women aged 35-39 and 45-49 years, and waiting times decreased in a constant manner over the study period.

CONCLUSIONS

the above-mentioned law met most of its goals. Comprehensive programmes regulating mammography practice at the population level can be effective."

HIV-1 early and late diagnosis in the Emilia Romagna Region (Italy): a three year study

It is crucial to establish the timing of infection and distinguish between early and long-lasting HIV-1 infections not only for partner notification and epidemiological surveillance, but also to offer early drug treatment and contain the spread of infection. This study analyzed serum and/or plasma samples with a first positive HIV antibody/antigen result coming from different Medical Centers in the Emilia Romagna Region, North East Italy, using the avidity assay, Western Blotting, RNA viral load, CD4 cell counts and genotyping assay. From May 2013 to May 2016, we certified 845 new HIV-1 infections, 18.7% of which were classified on the basis of avidity index as recent infections and 81.3% as long-lasting infections, with an estimated conversion time exceeding six months at the time of study. Western Blotting showed reactivity to only one or two HIV-1 proteins in recently infected patients (RIPs), while a complete pattern to gag, env and pol proteins was observed in most long-lasting infected patients (LLIPs). The median age, gender, nationality and risk transmission factors were comparable in RIPs and LLIPs. Phylogenetic analysis performed in available plasma disclosed B strains, non-B subtypes and circulating recombinant forms (CRFs) in both groups of patients, with a major presence of CRFs in non-Italian HIV subjects. The large number of patients unaware of their HIV status makes it crucial to discover hidden epidemics and implement appropriate targeted public health interventions.

Human infection with highly pathogenic A(H7N7) avian influenza virus, Italy, 2013

During an influenza A(H7N7) virus outbreak among poultry in Italy during August–September 2013, infection with a highly pathogenic A(H7N7) avian influenza virus was diagnosed for 3 poultry workers with conjunctivitis. Genetic analyses revealed that the viruses from the humans were closely related to those from chickens on affected farms.

Human and entomological surveillance of Toscana virus in the Emilia-Romagna region, Italy, 2010 to 2012

Toscana virus (TOSV), transmitted by phlebotomine sandflies, is recognised as one of the most important causes of viral meningitis in summer in Mediterranean countries. A surveillance plan based on both human and entomological surveys was started in 2010 in the Emilia-Romagna region, Italy. Clinical samples from patients with neurological manifestations were collected during 2010 to 2012. The surveillance protocol was improved during these years, allowing the detection of 65 human infections. Most of these infections were recorded in hilly areas, where sandflies reach the highest density. Entomological sampling around the homes of the patients resulted in a low number of captured sandflies, while later sampling in a hilly area with high number of human cases (n=21) resulted in a larger number of captured sandflies. Using this approach, 25,653 sandflies were sampled, of which there were 21,157 females, which were sorted into 287 pools. TOSV RNA was detected by real-time PCR in 33 of the pools. The results highlighted the role of Phlebotomus perfiliewi as the main vector of TOSV and a potential link between vector density and virus circulation. This integrated system shows that an interdisciplinary approach improves the sensitiveness and effectiveness of health surveillance.

The experience of West Nile virus integrated surveillance system in the Emilia-Romagna region: five years of implementation, Italy, 2009 to 2013

Predicting West Nile virus (WNV) circulation and the risk of WNV epidemics is difficult due to complex interactions of multiple factors involved. Surveillance systems that timely detect virus activity in targeted areas, and allow evidence-based risk assessments may therefore be necessary. Since 2009, a system integrating environmental (mosquitoes and birds) and human surveillance has been implemented and progressively improved in the Emilia-Romagna region, Italy. The objective is to increase knowledge of WNV circulation and to reduce the probability of virus transmission via blood, tissue and organ donation. As of 2013, the system has shown highly satisfactory results in terms of early detection capacity (the environmental surveillance component allowed detection of WNV circulation 3–4 weeks before human cases of West Nile neuroinvasive disease (WNND) occurred), sensitivity (capacity to detect virus circulation even at the enzootic level) and area specificity (capacity to indicate the spatial distribution of the risk for WNND). Strong correlations were observed between the vector index values and the number of human WNND cases registered at the province level. Taking into consideration two scenarios of surveillance, the first with environmental surveillance and the second without, the total costs for the period from 2009 to 2013 were reduced when environmental surveillance was considered (EUR 2.093 million for the first scenario vs EUR 2.560 million for the second). Environmental surveillance helped to reduce costs by enabling a more targeted blood unit testing strategy. The inclusion of environmental surveillance also increased the efficiency of detecting infected blood units and further allowed evidence-based adoption of preventative public health measures.

[The ideation of the Emilia-Romagna surveillance system for arbovirosis following the experience from the Chikungunya outbreak 2007]

Since 2008 the Emilia-Romagna Regional public health authority activated a regional Plan for arbovirosis surveillance and control, focused on Chikungunya, Dengue and West Nile. The Plan integrates sanitary, entomological and veterinary surveillance allowing a prompt adoption of efficient measures, aiming at the prevention and reduction of arbovirosis transmission risk. Following the 2007 Chikungunya outbreak, no autochthonous Chikungunya or Dengue cases has been registered, while an increase of confirmed imported cases of Dengue and Chikungunya has been observed. The integrated surveillance system allowed a prompt, appropriate and efficient intervention in 98.2% of imported suspected cases. The humanWNND (West Nile Neuroinvasive Disease) surveillance reported confirmed cases in 2008, 2009 and then in 2013 and 2014. In all cases the entomological and ornithological surveillance detected WNV circulation well in advance respect to the appearance of the first human case. The integration of information provided by different surveillance sources allows to evaluate, even through the vector index (VI) calculation, the risk of transmission, to optimize preventive measures on blood, tissues and organs donation and to implement further measures of vector fight.

Hepatitis A outbreak in Italy, 2013: a matched case–control study

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Impact of meningococcal C conjugate vaccination campaign in Emilia-Romagna, Italy

The incidence of reported meningococcal disease in Italy is among the lowest in Europe. The trend of the disease was increasing up to 2005 and then declined after the gradual introduction of a universal Men C vaccination program in 17/21 Italian regions. Since 2006, in Emilia-Romagna region vaccination against Neisseria meningitidis serogroup C was actively offered free of charge in a single dose to the age groups 12-15 months and 14-15 years, in addition to people with defined epidemiological risk. Our aim was to measure the impact of vaccination on the incidence of meningococcal disease caused by different serogroups among the population of Emilia Romagna Region, Northern Italy (approximately 4.5 million inhabitants) subdivided by age. Using surveillance data, we computed the incidence rates of Neisseria meninigitidis related invasive disease per 100.000 inhabitants for the years 2000 to 2012. In addition, the percentage change in incidence and the mortality rates were calculated. Results indicate a 70.1% decrease in the incidence of meningococcus C-related invasive disease after the introduction of MenC universal vaccination. No case of serogroup C related infection was observed since 2006 in children aged 1-4 years. These findings suggest that the single-dose vaccination strategy against serogroup C N.meningitidis targeted to the age groups 12-15 months and 14-15 years was effective in the Emilia-Romagna population. However, the occurrence of two cases of meningiditis in a 5-month child and in a 9-years child suggests caution and careful consideration in surveillance for the next years.

A model of laboratory surveillance for neuro-arbovirosis applied during 2012 in the Emilia-Romagna region, Italy

Arboviruses with neuroinvasive potential are gaining more attention due to the increased number of cases of autochthonous and imported infections in the human host. Diagnosis of infection caused by these viruses in patients with central nervous system (CNS) diseases is still underestimated and these infections represent an emerging threat to public health. We describe a model suitable for the laboratory surveillance of neuro-arbovirosis that was applied in the Emilia-Romagna region, north-eastern Italy, during the 2012 summer season. One hundred and twenty cases of suspected neuroinvasive infection were tested for arboviral agents on the basis of clinical and laboratory signs and epidemiological data. The most common virus detected was Toscana virus (TOSV): anti-TOSV specific antibodies or viral components were detected in 28.3% of the cases; 79.4% of the TOSV cases were in the acute phase of infection. No cases resulted in acute phase for West Nile (WNV), Usutu (USUV), Chikungunya (CHIKV) or Dengue (DENV) virus infection. Conversely, two patients with a history of staying in a tick-borne encephalitis virus (TBEV) endemic area showed a probable TBEV infection. These results emphasize the importance of a complete and 'ready to act' laboratory diagnostic system to be implemented within the larger frame of a regional integrated surveillance system.

Persistence of anti-West Nile virus-specific antibodies among asymptomatic blood donors in northeastern Italy

The development and persistence of anti-West Nile Virus (WNV) immunoglobulin G (IgG)- and IgM-specific antibodies were investigated in 68 asymptomatic blood donors (BDs) previously tested as positive between October, 2008, and September, 2009, and living in northeastern Italy. Our study showed that WNV-specific IgG titers became negative (41%) or decreased (33%) in a large percentage of BDs, while they increased in a smaller percentage (10%); 16% of BDs showed no titer variation. Reversion to seronegative status within a short time frame suggests that WNV surveillance should be maintained year after year.

Ongoing outbreak of visceral leishmaniasis in Bologna Province, Italy, November 2012 to May 2013

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Ongoing outbreak of visceral leishmaniasis in Bologna Province, Italy, November 2012 to May 2013

An increased number of autochthonous visceral leishmaniasis (VL) cases has recently been reported in Bologna Province in northern Italy. Over six months from November 2012 to May 2013, 14 cases occurred, whereas the average number of cases per year was 2.6 (range: 0-8) in 2008 to 2012. VL was diagnosed in a median of 40 days (range: 15-120) from disease onset. This delay in diagnosis shows the need for heightened awareness of clinicians for autochthonous VL in Europe.

Detection of specific antibodies against West Nile and Usutu viruses in healthy blood donors in northern Italy, 2010-2011

Neutralizing antibodies against West Nile (WNV) and Usutu (USUV) viruses were measured in 6000 samples collected, between 1 September 2010 and 30 June 2011, from blood donors living in different districts of Emilia-Romagna, northeastern Italy. On the basis of the microneutralization assay (MNTA), 47 (0.78%) subjects were positive for WNV and 14 (0.23%) for USUV. These results were compared with those obtained 2 years ago and suggest an increased circulation of USUV among humans in Emilia-Romagna.

Epidemiological surveillance of West Nile neuroinvasive diseases in Italy, 2008 to 2011

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Epidemiological surveillance of West Nile neuroinvasive diseases in Italy, 2008 to 2011

We describe the geographical and temporal distribution of West Nile neuroinvasive diseases (WNND) cases in Italy from 2008 to 2011. The increasing number of confirmed human cases from eight in 2008 to 18 in 2009 and the occurrence of the virus in a larger geographical area in 2009 (moving from east to west) prompted the Ministry of Health to publish, in spring 2010, a national programme for WNND human surveillance, comprising veterinary and vector surveillance. Subsequently, in 2011, a new national plan on integrated human surveillance of imported and autochthonous vector-borne diseases (chikungunya, dengue and West Nile disease) was issued. Between 2008 and 2011, 43 cases of WNND were reported from five regions in Italy with a case fatality rate of 16%. The incidence of WNND during the entire study period was 0.55 per 100,000 population (range: 0.06–0.23 per 100,000). During 2011, two new regions (Friuli-Venezia Giulia and Sardinia) reported confirmed cases in humans. Integrated human, entomological and animal surveillance for West Nile virus is a public health priority in Italy and will be maintained during 2012.

Long-term chikungunya infection clinical manifestations after an outbreak in Italy: a prognostic cohort study

OBJECTIVES

Following a Chikungunya (CHIKV) outbreak in Italy, a cohort study was conducted to describe the infection long-term clinical course and outcome.

METHODS

Persons identified through active and passive surveillance as confirmed or possible CHIKV cases during the outbreak were enrolled and interviewed by trained public health nurses, between 4-5 and 12-13 months following the acute stage. Patients reporting persistent clinical symptoms were evaluated by rheumatologists. Serum samples were obtained and anti-CHIKV specific IgG and IgM immune responses detected. Only confirmed cases who completed the follow-up were analysed.

RESULTS

Out of 250 patients, 66.5% still reported myalgia, asthenia or arthralgia (most frequent sign) after 12 months. Functional ability, measured by the ROAD index, was more impaired for lower extremities (3.75; Inter Quartile Range - IQR 4.4), and the activities of daily living (average 4.2; IQR 5). Variables independently associated with the presence of joint pain at 12-13 months were increasing age, and history of rheumatologic diseases). Elderly, females, and persons with history of rheumatologic diseases had higher anti-CHIKV IgG titres at 12-13 months.

CONCLUSIONS

This study confirms, in an unselected population, that the long-lasting burden of CHIKV infection is significant.

Imported cases of dengue virus infection: Emilia-Romagna, Italy, 2010

Dengue is a significant mosquito-borne infection in humans, and its worldwide prevalence is rapidly increasing. In 2010, 83 serum samples from febrile travellers returning from dengue-endemic countries to a region in north-eastern Italy, densely infested with Aedes albopictus, were analysed for dengue virus (DENV). DENV RNA was detected in 20.5% of patients. By RT-PCR, DENV serotypes 1 and 3 were the most common. DENV must be identified early in symptomatic travellers returning from high-risk countries, to prevent outbreaks where potential vectors exist.

West Nile virus circulation in Emilia-Romagna, Italy: the integrated surveillance system 2009

Following a large West Nile virus (WNV) epidemic in northeastern Italy in 2008, human and animal surveillance activities were implemented in Emilia Romagna. Human surveillance was performed by serology or genome detection on blood and cerebrospinal fluid for all suspected cases suffering from acute meningoencephalitis in the regional territory. Animal surveillance consisted of passive and active surveillance of horses and active surveillance of wild birds and mosquitoes. Between 15 June and 31 October 2009, nine of 78 possible cases of West Nile neuroinvasive disease were confirmed (three fatal). From May to October, 26 cases of neurological West Nile disease were confirmed among 46 horses. The overall incidence of seroconversion among horses in 2009 was 13%. In 2009, 44 of 1,218 wild birds yielded positive PCR results for WNV infection. The planned veterinary and entomological surveillance actions detected WNV activity from the end of July 2009, about 2-3 weeks before the onset of the first human neurological case. Passive surveillance of horses seems to be an early and suitable tool for the detection of WNV activity, but it will be less sensitive in the future, because an intensive programme of horse vaccination started in June 2009.

West Nile virus circulation in Emilia-Romagna, Italy: the integrated surveillance system 2009

Following a large West Nile virus (WNV) epidemic in northeastern Italy in 2008, human and animal surveillance activities were implemented in Emilia Romagna. Human surveillance was performed by serology or genome detection on blood and cerebrospinal fluid for all suspected cases suffering from acute meningoencephalitis in the regional territory. Animal surveillance consisted of passive and active surveillance of horses and active surveillance of wild birds and mosquitoes. Between 15 June and 31 October 2009, nine of 78 possible cases of West Nile neuroinvasive disease were confirmed (three fatal). From May to October, 26 cases of neurological West Nile disease were confirmed among 46 horses. The overall incidence of seroconversion among horses in 2009 was 13%. In 2009, 44 of 1,218 wild birds yielded positive PCR results for WNV infection. The planned veterinary and entomological surveillance actions detected WNV activity from the end of July 2009, about 2-3 weeks before the onset of the first human neurological case. Passive surveillance of horses seems to be an early and suitable tool for the detection of WNV activity, but it will be less sensitive in the future, because an intensive programme of horse vaccination started in June 2009.

Chikungunya virus in North-Eastern Italy: a seroprevalence survey

After an outbreak of Chikungunya infection in Emilia-Romagna Region (North-eastern Italy), a survey was performed to estimate the seroprevalence of antibody to Chikungunya virus and the proportion of asymptomatic infections, to identify factors associated with infection, and evaluate the performance of the surveillance system. The method used was a survey on a random sample of residents of the village with the largest number of reported cases. The prevalence was 10.2% (33 of 325), being higher in older people and males, and lower when window screens and insect repellents were used. Only 18% of infected persons were fully asymptomatic, 85% of the 27 symptomatic confirmed cases satisfied the surveillance case definition, and 63% of the persons meeting the criteria for suspect case were identified by the active surveillance system. This study provides basic parameters for modeling the transmission potential of outbreaks and planning control measures for Chikungunya infection in temperate settings.

West Nile virus transmission with human cases in Italy, August - September 2009

In 2009, to date 16 human cases of West Nile neuroinvasive disease (WNND) have been reported in Italy, in three regions: Veneto, Emilia-Romagna and Lombardia. The number of cases is higher compared with last year when nine cases were identified (eight cases of WNND and one case of West Nile fever) and the geographical distribution indicates spread from east to west.

West Nile virus transmission with human cases in Italy, August - September 2009

In 2009, to date 16 human cases of West Nile neuroinvasive disease (WNND) have been reported in Italy, in three regions: Veneto, Emilia-Romagna and Lombardia. The number of cases is higher compared with last year when nine cases were identified (eight cases of WNND and one case of West Nile fever) and the geographical distribution indicates spread from east to west.

Detection of West Nile virus infection in horses, Italy, September 2008

Six confirmed and five suspected cases of West Nile virus infection in horses have been reported in the vicinity of Ferrara in Italy. To verify the diffusion of viral circulation and to prevent the spread of disease, the regional authorities of Emilia-Romagna adopted a special plan of West Nile fever surveillance.

Effectiveness of service screening: a case-control study to assess breast cancer mortality reduction

The aim of this study was the evaluation of the impact of service screening programmes on breast cancer mortality in five regions of Italy. We conducted a matched case-control study with four controls for each case. Cases were defined as breast cancer deaths occurred not later than 31 December 2002. Controls were sampled from the local municipality list and matched by date of birth. Screening histories were assessed by the local, computerised, screening database and subjects were classified as either invited or not-yet-invited and as either screened or unscreened. There were a total of 1750 breast cancer deaths within the 50 to 74-year-old breast cancer cases and a total of 7000 controls. The logistic conditional estimate of the cumulative odds ratios comparing invited with not-yet-invited women was 0.75 (95% CI: 0.62-0.92). Restricting the analyses to invited women, the odds ratio of screened to never-respondent women corrected for self-selection bias was 0.55 (95% CI: 0.36-0.85). The introduction of breast cancer screening programmes in Italy is associated with a reduction in breast cancer mortality attributable to the additional impact of service screening over and above the background access to mammography.

[Chikungunya emergency in Emilia-Romagna: learning through experience]

This paper summarizes the Emilia-Romagna strategy to face the 2007 emergency, caused by a Chikungunya epidemic outbreak with local virus transmission by Ae. albopictus. The paper describes the trend of epidemic and the interventions adopted to face toward the event. The first cases were in Ravenna and Cervia and then the outbreak spread toward other areas: the Provinces of Forlì-Cesena, Rimini and Bologna. Last case was notified 2007 28th September; Health Ministry declared over the outbreak on 2007 20th November. Emilia-Romagna Region did not consider over the trouble and prepared a Plan for the fight against the asian tiger mosquito and the prevention of Chikungunya and Dengue fever for 2008, activating an health surveillance system and optimizing the entomological control of the territory.

Chikungunya epidemic outbreak in Emilia-Romagna (Italy) during summer 2007

During summer 2007, an outbreak due to the local transmission of CHIKV by Aedes albopictus mosquitoes occurred moreover in Italy, Emilia-Romagna Region, in the areas of Ravenna, Forli-Cesena, Rimini and Bologna cities. The original outbreak developed in Castiglione di Cervia and Castiglione di Ravenna, two small villages divided by a river. The first case was recorded on August 9th the epidemic outbreak then spread out, thus giving rise to smaller secondary outbreaks and further sporadic cases in the same area, for a total of 337 suspected cases, 217 of which confirmed by blood analysis. CHIKV has been isolated and characterized on both blood and mosquito samples.

Autochthonous chikungunya virus transmission may have occurred in Bologna, Italy, during the summer 2007 outbreak

In Italy, a national surveillance system for chikungunya fever coordinated by the National Public Health Institute has been in place since August 2006. In summer 2007, an outbreak of chikungunya fever affected the Italian provinces of Ravenna, Cesena-Forli and Rimini [1-3]. As of 16 December 2007, health authorities identified 214 laboratory-confirmed cases with date of onset from 15 July to 28 September 2007. Most cases (161) occurred in the two neighbouring villages of Castiglione di Cervia and Castiglione di Ravenna, but limited local transmission also took place in the cities of Ravenna, Cesena, Cervia, and Rimini. In September 2007, two confirmed cases (two women aged 68 and 70) were reported among residents of the city of Bologna (373,026 inhabitants). Both had a history of travel in the affected areas (municipality of Cervia). No unusual increase in the density of Aedes albopictus mosquitoes in the Bologna area was noted at that time (September).

Infection with chikungunya virus in Italy: an outbreak in a temperate region

BACKGROUND

Chikungunya virus (CHIKV), which is transmitted by Aedes spp mosquitoes, has recently caused several outbreaks on islands in the Indian Ocean and on the Indian subcontinent. We report on an outbreak in Italy.

METHODS

After reports of a large number of cases of febrile illness of unknown origin in two contiguous villages in northeastern Italy, an outbreak investigation was done to identify the primary source of infection and modes of transmission. An active surveillance system was also implemented. The clinical case definition was presentation with fever and joint pain. Blood samples were gathered and analysed by PCR and serological assays to identify the causal agent. Locally captured mosquitoes were also tested by PCR. Phylogenetic analysis of the CHIKV E1 region was done.

FINDINGS

Analysis of samples from human beings and from mosquitoes showed that the outbreak was caused by CHIKV. We identified 205 cases of infection with CHIKV between July 4 and Sept 27, 2007. The presumed index case was a man from India who developed symptoms while visiting relatives in one of the villages. Phylogenetic analysis showed a high similarity between the strains found in Italy and those identified during an earlier outbreak on islands in the Indian Ocean. The disease was fairly mild in nearly all cases, with only one reported death.

INTERPRETATION

This outbreak of CHIKV disease in a non-tropical area was to some extent unexpected and emphasises the need for preparedness and response to emerging infectious threats in the era of globalisation.

Estimate of overdiagnosis of breast cancer due to mammography after adjustment for lead time. A service screening study in Italy

INTRODUCTION

Excess of incidence rates is the expected consequence of service screening. The aim of this paper is to estimate the quota attributable to overdiagnosis in the breast cancer screening programmes in Northern and Central Italy.

METHODS

All patients with breast cancer diagnosed between 50 and 74 years who were resident in screening areas in the six years before and five years after the start of the screening programme were included. We calculated a corrected-for-lead-time number of observed cases for each calendar year. The number of observed incident cases was reduced by the number of screen-detected cases in that year and incremented by the estimated number of screen-detected cases that would have arisen clinically in that year.

RESULTS

In total we included 13,519 and 13,999 breast cancer cases diagnosed in the pre-screening and screening years, respectively. In total, the excess ratio of observed to predicted in situ and invasive cases was 36.2%. After correction for lead time the excess ratio was 4.6% (95% confidence interval 2 to 7%) and for invasive cases only it was 3.2% (95% confidence interval 1 to 6%).

CONCLUSION

The remaining excess of cancers after individual correction for lead time was lower than 5%.

A case of cholera imported from Senegal to Rimini, Italy, June 2005

On the evening of 15 June 2005, a 45 year old Senegalese man was admitted to hospital in Rimini, northeast Italy with severe acute diarrhoea.

Combined Pap smear, cervicography and HPV DNA testing in the detection of cervical intraepithelial neoplasia and cancer

OBJECTIVE

The sensitivity of the Pap smear (PAP) continues to be the subject of debate. During the past several years, cervicography (CER) and HPV DNA testing have been suggested as optional tools in the screening of cervical cancer precursors.

STUDY DESIGN

The performance characteristics of PAP, CER and HPV DNA testing (hybrid capture test [HCT]) in all potential combinations were evaluated in a series of 1,030 women (aged 16-70, median, 33), subjected to colposcopy (COLPO) as the reference tool.

RESULTS

Of the 992 evaluable cases, 402/992 (41%) had positive COLPO (i.e., an abnormal transformation zone). Of them, 298 women underwent directed punch biopsy, while of the COLPO negative patients, 18/93 positive by at least one of the three tests had endocervical curettage. Of the 402 COLPO positive women, 146 (36%) remained negative on all tests, whereas 256 (64%) had at least one positive test. There were 84 cervical intraepithelial neoplasia (CIN) 2 and 3 lesions and 6 invasive carcinomas. Of the former, 10 were detected by PAP alone, 4 by CER alone and 3 by HCT alone. Three of the 6 carcinomas were HCT negative. The predictive value (PPV) of a positive test was 45% for PAP, 51% for CER and 48% for HCT. The combinations of PAP with CER (for PAP negative cases) and PAP with HCT were more sensitive for CIN 2 and 3 (95% and 94%, respectively) as compared with PAP alone but were associated with a significant decrease in specificity (44% and 46% vs. 57%, respectively). However, both combinations retained a PPV (43%) similar to that of PAP alone (45%).

CONCLUSION

The potential combinations of PAP with CER and with HCT were more sensitive in detecting CIN 2 and 3 as compared with PAP alone and retained a PPV similar to that of PAP.