Access to SARS-CoV-2 diagnostic tests: are there barriers for the immigrants in Italy?

OBJECTIVES

to describe the epidemiology of SARS-CoV-2 infection in relation with the use of nasal swabs in the immigrant population in Italy, using data from the COVID-19 national surveillance system and to verify if a difference is present comparing natives and immigrant.

DESIGN

descriptive study based on longitudinal health-administrative data.

SETTING AND PARTICIPANTS

general population of six Italian Regions (Piedmont, Lombardy, Veneto, Emilia-Romagna, Tuscany, Lazio) covering about 55% of the resident population and 72% of foreigners' population.

MAIN OUTCOME MEASURES

regional rates of access to at least a nasal swab, separately by country of origin.

RESULTS

across all the periods, a lower rate in the foreigners' group was observed, with the only exception of the period May-June 2021. Considering separately High Migratory Pressure Countries (HMPCs) and Highly Developed Countries (HDCs), a higher proportion of nasal swabs performed in people coming from HDC with respect to HMPCs and natives was noticed. This observation is consistent in males and females.

CONCLUSIONS

during the first wave of the pandemic, Italians have had a higher proportion of nasal swabs compared to migrants across all Regions. This difference disappeared in the following periods, probably due to a major availability of diagnostic tests.

[SARS-CoV-2 epidemic among Italians e resident immigrant population: differential incidence from an interregional multicentre study]

OBJECTIVES

to describe differences in the incidence of SARS-CoV-2 infections between Italians and foreigners residing in seven Italian Regions during the different phases of the pandemic and by gender.

DESIGN

retrospective observational study.

SETTING AND PARTICIPANTS

all confirmed SARS-CoV-2 infections from 02.02. 2020 to 16.07.2021 in the seven Regions under study were included. Italian resident population calculated by the National Institute of Statistics as of 01.01.2020 was used to calculate the rates. The considered period is divided into 5 sub-periods (phases).

MAIN OUTCOME MEASURES

number of confirmed SARS-CoV-2 infections in the five phases of the pandemic and crude rates by citizenship (Italian vs foreign). Distribution of infections by age group and by week. Crude and age-adjusted incidence rates ratios (IRR) were calculated, by Region, gender, and phase of the pandemic.

RESULTS

an epidemic curve delay was observed in foreigners in the first phase of the epidemic, in particular in the northern Regions, the most affected in that phase. The first phase of the epidemic was characterized by a greater proportion of cases occurred in people aged over 60 years than the other phases, both in Italians and in foreigners. The incidence among foreigners is higher during the summer of 2020 (intermediate period: June-September 2020) and during the last period (May-July 2021) in all Regions. The overall figure shows a lower incidence among foreigners than Italians, except for males in Tuscany.

CONCLUSIONS

the lower incidence rates among foreigners should be interpreted with caution as the available data suggest that it is at least partly attributable to less access to diagnostic tests. Regional differences found in the study deserve further research together with the effect of gender and country of origin.

[Mortality and impact of COVID-19 by citizenship in seven Italian Regions from the beginning of the pandemic to mid-July 2021]

OBJECTIVES

to quantify the variability of COVID-19 mortality from the beginning of the pandemic to mid-July 2021, in relation to the immigrant status and by Region and period.

DESIGN

observational incidence study.

SETTING AND PARTICIPANTS

the study population consists of the residents at the beginning of 2020 in seven Regions (Piedmont, Lombardy, Veneto, Emilia-Romagna, Tuscany, Lazio, Sicily) aged <=74 years.

MAIN OUTCOME MEASURES

absolute frequency of deaths occurred in subjects who tested positive for SARS-CoV-2, crude and standardized rates (standard: Italian population at the beginning of 2020), and mortality rates ratios (obtained using Poisson models), by immigrant status and stratified by gender, Region of residence, and period. The study period was divided into 5 subperiods: 22.02.2020-25.05.2020, 26.05.2020-02.10.2020, 03.10.2020-26.02.2021, 27.02.2021-16.07.2021.

RESULTS

the study includes more than one half of the Italian population and most of the immigrants residing in the country, who are younger than Italians and experienced fewer COVID-19 deaths. Deaths among those who tested positive varied greatly between Regions and periods; standardized rates showed considerable increases over time among immigrants. In terms of rate ratios, there were excesses among immigrant males in the third period (MRR: 1.46; 95%CI 1.30-1.65) and in the fourth period (MRR: 1.55; 95%CI 1, 34-1.81). Among immigrant females, there is an indication of lower risk in the third period (MRR: 0.79; 95%CI 0.65-0.97) and of greater risk in the fourth period (MRR: 1. 46; 95%CI 1.21-1.77). Finally, the effect is modified by the Region of residence, both in the third and in the fourth period for males and only in the fourth period for females.

CONCLUSIONS

the risk of premature mortality due to COVID-19 is linked to immigrant status and with an intensity that varies by gender, Region, and period. More accessible tools for prevention, diagnosis and early healthcare can support immigrant communities in managing the risk factors linked to the spread of infections and, in particular, counteract their evolution into more severe disease outcomes.

[The impact of the COVID-19 pandemic on the Italian and foreign population in the various phases: the results of an interregional multicentre project]

OBJECTIVES

to analyze the difference of the SARS-CoV-2 infection impact between Italian and foreigner subjects, evaluating the trend of infections and access to diagnostic tests (molecular or antigenic swabs for the detection of SARS- CoV-2) in the two different populations, inducing the detection of new positive cases in the population.

DESIGN

retrospective population study for the period February 2020-June 2021.

SETTING AND PARTICIPANTS

Italian and foreign resident population on 1st January of the years 2020 and 2021 in the Regions participating to the project: Piedmont, Lombardy, Veneto, Emilia-Romagna (Northern Italy), Tuscany, Lazio (Central Italy), and Sicily (Southern Italy).

MAIN OUTCOME MEASURES

in the two populations, for every week and aggregated by macropandemic period were calculated: • the test rate (people tested on the population); • the swab positivity rate (positive subjects on those who are tested); • the new positives (positive subjects on study population); • the percentage of foreigners among the new positive cases. The ratio of the value of the indicators in the foreign and Italian populations (with 95% confidence interval) was calculated to evaluate the association between nationality (Italian vs not Italian) and outcome. The analyses were conducted at the regional level and at pool level.

RESULTS

the trend of new positives by nationality (Italian vs not Italian) has a similar tendency in the different pandemic waves. However, the incidence of new positives during pandemic waves among foreigners is lower than in Italians, while it tends to increase during intermediate periods. Except for the summer periods, foreigners are less tested than Italians, but the percentage of new positives out of the total of new ones tested is higher among foreigners compared to Italians. The relative weight of new positives among foreigners tends to increase in periods with the greatest risk of inflow of SARS-CoV-2 for foreigners.

CONCLUSIONS

the epidemic trends in the two populations are similar, although foreigners tend to show lower incidence values, probably in part because they are tested less frequently. Furthermore, in foreigners compared to Italians, there is a greater risk of contracting SARS-CoV-2 infection, especially in periods of relaxation of containment Coronavirus measures, reopening of national borders, production and commercial activities.

[Hospital assistance for COVID-19: a comparison between non-Italian and Italian resident population in five Italian Regions since the beginning of the pandemic until June 2021]

OBJECTIVES

to describe trends of overall and intensive care hospitalization for COVID-19 since the beginning of the pandemic in Italy until June 2021, and to compare the results between foreign and Italian population.

DESIGN

retrospective observational study.

SETTING AND PARTICIPANTS

hospital discharges of 28 million people living in Lombardy, Piedmont, Emilia-Romagna (Northern Italy), Toscana and Lazio (Central Italy) occurred between 22.02.2020 and 02.07.2021 in the hospitals located in each considered Region.

MAIN OUTCOME MEASURES

two weekly outcomes were examined: 1. the overall number of COVID-19 hospitalizations; 2. the number of COVID-19 hospitalizations in intensive care units.

RESULTS

a higher COVID-19 overall and intensive care unit hospitalization was found among the foreign population compared to Italians. The association emerged only after the adjustment for age, and it was consistent among all Regions, though less marked in Lombardy. The association varied across epidemic phases.

CONCLUSIONS

the issue of vulnerability of migrants to the risk of severe COVID-19 calls for a diversity-sensitive approach in prevention. The specific country of origin and the prevalence of preventable co-morbidities that are often underestimated in the migrant populations, and related to COVID-19 complications, should be taken into consideration in future analyses.

Early childhood vaccination coverage and timeliness by macro-area of origin in children born to foreign women residing in Italy

OBJECTIVES

Country of origin might affect vaccine uptake in children born to immigrants. We aimed to evaluate differences in childhood vaccination coverage (VC) and timeliness by macro-area of origin of foreign mothers residing in Italy.

STUDY DESIGN

Multicentre retrospective birth cohorts.

METHODS

We analysed data of 23,287 children born in 2009-2014 to foreign women in the cities of Rome, Turin and Treviso. We retrieved data through record-linkage of the population, vaccination and birth registries. We estimated VCs at different ages for vaccines against tetanus, measles and meningococcal group-C, using the Kaplan-Meier method. Factors associated with vaccine uptake were evaluated using multilevel Poisson models.

RESULTS

Estimates of VC at any age and for all antigens were significantly lower in children born to women from Asia and higher in children born to women from Africa, as compared to other macro-areas. Similar differences by area of origin were observed for timeliness; independently of mother's sociodemographic characteristics and neonatal outcomes, the probability of delay vaccination after 2 years of age for each antigen was highest in children born to women from Asia. The risk of missed vaccination for all antigens was significantly higher in children born to younger and unemployed women.

CONCLUSIONS

Factors related to area of origin (e.g., cultural habits, language skills) are likely to affect parents' decision to vaccinate their children. These factors, as well as sociodemographic characteristics, should be adequately investigated and addressed to increase vaccine uptake in foreign children, especially those born to Asian women.

[Evaluating health care of the immigrant population in Italy through indicators of a national monitoring system]

OBJECTIVES

to evaluate maternal and child healthcare, avoidable hospitalisation, access to emergency services among immigrants in Italy.

DESIGN

cross sectional study of some health and health care indicators among Italian and foreign population residing in Italy in 2016-2017.

SETTING AND PARTICIPANTS

indicators based on the national monitoring system coordinated by the Italian National Institute for Health, Migration and Poverty (INMP) of Rome, calculated on perinatal care (CedAP), hospital discharge (SDO), emergency services (EMUR) archives for the years 2016-2017, by of the following regions: Piedmont, Trento, Bolzano, Emilia-Romagna, Tuscany, Umbria, Lazio, Basilicata, Sicily.

MAIN OUTCOME MEASURES

number and timeliness of pregnancy visits, number of ultrasounds, invasive prenatal investigations; perinatal mortality rates, birth weight, Apgar score at 5 minutes, need for neonatal resuscitation; standardized rates of avoidable hospitalisation and access to emergency services by triage code.

RESULTS

more often than Italians, immigrant women have during pregnancy: less than 5 gynaecological examination (16.3% vs 8.5%), first examination after the 12th week of gestational age (12.5% vs 3.8%), less than 2 ultrasounds (3.8% vs 1.0%). Higher perinatal mortality rates among immigrants compared to Italians (3.6 vs 2.3 x1,000). Higher standardized rates (x1,000) among immigrants compared to Italians of avoidable hospitalisation (men: 2.1 vs 1.4; women: 0.9 vs 0.7) and of white triage codes in emergency (men: 62.0 vs 32.7; women: 52.9 vs 31.4).

CONCLUSIONS

study findings show differences in access and outcomes of healthcare between Italians and immigrants. National monitoring system of indicators, coordinated by INMP, represents a useful tool for healthcare intervention policies aimed to health equity.

[Inequalities in prenatal care and pregnancy outcomes in Piedmont Region (Northern Italy)]

OBJECTIVES

to evaluate the impact on prenatal/perinatal care and pregnancy outcomes of the main social determinants (education, professional status and citizenship), with the aim of identifying the areas of care and the subgroups of women who are most at risk as priority targets of interventions for the reduction of inequalities; to evaluate the impact of the pregnancy Agenda on the appropriateness of care.

DESIGN

cross-sectional observational study.

SETTINGS AND PARTICIPANTS

the childbirth assistance certificates (CedAP) related to childbirths occurred in the Piedmont region in the years 2010-2018 were analysed.

MAIN OUTCOMES MEASURES

for each indicator of prenatal and perinatal care, multiple Poisson regression models were performed to estimate the prevalence ratios for the social determinants, adjusted for maternal age, parity, year of birth, and area of residence/maternity ward.

RESULTS

the observed deliveries were 274,086 and the newborns were 278,473, with a 25% reduction over time. Among pregnant women, there has been an increase in schooling, a reduction in employed women, and a stabilization of the percentage of immigrant women from countries with strong migratory pressure. Foreigners and inactive women show greater risks of poor prenatal care and less adherence to screening; education has greater impact on pregnancy outcomes. The trend towards greater adherence to the guidelines appears to be related to the introduction of the pregnancy Agenda, in turn associated with a greater use of public health services.

CONCLUSIONS

social inequalities persist in prenatal/perinatal care and pregnancy outcomes. The results of this study support the hypothesis that offering quality and low-threshold services, such as family health centres, could be a first effective measure to tackle inequalities.

Childbirth Care among SARS-CoV-2 Positive Women in Italy

The new coronavirus emergency spread to Italy when little was known about the infection’s impact on mothers and newborns. This study aims to describe the extent to which clinical practice has protected childbirth physiology and preserved the mother–child bond during the first wave of the pandemic in Italy. A national population-based prospective cohort study was performed enrolling women with confirmed SARS-CoV-2 infection admitted for childbirth to any Italian hospital from 25 February to 31 July 2020. All cases were prospectively notified, and information on peripartum care (mother–newborn separation, skin-to-skin contact, breastfeeding, and rooming-in) and maternal and perinatal outcomes were collected in a structured form and entered in a web-based secure system. The paper describes a cohort of 525 SARS-CoV-2 positive women who gave birth. At hospital admission, 44.8% of the cohort was asymptomatic. At delivery, 51.9% of the mothers had a birth support person in the delivery room; the average caesarean section rate of 33.7% remained stable compared to the national figure. On average, 39.0% of mothers were separated from their newborns at birth, 26.6% practised skin-to-skin, 72.1% roomed in with their babies, and 79.6% of the infants received their mother’s milk. The infants separated and not separated from their SARS-CoV-2 positive mothers both had good outcomes. At the beginning of the pandemic, childbirth raised awareness and concern due to limited available evidence and led to “better safe than sorry” care choices. An improvement of the peripartum care indicators was observed over time.

[Effects of high temperature and air pollution on the risk of preterm births. Analysis in six Italian cities, 2001-2010]

OBJECTIVES

to evaluate the association between short term maternal exposure to high temperature and air pollution on preterm births (PBs), which represent the first cause of perinatal mortality and morbidity in developed Countries, and to identify maternal risk factors enhancing individual susceptibility.

DESIGN

time series. SETTING E PARTICIPANTS: all singleton live-births occurred in six Italian cities between 1st April and 31st October of each year in the period 2001-2010 were identified through the Certificate of Delivery Care Registry (CedAP).

MAIN OUTCOME MEASURES

births occurred between 22nd and 36th week of gestation were defined as preterm births. Daily values were obtained for maximum apparent temperature (MAT), PM10, NO2, and O3. Exposures-preterm births association was estimated using a generalized additive model (GAM) with a Poisson distribution. Exposure and city-specific lag structure were computed using a non-linear distributed lag model (DLNM).

RESULTS

121,797 newborns were enrolled, 6,135 (5.0%) of which were PBs. For MAT, a linear relationship was observed for Turin (Piedmont Region, Northern Italy), Trieste (Friuli Venezia Giulia Region, Northern Italy), Rome (Lazio Region, Central Italy), and Palermo (Sicily Region, Southern Italy), while non-linear relationship was found for Bologna (Emilia-Romagna Region, Northern Italy) and Venice (Veneto Region, Northern Italy). The relative risks (RR) for MAT, computed comparing the 90th vs. the 75th percentile, vary from 1.02 (95%CI 0.95-1.09; lag 0-2) in Palermo to 1.94 (95%CI 1.32-2.85; lag 0-3) in Venice. For pollutants, a significant effect for 10 µg/m3 (IQR) increase of PM10 in Rome (RR: 1.07; 95%CI 1.02-1.12; lag 12-22) and for 16 µg/m3 (IQR) increase of O3 in Palermo (RR: 1.29; 95%CI 1.03-1.62; lag 2-9) was detected. In Rome, a significant effect modification by age and education level of the MAT-PB relationship and by education level and clinical conditions of PM10-PB was found.

CONCLUSIONS

results showed a clear positive association between MAT and the risk of NP and a lower and variable effect of pollutants. It is important and necessary to limit the impact of these risk factors on the probability of NP with appropriate prevention programmes.

Maternal childbirth-related mortality in the last 40 years in Turin, Italy: the impact of universal health coverage on inequalities in a developed country

The aim of this study was to investigate social disparities in childbirth-related mortality in women (CRM) in Italy during 1972-2013, a period characterised by important changes in the organisation of healthcare services. The relationship between education and CRM was assessed using a Poisson regression model adjusted for age, area of birth and year of delivery.The risk of dying from childbirth related causes was more than double for less educated women when compared to women with better education (RR 2.3; 95% CI 1.1-3.9). CMR was almost 2.5 times higher in 1971-1979 than in the universalistic coverage period (1980-2013): RR 2.6, 95% CI 1.4-4.6. CMR in Turin has decreased in the last 40 years and this success is probably the result of the development of our public health system and of specific health facilities for pregnant women but free access to maternal care alone is not sufficient to erase inequalities.IMPACT STATEMENTWhat do we already know? Mother mortality due to childbirth-related causes has significantly decreased in the last 40 years and the development of the public health system is likely to have contributed to this success.What do the results of this study add? This study shows that, although there has been good progress in pregnancy and partum assistance, inequalities in the incidence of mortality from childbirth-related causes still exists even in a high-income country such as Italy.What are the implications of these findings for clinical practice and/or further research? The results are useful both for clinicians and for policy-makers as it suggests that the assessment of socioeconomic factors should be taken into account by clinicians along with other risk factors. Furthermore, community interventions targeted at more vulnerable women should be implemented to improve the use of healthcare and pre-partum facilities.

Comparison of early childhood vaccination coverage and timeliness between children born to Italian women and those born to foreign women residing in Italy: A multi-centre retrospective cohort study

BACKGROUND

Compared to hosting populations, immigrants are usually considered more vulnerable to communicable diseases, many of which are vaccine-preventable. This study aims to estimate vaccination coverage (VC) and timeliness in children born to women from high migratory pressure countries (HMPC) and to evaluate factors affecting differences with children born to Italian women or women from advanced development countries (ITA + ADC).

METHODS

We retrospectively analysed data of children born in 2009-2014 and resident in areas served by three local health units in the cities of Rome (n = 40,284), Turin (n = 49,600), and Treviso (n = 20,080). Data were retrieved through record-linkage of the population, vaccination, and birth registries. We used the Kaplan-Meier method to estimate VCs at different ages for the 3rd dose of vaccine against tetanus and the 1st dose of vaccines against measles and meningococcal group C. Factors affecting differences in VCs by citizenship were evaluated using log-binomial models.

RESULTS

In Rome, VCs at 2 years of age were consistently higher in children born to ITA + ADC women than in children born to HMPC women, while differences in VCs by citizenship varied according to antigen and birth-cohort in Turin and Treviso, respectively. Where differences were observed, these were only partially explained by the mother's socio-demographic characteristics, level of utilisation of health-services during pregnancy, and maternal, perinatal, and neonatal outcomes. Finally, we observed a reduction of VCs in recent birth cohorts (2012-14 vs. 2009-11), especially in children born to ITA + ADC women.

CONCLUSIONS

Differences in VCs by citizenship were not homogeneous and varied according to geographical context, antigen, and birth-cohort. These differences are likely to be also affected by informal barriers (e.g., linguistic and cultural barriers), which should be addressed in implementing strategies to increase vaccine uptake in foreign children. Moreover, our results suggest that effective strategies to promote vaccinations in the autochthonous population are also needed.

Gender, socioeconomic position, revascularization procedures and mortality in patients presenting with STEMI and NSTEMI in the era of primary PCI. Differences or inequities?

BACKGROUND

Several studies have reported gender and socioeconomic differences in the use of revascularization procedures in patients with acute myocardial infarction. However, it is not clear whether these differences influence patients' survival. Moreover, most of the studies neither considered STEMI and NSTEMI separately, nor included primary PCI, which nowadays is the treatment of choice in case of AMI. In an unselected population of patients admitted to hospital with a first episode of STEMI and NSTEMI we examined gender and socioeconomic differences in the use of cardiac invasive procedures and in one-year mortality.

METHODS

Subjects hospitalized with a first episode of STEMI (n=3506) or NSTEMI (n=2286) were selected from the Piedmont (Italy) hospital discharge database. We considered the percentage of patients undergoing PCI, primary PCI and CABG, and in-hospital mortality. Out of hospital mortality was calculated through record linkage with the regional register. The relation between outcomes and gender or educational level was investigated using appropriate multivariate regression models adjusting for available confounders.

RESULTS

After adjustment for age, comorbidity and hospital characteristics, women and low educated patients had a lower probability of undergoing revascularization procedures. However, neither in-hospital, nor 30-day, nor 1-year mortality showed gender or social disparities.

CONCLUSIONS

Despite gender and socioeconomic differences in the use of revascularization, no differences emerged in in-hospital and 1-year mortality. These findings could suggest that patients are differently, but equitably, treated; differences are more likely due to an inability to fully adjust for clinical conditions rather than to a selection process at admission.

Resource consumption and healthcare costs of acute coronary syndrome: a retrospective observational administrative database analysis

The objective of this study was to estimate resource consumption and direct healthcare costs of patients with a first hospitalization for acute coronary syndrome (ACS) in 2008 in the Piedmont Region, Italy. Subjects hospitalized with a first episode of ACS in 2008 were selected from the regional hospital discharge database. All hospitalizations, drug prescriptions, and outpatient episodes of care in the 12 months following discharge were considered to estimate resource consumption and direct healthcare costs from the Piedmont Regional Health Service perspective. The analysis was carried out separately for ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina (UA) populations. In the accrual period, 7765 subjects (1.75‰ of the total population) were hospitalized for ACS (64.2% men). The average age was 66.5 for men and 75.4 for women. The average in-hospital mortality was 6.5% (n = 508). The total ACS population was classified as: STEMI 45.2%, NSTEMI 29.4%, and UA 25.4%. The average yearly costs per patient alive at the end of follow-up (n = 6851) were 14,160.8&OV0556; (18,678.7 USD): 83.9% for inpatient admissions [11,881.2&OV0556; (15,671.8 USD)], 9.3% for drugs [1311.6&OV0556; (1730.1 USD)], 5.0% for diagnostic and therapeutic procedures and outpatient visits [708.2&OV0556; (934.1 USD)], and 1.8% for 1-day hospital stays [259.8&OV0556; (342.7 USD)]. The average yearly direct healthcare costs by ACS event were 14,984.5&OV0556; (19,765.2 USD) for STEMI, 14,554.1&OV0556; (19,197.4 USD) for NSTEMI, and 12,481.5&OV0556; (16,463.6 USD) for UA. In each subpopulation, costs were significantly higher for men than for women. ACS imposes a significant burden in terms of morbidity and mortality and generates major public health service costs.

[MADEsmart: a web-based system for accessing data and healthcare indicators]

Methods for accessing information have evolved making thus possible the planning of a new generation of web applications. In the Piemonte region, tools for accessing demographic data and main health and epidemiologic indicators are available since several years. A new application named MADEsmart (from the Italian for "Engine for demographic and epidemiological analysis") provides various functions that allow the user to obtain information useful for creating health reports and health profiles at the subregional level.