Hepatitis: Puro V

FitzSimons D, François G, De Carli G, Shouval D, Prüss-Ustün A, Puro V, Williams I, Lavanchy D, De Schryver A, Kopka A, Ncube F, Ippolito G, Van Damme P. · World Health Organization, Geneva, Switzerland. · Occup Environ Med. · Pubmed #18562683 No free full text.

Abstract: The Viral Hepatitis Prevention Board (VHPB) convened a meeting of international experts from the public and private sectors in order to review and evaluate the epidemiology of blood-borne infections in healthcare workers, to evaluate the transmission of hepatitis B and C viruses as an occupational risk, to discuss primary and secondary prevention measures and to review recommendations for infected healthcare workers and (para)medical students. This VHPB meeting outlined a number of recommendations for the prevention and control of viral hepatitis in the following domains: application of standard precautions, panels for counselling infected healthcare workers and patients, hepatitis B vaccination, restrictions on the practice of exposure-prone procedures by infected healthcare workers, ethical and legal issues, assessment of risk and costs, priority setting by individual countries and the role of the VHPB. Participants also identified a number of terms that need harmonization or standardisation in order to facilitate communication between experts.

Puro V, De Carli G, Cicalini S, Soldani F, Balslev U, Begovac J, Boaventura L, Campins Martí M, Hernández Navarrete MJ, Kammerlander R, Larsen C, Lot F, Lunding S, Marcus U, Payne L, Pereira AA, Thomas T, Ippolito G, Anonymous00733. · Istituto Nazionale per le Malattie Infettive Lazzaro Spallanzani, IRCCS, Rome, Italy. · Euro Surveill. · Pubmed #16282641 links to  free full text

Abstract: Exposure prevention is the primary strategy to reduce the risk of occupational bloodborne pathogen infections in healthcare workers (HCW). HCWs should be made aware of the medicolegal and clinical relevance of reporting an exposure, and have ready access to expert consultants to receive appropriate counselling, treatment and follow-up. Vaccination against hepatitis B virus (HBV), and demonstration of immunisation before employment are strongly recommended. HCWs with postvaccinal anti-HBs levels, 1-2 months after vaccine completion, >or=10 mIU/mL are considered as responders. Responders are protected against HBV infection: booster doses of vaccine or periodic antibody concentration testing are not recommended. Alternative strategies to overcome non-response should be adopted. Isolated anti-HBc positive HCWs should be tested for anti-HBc IgM and HBV-DNA: if negative, anti-HBs response to vaccination can distinguish between infection (anti-HBs >or=50 mUI/ml 30 days after 1st vaccination: anamnestic response) and false positive results(anti-HBs >or=10 mUI/ml 30 days after 3rd vaccination: primary response); true positive subjects have resistance to re-infection. and do not need vaccination The management of an occupational exposure to HBV differs according to the susceptibility of the exposed HCW and the serostatus of the source. When indicated, post-exposure prophylaxis with HBV vaccine, hepatitis B immunoglobulin or both must be started as soon as possible (within 1-7 days). In the absence of prophylaxis against hepatitis C virus (HCV) infection, follow-up management of HCV exposures depends on whether antiviral treatment during the acute phase is chosen. Test the HCW for HCV-Ab at baseline and after 6 months; up to 12 for HIV-HCV co-infected sources. If treatment is recommended, perform ALT (amino alanine transferase) activity at baseline and monthly for 4 months after exposure, and qualitative HCV-RNA when an increase is detected.

Lanini S, Puro V, Lauria FN, Fusco FM, Nisii C, Ippolito G. · Istituto Nazionale per le Malattie Infettive, Lazzaro Spallanzani-Roma, Rome, Italy. · BMC Med. · Pubmed #19356228 links to  free full text

Abstract: BACKGROUND: Hepatitis B outbreaks in healthcare settings are still a serious public health concern in high-income countries. To elucidate the most frequent infection pathways and clinical settings involved, we performed a systematic review of hepatitis B virus outbreaks published between 1992 and 2007 within the EU and USA. METHODS: The research was performed using two different databases: the PubMed Database and the Outbreak Database, the worldwide database for nosocomial outbreaks. Selection of papers was carried out using the Quorom algorithm, and to avoid selection biases, the inclusion criteria were established before the articles were identified. RESULTS: Overall, 30 papers were analyzed, reporting on 33 hepatitis B virus outbreaks that involved 471 patients, with 16 fatal cases. Dialysis units accounted for 30.3% of outbreaks followed by medical wards (21.2%), nursing homes (21.2%), surgery wards (15.2), and outpatient clinics (12.1%). The transmission pathways were: multi-vial drugs (30.3%), non-disposable multi-patient capillary blood sampling devices (27.2%), transvenous endomyocardial biopsy procedures (9.1%), and multiple deficiencies in applying standard precautions (9.1%). CONCLUSION: The analysis of transmission pathways showed that some breaches in infection control measures, such as administration of drugs using multi-vial compounds and capillary blood sampling, are the most frequent routes for patient-to-patient transmission of hepatitis B virus. Moreover some outbreak reports underlined that heart-transplant recipients are at risk of contracting hepatitis B virus infection during the transvenous endomyocardial biopsy procedure through indirect contact with infected blood as a result of environmental contamination. To prevent transmission, healthcare workers must adhere to standard precautions and follow fundamental infection control principles, such as the use of sterile, single-use, disposable needles and avoiding the use of multi-vial compounds in all healthcare settings including outpatient settings.

Puro V, Scognamiglio P, Ippolito G. · Istituto Nazionale per le Malattie Infettive IRCCS Lazzaro Spallanzani, Dipartimento di epidemiologia, Via Portuense 292, 00149 Roma. · Med Lav. · Pubmed #14768247 No free full text.

Abstract: BACKGROUND: The report of transmission of viruses, such as human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV), from health care workers (HCWs) to patient has alarmed public opinion with potential repercussions on health organisation. OBJECTIVES: To review available information on cases of transmission of HIV, HBV and HCV from HCW to patient reported worldwide. METHODS: A literature review was conducted with a Medline search of English language full papers, using the following key terms: HIV, HBV, HCV; healthcare workers, occupational and hospital transmission, outbreak, look back investigation. The Medline search was supplemented by a manual search using reference lists of published studies and proceedings of meetings, including some personal communications already reported in a previous review. RESULTS: Since 1972, 50 outbreaks have been reported in which 48 HBV infected HCWs (39 surgeons) transmitted the infection to approximately 500 persons. To date, 3 cases of transmission of HIV and 8 confirmed cases of transmission of HCV (to a total of 18 patients) from infected healthcare workers to patients have been reported. The factors influencing the transmissibility of infection include: type of procedures performed, surgical techniques used, compliance with infection control precautions, the clinical status and viral burden of the infected HCW and susceptibility of the patient to infection. The risk of transmission of HIV, HBV and HCV from HCWs to patients is associated primarily with certain types of surgical specialties (obstetrics and gynaecology, orthopaedics, cardiothoracic surgery) and surgical procedures that can expose the patient to the blood of the HCW: exposure-prone procedures. Since the early 90's industrialized countries have issued recommendations for preventing transmission of blood-borne pathogens to patients during "exposure prone" invasive procedures. With regard to HBV there is common consent to restricting or excluding HCWs tested HbeAg positive or HBV DNA-positive from performing exposure-prone procedures, while there are still some discrepancies in the different countries for dealing with HCV-infected personnel and in some cases also for those with HIV infection. CONCLUSIONS: Efforts to prevent surgeon-to-patient transmission of blood-borne infections should focus not only on ascertaining the infection status of the HCW but principally on eliminating the cause of blood-borne exposures, for example by the use of blunt suture needles, improved instruments, reinforced gloves, changes in surgical technique and the use of less invasive alternative procedures. These measures should be implemented in order to minimize the risk of blood exposure and consequently of virus transmission both to and from HCW to patients.

Puro V, De Carli G, Scognamiglio P, Porcasi R, Ippolito G, Anonymous00392. · Dipartimento di Epidemiologia, Istituto Nazionale per le Malattie Infettive Lazzaro Spallanzani-IRCCS, Rome, Italy. · Ann N Y Acad Sci. · Pubmed #11762993 No free full text.

Abstract: Health care workers (HCWs) face a well-recognized risk of acquiring blood-borne pathogens in their workplace, in particular hepatitis B and C viruses (HBV/HBC) and human immunodeficiency virus (HIV). Additionally, infected HCWs performing invasive exposure-prone procedures, including in the cardiac setting, represent a potential risk for patients. An increasing number of infected persons could need specific cardiac diagnostic procedures and surgical treatment in the future, regardless of their sex or age. The risk of acquiring HIV, HCV, HBV infection after a single at-risk exposure averages 0.5%, and 1-2%, and 4-30%, respectively. The frequency of percutaneous exposure ranges from 1 to 15 per 100 surgical interventions, with cardiothoracic surgery reporting the highest rates of exposures; mucocutaneous contamination by blood-splash occurs in 50% of cardiothoracic operations. In the Italian Surveillance (SIROH), a total of 987 percutaneous and 255 mucocutaneous exposures were reported in the cardiac setting; most occurred in cardiology units (46%), and in cardiovascular surgery (44%). Overall, 257 source patients were anti-HCV+, 54 HBsAg+, and 14 HIV+. No seroconversions were observed. In the literature, 14 outbreaks were reported documenting transmission of HBV from 12 infected HCWs to 107 patients, and 2 cases of HCV to 6 patients, during cardiothoracic surgery, especially related to sternotomy and its suturing. The transmission rate was estimated to be 5% to 13% for HBV, and 0.36% to 2.25% for HCV. Strategies in risk reduction include adequate surveillance, education, effective sharps disposal, personal protective equipment, safety devices, and innovative technology-based intraoperative procedures.

Gunson RN, Shouval D, Roggendorf M, Zaaijer H, Nicholas H, Holzmann H, de Schryver A, Reynders D, Connell J, Gerlich WH, Marinho RT, Tsantoulas D, Rigopoulou E, Rosenheim M, Valla D, Puro V, Struwe J, Tedder R, Aitken C, Alter M, Schalm SW, Carman WF, Anonymous00527. · West of Scotland Specialist Virology Centre, Gartnavel General Hospital, 1053 Great Western Road, G12 OZA Glasgow, UK. · J Clin Virol. · Pubmed #12878084 No free full text.

Abstract: The transmission of viral hepatitis from health care workers (HCW) to patients is of worldwide concern. Since the introduction of serologic testing in the 1970s there have been over 45 reports of hepatitis B virus (HBV) transmission from HCW to patients, which have resulted in more than 400 infected patients. In addition there are six published reports of transmissions of hepatitis C virus (HCV) from HCW to patients resulting in the infection of 14 patients. Additional HCV cases are known of in the US and UK, but unpublished. At present the guidelines for preventing HCW to patient transmission of viral hepatitis vary greatly between countries. It was our aim to reach a Europe-wide consensus on this issue. In order to do this, experts in blood-borne infection, from 16 countries, were questioned on their national protocols. The replies given by participating countries formed the basis of a discussion document. This paper was then discussed at a meeting with each of the participating countries in order to reach a Europe-wide consensus on the identification of infected HCWs, protection of susceptible HCWs, management and treatment options for the infected HCW. The results of that process are discussed and recommendations formed. The guidelines produced aim to reduce the risk of transmission from infected HCWs to patients. The document is designed to complement existing guidelines or form the basis for the development of new guidelines. This guidance is applicable to all HCWs who perform EPP, whether newly appointed or already in post.

Iacomi F, Vincenti D, Vairo F, Solmone M, Mariano A, Piselli P, Puro V, Capobianchi MR, Antonucci G. · Clinical Department of Infectious Diseases, National Institute for Infectious Disease, L. Spallanzani, Rome, Italy. · J Med Virol. · Pubmed #19475624 No free full text.

Abstract: A retrospective review was performed comparing lamivudine-resistance mutation patterns between patients infected with hepatitis B virus (HBV) with or without human immunodeficiency virus (HIV) co-infection. Medical records that included a genotypic test of patients infected with HBV and treated with lamivudine as the only anti-HBV drug were reviewed. Pol gene mutations were assessed by direct sequencing of the reverse transcriptase fragment 125-213 aa. Eighty-nine patients infected with HBV (29 co-infected with HIV) with rtM204V or rtM204I mutations were included. Multiple mutations associated with the YMDD motif were observed in 33 (55%) of 60 patients infected with HBV only and in 28 (96.6%) of patients co-infected with HIV/HBV. In this latter group, the prevalence of the rtV173L + rtL180M + rtM204V triple mutation was 31% versus a prevalence of 3.4% observed among patients infected with HBV only. All patients with the triple mutational pattern showed sE164D + sI195M changes in the envelope gene. Multivariate analysis demonstrated that HIV co-infection (adjusted OR 11.2, 95% CI 2.0-61.0) and HBV genotype A (adjusted OR 7.2, 95% CI 1.5-34.8) were the only independent variables associated with the chance of harboring rtM204V. Patients with HBV genotype A or HIV co-infection were more likely to harbor the rtM204V mutation. Patients co-infected with HIV showed multiple mutations more frequently, including the triple mutation that may elicit a vaccine escape phenotype. Among patients co-infected with HIV/HBV, strict HBV DNA monitoring is essential to detect treatment failure and adapt therapy to avoid limitations of future therapeutic options or the emergence of a public health threat.

Bibbolino C, Pittalis S, Schininà V, Busi Rizzi E, Puro V. · Unità Operativa Complessa di Radiologia e Diagnostica per Immagine, Dipartimento di Epidemiologia e Ricerce Pre-Clinica, Istituto Nazionale per le Malattie Infettive Lazzaro Spallanzani IRCCS, Via Portuense 292, 00149, Roma, Italy. · Radiol Med. · Pubmed #19184331 No free full text.

Abstract: Healthcare-associated infections are a critical challenge for the public health sector. Most are acquired through contact, predominantly with the hands of health care personnel. Hand hygiene, therefore, is the single most effective measure for preventing and controlling infectious diseases. Recently, cases of acute hepatitis C occurred in patients who had undergone contrast-enhanced computed tomography. This was probably related to inadequate handling by health care staff. Rigorous compliance with standard precautions is therefore compulsory even in radiology, a setting traditionally considered at low risk for the transmission of pathogens. Adherence to standard precautions is still poor and the persistence of inappropriate practices responsible for preventable incidents is very common in radiology, often owing to underestimation of risk. Radiology units must promote compliance with correct hand hygiene through appropriate education programmes and provision of adequate areas and hand hygiene products. The evidence base to support the use of alcohol-based hand rub is demonstrating that these formulations are effective in improving hand hygiene compliance and preventing infections.

Antonucci G, Vairo F, Iacomi F, Comandini UV, Solmone M, Piselli P, Boumis E, Lauria FN, Capobianchi MR, Ippolito G, Puro V. · Clinical Department of Infectious Disease, National Institute for Infectious Diseases, L. Spallanzani, Rome, Italy. · Scand J Infect Dis. · Pubmed #18651264 No free full text.

Abstract: The role of hepatitis B virus (HBV) or hepatitis D virus (HDV) coinfections as determinants of hepatitis C virus (HCV) suppression in the setting of HIV-HCV coinfection are poorly understood. Our aim was to assess whether HCV viral replication may be affected by HBV or HDV coinfection in the setting of immunodeficiency driven by HIV.Among the 138 enrolled patients 28(20.3%) tested HCV RNA negative and 110 (79.7%) tested HCV RNA negative. The HCV RNA negative patients showed an higher rate of HBsAg positivity compared with those tested HCVRNA positive [12/28 (42.9%) and 5/110 (4.6%), respectively]. Patients with HCV-HBV-HDV coinfection had the highest chance of having an undetectable HCV RNA (adjusted odds ratio (AOR): 92.0, 95% confidence interval (CI) 5.7-1483.5, p<0.0001). Furthermore, HBV coinfection per se was also found to be independently associated with negative HCV viraemia (AOR: 18.5, 95% CI 2.4-143.5, p<0.0001). HBsAg-positive patients with negative HCV viraemia maintained undetectable levels over time. Our results support a direct role of HBV and HDV coinfections in suppressing HCV viraemia in HIV infected patients. This effect is durable over time, and is not influenced by HAART including anti-HBV drugs.

Magnavita N, Cicerone M, Cirese V, De Lorenzo G, Di Giannantonios M, Fileni A, Goggiamani A, Magnavita G, Marchi E, Mazzullo D, Monami F, Monami S, Puro V, Ranalletta D, Ricciardi G, Sacco A, Spagnolo A, Spagnolo AG, Squarcione S, Zavota G. · Istituto di Medicina del Lavoro, Università Cattolica del Sacro Cuore, Roma. · Med Lav. · Pubmed #17171984 No free full text.

Abstract: BACKGROUND: A worker is considered to be hazardous to others when, in the course of performing a specific work task, his/her health problems (e.g., substance dependence, emotional disorders, physical disability, transmissible diseases) pose a risk for other workers' or the public's health and safety, or begins to interfere with ability to function in profession life. The presence of certain illnesses or the fact that a health care worker is impaired because of them do not necessarily imply that he, or she, is hazardous for others. Working in health care increases the probability that an impaired worker being hazardous for others. Management of hazardous workers requires new techniques and procedures, and specific policies. OBJECTIVE AND METHODS: An interdisciplinary group of experts from medical, bioethical, legal and administrative disciplines, together with trade union and employers' representatives, is currently attempting to define a way to put prevention measures into practice in accordance with state laws and individual rights. RESULTS: A consensus document is presented, covering critical aspects such as: social responsibility of the employer, risk management, informed consent, non compliance, confidentiality, responsibility of workers, disclosure of risk to patients, non-discrimination, counselling and recovery of impaired workers, effectiveness of international guidelines. CONCLUSIONS: Occupational health professionals are obliged to adhere to ethical principles in the management of "hazardous" workers; the assessment of ethical costs and benefits for the stakeholders is the basis for appropriate decisions.

Yazdanpanah Y, De Carli G, Migueres B, Lot F, Campins M, Colombo C, Thomas T, Deuffic-Burban S, Prevot MH, Domart M, Tarantola A, Abiteboul D, Deny P, Pol S, Desenclos JC, Puro V, Bouvet E. · Service des Maladies Infectieuses et du Voyageur, Centre Hospitalier de Tourcoing. · Rev Epidemiol Sante Publique. · Pubmed #17073127 No free full text.

Abstract: BACKGROUND: Factors that influence the risk for HCV infection after occupational exposure to hepatitis C virus (HCV) have not yet been determined. The objective of this study was to assess potential risk factors for Hepatitis C seroconversion after occupational exposure to HCV. METHODS: We conducted a European matched case-control study from 01/01/1991 through 31/12/ 2002. Cases were Health Care Workers (HCWs) who were HCV seronegative at the time of exposure, sustained a documented exposure to HCV, and present documented HCV seroconversion temporally associated with the exposure. Controls-HCWs had a documented exposure to HCV, were HCV seronegative at the time of exposure, and remained so at least 6 months later. Controls were matched to cases for the center and the time period of the exposure occurrence. RESULTS: 60 cases and 204 controls were included. All cases were exposed to HCV-infected materials through percutaneous injuries. Those for whom information was available (61.6%) were exposed to viremic source patients. Multivariate conditional logistic regression analysis, in which HCV viral load was not introduced because of missing values, identified needle placed in the source patient's vein or artery (Odds Ratio [OR]=100.1; 95% Confidence Interval [CI]=7.3-1365.7), deep injury (OR=155.2; 95%CI=7.1-3417.2), and HCW's gender (M vs. F: OR=3.1; 95%CI=1.0-10.0) as risk factors for HCV infection. In univariate unmatched analysis the risk of HCV transmission was increased 11-fold (C195%=1.1-114.1) in HCWs exposed to sources with a viral load>6 log10 copies/mL when compared to sources with a HCV viral load<4 log10 copies/mL. CONCLUSION: The risk of HCV transmission after percutaneous exposure increases with a larger volume of blood, and, a higher titer of HCV in the source patient's blood. The role of HCW's gender need to be further investigated. The results of this study have important implications for counselling and follow-up of HCWs after exposure.

Yazdanpanah Y, De Carli G, Migueres B, Lot F, Campins M, Colombo C, Thomas T, Deuffic-Burban S, Prevot MH, Domart M, Tarantola A, Abiteboul D, Deny P, Pol S, Desenclos JC, Puro V, Bouvet E. · Service des Maladies Infectieuses et du Voyageur, Centre Hospitalier de Tourcoing, Faculté de Médecine de Lille, Tourcoing, France. · Clin Infect Dis. · Pubmed #16231252 No free full text.

Abstract: BACKGROUND: Additional studies are required to identify risk factors for hepatitis C virus (HCV) transmission to health care workers after occupational exposure to HCV. METHODS: We conducted a matched case-control study in 5 European countries from 1 January 1991 through 31 December 2002. Case patients were health care workers who experienced seroconversion after percutaneous or mucocutaneous exposure to HCV. Control subjects were HCV-exposed health care workers who did not experience seroconversion and were matched with case patients for center and period of exposure. RESULTS: Sixty case patients and 204 control subjects were included in the study. All case patients were exposed to HCV-infected fluids through percutaneous injuries. The 37 case patients for whom information was available were exposed to viremic source patients. As risk factors for HCV infection, multivariate analysis identified needle placement in a source patient's vein or artery (odds ratio [OR], 100.1; 95% confidence interval [CI], 7.3-1365.7), deep injury (OR, 155.2; 95% CI, 7.1-3417.2), and sex of the health care worker (OR for male vs. female, 3.1; 95% CI, 1.0-10.0). Source patient HCV load was not introduced in the multivariate model. In unmatched univariate analysis, the risk of HCV transmission increased 11-fold for health care workers exposed to source patients with a viral load >6 log(10) copies/mL (95% CI, 1.1-114.1), compared with exposures to source patients with a viral load < or =4 log10 copies/mL. CONCLUSION: In this study, HCV occupational transmission was found to occur after percutaneous exposures. The risk of HCV transmission after percutaneous exposure increased with deep injuries and procedures involving hollow-bore needle placement in the source patient's vein or artery. These results highlight the need for widespread adoption of needlestick-prevention devices in health care settings, together with other preventive measures.

Serraino D, Bidoli E, Piselli P, Angeletti C, Bruzzone S, Pappagallo M, Puro V, Girardi E, Lauria F, Ippolito G, Anonymous00339. · Dipartimento di epidemiologia, Istituto nazionale perle malattie infettive L. Spallanzani, IRCCS, Roma. · Epidemiol Prev. · Pubmed #15792154 No free full text.

Abstract: OBJECTIVE: To describe the global impact of infectious diseases on mortality in Italy from 1969 to 1999. DESIGN: Statistical analysis of routinely collected mortality data, using a revised definition of infectious causes of death based on target organs. SETTING: The present paper summarizes time trends of infectious disease mortality widely discussed in the Atlas "30 Anni di Malattie Infettive in Italia: Atlante di Mortalità". MAIN OUTCOME MEASURES: Age standardized mortality rates (/100,000); standardized mortality ratios (SMR); percentage of deaths attributable to infectious diseases. RESULTS: Apart from HIV infection and AIDS, infectious diseases were responsible of 1.7% of the overall mortality that occurred in Italy in the study period: 57.5% of such deaths were not included in the ICD8 and ICD9 codes for infectious diseases. The mortality for all infectious diseases showed a very strong downward trend up to 1994, (with a 6-fold decline). Thereafter, a slight increase in deaths for septicaemias, heart infections and hepatitis was recorded. Over time, an increasing proportions of deaths due to infections occurred in the elderly (i. e., > or = 65 years of age), from 48.1% in 1969-1979 to 77.3% in 1990-1999. Mortality rates were consistently higher in men than in women, and showed a substantial geographic heterogeneity. In newborns, from 1969 thru 1999 mortality rates declined 10-fold all over the country, but an inverse north-south geographic gradient persisted during the whole study period. The spread of HIV infection and AIDS epidemic in the first '80s dramatically interrupted the downward trend in infectious disease mortality outlined above. Between 1993 and 1996, HIV/AIDS was the main cause of death among Italian men aged 30 to 39 years. CONCLUSIONS: This statistical analysis allowed to better quantify the impact of infectious diseases on overall mortality in Italy. Observed time trends were in accordance to the picture recorded in other western Countries, whereas the higher newborn mortality in southern Italy reflects the persistence of geographical inequalities in the health care organization.

Angeletti C, Piselli P, Bidoli E, Bruzzone S, Puro V, Girardi E, Ippolito G, Serraino D, Anonymous00225. · Dipartimento di Epidemiologia, Istituto Nazionale per le Malattie Infettive L. Spallanzani, IRCCS, Rome, Italy. · Infez Med. · Pubmed #15711130 links to  free full text

Abstract: Our research aimed to describe infectious disease mortality in Italy between 1969 and 1999, with particular emphasis on sex, age, and geographic differences. Using mortality data provided by the Italian Central Institute for Statistics (ISTAT), we evaluated all codes of the ICD8 and ICD9 classifications to identify each cause of death attributable to infectious agents. Deaths for HIV/AIDS were excluded. Infectious diseases accounted for 1.7% of overall mortality between 1969-1999, and our approach identified 57.5% of all deaths from infections not included in the ICD8 and ICD9 infectious disease codes. Up to 1994, the mortality for all infectious diseases showed a very strong downward trend, with a 6-fold decline. This trend levelled off in 1995-1999, mainly due to increasing deaths due to septicaemias, heart infections and hepatitis. An increasing proportion of deaths due to infectious diseases occurred in the elderly, from 48.1% in 1969-1979 to 77.3% in 1990-1999. Mortality rates were consistently higher in men than in women and showed a substantial geographic heterogeneity. In the newborn, mortality rates declined 10-fold and an inverse north-south geographic gradient persisted during the study period. This exhaustive methodological approach to identifying infectious causes of deaths allows us to better define the burden of infections on mortality and register downward trends similar to those found in other industrialized countries.

De Carli G, Puro V, Ippolito G, Anonymous00318. · Dept. of Epidemiology, National Institute for Infectious Diseases, Lazzaro Spallanzani-IRCCS, Via Portuense 292, I-00149 Rome, Italy. · Infection. · Pubmed #15018469 No free full text.

Abstract: BACKGROUND: We wanted to determine the incidence of anti-hepatitis C virus (HCV) seroconversion after percutaneous exposure to infectious fluids of an anti-HCV positive source in healthcare workers (HCW) and to investigate related risk factors. PATIENTS AND METHODS: Prospective observation in 55 Italian hospitals of anti-HCV-negative exposed HCW were followed clinically and serologically for at least 6 months. RESULTS: Of 4,403 exposed HCW, 14 seroconverted (0.31%; 95% CI 0.15-0.48) after an injury with a hollow-bore, blood-filled needle (14/1,876=0.74%; 95% CI 0.41-1.25). Deep injuries increased the seroconversion risk (OR 6.53; 95% CI 2.01-20.80). Exposure to an HIV co-infected source was associated with an higher, though not yet statistically significant, risk (OR 2.76, 95% CI 0.49-10.77). Source's HCV viremia was available in 674 cases, 566 of whom tested positive, including the nine seroconversion cases for whom this information was available. CONCLUSION: The risk of acquiring HCV after percutaneous exposure seems to be lower than previously reported. Deep injury, injury with a blood-filled needle and HIV co-infection of source seem to be associated with occupational transmission. Needlestick prevention devices could decrease the risk of infection with HCV and other bloodborne pathogens in HCW.

Mele A, Ippolito G, Craxì A, Coppola RC, Petrosillo N, Piazza M, Puro V, Rizzetto M, Sagliocca L, Taliani G, Zanetti A, Barni M, Bianco E, Bollero E, Cargnel A, Cattaneo M, Chiaramonte M, Conti E, D'Amelio R, De Stefano DM, Di Giulio S, Franco E, Gallo G, Levrero M, Mannella E, Erli SM, Milazzo F, Moiraghi A, Polillo R, Prati D, Ragni P, Sagnelli E, Scognamiglio P, Sommella L, Stroffolini T, Terrana T, Tosolini G, Vitiello E, Zanesco L, Ziparo V, Maffei C, Moro ML, Satolli R, Traversa G. · Institute of Health, L. Spallanzani Hospital, Italian Association for the Study of the Liver, Rome, Italy. · Dig Liver Dis. · Pubmed #11838616 No free full text.

Abstract: Recommendations are made for controlling the transmission of the hepatitis B and hepatitis C viruses from healthcare workers to patients. These recommendations were based both on the literature and on experts' opinions, obtained during a Consensus Conference. The quality of the published information and of the experts' opinions was classified into 6 levels, based on the source of the information. The recommendations can be summarised as follows: all healthcare workers must undergo hepatitis B virus vaccination and adopt the standard measures for infection control in hospitals; healthcare workers who directly perform invasive procedures must undergo serological testing and the evaluation of markers of viral infection. Those found to be positive for: 1) HBsAg and HBeAg, 2) HBsAg and hepatitis B virus DNA, or 3) anti-hepatitis C virus and hepatitis C virus RNA must abstain from directly performing invasive procedures; no other limitations in their activities are necessary. Infected healthcare workers are urged to inform their patients of their infectious status, although this is left to the discretion of the healthcare worker; whose privacy is guaranteed by law. If exposure to hepatitis B virus occurs, the healthcare worker must undergo prophylaxis with specific immunoglobulins, in addition to vaccination.

Petrosillo N, Gilli P, Serraino D, Dentico P, Mele A, Ragni P, Puro V, Casalino C, Ippolito G. · National Institute for Infectious Diseases, IRCCS Lazzaro Spallanzani. · Am J Kidney Dis. · Pubmed #11325683 No free full text.

Abstract: To assess hepatitis C virus (HCV) incidence rates and identify determinants of infection among hemodialysis patients, a multicenter study was conducted in 58 units in ITALY: An initial seroprevalence survey was conducted among 3,492 patients already on hemodialysis therapy as of January 1997 and among an additional 434 patients who began dialysis up to January 1998. HCV antibodies were assessed by third-generation enzyme immunoassays. Patients testing seronegative at baseline were enrolled into a 1-year incidence study with serological follow-up at 6 and 12 months. For patients who seroconverted, an HCV RNA assay was performed on stored baseline samples to confirm new infection. A nested case-control study was subsequently performed to investigate potential risk factors. For each incident case, three controls negative for both HCV antibodies and HCV RNA were randomly selected. At enrollment, HCV seroprevalence was 30.0%. During follow-up, 23 new HCV cases were documented, with a cumulative incidence of 9.5 cases/1,000 patient-years. By logistic regression analysis, an increased risk for HCV infection emerged for patients attending the dialysis units with a high prevalence of HCV-infected patients at baseline (odds ratio [OR], 4.6) and for those attending units with a low personnel-patient ratio (OR, 5.4). Among extradialysis factors, a history of surgical intervention in the previous 6 months (OR, 16.7) significantly increased HCV risk. These findings suggest that the combination of understaffing and a high level of infected patients in the dialysis setting increases the risk for HCV nosocomial transmission. This is likely related to an increased likelihood for breaks in infection control measures.

Yazdanpanah Y, De Carli G, Bouvet E, Puro V. · No affiliation provided · J Infect Dis. · Pubmed #16518770 No free full text.

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De Carli G, Puro V, Scognamiglio P, Ippolito G, Anonymous00187, Anonymous00188. · No affiliation provided · Clin Infect Dis. · Pubmed #14689357 No free full text.

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Magnavita N, Puro V. · No affiliation provided · J Clin Virol. · Pubmed #12878096 No free full text.

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Magnavita N, Placentino RA, Puro V, Sacco A. · No affiliation provided · Arch Intern Med. · Pubmed #12824103 No free full text.

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Magnavita N, Iavicoli I, Placentino RA, Sacco A, Puro V. · No affiliation provided · Hepatology. · Pubmed #12774032 No free full text.

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Jagger J, Puro V, De Carli G. · No affiliation provided · JAMA. · Pubmed #12243628 No free full text.

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