Why compulsory notification of human cystic echinococcosis should be reintroduced in Italy

In Italy, compulsory notification of human cystic echinococcosis (CE) to the Italian Ministry of Health was discontinued in 1991, and under the current legislation, the Ministry requires only a summary of the regional cases. Therefore, data of CE no longer reach the Central Institute of Statistics (ISTAT), making the assessment of human CE occurrence even more difficult. It should be noted that, according to the European Directive 2003/99/CE, the Italian regulations (Legislative Decree 4 April 2006, No. 191) officially included CE among zoonoses under surveillance. Thus, it is up to the individual physician’s goodwill to notify individual cases to the Local Health Unit, which in turn will fill out an electronic record to be transmitted to the Health Regional Council, which in turn will transmit the data to the Italian Ministry of Health. Unsurprisingly, with regard to Italy, the ECDC-EFSA Community Summary Reports (2003-2008) on trends and sources of zoonoses indicate that only 1 case (imported) of CE was reported in 2003 and that no surveillance system exists. This contrasts with hundreds of cases per year reported in single Italian Regions, when research was done using different methods and information, e.g. Hospital Discharge Records (HDRs). Diagnosis of human CE relies on modern imaging techniques, with ultrasound (US) being the most frequently used, complemented by serology. The widespread use of US has shown that the cysts go through different stages of involution, either spontaneously or as a result of non-surgical therapies (medical treatment with benzimidazoles and percutaneous treatments) The use of US has spawned several sonographic classifications over the years. Recently, the WHO Informal Working Group on Echinococcosis issued a standard ultrasound classification of echinococcal cysts based on their ultrasound appearance. In this classification, cysts are grouped as active, transitional and inactive, and determining the cyst stage has important consequences for clinical management and prognosis. No case of acute CE has ever been reported, so incidence is generally related to the first diagnosis of the disease, irrespective of cyst stage. Reports based on surgery-based surveys are known to greatly underestimate rates of infection. Several papers published in the last years evaluated a mean incidence of 1.3 cases/100,000 inhabitants in Italy. CE is most prevalent in the southern regions and in the islands of Sardinia (4-8 cases/100,000 inhabitants) and Sicily (Pozio E, 2008, Parassitologia 50: 17-24; Garippa G & Manfredi MT, 2009, Vet Res Commun 33, Suppl 1: 35-39). Some studies performed in some regions analyzed the HDRs in order to estimate the occurrence of CE. In Emilia-Romagna, the mean yearly incidence (1997-2002) in Italian citizens residing in the region was 1.07/100,000 inhabitants; the average incidence of persons born in Italy was 0.97/100,000. The existence of an area in the Apennines between the provinces of Reggio Emilia and Modena with a significantly higher risk and incidence (7.1/100,000) similar to that encountered in areas considered endemic, was demonstrated (Battelli G et al, 2004, Parassitologia 46: 415-416). In Lombardy, in 2004, there were 156 admissions for CE; of the patients, 72% resided in the region (Brunetti E et al, 2006, Parassitologia 48: 220). In Tuscany, the mean yearly incidence (1995-2001) in citizens residing in the region was 1.61/100,000 (Montinaro L et al, 2004, G Ital Med Lav Erg 26: 202-207). In Apulia, the period prevalence of hepatic CE during the years 1996-2000 was 6.4/100,000 (Punzo C et al, 2002, Ann Ital Chir 73: 605-609). In Sardinia, the mean yearly incidence (2001-2005) in citizens residing in the region was 6.6/100,000, rising to 10.6/100,000 in the Nuoro province (Conchedda M et al, 2008, Parassitologia 50, Suppl 1: 40). True occurrence of human CE is probably best assessed by ultrasound mass surveys, an increasingly popular method in highly endemic...