A complex European surveillance system collects epidemiological data on sexually transmitted infections in 30 EU member states, available on the European Centre for Disease Prevention and Control (ECDS) website.
Most countries report gonorrhea data from comprehensive surveillance systems (24 countries). Three have sentinel systems that capture only gonorrhea diagnoses from a selection of health services (Belgium, France, and the Netherlands); these systems are based on voluntary reporting. All countries with comprehensive surveillance systems have mandatory reporting with the exception of the United Kingdom.
In 2017, 89,239 confirmed cases of gonorrhea were reported in 27 countries, a 17 percent increase from 2016.
The United Kingdom reported 55% of all reported cases in 2017, which represents one of the highest rates in 2017 (>25/100 000 population).
The crude reporting rate in 2017 was 22.2 per 100,000 population for countries with comprehensive surveillance systems, an increase of 22% from 2016.
Figure 1 shows the distribution of gonorrhea rates among countries reporting from comprehensive surveillance systems.
Gender and Age
The reporting rate was 35 per 100,000 population among men (61,390 cases) and 11 per 100,000 population among women (19,320 cases). The highest male-to-female ratios were reported by Poland, Croatia, and Romania; while Cyprus reported no cases among women.
Age information is available for 23.
Most of the cases reported in 2017 were among the age groups 25-34 years (37 percent of cases) and 15-24 years (36 percent of cases).
Among the older age groups, rates were highest among males. The highest age- and gender-specific rates were among males aged 20-24 years (124 per 100,000).
Transmission
In 2017, 17 countries (accounting for 77 percent of reported gonorrhea cases) also reported data on mode of transmission for 60 percent or more of their cases.
- 47% of all cases involved men who have sex with men (MSM);
- 45% were reported among heterosexuals;
- 9% of cases, the transmission group was reported as "unknown."
Data on HIV status were also provided by only a few countries in the surveillance system
(accounting for 81% of all reported gonorrhea cases).
Of these 72,266 cases, information on HIV status was available for 48,568 cases (67%).
Among cases with known HIV status, 14% were HIV-positive (either known or newly diagnosed).
Among MSM (31,693 cases), HIV status was known for 27,055 cases (85%).
Of these, 22% were HIV-positive.
Trends 2008-2017
From 2008 to 2017, 558,155 confirmed gonorrhea cases were reported in 29 countries, with varying degrees of data completeness during this period.
During this period, rates in men have been consistently higher than women.
Rates have more than doubled for both sexes since 2008, but the increase has been more pronounced among men (+190%) than among women (+127%).
The number of reported cases from 2008 to 2017 increased in 20 of the 28 reporting countries.
The largest increases since 2008 in countries reporting more than 15 cases each year were reported by France and Portugal, Denmark and Ireland.
Conclusions
With 89,239 cases reported in 2017, gonorrhea is the second most reported sexually transmitted infection (STI) in the EU/EEA after chlamydia. The overall gonorrhea notification rate increased again in 2017, after a slight decrease in 2016.
Increasing notification rates were reported by most countries with some notable year-on-year increases, for example in Finland and Sweden, where the number of cases increased by more than 40 percent.
The high rate of gonorrhea infections reported throughout the EU indicates the persistence of high levels of risk behavior. This is of particular concern considering the high levels of azithromycin resistance reported in the latest data from the European Gonococcal Antimicrobial Surveillance Program.
The data show that the dual treatment regimen currently recommended for gonorrhea (ceftriaxone and azithromycin) may be ineffective due to the growing phenomenon of antibiotic resistance.
The upward trend in the number of gonorrhea cases reported in many countries continues to be driven primarily by the increase in MSM cases, but increases among heterosexual women were also reported from 2016 to 2017.
The increase in reported cases of MSM could be related to an increase in risk behavior, perhaps in some cases also related to changing sexual behavior with the use of HIV pre-exposure prophylaxis.
The United Kingdom reported more than half of the total number of EU/EEA cases in 2017. High rates (over 15 per 100,000 population) were reported in Denmark, Iceland, Malta, Norway, Spain and Sweden. This geographic pattern has remained stable in recent years. The variation in rates could be related to real differences in the incidence of infection. However, there are important differences across Europe in terms of testing policies and methods, health care systems and access to services, the role of private health care providers, and the inclusion of data in reporting systems and surveillance system structures.
Undoubtedly, the urgency to strengthen preventive prevention efforts remains well-established, particularly to increase the uptake of testing and the frequency of testing in those most at risk.
For the past few years much discussion has been going on regarding vaccinations: there are those who strongly support the need for them and those, on the other hand, who even demonize them; often debates on the topic have turned into fierce clashes or political instrumentalization. Even through social networks or through the Internet, all kinds of theories and statements have passed, as well as through ministerial, regional, and municipal circulars. In this chaotic succession of rumors, interviews, communications and stances, we risk losing sight of the foundational aspect: ensuring effective and scientifically valid protection for the individual and the community.
Let us then take stock of today's vaccine situation objectively and with the support of clinical evidence on the subject. A statistically significant and scientifically proven fact, for example, is the following: today serious diseases identified until a few years ago as "rare" or "eradicated" have resumed spreading threateningly in Italy.
The law
The law on compulsory vaccinations (Legislative Decree No. 73 of June 7, 2017, converted by Law No. 119 of July 31, 2017, as amended, www.salute.gov.it/vaccini) has been in effect for some time now. The Ministry of Health, through a circular on the new provisions on vaccinations, explains why the choice was made to introduce mandatory certain specific vaccines: since 2013, there has been a gradual decline in the use of vaccinations, both mandatory and recommended. This has meant that, for some diseases, vaccination coverage has fallen below that 95 percent of the citizenry indicated by the World Health Organization as the minimum threshold for so-called "population immunity. " Only above this threshold, for certain infectious diseases, is it guaranteed that the responsible microorganism actually stops spreading, protecting even those who cannot be subjected to direct prophylaxis or do not respond to vaccination.
Particularly worrisome are the figures for measles and rubella vaccinations, which lost as much as 5 percentage points from 2013 to 2015, from 90.4 percent to 85.3 percent, also undermining our country's international credibility, which threatens to derail WHO's "Global Plan for Elimination," in which we have been engaged since 2003, as the prerequisite for declaring the elimination of an infectious disease from a WHO region is that all member countries be declared "free."
Mandatory vaccinations
There are 10mandatory vaccinations, in the pediatric range from zero to 16 years; the obligation covers both first doses and booster shots and also affects unaccompanied foreign minors.
The 10 mandatory vaccines are as follows:
Those born from 2017 onwards will have to take them all, according to the schedule set out in the National Vaccine Prevention Plan 2017-2019. Those born from 2001 to 2016, on the other hand, are exempt from the varicella vaccine, because at the time they should have been vaccinated, the obligation in this regard was not included in the calendar then in force.
For measles, mumps, rubella, and varicella vaccines, the law stipulates that the obligation provision should be reviewed every three years: in fact, consistent with data on the spread of diseases and vaccination coverage, the obligation could be lifted.
What happens if mandatory vaccines are not taken
If a child or adolescent is not in compliance with the vaccinations required by law, and if his or her parents refuse to bring him or her into compliance even after being summoned by the ASL for the information interview, first there is a fine: from 100 to 500 euros.
In the case of grouped vaccinations, the fine is a single one; for example, parents who should subject their three-month-old baby to the six vaccinations on the calendar (against polio, diphtheria, tetanus, whooping cough, Haemophilus and hepatitis) if they do not comply with the relevant obligation will be fined only one fine, not six; following payment, the obligation towards those vaccinations is considered extinguished. The same family, however, may face a new fine if they fail to subject their child to subsequent vaccinations (measles, mumps, rubella and chickenpox, at 13-15 months).
Regardless of the fine payments, a child who has not undergone the mandatory vaccinations will not be allowed to enter kindergartens and preschools. He or she will be able to access compulsory schooling instead.
Recommended vaccines
The circular also reports that, by law, the following vaccinations must be offered free of charge to parents of newborns:
- antimeningococcal B;
- antimeningococcal C (in the first years of life), or tetravalent antimeningococcal ACWY in adolescence;
- antipneumococcal;
- antirotavirus;
In addition, there is HPV (papilloma virus) vaccination in adolescence for both males and females.
These vaccines are optional because they prevent diseases that are less common in our country, or not particularly contagious, but are strongly recommended by all Scientific Societies.
Exemptions
Vaccination can be waived in three cases:
If the child has already contracted the disease against which he or she was to be vaccinated; this condition must be certified through a notification from the treating physician, to which a blood test attesting to the presence of protective antibodies must be attached; The test is not free, but charged to the person requesting it; instead, the law provides that it is free for the family to receive the certificate from the treating pediatrician.
If the vaccine against the disease already contracted is contained within multicomponent formulations; the family may request that the child be vaccinated only for the other diseases, with single-component vaccines or combined vaccines, but without the antigen in question.
It should be pointed out, however, that it is not certain that these vaccines will be available. At present, for example, no single-component vaccines against diphtheria, pertussis, measles, rubella, and mumps are licensed in Italy. And even if they were, it is not necessarily always possible to obtain them.
The circular specifies, therefore, that if "special" formulations are not available, prophylaxis should be completed with existing combination vaccines, stressing that there is no contraindication to vaccinating those who have already had the disease. For that matter, combined vaccines should not be of much concern, both because the child's immune system is perfectly capable of receiving several "active ingredients" at the same time, and because such vaccines also contain fewer excipients than the sum of monovalent ones; moreover, as Prof. Pier Luigi Lopalco points out, "they reduce the number of adverse events, such as febrile convulsions or severe allergic events, which is related to the number of administrations."
The other possibility of exemption occurs when the vaccine itself poses a health hazard to the child. In cases where the individual has had a severe allergic reaction to a dose of a vaccine, or to a component of it, further vaccination is absolutely contraindicated. In contrast, the presence of a severe or moderate illness, with or without fever, is not in itself an absolute contraindication: the risk-benefit ratio should be assessed on a case-by-case basis to decide whether or not to vaccinate.
The following are contraindications (Italian Society of Pediatrics, Italian Federation of Pediatricians, Italian Federation of General Practitioners, Italian Society of Hygiene, Ministry of Health)
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What is the vaccine
By definition, a vaccine is a preparation aimed at the production of protective antibodies by the body, conferring specific resistance against a given infectious disease. It consists of the antigen (viruses or bacteria or their parts or products or attenuated or inactivated synthetic substances), the suspending liquid (often sterile distilled water or sterile saline) and preservatives (Aluminum salts, also used as adjuvants). It should be mentioned that mercury-based preservatives have been abandoned since 2002 due to the disappearance of the multi-dose packages for which it was used, as well as the media attention that exploded at that time.
Vaccines, therefore, are pharmaceutical products consisting of very small amounts of killed or attenuated microorganisms (viruses or bacteria) capable of causing an infectious disease. Vaccines are designed so that the microorganisms lose their infectiouscapacity (i.e., to generate disease) but not their immunogenic capacity (i.e., the ability to trigger the immune defense reaction).
Vaccines use our body's natural defense mechanism to build specific resistance to infection. This immune defense, similar to that which is triggered by disease, protects against attack by microorganisms in the environment and people in our community without developing the symptoms and complications of disease.
By using this strategy, viruses are weakened so that they reproduce with great difficulty within the body. Vaccines against measles, mumps, rubella and chickenpox are made in this way.
Natural viruses cause disease by multiplying thousands of times in the body; attenuated viruses in vaccines, on the other hand, usually replicate no more than 20 times, and for this reason are unable to cause disease.
The advantage of live "attenuated" viruses is that one or two doses of vaccine result in lifelong immunity.
The limitation of these vaccines is that they generally cannot be given to people with immune system defects.
Viruses that are completely inactivated (or killed) by chemical systems, on the other hand, cannot multiply. The advantage of this approach is that the vaccine cannot cause, even in a mild form, the disease it prevents and can be given even to people with compromised immune systems.
The limitation is that multiple doses of vaccine must be given to ensure immunization.
In conclusion.
In view of the objective data reported and what has been highlighted so far, we recommend that every parent should constantly pay the utmost attention to the welfare and health of their children, with special reference to those with fragile conditions or pathological states.
We also recall that, for the good of the individual and the community, it is imperative to adhere to current health regulations, such as those related to vaccinations: safeguarding health is a right but also a duty of every citizen. It is also most important to seek the advice of experts and to document ourselves in order to properly understand and investigate the psycho-physical state of minors; in this way, in compliance with the common rules, we will be able to consciously make the correct choices for prevention, care and health protection.
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