The aim of this retrospective, multicenter, epidemiological study was to investigate the prevalence of tropical diseases in immigrated patients hospitalized in Italian infectious disease clinics during 2002. Imported tropical diseases were found in only a few patients, representing 6% of the total of hospitalized immigrants, with a prevalence of malaria (95 cases [79.2%]), whereas prevalent infectious diseases included HIV infection (16%), tuberculosis (13%), and acute or chronic viral hepatitis (12%). We have compared our data with the results evidenced in other Italian and European reports, and we have observed that also in these studies, the rate of tropical diseases in immigrants was very low, with an evident prevalence of malaria.10,11,13-15 The only difference concerned the proportion of patients arriving from Asia and South America; in fact, although in our and in the other Italian studies, the major part of patients come from Africa (90% in our experience), in some European studies, the distribution of patients according to country of origin was different, with many cases of malaria, particularly caused by P. vivax, not only in subjects coming from Africa, but also in patients coming from Asia and South America. Italy, in fact, is the most important reference point for immigrants from Africa and East Europe, although in the last 10 years, the migratory flow toward our country of Asiatic and South American subjects is decreased, and it is increased in other European countries, such as Germany and France.3,4 Thus, our experience, in accordance with literature, evidences that only a few tropical diseases have been imported, and therefore, immigrants should not be considered as infectious disease carriers. Economic need is the principal factor of immigration movement, and these people come to Italy principally to work and it justified the need for relatively young and healthy workers; for this reason, most immigrated people are healthy when they arrive in Italy, whereas ill subjects are unable to enterprise the migratory flow. The range of health issues in these people became inevitably broad after their arrival in Italy, and it included infectious diseases such as HIV infection, tuberculosis, hepatitis, and other diseases such as respiratory or gastrointestinal disorders, directly correlated with the condition of poverty present in many immigrant communities (deficiency of food, unhealthy condition of life, promiscuous sexual relationships).5,6,8
Malaria has represented the prevalent tropical infection, and in literature, it is evident that cases of imported malaria in immigrants are likely to increase in the next few years in many European countries, with the emergence of increasing resistance of parasites to several antimalarial drugs.16 Reports of malaria are increasing in many countries and in areas thought free of the disease, as Italy, and actually it is endemic in 92 countries, with each year having 300 million to 500 million clinical new cases of infection, particularly in the African regions (80%-90% of the total cases in the world).17 In Italy, there are about 500 to 600 new cases per year of imported malaria, and half of these cases are observed in immigrated subjects, whereas the other cases concerned Italian people with a recent temporary stay in an endemic area.18 Thus, the most important factor contributing to the reemergence of this historical disease is human migration. For this reason, it is necessary that any immigrant, or Italian subject, with fever who has traveled to a malaria-endemic area in the last year should be screened with a blood smear for malaria as soon possible.
Most patients affected by tropical diseases were hospitalized in the northern regions of Italy (64.2%) versus 25% in the central regions and 8.5% in southern area. This simply reflects the disparity of immigrant distribution in Italy and indicates that southern Italy is only an arrival point leading to a location in the northern regions.4,5 Another important result regards the resident status of all patients (clandestine or legal resident). In fact, in our population, most of the patients were clandestine, and only 22 (18.3%) people had a regular residence permit and were covered by the National Health Service. These data are in contradiction with other studies that evidenced that most immigrants hospitalized in Italy, independent of the admission diagnosis, have a regular residence permit, whereas clandestine prevents, if possible, any relationship with public structure.9 This difference is probably connected to the relevant clinical aspects of some tropical infections, such as malaria, often well known by these patients, with an inevitable hospitalization.
According to our experience, we can conclude that:
1. The range of health problems in immigrants often became broad after their arrival in Italy and included infectious diseases, such as HIV infection, tuberculosis, and viral hepatitis (the prevalent diseases in hospitalized immigrated patients), which reflect their poor conditions in life.
2. The international community should establish a set of priorities to reduce poverty and social inequalities that facilitate and maintain epidemic infections, such as malaria, in many areas of the world, and all these interventions should provide the involvement of local governments.19,20
The Italian Group for Immigrants Infectious Diseases Study includes:
L. Sacco Hospital Milano (T. Quirino, MD), San Salvatore Hospital Pesaro (M. Calducci, MD), Spedali Civili Hospital Brescia (G. Cadeo, MD), Universitari Clinic Brescia (I. El-Hamad, MD), Civile Hospital Ascoli Piceno (N. Vitucci, MD), Misericordia Hospital Grosseto (M.P. Allegri, MD), S. Carlo Hospital Potenza (B. Piretti, MD), Umberto I Policlinic II Hospital Division Roma (A. Paffetti, MD), Hospital Risceglie (R. Losappio, MD), Hospital Perugia (C. Sfara, MD), Universitari Clinic Foggia (G. Scotto, MD), S. Maria Goretti Hospital Latina (G. Salome, MD), Universitari Clinic Bari (P. Maggi, MD), C. Poma Hospital Mantova (S. Miccolis, MD), Umberto I Policlinic I Hospital Division Roma (A. Brogi, MD), Bambino Gesù Hospital Roma (L. Lancella, MD), S. Maria Annunziata Hospital Firenze (A. Gabbati, MD), Civile Hospital Legnano (M. Villa, MD), Hospital Biella (A. Salatino, MD), Universitari Clinic Ancona (D. Drenaggi, MD), II Universitari Clinic La Sapienza Roma (Prof. M. Ciardi), Umberto I Hospital Frosinone (M. Limodio, MD), Umberto I Policlinic III Hospital Division Roma (Prof. S. Delia), Universitari Clinic Catania (E. Caltabiano, MD; G. Cosentino, MD), Hospital Catania (M. Raspaglieli, MD), Hospital Avezzano (R. Mariani, MD), Universitary Clinic Bologna (S. Sabbatani, MD), Hospital Asti (A. Casabianca, MD), Hospital Cremona (D. Galloni, MD), S. Anna Hospital Ferrara (M. Pantaleoni, MD), Hospital Formia (F. Purificato, MD), S. Antonio Hospital Trapani (V. Portelli, MD), Hospitial Aosta (R. Chasseur, MD), Basilotta Hospital Nicosia (B. Benenat, MD), Hospital Campobasso (P. Sabatini, MD), Hospital Ravenna (G. Bellardini, MD), Hospital Trieste (A. Valencic, MD), Hospital Macerata (P. Milini, MD), Hospital Modica (F. Sebbia, MD), Universitari Clinic Chieti (Prof. E. Pizzigallo), Pugliese-Ciaccio Hospital Catanzaro (P. Scerbo, MD), Hospital Pescara (A. Consorte, MD), Hospital Varese (M. Gioia, MD), Hospital Caserta (G. Coviello, MD), Universitari Clinic Verona (A. Azzimi, MD), Papardo Hospital Messina (M. Allegra, MD), Gaslini Hospital Genova (G. Losurdo, MD), and Galliera Hospital Genova (P. Cristalli, MD).
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