Gianmarco D'Alessio

CURRENT WEATHER IN ITALY AND SHORT-TERM FORECAST

UPDATES TO 23 April 2023

WEATHER TENDENCY FOR SUMMER 2023: Seasonal forecasts

After the Winter ’22/’23 characterised by almost spring-like temperatures with a prevailing drought, the first part of Spring was characterised by rain and thunderstorms, localised but strong. A trend that is now well established. But these rains have not solved the serious problem of drought.
The forecasts confirm the trend of recent years. Summer 2023 will be marked by above-average temperatures of between +1.5°C and +2°C between June and July, in Italy but over most of the European continent.

For the countries of the Mediterranean basin, and in particular for Italy due to the infamous African anticyclone, heat and humidity will dominate. Until 10-15 years ago, the high pressure of the Azores, coming from the Atlantic, was characterised by mild air is
bearable. In recent years, on the other hand, we are witnessing an increasing presence of hot air masses from North Africa. Strong and persistent heat waves enveloping Italy but taking over the whole of Europe.
Very high temperatures between June and July (Source: ECMWF)

Climate change is becoming more and more evident and pressing, everywhere. Studies have always shown that among the effects of the changing climate, the increase in the frequency of heat waves is a constant.
The humidity, or rather the mugginess, creates a condition of unbearable heat. The reason lies in the characteristics of the ‘boot’: in fact, the ‘mare nostrum’ enriches the hot air masses arriving from the African continent with humidity, causing a series of negative effects in the organism.

In addition to increased physical discomfort, excessive perspiration, heart and lung problems for those already suffering from them, and much more.
Another problem is the risk of extreme weather events. Heat causes an increase in potential energy at play and thermal contrasts. This facilitates the development of massive storm cells, up to 10 to 15 km high. The risk of hailstorms, even tornadoes, is increasing.
For the month of August, the very long-term forecasts indicate very high temperature values above the averages we are used to.

All of this will have health repercussions for each and every one of us. We will soon begin to address the questions of how to defend ourselves against these events

THE EFFORTS OF THE EUROPEAN ENVIRONMENT AGENCY

From ECMWF European Centre for Medium-Range Weather Forecasts

Climate: Italy’s mild and temperate climate is certainly one of the factors that attracts millions of tourists every year. Only rarely do we have temperatures higher than 38°C in summer or below 8 degrees below zero in winter. The influence of the two mountain systems (Alps and Apennines) and the presence of the sea contribute to determine as many as 6 climate zones. Alpine: with long, very cold winters and abundant snowfall. Summers are short and cool, with frequent rainfall in spring and autumn. Padana: less long but cold and wet winters and muggy summers. Rainfall is frequent in spring and autumn. Ligurian-Tyrrhenian: the winters are warm and the summers hot but windy make it the ‘ideal’ climate. Spring and autumn rains are abundant, especially in the Ligurian region. Apennine: with cold winters and cool summers. Rains are frequent in autumn. Adriatic: cold but not too long winters, hot and not too sultry summers. Rainfall is moderate in autumn and winter. Mediterranean: winters are warm and allow swimming in the sea until late October, summers are very hot and long. Rainfall is only frequent in winter.

Malarone: an increasingly ineffective preventive drug. At the “Cesmet Traveller’s Clinic”, book consultations for information on malaria prevention; assistance during the trip with the THCARD insurance; specialised laboratory tests and tropical examinations on return. Call 0639030481 or write to ambulatorio@ cesmet.com

“Atovaquone-Proguanil (Malarone): the drug has been on the market for almost 30 years. For more than a decade, its efficacy has been declining due to an increase in plasmodium resistance to the drug.  The countries of South East Asia were the first where this type of resistance appeared and grew. Doxycycline 100 mg has been indicated for years in these areas. Increased resistance of the malarial parasite to these molecules has also been shown in many African and Latin American countries. This increase in parasite resistance to Atovaquone has forced the drug’s use in therapy to be avoided. Indeed, to treat malaria, Malarone has for years been replaced by combination drugs based on Artemisia, a principle that is still particularly active on Plasmodia. And if the parasites are so strongly resistant that this molecule cannot be used, it has also often proved to be fallacious in prevention. And this resistance continues to spread and increase in many areas of the equatorial and intertropical belt. And this is proven by clinical practice. More and more cases of malaria are occurring while taking the drug as chemo prophylaxis.
The drug is generally well tolerated although several people complain of adverse effects.  For this reason, when prescribing Malarone for use in prophylaxis, some travellers complain about the potential deleterious effects of this drug on their metabolism and in particular on their ‘poor liver’. In malaria prevention, however, the opposite is true: if a traveller falls ill with malaria, the problems for the ‘poor liver’ will be real and serious. Point necrosis of liver cells is typical of the disease. Liver toxicity from Malarone at preventive and therapeutic doses is absent. The drug was put on the market after years of research into its safety. The most common complaints are discomfort and heaviness in the stomach, vomiting, fever, headache, mild insomnia, cough, and rare cases of hair loss.

Contraindications
When Malarone should not be used

In case of allergy to atovaquone, proguanil hydrochloride or any of the other components of this medicinal product.
In case of severe renal disease.
Malarone is contraindicated in patients with intolerance to the drug and renal insufficiency.
Its use during pregnancy is still not recommended, although definite data on possible teratogenicity in the foetus have never been provided. On the other hand, with regard to the time interval between discontinuation of the drug and conception of a child, a very conservative estimate is that one month is more than sufficient. Thus, after a trip to tropical territory, even a few weeks after stopping taking malarone are sufficient to become pregnant without worry. And if one has taken the drug and become pregnant while taking it, one should not think about malarone because the data tell us that there are no negative effects on the foetus in such cases. Children weighing less than five kilograms should not take the drug while breastfeeding.

It continues to be used and prescribed, mainly for prophylaxis and less so for treatment, but as the drug’s efficacy is greatly reduced, if suspicious symptoms, malaise, tiredness, heaviness of the head, and perhaps fever and chills appear after a trip, do not hesitate to immediately ask for a malaria test and a specialist visit.

How to use Malarone in malaria prophylaxis

Malarone should be taken on a full stomach, or after drinking milk, to facilitate absorption, at a dose of one tablet per day, from one day before departure, for the duration of the stay, and up to seven days after return from the malaria-risk zone. Always at the same time of day.

The paediatric dose to be administered to children is shown in the following table:

Daily dosage    

Body weight Atovaquone (mg) Proguanil (mg) No. of tablets
11-20 62.5 25 1 cpr of Malarone Children
21-30 125 50 2 cpr of Malarone Child
31-40 187.5 75 3 cpr of Malarone Children

40 250 100 Persons over 40 kg should take 1 cpr per day of Malarone 250/100 mg

Undesirable effects
What are the side effects of Malarone

Like all medicines, this medicine can cause undesirable effects in some people.

Very common side effects

Headache, dizziness, nausea and vomiting, stomach upset, diarrhoea, insomnia, strange dreams, depression;

Allergic reactions also important but very rare: rash and itching; difficulty breathing; sudden swelling of eyelids, face and lips; rarely rashes.

Mechanism of action

The constituents of Malarone, Atovaquone and Proguanyl hydrochloride, interfere with two different pathways involved in the biosynthesis of pyrimidines, which are required for replication of Plasmodium nucleic acids. This dual mechanism is synergistic and particularly effective.
The mechanism of action of Atovaquone is through the inhibition of mitochondrial electron transport at the cytochrome bc1 complex and a fall in mitochondrial membrane potential. Proguanyl hydrochloride inhibits ‘dihydrofolate reductase’, a key substance in the reproduction of malaria parasites: these two molecules have for years formed the framework for highly effective prophylaxis.

Malarone has a different mechanism of action from the other drugs, i.e. a causal activity: it blocks the malaria parasites inside the liver cells. Proguanil has an antimalarial activity independent of its metabolisation into ‘cycloguanil’, and proguanil, but not cycloguanil, is able to enhance the ability ofatovaquone to break down the mitochondrial membrane potential in malaria parasites. This latter mechanism could explain the synergy observed when ‘atovaquone and proguanil’ are used in ssociation.

A bit of history

When Wellcome launched Atovaquone for the treatment of ‘Pneumocystosis’ in AIDS patients more than twenty years ago, they perhaps did not think that, on the one hand, the clinical course of HIV+ patients would change so radically within a few years, but also that the molecule would become important in the treatment of another parasitic disease, malaria. Treated with Malarone, in fact, pneumocystosis, a lethal manifestation secondary to the dreaded viral infection, decreased in prevalence. The valuable antiprotozoal (anti-parasitic) properties could still be recovered at the clinic, and the combination of Atovaquone and Proguanil, a chemotherapeutic drug, was conceived to treat a no less important disease: Plasmodium malaria.

The resulting drug was called Malarone and was intended for use in prophylaxis but also in the treatment of malaria. Malarone tablets currently contain: Atovaquone 250 mg / Proguanil hydrochloride 100 mg.

Read the full sheet

Compulsory vaccinations
YELLOW FEVER se….

YELLOW FEVER: Any person (except children under 9 months of age), arriving by air or sea without a certificate of vaccination is isolated for a maximum of 6 days, (i) if he/she has left an area where there is a risk of transmission of the disease less than 6 days before his/her arrival or (ii) if it has passed through one of those areas in transit, with the exception of those passengers and crew members who, for the duration of their transit through an airport situated in an area where there is a risk of transmission of the disease, stay in the buildings of the airport, provided that the airport doctor allows this exemption or (iii) if it has arrived in a ship which has left or touched a port situated in an area where the risk of transmission of the disease is present less than 30 days before its arrival in India, unless that ship has been disinfected in accordance with the procedure laid down by WHO, or (iv) if it has arrived in an aircraft which, having been in an area where the risk of transmission of the disease is present, has not been disinfected in accordance with the provisions of the Indian Air Navigation (Public Health) Regulations, 1954 or the provisions recommended by WHO. The following countries and areas are considered to be at risk of transmission: -Africa: Angola, Benin, Burkina Faso, Burundi, Cameroon, Chad, Congo, Ivory Coast, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea Bissau, Equatorial Guinea, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Central African Republic, Democratic Republic of Congo, Rwanda, Senegal, Sierra Leone, Sudan, South Sudan, Togo, Uganda. -America: Argentina, Bolivia, Brazil, Colombia, Ecuador, French Guiana, Panama, Paraguay, Peru, Suriname, Trinidad and Tobago, Venezuela. Note: When a case of yellow fever is reported in a country other than those mentioned above, that country is considered by the Government of India as an area where the risk of transmission of the disease is present and is added to this list.

This country considers the Yellow Fever vaccination certificate valid for life (amendment 0MS 11.07.2016). However, we recommend direct verification before travelling, considering the constant changes in the regulations of individual countries.

Updated January 2023

Recommended vaccinations
HEPATITIS A

read more….

EPATITIS B

read more….

TYPHOID FEVER

read more….

POLIO

read more…

DIARRHOEAL AND CHOLERIFORM SYNDROMES

• Vaccination is not compulsory, but should be considered depending on the type of trip and stay, and above all on the epidemiological situation of the country at the time of the trip. The new ‘oral’ formulation of the cholera vaccine now also protects against intestinal infections caused by many enterotoxic agents that cause ‘traveller’s diarrhoea’. The vaccine is therefore recommended for travel to many countries in the world.

TETANUS

read more…

ROUTINE VACCINATIONS

Make sure you have had all the vaccinations required by the National Health System. These include: tetanus, diphtheria, polio, pertussis, haemophilus B, hepatitis B, measles, mumps, rubella, chickenpox.

JAPANESE ENCEPHALITIS

Japanese Encephalitis is a viral disease carried by mosquitoes of the genus Culex, endemic in a vast area of Asia, from China to Australia, from Pakistan to Japan and the Philippines.
Transmission is generally predominant in agricultural and rural areas, often associated with rice production,
but more and more cases are also found in large urban agglomerations.

Learn more about malaria
WHAT IT IS

Malaria is an infectious, acute disease present in the country, very much linked to wet, rainy environments, seasons and weather conditions. Check your travel itinerary and the weather conditions in the areas where you will be staying before you leave. Remember that Malaria is a potentially serious and even fatal disease. Do not underestimate it. It can be prevented by paying attention to clothing that covers your uncovered parts at sunset and at night, the use of repellents and the use of appropriate prophylaxis drugs in the seasons of greatest risk.

IN THE COUNTRY

The risk of malaria (P. vivax 50%, P. falciparum 40%, P. malariae and P. ovale rare) exists year-round throughout the country, including the cities of Bombay (Mumbai) and Delhi, except in areas > 2,000 m (6,562 ft) in Himachal Pradesh, Jammu and Kashmir and Sikkim . 

Updated to January 2023

from CDC- YELLOW BOOK 2020

PROFILASIS

It is advisable to enquire at specialised centres about the need for pharmacological prophylaxis and with which drug.In areas at risk for Pl. Vivax the use of Chloroquine is recommended, without other drugs; in other areas, where the presence of Pl. Falciparum, the use of the following drugs is recommended: doxycycline, above 12 years of age, even for prolonged periods, in adventurous stays, in tents, or for treccking, or atovaquone-proguanil, in the under-12 population, and in the adult population, as an alternative to bassado.

It is advisable to inquire at specialised centres about the need for pharmacological prophylaxis and with which drug. In areas at risk for Pl. Vivax, the use of Chloroquine is recommended, without other drugs; in other areas, where Pl. Falciparum the use of the following drugs is recommended: doxycycline, over 12 years of age, even for prolonged periods, in adventurous stays, in tents, or for trekking, or atovaquone-proguanil, in the under-12 population, and in the adult population, as an alternative to doxycycline.
Mefloquine, in young adults in good health and subjects free of cardiovascular, neurological and psychiatric diseases. Do not use in states of anxiety and in cases of insomnia.

RETURN

In the event of fever, diarrhoea or otherwise feeling unwell, it is essential to consult a specialist doctor or expert in tropical diseases without delay (if possible within 24 hours, due to the possibility of having contracted malaria, if you are returning from a risk zone).

MANTOUX or TST test: the tuberculin test on the arm

updates 24 october 2022

you can book your MANTOUX test here (click here)

Apply for your TB test (MANTOUX or TST – IGRA or QUANTIFERON) at the CESMET Traveller’s Clinic – Etimedica authorised by the Lazio region (GU. N-G11683 of 09/10/20).
The centre is authorised to carry out tests for university, school, armed forces and public competitions (for the Convention for Universities and Competitions ask the secretariat directly). The answer is accompanied by an infectious diseases assessment and certification.

You can write and leave your details here to book. or call +390639030481

In order to identify a ‘latent tubercular infection’ or to study your immune status against the Tuberculous Bacillus, i.e. to undergo a screening test, you can use and request two different tests that are able to provide you with precise information on ‘possible contacts’ or possible ‘contagion’ with the ‘tuberculous bacterium’, being able to assess your ‘cell-mediated immune status’.  Naturally, the tests are used to help the clinician diagnose any latent or ongoing tuberculosis.

Let us consider the mantoux test – an in vivo test, with a reading of the cellular response in situ, where the tubercular antigen is injected, a more sensitive and more interpretable test, related to the person’s clinical parameters.
The QUANTIFERON test replaces skin tests (Tine-Test, Mantoux intradermal test) and detects the amount of cytokine ‘Interferon Gamma’ released following stimulation of T lymphocytes with two highly specific TB antigens (ESAT-6 and CFP-10).
The in vitro response, although specific and quantitative, does not replace the cellular reaction in response to antigens inoculated into the forearm.

Where to do the tst test or mantoux test
You can request the tst test or mantoux test at Cesmet-Clinica del Viaggiatore – Etimedica. The medical centre specialising in infectious, tropical diseases and parasitology is officially authorised by the Region of Lazio by decree published in the official gazette (OJ. N-G11683 of 09/10/20). The reports and certifications attesting the test result are therefore officially recognised for competitions, university institutions and other official requests. Naturally, the test is used to provide an answer in cases where tuberculosis is suspected. Agreements are in place for university and public competitions.
The performance of the test, assessment of the skin reaction, and interpretation is performed by experienced infectious disease physicians. Click here for information, leaving your details and the reason for the booking call, or phone the centre’s secretariat +390639030481

The tests you can undergo are:
(1) tuberculin skin test (Mantoux Test)
(2) interferon gamma release serum test (IGRA), which includes the Quantiferon test.

The test is performed to identify a ‘latent state’ at an early stage, which is possible in those who have lived for a long time in hyperendemic environments, i.e. where a lot of Mycobacterium is found, particularly in areas of tropical countries. These findings enable early treatment of latent tuberculous infection (LTBI), and greatly reduce the possible risk of reactivation of tuberculous disease.
This is why carrying out tubercular tests, first the skin test and eventually the confirmation test, can be important for the protection of your health.
Testing and possible treatment for LTBI, in the event of a positive result, should be performed in the categories of persons considered to be at risk. Among
these doctors, healthcare personnel, healthcare workers.
International travellers to areas where Mycobacterium is present should perform the Mantoux test before leaving and upon return from their trip.  This is because they work in risky situations or in healthcare environments or because of repeated work and contact with local people and workers, especially in closed and crowded environments. Teachers, volunteers, religious, workers of all kinds in contact with counterparts.
If you fall into one of these categories, you should consider taking an initial and periodic test.

The tuberculin skin test (TST or MANTOUX) evaluates the delayed intradermal response, i.e. under the skin, from hypersensitivity to the administered antigen, a purified protein derivative (PPD) from Mycobacterium tuberculosis.
Normally, a period of up to two to three months is necessary, after any contact and infection with the tubercle bacillus, for the conversion of the tuberculin skin test to occur, i.e. for this test to become positive and signal contact with the bacterium.
In the case of international travellers in the categories identified above, it would be desirable to carry out a MANTOUX test before travelling and 2 months after returning. In the case of prolonged stays, in working environments where prolonged contact is encouraged, it would be advisable to perform the test once a year.
For immuno-compromised persons, with weak or compromised immune defences, who have recently had close contact with known infectious cases of tuberculosis, treatment for LTBI may be initiated even if the TST is negative.
Patients who test positive for TST or IGRA should undergo clinical evaluation to exclude active tuberculosis and to assess the possible need for therapy against latent infection. A clinical evaluation of symptoms, pulmonary and systemic objectivity is always necessary, followed by a chest X-ray examination, after a positive Mantoux test.

TUBERCULIN SKIN TEST
The tuberculin skin test is considered the main test to detect infection or contact with the tuberculosis (or TB) bacterium.
Tuberculin is a fraction of the tubercle bacillus that, when injected, provokes an immune response in the body, which is manifested by an inflammatory reaction on the skin.
The test is harmless and safe and has no health consequences. If positive, it may provoke an even intense reaction at the site of inoculation characterised by swelling, soreness and a few lines of fever.
It is performed to find out whether there has been contact in the past with ‘Mycobacterium Tubercolosis’, the bacterium responsible for tuberculosis disease. A positive test indicates past or recent contact with the tuberculosis bacterium, but this is not the same as being ill.

How it is performed:
A small area of the forearm is chosen and disinfected and a dose of tuberculin is injected superficially with an insulin syringe with a very fine needle. A pompho on the skin appears, which slowly reabsorbs (Mantoux intradermal reaction). The skin response occurs 48 to 72 hours after inoculation.
A negative test leaves no trace, in the case of a positive test an area of inflamed skin with a central indurated papule appears.

The response is classified as follows

negative: absence of induration and erythema of less than 2 mm in diameter;
doubtful: with appearance of induration and erythema between 2 and 4 mm in diameter;
positive: with evident dermal induration and erythema greater than 5 mm in diameter.
intensely positive: if the papule necrotises centrally and the inflammatory reaction is very evident.

The negative test shows absence of contact with the tuberculosis bacillus.

The positive test shows contact with the tubercle bacillus and the response is proportional to the state of disease activity. In any case it must be emphasised that the test does not diagnose tuberculosis but only highlights the presence of an immunological response, the diagnosis being purely clinical with the aid of the radiological picture.

A clear contribution to the interpretation of the Mantoux test

1) Countries at risk of transmission

*In these countries, the risk of transmission is limited to certain areas.

Africa:

Angola
Benin
Burkina Faso
Burundi
Cameroon
Chad*
Congo, Rep
Ivory Coast
Ethiopia*
Gabon
Gambia
Ghana
Guinea
Guinea Bissau
Equatorial Guinea
Kenya*
Liberia
Mali*
Mauritania*
Niger*
Nigeria
Central African Republic
Democratic Republic of Congo*
Senegal
Sierra Leone
Sudan*
South Sudan
Togo
Uganda

America

Argentina*
Bolivia*
Brazil*
Colombia*
Ecuador*
Guyana
French Guiana
Panama*
Paraguay
Peru*
Suriname
Trinidad and Tobago*
Venezuela*

2) Countries at low risk of transmission

 Eritrea
 Rwanda
 Sao Tome
 Somalia
 Tanzania
 Zambia