Legionella spp. is widespread in many natural and artificial water systems, such as hot water distribution networks, cooling towers, and spas. A particular risk factor has been identified in the use of whirlpools and hot tubs in spa facilities and public baths. However, there has been no systematic synthesis of the published literature reporting legionellosis cases or outbreaks related to swimming/spa pools or similar environments used for recreational purposes (hot springs, hot tubs, whirlpools, natural spas). This study presents the results of a systematic review of the literature on cases and outbreaks associated with these environments. Data were extracted from 47 articles, including 42 events (17 sporadic cases and 25 outbreaks) and 1079 cases, 57.5% of which were diagnosed as Pontiac fever, without any deaths, and 42.5% were of Legionnaires’ disease, with a fatality rate of 6.3%. The results are presented in relation to the distribution of Legionella species involved in the events, clinical manifestations and diagnosis, predisposing conditions in the patients, favourable environmental factors, and quality of the epidemiological investigation, as well as in relation to the different types of recreational water sources involved. Based on the epidemiological and microbiological criteria, the strength of evidence linking a case/outbreak of legionellosis with a recreational water system was classified as strong, probable, and possible; in more than half of the events the resulting association was strong.

Issue Fragility is a major challenge that demand a comprehensive public health response, since a high rate of population is aging and becoming vulnerable. Description of the Problem The Local Health Authority of Bologna, about 850,000 inhabitants, has implemented a new qualitative and quantitative Project on fragile patients. Frailty was measured by the “Risk Profile of the Emilia-Romagna region,”, an algorithm that provides a risk index, based on patients'record, which divide population in risk categories (high/very high, moderate and low risk) of hospitalization. The 585 General Practitioners (GPs) have enrolled their fragile patients with high and very high risk (about 6% of the population). GPs and other healthcare professionals are asked to define an Individualized Care Plan (ICP) according to an integrated and multi-professional management perspective. Patients' and healthcare professionals' subjective experience was collected throughout a structured interview. Results From October 2018 to April 2019, 260 patients were included in the project and they received a ICP which included different interventions such as: integrated nursing care (105), nursing care in chronic ambulatory (55), community hospital care (9), social assistance (92), physiotherapy (88), specialist activities (114). Qualitative data highlighted high level of satisfaction both in patients and clinicians. The strengths of the Project are: 1) an integrated management (with a multi- professional team) of frailty population, 2) proactive and individualized treatment plan. Limitations are: 1) different approaches among clinicians in the Local Health Authority of Bologna with possible inequalities of accessibility to the treatment; 2) difficulties in the relationships among clinicians. The early recognition and the specialistic management of the fragile population have to be considered a priority in health practice in order to provide effective medical intervention. Key messages Individualized Care Plan (ICP) and integrated and multi-professional management. Importance of fragility early recognition.

Background Measles is increasing globally, with a 300% increase in the first three months of 2019 in the WHO European Region. Measles cases recorded annually over the last decade in Italy have been cyclical with the last peak in 2017 with 84 cases per million inhabitants. In the same year, national coercive vaccination measures were introduced for access to educational services. Although the country is again achieving adequate vaccination coverage (VC) for the second dose of MRR (93.2% in 2018), outbreaks can still occur in communities with low VCs. Methods The aim of this study was to analyze measles epidemiology in Bologna Local Health Authority (LHA) from 2010 to 2018, focusing on age groups at higher risk of spread. Aggregate data on measles incidence were provided by Bologna HLA and VCs in residents were provided by the Emilia-Romagna Region (RER). Results The number of cases in the period of reference was 261 cases, 240 of which were laboratory confirmed (92%). The overall average age was 28.5 years (standard deviation, ds: ±14.73 years). The age group with the highest average incidence rate was 20-24 years (93 per 1.000.000 inhabitants), followed by 25-29 years (88) and 30-34 years (75). With regard to occupation at highest risk of prevalence, students represented the largest group with 22.6% of cases. VC data in residents in RER showed that in the age group 19-35 the fraction of the population not vaccinated with two doses of vaccine decreased significantly in the birth cohorts of the 1990s with a coverage of 6.9% for the 1984 birth cohort. None of the cohorts taken into consideration achieved a VC of 95% for the second dose. Conclusions Our results confirm the high proportion of measles cases among young adults. This highlights the need to consider catch-up actions and awareness campaign. For example, by focusing on students without previous documented vaccinations, considering that Bologna is home to tens of thousands of University students every year. Key messages The measles epidemiology analysis in the Local Health Authority of Bologna (Italy) over the last decade showed that the young adults (aged 20-35) have the highest average incidence rate of measles. Considering the need to focus on young adults in order to contain new cases of measles; checks on previous vaccinations, catch-up actions and improved awareness campaign are essential.

Background Climate change (CC) is one of the most important global issues, and exerts a strong impact on public health (PH). Correlation between CC and PH is a matter of concern in the whole scientific community and requires an interdisciplinary approach. Nevertheless, the need to take action on CC sometimes contrasts with national and local policies, involved professionals’ training and citizens’ education. In order to face these challenges, the Italian network of public health residents “Consulta Specializzandi” of the Italian Society of Hygiene, Preventive Medicine and Public Health (SItI) decided to create a specific working group. Objectives Main objectives are education of PH residents and practitioners on CC, argument disclosure among the SItI and creation of interdisciplinary networks to promote and extend group activities. Secondary objective is development of a study to identify the gap between scientific evidence, recommendations and guidelines, and the European, national and local policies, with the aim of promoting bottom-up researches and good practices in CC management. Results The group was created in January 2019; activities started in March. Firstly we defined priorities and work mode. Then we analyzed scientific evidence and promoted self-training on the link between environment and CC and on the impact of CC on individual and public health. Finally, through attendance at workshops and scientific events, we began to train other PH residents and practitioners and started to create networks with other scientific societies, research centers and foreign academies, in order to promote international research, advocacy and disclosure between different institutions regarding the relationship between CC and PH. Conclusions The group has already partially achieved its main objectives, especially increasing awareness and training in CC and related issues. Further activities will permit to strength interdisciplinary networks and to move to secondary objectives. Key messages CC severely impacts society. Yet there is no widespread feeling of urgency to act towards its causes and consequences. A change in mindset is mandatory, from individual citizens to decision makers. PH residents and practitioners must be the main actors in training and education, advocacy, disclosure and network creation in CC research and management.