Italian expert questions need for expanded vaccination scheduleBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h6181 (Published 16 November 2015) Cite this as: BMJ 2015;351:h6181
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Dear Dr. Anand,
Thank you for your question and the interest around this topic and I am very sorry for the delay in responding to it. As a representative of the scientific community (currently I am the President of the Italian Society of Hygiene, Preventive Medicine and Public Health, SItI) and not a government officer it is not my role to comment on the political or judicial aspects of the issue. All the Italian Scientific societies are very much convinced that the draft of the new vaccination plan is based on robust scientific evidence with specific arguments that are available here:
Competing interests: Carlo Signorelli in the last two years was part of a Sanofi Pasteur MSD advisory board on HPV-9 vaccine and he was invited to five conferences where expenses reimbursements were supported by Pfizer, Sanofi Pasteur MSD and Reckitt Benkiser.
A simple question to Prof Signorelli and his co-signatories:
Is it true that Dr Demicelli is being threatened with legal action by tbe government officers? Yes? No?
Competing interests: Strong opposition to public health doctors being gagged in ANY COUNTRY.
If the issue of vaccination polices in Italy has to be brought to the BMJ’s international audience in a sound and transparent way, as representatives of the Italian scientific community, we believe that the content of the NEWS by the journalist Michael Day published in BMJ on November 16th, 2015  requires a number of clarifications.
The new Italian National Immunization Plan has been built on the best available scientific evidence. The Working Group of the Ministry of Health which set up the proposal invited and heard on two different occasions the scientific societies that approved, in 2014, the ‘Lifetime Immunization Schedule’  . The Working Group found convincing evidence about the efficacy, safety and pharmaco-economic data supporting most of the newly-proposed vaccinations (not all of them – a decrease of the age threshold for universal free-of-charge influenza immunisation to 50 years, as proposed in the ‘Lifetime Immunisation Schedule’ was not included in the new Plan).
For instance, HPV immunization extension to the male population is supported by the scientific literature that valued the great potential of universal protection against at least seven cancers in both males and females [3,4]. Vaccination against rotavirus is offered to infants in many European countries whose authorities have considered its optimal cost-effectiveness profile . Pneumococcal conjugate vaccination in at risk categories, but also in one or more age-based cohorts of the elderly population is already offered in half of the Italian Regions (Puglia, Liguria, Veneto, Sicily, Tuscany, Friuli, Basilicata, Calabria, Trentino Alto Adige, Molise) on the basis of robust scientific evidence  . The recent CAPITA study, published in the NEJM, gives strong medical support to this policy .
Day’s picture omits to mention that – strangely enough - although the new National Immunization Plan on news media was criticized , the technical board of the State-Regions Conference - whose members represent all the Italian Regions - on 15th October 2015 released a formal positive position statement on the new National Immunization Plan draft. Far from opposing the proposed introduction of selected new immunization offers, the statement only asked the Ministry of Health for few minor integrations.
We were also surprised to read that Piedmont Region was claimed to rank within the Italian Regions with the highest immunization coverage rates: as reported in a recent study conducted by the Italian Society of Hygiene, Preventive Medicine and Public Health (SItI) in collaboration with the Ministry of Health, this is not true . Overall, at the national level, immunization coverage rates have been decreasing since 2012 and – as for now - are still below the targets established by the Ministry of Health . There still is a high degree of heterogeneity within the different Italian Regions and by vaccine: in Piedmont, MMR vaccine coverage does not reach 90% for the first dose (being 95% the WHO target) and HPV vaccine does not reach the 70% minimum target coverage for all invited birth cohorts .
A comprehensive framework of immunization polices in Italy should have mentioned that - as some Italian Regions (namely Veneto, Liguria, Puglia and Sicily) have already adopted the immunization offer included in the new Italian Immunization Plan - its adoption at the national level is a powerful tool to harmonize immunization strategies across the Regions and ultimately ensure to all citizens equity in access to infectious diseases prevention. We recall that, at this time, there are no differences in infectious diseases’ burden across Regions that could justify different immunization strategies by Region.
Last but not least, economic aspects deserve a comment. In recent years – far from what planned - Italy has never been able to invest in prevention 5% of the total health expenditure. This missing investment in prevention needs to be considered when allocating resources. The estimated increase of the total immunisation bill associated with the new Immunization Plan (200-250 million Euro) barely corresponds to 0.002% of total Italian health expenditure and to 0.04% of current expenditure for prevention services. A comprehensive framework should have also mentioned that the new Immunization Plan complements the new immunization offer endorsing and transposing recent European recommendations in terms of strengthened healthcare providers’ training, health education interventions, immunization services as well as immunization registries’ implementation at the national level .
As representatives of the Italian scientific community being called upon by the NEWS paper, we stringently felt the scientific community had to clarify on what reported  Since two Parliamentary questions have been posed on the recent public statements by a Public health officer of the Piedmont Region , we are confident that political responses will soon be handled at the institutional level.
1. Day M (2015) Italian expert questions need for expanded vaccination schedule. BMJ 351: h6181.
2. Bonanni P, Azzari C, Castiglia P, Chiamenti G, Conforti G, et al. (2014) [The 2014 lifetime immunization schedule approved by the Italian scientific societies. Italian Society of Hygiene, Preventive Medicine, and Public Health. Italian Society of Pediatrics. Italian Federation of Pediatric Physicians. Italian Federation of General Medical Physicians. Arezzo Service of Legal Medicine]. Epidemiol Prev 38: 131-146.
3. Crosignani P, De Stefani A, Fara GM, Isidori AM, Lenzi A, et al. (2013) Towards the eradication of HPV infection through universal specific vaccination. BMC Public Health 13: 642.
4. Audisio RA, Icardi G, Isidori AM, Liverani CA, Lombardi A, et al. (2015) Public health value of universal HPV vaccination. Crit Rev Oncol Hematol.
5. Bonanni P, Signorelli C. Anti-rotavirus: no evidence to discontinue the universal vaccination policy. Ig San Pub 2015 LXXI.5.2015: 559-567.
6. Bonten MJ, Huijts SM, Bolkenbaas M (2015) Vaccine against Pneumococcal Pneumonia in Adults. N Engl J Med 373: 93.
7. Demicheli V. Piano nazionale vaccini, cura di trasparenza contro la “teoria del complotto.” Il Sole 24 Ore 2015 Oct 27. http://bit.ly/1kZCqBT. [In Italian.].
8. Bonanni P, Ferro A, Guerra R, Iannazzo S, Odone A, et al. (2015) Vaccine coverage in Italy and assessment of the 2012-2014 National Immunization Prevention Plan. Epidemiol Prev 39: 146-158.
9. Odone A, Fara GM, Giammaco G, Blangiardi F, Signorelli C (2015) The future of immunization policies in Italy and in the European Union: The Declaration of Erice. Hum Vaccin Immunother 11: 1268-1271.
Competing interests: Carlo Signorelli in the last two years was part of a Sanofi Pasteur MSD advisory board on HPV-9 vaccine and he was invited to five conferences where expenses reimbursements were supported by Pfizer, Sanofi Pasteur MSD and Reckitt Benkiser. Paolo Bonanni received In the last two years grants for joining GSK, Sanofi Pasteur MSD and Pfizer advisory boards and expenses reimbursements for conferences participation.
Dr Demicheli's attackers suffer from cognitive dissonance, a psychological discomfort that people experience when their deeply held dogmas are contradicted by sound information that disproves them. The hostile reactions against the news-bearer more often than not adopt the form of “ad hominem attacks”. Attacking the messenger who shakes one's previous beliefs, rather than rationally dealing with the truth he/she presents, is the only choice of action when the new information can’t be refuted using sound logic.
Competing interests: No competing interests
Dr Demiceli, a Piedmontese former director of public health, is being threatened with legal action by government medical officers because, it appears, he refuses to become a chorus girl.
Competing interests: Contempt for " singing from the same hymn sheet".
Re: Italian expert questions need for expanded vaccination schedule: Response to Prof Signorelli and question to the European Public Health Doctors
I appreciate Prof Signorelli's reply. He does not feel able to comment on my question.
Therefore I ask the European Public Health Doctors:
Are you ladies and gentlemen happy at the seeming attempt to strangle free debate, to gag one of your fellow doctors?
Do we live in" Free Europe"? Or, do we live in a state controlled censorship?
Now, to the Public in Europe: Are you happy to be served a diet of public health messages, sanitised to remove the sayings of those who do not obey the Ministerial Diktats?
Competing interests: Member of public who never accepted gagging in theory or in practice.