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Inclusion Criteria:

• - age >12 and <18 years for subjects enrolled in Malta; - age >18 years for subjects enrolled in Sicily.

Exclusion Criteria:

• - age <12 and >18 years for subjects enrolled in Malta; - age <18 years for subjects enrolled in Sicily; - refusal to undergo the proposed diagnostic procedures; - lack of informed consent.

Background The diagnosis of celiac disease (CD), a known autoimmune disease, presupposes the recognition of symptoms/signs, the carrying out of serological tests and the diagnostic confirmation with histological examination of intestinal biopsies. The pediatric guidelines European Society for Pediatric Gastroenterology Hepatology and Nutrition report the possibility of avoiding biopsy in some classes of pediatric patients. It is estimated that about 1% of the world population is affected by CD, but only 0.37% of the Italian population and 0.40% in Malta, to date, has been diagnosed. In Sicily in particular, the cases not yet diagnosed are probably even more than in the rest of the Italian territory, because the prevalence was slightly lower than the national average (0.35%). It is clear from these data that CD is an underestimated pathology throughout the national territory and even more in Sicily. It is also known that CD is associated with various pathologies with an autoimmune component (including type 1 diabetes mellitus and Hashimoto's thyroiditis) and that, among its complications, more present in subjects who do not practice or are refractory to a gluten-free diet, neoplastic diseases are also included, such as intestinal T-cell lymphoma and small intestine adenocarcinoma. The ITAMA project, which ended in March 2022, was born from the need to increase/anticipate the number of diagnosed cases of CD by optimizing its diagnosis. The project has developed 'software tools' (Graphical User Interface (GUI), DATABASE, Decision Support System (DSS)) to support the physicians in optimizing CD diagnosis. Through a screening, conducted on 20,000 school-age subjects in Malta and about 1,000 subjects in Sicily, it was demonstrated that, in compliance with the European Society Paediatric Gastroenterology, Hepatology and Nutrition guidelines, it was possible to anticipate the diagnosis of CD and make it easy with the aid of a test performed directly "at the points where treatment is provided" (e.g. schools, medical clinics), i.e. with a Point-of-Care-Test (PoCT, Celiac Disease Quick TestBIOHIT HealthCare Srl, Milan, Italy), conducted on capillary blood obtained through simple and low cost finger prick. This system has proved to be an effective, and the method to be minimally invasive and inexpensive making it possible, at least in certain pediatric cases, to bring out a submerged part of the "CD iceberg", avoiding further investigations, even invasive, in patients with negative PoCT. With ITAMA it was therefore possible to transfer the "know-how" to commercial companies in the medical sector, activating a network between research and production areas in the healthcare sector through the development of information and communication technologies (ICT) for the diagnosis of the CD. The results made it possible to verify/validate, on a large sample of subjects, that:

• - the diagnosis can be anticipated/facilitated through the combined use of a rapid test (PoCT), medical history and traditional serological tests.

• - the diagnosis can be optimized thanks to the support of computer tools based on artificial intelligence (AI).

The capitalization of the aforementioned results is probably possible through the National Health System (NHS) and schools and could be strategic because:

• - non-invasive methods, if correctly applied, allow an early and effective diagnosis of CD (currently underdiagnosed) and, in some cases, can also allow patients not to be subjected to invasive diagnostic methods.

• - the aforementioned procedures allow a considerable saving for the NHS.

Objectives The present project aims to capitalize and extend the previous experience of ITAMA in a larger population with heterogeneous characteristics (young people and adults), through the Sicilian network of General Practitioners (GPs) and the involvement of numerous schools in Malta . The goal is to use ITAMA outputs/results to increase/anticipate the diagnosis of CD and, therefore, bring the number of diagnosed subjects closer to the expected number of CD cases in Sicily and Malta. The consequence could be the improvement of the quality of life of the diagnosed patients (anticipation of diagnosis and therapy, with consequent reduction of symptoms/signs, reduction of medical visits/instrumental tests performed, reduction of lost working days, improvement of social relationships) and a significant reduction in costs for the NHS, as well as a reduction in the number of conventional tests (laboratory and instrumental investigations) not recommended in patients with negative PoCT and the further consequent costs caused by these. Expected results The expected results from this "extension" of the ITAMA project would essentially consist in the capitalization of the previously observed results, through: A) the involvement of the Sicilian network of GPs and Maltese schools and their greater knowledge and awareness of the need to bring out the diagnoses miss you today; B) the confirmation of a possible and extensive outpatient use of the PoCT method to facilitate diagnosis. From a clinical point of view, we also expect: 1) an increase in CD diagnoses, bridging the gap between diagnosed cases and estimated cases, also showing any differences in prevalence between adults and children; 2) a reduction in diagnostic delays, with a consequent improvement in the quality of life of patients and a reduction in costs for the NHS; 3) a reduction in the number of conventional tests (laboratory and instrumental investigations) not recommended in patients with negative PoCT and in the further consequent costs caused by these. From a scientific point of view, this study will contribute to: 1) define more precisely the prevalence of CD in two populations of the Mediterranean area; 2) create a database usable by researchers for this and future research; 3) to demonstrate the utility of a minimally invasive and low-cost screening test for the early identification of patients with CD.

Arms

Experimental: General population

25,000 subjects, divided between Sicily and Malta. Approximately 10,000 students aged between 12 and 18 will be enrolled in Malta and approximately 15,000 adults (>18 years) will be enrolled in Sicily. These numbers are dictated by the need to obtain heterogeneous samples comparable with the subjects diagnosed in the previous ITAMA project (20,000). In Sicily, screening will be carried out in the GPs (Italian takers) clinics. In Malta the recruitment will be performed in the schools (Maltese takers). Furthermore, in Malta, a further extension of the results provides for the execution of the PoCT+questionnaire in the asymptomatic first-degree relatives of the pediatric subjects with an ascertained diagnosis of CD identified in the previous project.

Interventions

Diagnostic Test: - PoCT+questionnaire administration

In Sicily, screening will be carried out in the general practitioner's clinics (GPs). GPs will have to submit the patients attending their clinics to the PoCT + software tools questionnaire. Subjects who are PoCT positive and/or who reach the minimum score in the questionnaire will be considered 'patients at risk of CD' and must be subjected, with prior consent, to in-depth diagnostics using standard serological methods. The subjects resulting positive in the serological investigations will then undergo the appropriate endoscopic and biopsy investigations to ascertain the presence of CD. In Malta the recruitment will exactly repeat the modalities already carried out in the ITAMA project, through the schools of Malta (Maltese takers), while the laboratory and endoscopic examinations of the subjects who tested positive for the PoCT and/or who will reach the minimum score in the software tools questionnaire will be centralized at the "Mater Dei" hospital.