Pneumococcal serotypes in children, clinical presentation and antimicrobial susceptibility in the PCV13 era.

The aim was to analyse invasive pneumococcal disease (IPD) serotypes in children aged ⩽17 years according to clinical presentation and antimicrobial susceptibility. We conducted a prospective study (January 2012-June 2016). IPD cases were diagnosed by culture and/or real-time polymerase chain reaction (PCR). Demographic, microbiological and clinical data were analysed. Associations were assessed using the odds ratio (OR) and 95% confidence intervals (CI). Of the 253 cases, 34.4% were aged <2 years, 38.7% 2-4 years and 26.9% 5-17 years. Over 64% were 13-valent pneumococcal conjugate vaccine (PCV13) serotypes. 48% of the cases were diagnosed only by real-time PCR. Serotypes 3 and 1 were associated with complicated pneumonia (P < 0.05) and non-PCV13 serotypes with meningitis (OR 7.32, 95% CI 2.33-22.99) and occult bacteraemia (OR 3.6, 95% CI 1.56-8.76). Serotype 19A was more frequent in children aged <2 years and serotypes 3 and 1 in children aged 2-4 years and 5-17 years, respectively. 36.1% of cases were not susceptible to penicillin and 16.4% were also non-susceptible to cefotaxime. Serotypes 14, 24F and 23B were associated with non-susceptibility to penicillin (P < 0.05) and serotypes 11, 14 and 19A to cefotaxime (P < 0.05). Serotype 19A showed resistance to penicillin (P = 0.002). In conclusion, PCV13 serotypes were most frequent in children aged ⩽17 years, mainly serotypes 3, 1 and 19A. Non-PCV13 serotypes were associated with meningitis and occult bacteraemia and PCV13 serotypes with pneumonia. Non-susceptibility to antibiotics of non-PCV13 serotypes should be monitored.

Cost-effectiveness of rifampin for 4 months and isoniazid for 9 months in the treatment of tuberculosis infection.

The purpose of this study was to evaluate the cost-effectiveness of the strategy of controlling the contacts of tuberculosis patients with latent tuberculosis infection by means of treatment with rifampin for 4 months or isoniazid for 9 months. The cost was the sum of the cost of treating latent tuberculosis infection in all contacts plus the cost of treating tuberculosis in whom the disease was not avoided. The effectiveness was expressed as cases avoided. The efficacy adopted was 90 % for rifampin for 4 months and 93 % for isoniazid for 9 months. We carried out a sensitivity analysis for efficacies of rifampin for 4 months of 80 %, 75 %, 69 % and 65 %. Of the 1,002 patients studied, 139 were treated with rifampin for 4 months and 863 were treated with isoniazid for 9 months. The cost-effectiveness was 436,842.83/50 cases avoided with rifampin for 4 months and 692,164.42/40 cases avoided with isoniazid for 9 months. Rifampin for 4 months was dominant. In the sensitivity analysis, rifampin for 4 months was dominant for efficacies of 75 % or greater. The cost-effectiveness analysis favoured the use of rifampin for 4 months when its efficacy was 75 % or greater.

Serotype 3 is a common serotype causing invasive pneumococcal disease in children less than 5 years old, as identified by real-time PCR.

Serotype 3 is one of the most often detected pneumococcal serotypes in adults and it is associated with serious disease. In contrast, the isolation of serotype 3 by bacterial culture is unusual in children with invasive pneumococcal disease (IPD). The purpose of this study was to learn the serotype distribution of IPD, including culture-negative episodes, by using molecular methods in normal sterile samples. We studied all children<5 years of age with IPD admitted to two paediatric hospitals in Catalonia, Spain, from 2007 to 2009. A sequential real-time polymerase chain reaction (PCR) approach was added to routine methods for the detection and serotyping of pneumococcal infection. Among 257 episodes (219 pneumonia, 27 meningitis, six bacteraemia and five others), 33.5% were identified by culture and the rest, 66.5%, were detected exclusively by real-time PCR. The most common serotypes detected by culture were serotypes 1 (26.7%) and 19A (25.6%), and by real-time PCR, serotypes 1 (19.8%) and 3 (18.1%). Theoretical coverage rates by the PCV7, PCV10 and PCV13 vaccines were 10.5, 52.3 and 87.2%, respectively, for those episodes identified by culture, compared to 5.3, 31.6 and 60.2% for those identified only by real-time PCR. Multiplex real-time PCR has been shown to be useful for surveillance studies of IPD. Serotype 3 is underdiagnosed by culture and is important in paediatric IPD.

Measles antibodies and response to vaccination in children aged less than 14 months: implications for age of vaccination.

Passive immunity against measles decreases during the first months of life. The objective of this study was to determine titres of measles antibodies in children aged 9-14 months and their mothers before vaccination, and the children's response to vaccination. Blood samples were collected by capillary puncture before and 28 days after vaccination. Samples were obtained between February and June 2007 during an ongoing measles outbreak. Titres of specific measles IgG antibodies were determined by enzyme-linked immunosorbent assay. Seroconversion was defined as the presence of antibodies after vaccination in subjects without antibodies before vaccination. Maternal antibodies were present in 37·7% of all 69 children included and in 45·1% of children aged 9 months. Of the 51 children in whom a second sample was obtained, 31 (60·8%) were seronegative before vaccination and 61·3% seroconverted. Interference of maternal antibodies was 30%. Advancing the first dose of measles vaccination from 15 to 12 months is a correct strategy, given the increase in the time of susceptibility of infants to measles.

Effectiveness of the pneumococcal polysaccharide vaccine in preventing pneumonia in the elderly.

The objective of our study was to evaluate the effectiveness of the 23-valent pneumococcal polysaccharide vaccine (PPV) in preventing hospital admission for community-acquired pneumonia (CAP) in people ≥65 yrs of age. We conducted a matched case-control study in patients with CAP admitted to five Spanish hospitals. Cases were persons aged ≥65 yrs admitted to hospital through the emergency department, who presented a clinical and radiological pattern compatible with pneumonia, assessed using established criteria. We matched each case with three control subjects by sex, age (±5 yrs), date of hospitalisation (±30 days) and underlying disease. The study period was May 1, 2005 to January 31, 2007. The PPV immunisation status of cases and controls was investigated. Adjusted ORs for vaccination were calculated using logistic regression analysis. A total of 489 cases and 1,467 controls were included in the final analysis. The overall adjusted vaccination effectiveness for all patients was 23.6% (95% CI 0.9-41.0). The adjusted vaccination effectiveness for immunosuppressed patients was 21.0% (95% CI -18.7-47.5). Our results suggest that the PPV may potentially reduce hospitalisations for pneumonia in the elderly and supports vaccination programmes in this age group.

The influence of public or private paediatric health care on vaccination coverages in children in Catalonia (Spain).

BACKGROUND: Maintaining high vaccination coverages is necessary in order to control vaccine-preventable diseases. We studied vaccination coverages in a representative sample of 630 children aged <3 years in Catalonia in order to determine the relationship between vaccination coverages and socioeconomic factors. METHODS: Sampling was carried out in a representative sample of the health regions in Catalonia stratified according to habitat. A sample of 630 parents of children aged <3 years born in October 2001 were interviewed by telephone. Information collected included sociodemographic data, type of health care provider (public or private) and information on vaccination coverage for the basic plus booster immunization series (BBI) which consisted of: four DTP, four OPV, one MMR and the doses of Hib and MenC necessary according to age of administration of the first dose. RESULTS: A total of 87.62% of the children were vaccinated with the BBI series, and no statistically significant differences in coverage between public (87.93%) and private (88.30%) paediatric providers, or between social classes (high: 87.58%, low: 88.81%) were found. Vaccination coverage was associated with attending a day-care centre (OR: 1.89; 95% CI: 1.12-3.21) and maternal university education (OR: 1.84; 95% CI: 1.01-3.33). CONCLUSION: Vaccination coverages are high and are similar between types of provider, probably due to preventive policies which have made a concerted effort to ensure universal vaccination.

Epidemiology of hepatitis A before and after the introduction of a universal vaccination programme in Catalonia, Spain.

A universal vaccination program for preadolescents, aged 12 years, with the hepatitis A + B vaccine was introduced in 1998 in Catalonia (Spain) with the aim of protecting the whole population against hepatitis A. The hepatitis A + B vaccine program replaced the hepatitis B vaccination program for preadolescent started in 1991. The impact of the hepatitis A + B vaccination program was studied by assessment of the trend of reported cases of hepatitis A. All cases of viral hepatitis reported from 1992 to 2006 were included in the study. To evaluate changes in the epidemiology of hepatitis A, two periods were considered: a prevaccination period (1992-1998) and a post-vaccination period (2001-2006). The ratios of the rates were calculated according to age and sex. The comparison of rates and proportions was made by calculation of the normal z statistic. A total of 7536 cases of viral hepatitis were reported, of which 4109 (54.52%) were hepatitis A. The incidence rate of hepatitis A fell from 5.44 per 100 000 person-years in the prevaccination period to 3.02 in the post-vaccination period. In males, the rate fell from 6.85 to 3.89 and in females from 4.10 to 2.18. The male-female ratio of incidence rates was lower in the post-vaccination period. In males the global decline of incidence rate was 43.26% and in females 46.96%. The greatest decline occurred in the 15 to 19 years age group in both sexes (79.1% in men and 78.34% in women) but declines in the 10-14 years age group were also very important (69.21% and 67.88%, respectively). In conclusion, hepatitis A incidence fell in Catalonia in the post-vaccination period in vaccinated adolescents and also in other unvaccinated groups who have benefited from the indirect effects of the vaccination program.

Prevalence of varicella-zoster antibodies in pregnant women in Catalonia (Spain). Rationale for varicella vaccination of women of childbearing age.

OBJECTIVE: The objective of this study was to determine the prevalence of antibodies against varicella-zoster virus (VZV) in pregnant women in Catalonia (Spain). SETTING: The prevalence of antibodies against VZV was assessed in a representative sample (n = 1522) of pregnant women of Catalonia obtained in 2003. METHOD: The sample was obtained including all women attended for childbirth, during 2 months of 2003, in 27 randomly selected hospitals with maternity clinics. MAIN OUTCOME MEASURES: Varicella-zoster antibodies were determined using the enzyme-linked immunosorbent assay test. RESULTS: The total number of women included in the study was 1522, corresponding to a participation rate of 83%. The prevalence of varicella-zoster antibodies in pregnant women was 96.1% (95% CI 95.1-97.1). The prevalence of antibodies was 94% in pregnant women aged 15-24 years, 95% in those aged 25-29 years and >95% in those aged 30-49 years. The prevalence of antibodies was not associated to the place of birth, place of residence (urban or rural), educational level and social class. The study showed that 6% of pregnant women aged 15-24 years and 5% of those aged 25-29 years were susceptible to varicella-zoster infections in Catalonia (Spain). CONCLUSION: The study showed that a varicella-zoster vaccination programme aimed at women of childbearing age could be necessary in Catalonia to prevent all varicella-zoster infections during pregnancy.

A community outbreak of Legionnaires' disease: evidence of a cooling tower as the source.

A community outbreak of Legionella pneumonia in the district of Cerdanyola, Mataró (Catalonia, Spain) was investigated in an epidemiological, environmental and molecular study. Each patient was interviewed to ascertain personal risk-factors and the clinical and epidemiological data. Isolates of Legionella from patients and water samples were subtyped by pulsed-field gel electrophoresis. Between 7 August and 25 August 2002, 113 cases of Legionella pneumonia fulfilling the outbreak case definition criteria were reported, with 84 (74%) cases being located within a 500-m radius of the suspected cooling tower source. In this area, the relative risk of being infected was 54.6 (95% CI 25.3-118.1) compared with individuals living far from the cooling tower. Considering the population residing in the Cerdanyola district (28,256 inhabitants) as a reference population, the attack rate for the outbreak was 399.9 cases/100,000 inhabitants, and the case fatality rate was 1.8%. A single DNA subtype was observed among the ten clinical isolates, and one of the subtypes from the cooling tower matched exactly with the clinical subtype. Nine days after closing the cooling tower, new cases of pneumonia caused by Legionella ceased to appear. The epidemiological features of the outbreak, and the microbiological and molecular investigations, implicated the cooling tower as the source of infection.

Seroepidemiology of HIV-1 infection in a Catalonian penitentiary.

A seroepidemiological study of HIV-1 infection was carried out among all the subjects who were imprisoned in a correctional centre in Catalonia (Spain) between October 1987 and April 1988. Six hundred and thirty-one inmates (male, mean age 19.1 +/- 1.7 years) were surveyed. The overall prevalence of HIV-1 infection was 33.6%. Statistically significant differences were observed between intravenous drug users (IVDUs) and non-IVDUs (P less than 0.0000001) and between regular and irregular IVDUs (P less than 0.000001). The age at which the person started using drugs and the length of time spent in prison were also significantly associated with the prevalence of infection. No other variables, except the higher prevalence among the gipsy ethnic group, showed any statistically significant association with HIV-1 infection.

How could changes in diet explain changes in coronary heart disease mortality in Spain? The Spanish paradox.

We review and compare trends in coronary heart disease (CHD) and stroke mortality in Spain from 1966 to 1990 and changes in food consumption at national and regional levels. Since 1976, a decrease in cardiovascular disease (CVD) mortality in males and females has been observed, and standardized CHD mortality rates have fallen. Stroke mortality decreased during the same period. Trends in food consumption show increases in intakes of meat, dairy products, fish, and fruit, but decreases in consumption of olive oil, sugar, and all foods rich in carbohydrates. Although fat and saturated fat intakes increased, these changes were not accompanied by an increase in CHD mortality rates. This paradoxical situation can be explained by expanded access to clinical care, increased consumption of fruit and fish, improved control of hypertension, and a reduction in cigarette smoking. Diet appears to have an important role in this paradox, but it may not be as critical as other factors. Nevertheless, we suggest dietary guidelines for prevention of CHD in Spain.

Inclusion of laboratory test results in the surveillance of infectious diseases.

We studied certain indicators of the speed with which infectious diseases were notified and epidemiological case records carried out by public health workers for notifications with and without inclusion of laboratory test results. The notification records for brucellosis, dysentery, typhoid fever, viral hepatitis, meningococcal meningitis, and pulmonary tuberculosis in the province of Barcelona between 1982 and 1986 have been reviewed. For each disease notified the time lapse between the onset of symptoms and notification (Delay 1), between notification and implementation of the epidemiological investigation (Delay 2), and the sum of both time lapses (Delay 3) were calculated. In all diseases (with the exception of meningococcal meningitis) when significant differences in delays were noted, the longest were found in those notifications that included laboratory data in the epidemiological investigation. This means that the provision of laboratory data makes the process of notification slower (Delays 1, 2, and 3). Both notification when laboratory results are available and the inclusion of laboratory data in the epidemiological investigation, have a negative influence on the speed of the statutory notification process.

Measles epidemiology in Catalonia (Spain): implications for a regional vaccination programme.

BACKGROUND: To analyse progress in measles control it is recommended that immunization programmes be evaluated by means of specific epidemiological disease surveillance. The aim of the study was to analyse a series of measles cases in Catalonia in the light of vaccination records. METHODS: Cases were detected by means of the epidemiological surveillance system and then surveyed for information on: age, sex, clinical symptoms, laboratory confirmation, record of vaccination, place of infection and possible outbreak-related links. The relationship between 'record of vaccination' and the remaining variables was determined using the adjusted odds ratio (OR) and its 95% confidence interval (CI). RESULTS: The epidemiological survey confirmed that 82.2% of patients (171/208) fulfilled the case criteria. In the multivariate analysis, lack of record of vaccination was associated with age groups < 5 years (OR = 4.0; 95% CI: 1.4-11.8) and > 14 years (OR = 19.2; 95% CI: 5.1-220.5). CONCLUSIONS: Improvement in vaccination coverage at 15 months and the introduction of vaccination-status monitoring at school-entry age and among those aged > 14 years on entry into the job market, university or military service could contribute to the elimination of measles.

Dramatic decline of serogroup C meningococcal disease incidence in Catalonia (Spain) 24 months after a mass vaccination programme of children and young people.

STUDY OBJECTIVES: The objective of this study was to evaluate the effectiveness of a mass vaccination programme carried out in Catalonia (Spain) in the last quarter of 1997 in response to an upsurge of serogroup C meningococcal disease (SCMD). DESIGN: Vaccination coverage in the 18 month to 19 years age group was investigated by means of a specific vaccination register. Vaccination effectiveness was calculated using the prospective cohort method. Cases of SCMD were identified on the basis of compulsory reporting and microbiological notification by hospital laboratories. Vaccination histories were investigated in all cases. Unadjusted and age adjusted vaccination effectiveness referred to the time of vaccination and the corresponding 95% confidence intervals (CI) were estimated at 6, 12, 18 and 24 months of follow up. SETTING: All population aged 18 months to 19 years of Catalonia. MAIN RESULTS: A total of seven cases of SCMD were detected at six months of follow up (one in the vaccinated cohort), 12 cases at 12 months (one in the vaccinated cohort), 19 cases at 18 months (two in the vaccinated cohort) and 24 at 24 months (two in the vaccinated cohort). The age adjusted effectiveness was 84% (95%CI 30, 97) at six months, 92% (95%CI 63, 98) at 12 months, 92% (95% CI 71, 98) at 18 months and 94% (95%CI 78, 98) at 24 months. In the target population, cases have been reduced by more than two thirds (68%) two years after the vaccination programme. In the total population the reduction was 43%. CONCLUSION: Vaccination effectiveness has been high in Catalonia, with a dramatic reduction in disease incidence in the vaccinated cohort accompanied by a relevant reduction in the overall population. Given that vaccination coverage was only 54.6%, it may be supposed that this vaccination effectiveness is attributable, in part, to the herd immunity conferred by the vaccine.

Mortality in hypertensive patients in Hospitalet de Llobregat, Barcelona (Spain).

A retrospective cohort study was carried out on 729 hypertensive patients (male and female 40 years and older) in Hospitalet de Llobregat (Barcelona, Spain) to assess possible differences between the mortality of this group of hypertensives and the general population of the same area matched by age and sex. Patient mortality was assessed during a six year period, resulting in a mean follow-up of 2.6 years at the end of the study. The results reflect an increased risk of dying among hypertensives compared with the general population, with standardised mortality ratio by age and sex of 1.88 (95% confidence interval 1.21-2.44). Cardiovascular mortality was significantly higher for males, while noncardiovascular mortality was significantly higher for females. The study also shows that the presence of smoking habit, diabetes or hyperglycaemia, uncontrolled hypertension and age > or = 60 years can increase the risk of dying among hypertensive patients. Although a higher level of BP control is achieved in hypertension hospital clinics than in the primary health care system, the study shows that hypertensives have an excess of mortality than expected considering their own general population by age and sex.

Ecological association between hypertension and stroke in Catalonia (Spain): development and use of an ecological regression model.

The objectives of this paper were to study the association between the prevalence of uncontrolled hypertension (PUHT) and stroke mortality at the ecological level, in nine geographical areas of Catalonia (Spain); to develop an ecological regression model and to assess its ability to predict crude stroke mortality rate (CMR) from the PUHT. The regression equation obtained for the population older than 25 yrs was CSMR x 10(3) = 0.67035 + 4.94752 PUTH x 10(-2). The ecological risk ratio was 8.38 and the ecological attributable proportion 71.1%. The CSMR estimation obtained by applying the model in a concrete case was close to that observed. The results support an ecological association between the studied variables. The ecological model can be useful in the assessment of observed changes in health problems and risk factor levels in the community. It could also be used in the evaluation of intervention programmes.

Prevalence of diabetes in Catalonia (Spain): an oral glucose tolerance test-based population study.

The goal of this study was to investigate the prevalence of diabetes mellitus and impaired glucose tolerance in the adult population of Catalonia and study their association with obesity, central obesity, hypertension and smoking habit. A random sample of 3839 subjects aged 30-89 years participated in this cross-sectional study: 2214 subjects underwent a health examination with oral glucose tolerance test (OGTT) and 1625 were interviewed by phone. Diabetes prevalence (known and unknown) in the 30-89-year-old population was 10.3%, (95% CI: 9.1-11.6). In this age group, the prevalence rates of known diabetes, unknown diabetes and impaired glucose tolerance were 6.4, 3.9 and 11.9% in men and 6.9, 3.4 and 11.9% in women. The age adjusted prevalence to the world population for the 30-64-year-old age group was 6.1% (7.1% in men and 5.2% in women).The factors significantly associated with diabetes were age, obesity, hypertension and family history of diabetes. The high ratio of previously known diabetic cases to newly discovered ones, specially in the oldest age group, suggests good levels of awareness and medical services. The prevalence in Catalonia is similar to that observed in other Mediterranean countries.

Cost-effectiveness analysis of hepatitis B vaccination strategies in Catalonia, Spain.

Hepatitis B virus (HBV) infection is an important public health problem all over the world. Vaccination is one way to prevent it, and several strategies can be used depending on endemicity, the main pattern of HBV transmission and the demographic structure of the population. In this study, an economic comparison of 3 vaccination strategies (mass adolescent vaccination, mass infant vaccination and mass combined vaccination) was performed in Catalonia, Spain. Screening pregnant women for HBV infection in combination with these strategies was also evaluated. Epidemiological models to analyse patterns of HBV infection with and without vaccination and to calculate HBV-associated costs were designed. Comparison between strategies was done using cost-effectiveness analysis from the perspective of the healthcare system. Epidemiological model results indicate that implementation of HBV vaccination could prevent as many as 104,778 new acute infections, and avoid up to 5239 chronic infections, 2096 cases of cirrhosis and 419 cases of hepatocarcinoma over a 20-year period in Catalonia. Cost-effectiveness analysis shows that mass adolescent vaccination is the most efficient strategy, with lower costs per avoided case than the other 2 strategies. When any of these strategies is complemented by screening for HBV in pregnant women, the number of avoided cases is always higher and the cost per avoided case decreases or remains unchanged.

Changing patterns of fat consumption in Spain.

Trends of fat and fat-containing food consumption in Spain are analysed; information was obtained from data collected at two different levels: household and individual. Three major household budget surveys conducted by the National Institute of Statistics in 1964, 1980-1981, and 1990-1991 show the trends of food and fat consumption in Spain; we can observe a decrease in cereals, potatoes and pulses and an increase in dairy products and meat, similar to that observed in other countries. According to these studies, the consumption of fat and saturated fat and the other vegetable oils have increased, while olive oil intake has decreased. Food and fat consumption in Spain presents a large variation between the Spanish regions. Six individual dietary studies conducted among adult free-living populations are reviewed; intakes of fat ranged from 90 to 110 g/person/day, and percentage of total energy from saturated fat from 12 to 15%. The rise in fat intake in Spain urges dietary interventions.

Changes in diet and mortality from selected cancers in southern Mediterranean countries, 1960-1989.

Mortality trends of breast, colorectal, ovarian and prostate cancer in Spain, Italy, Greece, Yugoslavia, and England and Wales are presented. Figures are discussed with regard to patterns of consumption of fat-containing foods in these countries. An increase of all cancer site mortality is shown in southern European countries, whereas in England and Wales a decrease in ovarian and colorectal cancer among women is observed. Consumption of milk, meat and animal fat products increased in all Mediterranean countries but decreased in England and Wales. Some differences regarding cancer mortality and food consumption patterns among southern European countries are pointed out. This markedly divergent fat consumption pattern between northern and southern Europe appears to antedate and be associated with their substantial differences in ovarian and colorectal cancer mortality trends, and to a lesser extent with breast cancer.